Need for open access non-screening mammography in a hospital with a specialist breast clinic service.

OBJECTIVE--Assessment of open access non-screening mammography in a hospital with a breast clinic. DESIGN--Retrospective analysis of patients sent for first mammogram to our open access service by general practitioners and breast clinic in the year April 1989 to March 1990. SETTING--District general hospital serving 200,000 people before the introduction of breast screening. SUBJECTS--361 symptomatic women referred directly by general practitioners and 226 women referred by the breast clinic for first, non-screening mammograms. MAIN OUTCOME MEASURES--Radiographic reports on all patients. Final diagnosis in patients reported as having possible or probable neoplasm. RESULTS--Of the women referred directly by general practitioners one (0.2%) was reported as showing probable malignancy (later histologically confirmed) and 15 (4%) as showing possible malignancy (on follow up none had proved malignancy). Of the women referred by the breast clinic 38 (17%) were reported as showing probable malignancy (all had confirmed carcinomas) and 35 (15%) as showing possible malignancy (19 (54%) had proved malignancy). 18 of the proved malignancies were in women under 50 years old, 26 were in women over 64 years, and 14 were in women of screening age. 54 (93%) of the 58 patients with proved breast cancer and an abnormal mammogram had a discrete breast lump. CONCLUSIONS--General practitioners accurately divided women into low and high risk groups, resulting in few abnormalities being detected in patients referred directly for mammography. This suggests that an open access non-screening mammography service for general practitioners is unnecessary in an area with a specialist breast clinic. The large proportion of cancers in women outside of screening age emphasises the need for such clinics.     

Age as a factor in breast cancer knowledge,attitudes and screening behaviour.

OBJECTIVE: To determine whether there are age-related differences in knowledge, attitudes and behaviour with respect to breast cancer and whether the differences reflect the age-specific Canadian recommendations on breast cancer screening. DESIGN: Telephone survey. SETTING: Two cities and five towns and their surrounding areas in Alberta. PARTICIPANTS: The age-specific, randomly selected sample comprised 1284 women aged 40 to 75 years who did not have breast cancer. Of the 1741 eligible women who were contacted, 1350 (78%) agreed to participate; 66 were excluded because of age ineligibility or a history of breast cancer. MAIN OUTCOME MEASURE: Frequency of knowledge, attitudes and behaviour with respect to breast cancer, by age group. RESULTS: Knowledge of breast cancer risk factors was generally low and decreased with age. Few women were aware of the Canadian recommendations on breast self-examination, physical examination of the breasts by a health care practitioner and mammographic screening. Older women believed they were less susceptible to breast cancer than younger women and were less likely to have positive attitudes toward screening. Self-examination was performed 9 to 15 times per year by 424 women (33%), and 810 (63%) had been examined by a health care professional in the past year. Although 664 (52%) had undergone mammography, the proportion decreased with age after age 59. The main barriers to mammography were lack of physician referral and the woman''s belief that the procedure is unnecessary if she is healthy. CONCLUSIONS: Education is needed to increase breast cancer knowledge, promote the Canadian recommendations for early detection of breast cancer and decrease negative beliefs about the disease. Changes in the behaviour of women and physicians are needed to increase the use of breast self-examination, clinical breast examination by a health care professional and mammographic screening. Reaching women in the upper range (60 to 69 years) of the target group for mammographic screening should be a focus in promoting early detection of breast cancer.     

Incidence of breast cancer in Norway and Sweden during introduction of nationwide screening: prospective cohort study

Objective To determine whether any increase in the incidence of breast cancer in women detected by mammography is compensated for by a drop in the incidence after age 69, years when women are no longer invited for screening.Design Population based cohort study of incidence of breast cancer during the introduction of nationwide screening programmes.Setting Norway and Sweden.Participants All women aged above 30 years (1.4 and 2.9 million, respectively, in 2000).Main outcome measures Changes in age specific incidence rates of invasive breast cancer associated with the introduction of the screening programmes.Results As a result of screening the recorded incidence of breast cancer in women aged 50-69 years increased by 54% in Norway and 45% in Sweden. There was no corresponding decline in incidence after the age of 69 years.Conclusions Without screening one third of all invasive breast cancers in the age group 50-69 years would not have been detected in the patients'' lifetime. This level of overdiagnosis is larger than previously reported.     

Effectiveness of the public health policy for breast cancer screening in Finland: population based cohort study.

OBJECTIVE: To evaluate the effectiveness of screening for breast cancer as a public health policy. DESIGN: Follow up in 1987-92 of Finnish women invited to join the screening programme in 1987-9 and of the control women (balanced by age and matched by municipality of residence), who were not invited to the service screening. SETTING: Finland. SUBJECTS: Of the Finnish women born in 1927-39, 89893 women invited for screening and 68862 controls were followed; 1584 breast cancers were diagnosed. MAIN OUTCOME MEASURES: Rate ratio of deaths from breast cancer among the women invited for screening to deaths among those not invited. RESULTS: There were 385 deaths from breast cancer, of which 127 were among the 1584 incident cases in 1987-92. The rate ratio of death was 0.76 (95% confidence interval 0.53 to 1.09). The effect was larger and significant (0.56; 0.33 to 0.95) among women aged under 56 years at entry. 20 cancers were prevented (one death prevented per 10000 screens). CONCLUSIONS: A breast screening programme can achieve a similar effect on mortality as achieved by the trials for breast cancer screening. However, it may be difficult to justify a screening programme as a public health policy on the basis of the mortality reduction only. Whether to run a screening programme as a public health policy also depends on its effects on the quality of life of the target population and what the resources would be used for if screening was not done. Given all the different dimensions in the effect, mammography based breast screening is probably justifiable as a public health policy.     

Older women's attitudes towards breast disease,self examination,and screening facilities: implications for communication.

Qualitative research techniques were used in two studies in Edinburgh to explore older women''s attitudes and motivations towards breast disease, self examination, and screening, with a view to identifying appropriate strategies for communication. The results indicated that knowledge of breast disease and screening facilities was poor and that many psychological and emotional issues inhibited self examination. Increasing information about self examination and clinics is unlikely to influence uptake unless it is presented together with emotional support rather than through conventional mass media channels. Such support may best be provided by setting breast screening within general health screening rather than emphasising the single disease.     

Adding retinal photography to screening for diabetic retinopathy: a prospective study in primary care.

OBJECTIVE--To evaluate whether adding retinal photography improved community screening for diabetic retinopathy. SETTING--Mobile screening unit at rural and urban general practices in south west England. SUBJECTS--1010 diabetic patients from primary care. DESIGN--Prospective study; patients were examined by ophthalmoscopy by general practitioners or opticians without fundal photographs and again with photographs, and assessments were compared to those of an ophthalmologist. MAIN OUTCOME MEASURES--Whether fundal photography improved the sensitivity of detection of retinopathy and referrable diabetic retinopathy, and whether this sensitivity could be improved by including a review of the films by the specialist. RESULTS--Diabetic retinopathy was detected by the ophthalmologist in 205 patients (20.5%) and referrable retinopathy in 49 (4.9%). The sensitivity of the general practitioners and opticians for referrable retinopathy with ophthalmoscopy was 65%, and improved to 84% with retinal photographs. General practitioners'' sensitivity in detecting background retinopathy improved with photographs from 22% to 65%; opticians'' sensitivity in detecting background retinopathy improved from 43% to 71%. The sensitivity of detecting referrable retinopathy by general practitioners improved from 56% to 80% with photographs; for opticians it improved from 75% to 88%. CONCLUSIONS--Combining modalities of screening by providing photography with specialist review of all films in addition to direct ophthalmoscopy through dilated pupils improves assessment and referral for diabetic retinopathy by general practitioners and opticians. With further training and experience, primary care screeners should be able to achieve a sensitivity that will achieve an effective, acceptable, and economical community based screening programme for this condition.     

Response by women aged 65-79 to invitation for screening for breast cancer by mammography: a pilot study.

OBJECTIVE--To determine whether there is sufficient benefit to be gained by offering screening for breast cancer with mammography to women aged 65-79, who are not normally invited for screening. DESIGN--Pilot study of women eligible for screening but not for personal invitation. The results of this study were compared with the results of routinely screened younger women (aged 50-64) from the same general practice. SETTING--One group general practice in south Manchester. PATIENTS--The 631 women aged 65-79 on the practice list. A total of 42 (7%) were excluded by the general practitioner, and 22 (4%) invitation letters were returned by the post office. MAIN OUTCOME MEASURES--Response rates to invitation for screening assessed by three indices: crude population coverage ratio, crude invited population coverage ratio, and corrected invited population coverage ratio. RESULTS--344 Patients aged 65-79 (61% of those invited, excluding those who could not be traced) were screened compared with 77% of women aged 50-64. The three response indices were higher for younger women than older: crude population coverage ratio = 66.5%, crude invited population coverage ratio = 69.3%, corrected invited population coverage ratio = 76.8% for women aged 50-64, compared with 54.5%, 58.4%, and 60.7% respectively for women aged 65-79. All four biopsies done in the older women gave positive results, giving a cancer detection rate of 11.6/1000 compared with 4.1/1000 among younger women. CONCLUSIONS--These results show that there is a potential for high attendance at routine screening by older women if they are invited in the same way as younger women. If these results are found elsewhere the costs and benefits of screening older women should be reassessed.     

Antenatal maternal serum screening for Down's syndrome: results of a demonstration project.

OBJECTIVES--To assess the implementation of antenatal screening for Down''s syndrome in practice, using individual risk estimates based on maternal age and the three serum markers: alpha fetoprotein, unconjugated oestriol, and human chorionic gonadotrophin. DESIGN--Demonstration project of Down''s syndrome screening; women with a risk estimate at term of 1 in 250 or greater were classified as "screen positive" and offered diagnostic amniocentesis. SETTING--Hospital and community antenatal clinics in four health districts in London. SUBJECTS--12,603 women of all ages with singleton pregnancies seen between February 1989 and the end of May 1991, with follow up of the outcome of pregnancy completed to the end of 1991. MAIN OUTCOME MEASURES--Uptake of screening, detection rate for Down''s syndrome, false positive rate, odds of being affected given a positive result, and uptake of amniocentesis in women with positive screening results, together with the costs of the screening programme. RESULTS--The uptake of screening was 74%. The detection rate was 48% (12/25), and the false positive rate was 4.1%, consistent with results expected from previous work based on observational studies. There was a loss of detection due to the selective use of ultrasound scans among women with positive screening results. One affected pregnancy occurred among 205 reclassified as negative; this illustrated the danger of false negatives occurring in this group and lends weight to the view that if an ultrasound estimate of gestational age is used it should be carried out routinely on all women rather than selectively among those with positive results. The estimated cost of avoiding the birth of a baby with Down''s syndrome was about 38,000 pounds, substantially less than the lifetime costs of care. CONCLUSION--Antenatal maternal serum screening for Down''s syndrome is effective in practice and can be readily integrated into routine antenatal care. It is cost effective and performs better than selection for amniocentesis on the basis of maternal age alone.     

Maternal serum screening for Down's syndrome in early pregnancy.

The possibility of improving the effectiveness of antenatal screening for Down''s syndrome by measuring human chorionic gonadotrophin concentrations in maternal serum during the second trimester to select women for diagnostic amniocentesis was examined. The median maternal serum human chorionic gonadotrophin concentration in 77 pregnancies associated with Down''s syndrome was twice the median concentration in 385 unaffected pregnancies matched for maternal age, gestational age, and duration of storage of the serum sample. Measuring human chorionic gonadotrophin in maternal serum was an effective screening test, giving a lower false positive rate (3%) at a 30% detection rate than that for maternal age (5%) and the two existing serum screening tests, unconjugated oestriol (7%) and alpha fetoprotein (11%). The most effective screening results were obtained with all four variables combined; at the same 30% detection rate the false positive rate declined to 0.5%. The new screening method would detect over 60% of affected pregnancies, more than double that achievable with the same amniocentesis rate in existing programmes (5%), and could reduce the number of children born with Down''s syndrome in the United Kingdom from about 900 a year to about 350 a year.     

Variation in management of small invasive breast cancers detected on screening in the former south east Thames region: observational study.

OBJECTIVE: To examine the variation in surgical and adjuvant treatment of breast cancer of known histology and detected on screening in a large cohort of patients treated by the surgeons of a health region. DESIGN: Part prospective, part retrospective observational study using the databases of a region''s breast screening programme and of the cancer registry. SETTING: The former South East Thames region. SUBJECTS: 600 women aged 49-79 who presented during 1991-2 with invasive breast cancer up to 20 mm in diameter that had been detected on screening. These patients were treated by 35 surgeons. MAIN OUTCOME MEASURES: Mastectomy rate by surgeon and the use of adjuvant treatment (radiotherapy, tamoxifen, and chemotherapy) were compared with risk factors, tumour grade, resection margins, and axillary node status. RESULTS: The mastectomy rate varied between nil and 80%, although the numbers at these extremes were small (0/13 v 8/10). Surgeons operating on more than 20 such cases had a lower mastectomy rate (15%) than surgeons treating fewer cases (23%), but this difference was confounded by variation in casemix. There were also wide variations in mastectomy rates and in axillary sampling rates that were independent of casemix or caseload. There was broad agreement on the use of adjuvant tamoxifen (94%), but few patients received chemotherapy (2.5%). 78 patients (19%) did not receive radiotherapy, including 51 out of 317 patients with unfavourable tumours, and 26 patients did not receive tamoxifen. Whether the patient received adjuvant treatment was more dependent on referral by the surgeon than the risk factors for local recurrence and was independent of caseload. CONCLUSION: Mastectomy rates for similar tumours vary widely by surgeon independently of casemix or caseload, but surgeons with a higher caseload tend to have a lower mastectomy rate. Omission of postoperative radiotherapy or tamoxifen after conservative treatment is not related to risk factors for local recurrence or caseload. Confidential feedback of treatment profiles to individual surgeons has been used, but when benefit has been established treatment should be guided by evidence based protocol.     

Trends in breast cancer mortality in Sweden before and after implementation of mammography screening

Background

Incidence-based mortality modelling comparing the risk of breast cancer death in screened and unscreened women in nine Swedish counties has suggested a 39% risk reduction in women 40 to 69 years old after introduction of mammography screening in the 1980s and 1990s.

Objective

We evaluated changes in breast cancer mortality in the same nine Swedish counties using a model approach based on official Swedish breast cancer mortality statistics, robust to effects of over-diagnosis and treatment changes. Using mortality data from the NordCan database from 1974 until 2003, we estimated the change in breast cancer mortality before and after introduction of mammography screening in at least the 13 years that followed screening start.

Results

Breast mortality decreased by 16% (95% CI: 9 to 22%) in women 40 to 69, and by 11% (95% CI: 2 to 20%) in women 40 to 79 years of age.

Discussion

Without individual data it is impossible to completely separate the effects of improved treatment and health service organisation from that of screening, which would bias our results in favour of screening. There will also be some contamination of post-screening mortality from breast cancer diagnosed prior to screening, beyond our attempts to adjust for delayed benefit. This would bias against screening. However, our estimates from publicly available data suggest considerably lower benefits than estimates based on comparison of screened versus non-screened women.     

Mammographic screening and mortality from breast cancer: the Malm? mammographic screening trial.

STUDY OBJECTIVE--To determine whether mortality from breast cancer could be reduced by repeated mammographic screening. DESIGN--Birth year cohorts of city population separately randomised into study and control groups. SETTING--Screening clinic outside main hospital. PATIENTS--Women aged over 45; 21,088 invited for screening and 21,195 in control group. INTERVENTIONS--Women in the study group were invited to attend for mammographic screening at intervals of 18-24 months. Five rounds of screening were completed. Breast cancer was treated according to stage at diagnosis. END POINT--Mortality from breast cancer. MEASUREMENTS AND MAIN RESULTS--All women were followed up and classed at end point as alive without breast cancer, alive with breast cancer, dead from breast cancer, or dead from other causes. Cause of death was taken from national mortality registry and for patients with breast cancer was validated independently. Mean follow up was 8.8 years. Altogether 588 cases of breast cancer were diagnosed in the study group and 447 in the control group; 99 v 94 women died of all causes and 63 v 66 women died of breast cancer (no significant difference; relative risk 0.96 (95% confidence interval 0.68 to 1.35)). In the study group 29% more women aged less than 55 died of breast cancer (28 v 22; relative risk 1.29 (0.74 to 2.25)). More women in the study group died from breast cancer in the first seven years; after that the trend reversed, especially in women aged greater than or equal to 55 at entry. Overall, women in the study group aged greater than or equal to 55 had a 20% reduction in mortality from breast cancer (35 v 44; relative risk 0.79 (0.51 to 1.24)). OTHER FINDINGS--In the study group 100 (17%) cancers appeared in intervals between screenings and 107 (18%) in non-attenders; 51 of these women died from breast cancer. Cancers classed as stages II-IV comprised 33% (190/579) of cancers in the study group and 52% (231/443) in the control group. CONCLUSIONS--Invitation to mammographic screening may lead to reduced mortality from breast cancer, at least in women aged 55 or over.     

Serum screening for Down's syndrome: some women's experiences.

OBJECTIVES--To describe the experiences of a small group of women who had positive results after serum screening for Down''s syndrome. DESIGN--Semistructured telephone interviews and correspondence with women after a positive screening result (four women) negative amniocentesis results (eight), or termination of a pregnancy with a confirmed abnormality (eight). SUBJECTS--20 women who contacted Support After Termination For Abnormality about their experiences of serum screening for Down''s syndrome. MAIN OUTCOME MEASURES--Women''s knowledge and understanding of the test; staff misconceptions; communication of results; how women coped with the diagnostic process; attitudes to the test and to termination of abnormal fetuses. RESULTS--All women were made anxious by their positive screening test, no matter how they were told. The women''s experiences suggested that medical staff were unclear about the implications of screening tests and how to interpret risk. Even after receipt of negative amniocentesis results some women remained anxious. Staff did not always recognise women''s concerns while awaiting amniocentesis results. CONCLUSIONS--The way in which serum screening is being implemented does not always meet the needs of women with positive results. Some of the problems were not specific to screening for Down''s syndrome. When screening tests are introduced policies should be adopted to ensure appropriate support for participants.     

Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders.

OBJECTIVES: To determine whether a two hour training programme for general practice reception staff could improve uptake in patients who had failed to attend for breast screening, and whether women from different ethnic groups benefited equally. DESIGN: Controlled trial, randomised by general practice. SETTING: Inner London borough of Newham. SUBJECTS: 2064 women aged 50-64 years who had failed to attend for breast screening. Women came from 26 of 37 eligible practices, 31% were white, 17% were Indian, 10% Pakistani, 14% black, 6% Bangladeshi, 1% Chinese, 4% were from other ethnic groups, and in 16% the ethnic group was not reported. MAIN OUTCOME MEASURES: Attendance for breast screening in relation to ethnic group in women who had not taken up their original invitation. RESULTS: Attendance in the intervention group was significantly better than in the control group (9% v 4%). The response was best in Indian women--it was 19% in the intervention group and 5% in the control group. CONCLUSIONS: This simple, low cost intervention improved breast screening rates modestly. Improvement was greatest in Indian women--probably because many practice staff shared their cultural and linguistic background. This intervention could be effective as part of a multifaceted strategy to improve uptake in areas with low rates.     

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.     

Deprivation and mass screening: Survival of women diagnosed with breast cancer in France from 2008 to 2010

BackgroundSome studies have investigated the role of socio-demographic inequalities in the association between screening and survival. However, in France, no study has been conducted to describe the socio-demographic characteristics and survival of women with breast cancer based on their participation to mass screening. The aim of this study was to assess the impact of socio-demographic inequalities on the association between participation in mass screening program and survival of women with breast cancer.MethodsData for 2,244 women aged 50–74 years diagnosed with breast cancer over the period 2008–2010 were obtained from the cancer registry and the screening structure of Gironde. We used the aggregated European Deprivation Index (EDI) to define the deprivation level of women. Net survival rates were estimated with the Pohar-Perme method, with and without correcting for lead-time bias.ResultsSurvival rates were lower for non-attenders than for screen-detected women (83.8% vs 97.3%, p < 0.0001), even after correcting for lead-time bias. Among the most deprived women, the survival rate was significantly different between non-attenders and screen-detected women (78.1% vs 95.6%, p = 0.0002), suggesting an important effect of mass screening in this group.ConclusionThe introduction of incentive actions in deprived areas could play a key role in the adherence of women to mass screening and in improving their survival in case of a breast cancer diagnosis.     

Volume of screening mammography and performance in the Quebec population-based Breast Cancer Screening Program

Background

In the Quebec Breast Cancer Screening Program (Programme québécois de dépistage du cancer du sein [PQDCS]), radiologists'' and facilities'' volumes of screening mammography vary considerably. We examined the relation of screening-mammography volume to rates of breast cancer detection and false-positive readings in the PQDCS.

Methods

The study population included 307 314 asymptomatic women aged 50–69 years screened during 1998–2000. Breast cancer detection rates were analyzed by comparing all women with screening-detected breast cancer (n = 1709) and a 10% random sample of those without (n = 30 560). False-positive rates were analyzed by comparing the 3159 women with false-positive readings and the 27 401 others in the 10% random sample. Characteristics of participants, radiologists and facilities were obtained from the PQDCS information system. Data were analyzed by means of logistic regression.

Results

The rate of breast cancer detection appeared to be unrelated to the radiologist''s screening-mammography volume but increased with the facility''s screening-mammography volume. The breast cancer detection rate ratio for facilities performing 4000 or more screenings per year, compared with those performing fewer than 2000, was 1.28 (95% confidence interval [CI] 1.07–1.52). In contrast, the frequency of false-positive readings was unrelated to the facility''s screening volume but was inversely related to the radiologist''s screening volume: the rate ratio for readers of 1500 or more screenings per year compared with those reading fewer than 250 was 0.53 (95% CI 0.35–0.79).

Interpretation

Radiologists'' and facilities'' caseloads showed independent and complementary associations with performance of screening mammography in the PQDCS. Radiologists who worked in larger facilities and read more screening mammograms had higher breast cancer detection rates while maintaining lower false-positive rates.Caseload of health care providers and organizations has been linked with performance.^1,2,3,4 Providers with larger volumes of patients or procedures have often been shown to have better outcomes.^2,5 However, a recent comprehensive review of the literature underlined the methodologic limitations of published studies, especially poor adjustment for case mix and failure to account for characteristics of providers and organizations simultaneously.⁶The population-based Quebec Breast Cancer Screening Program (Programme québécois de dépistage du cancer du sein [PQDCS]), launched in 1998, follows the North American standard of a minimum annual reading volume of 480 mammographic examinations (diagnostic and screening combined) for each collaborating radiologist.⁷ In addition, facilities in urban areas have to perform at least 4000 diagnostic or screening examinations each year to be eligible for the program.⁸ However, there is a large variability in radiologists'' and facilities'' volumes of screening examinations.The objective of our study was to assess whether differences in screening volume were associated with rates of breast cancer detection and of false-positive readings. We examined the separate and combined effects of radiologists'' and facilities'' screening-mammography volumes.     

Mammography screening: an incremental cost effectiveness analysis of double versus single reading of mammograms.

OBJECTIVE--To compare mammography reading by one radiologist with independent reading by two radiologists. DESIGN--An observational non-randomised trial at St Margaret''s Hospital, Epping. SUBJECTS-- 33 734 consecutive attenders for breast screening in the main trial and a sample of 132 attenders for assessment who provided data on private costs. INTERVENTIONS--Three reporting policies were compared: single reading, consensus double reading, and non-consensus double reading. MAIN OUTCOME MEASURES--Numbers of cancers detected, recall rates, screening and assessment costs, and cost effectiveness ratios. RESULTS--A policy of double reading followed by consensus detected an additional nine cancers per 10 000 women screened (95% confidence interval 5 to 13) compared with single reading. A non-consensus double reading policy detected an additional 10 cancers per 10 000 women screened (95% confidence interval 6 to 14). The difference in numbers of cancers detected between the consensus and non-consensus double reading policies was not significant (95% confidence interval -0.2 to 2.2). The proportion of women recalled for assessment after consensus double reading was significantly lower than after single reading (difference 2.7%; 95% confidence interval 2.4% to 3.0%). The recall rate with the non-consensus policy was significantly higher than with single reading (difference 3.0%; 2.5% to 3.5%). Consensus double reading cost less than single reading (saving 4853 pounds per 10 000 women screened). Non-consensus double reading cost more than single reading (difference 19 259 pounds per 10 000 women screened). CONCLUSIONS--In the screening unit studied a consensus double reading policy was more effective and less costly than a single reading policy.     

National Health Service breast screening programme results for 1991-2.

OBJECTIVES--To report the results of the NHS breast screening programme for the year March 1991 to April 1992. DESIGN--A report of statistics was derived from Körner (K62) returns and from the radiology quality assurance programme. MAIN OUTCOME MEASURES--Detection rates for breast cancer and small (< or = 10 mm diameter) invasive cancer, benign biopsy rates, and recall and acceptance rates. RESULTS--The acceptance rate for screening across the United Kingdom was 71.3%. The referral rate for further investigation was 6.2% (regional 4.3-9.0%). The breast cancer detection rate was 6.2 cancers per 1000 women screened (5.1-9.0) and the detection rate of invasive cancers < or = 10 mm was 1.4/1000 (1.0-2.3). 72% of screening programmes reached the target 70% acceptance rate, and 95% of programmes achieved a recall rate of less than 10%. 75% of programmes had a cancer detection rate of more than 5/1000, but only 32% had a detection rate for invasive cancers < or = 10 mm of more than 1.5/1000. CONCLUSIONS--Overall, the results of the screening programme for the year 1991-2 can be regarded as extremely satisfactory, given the size and complexity of the operation.     

Serum screening for Down's syndrome: experiences of obstetricians in England and Wales.

OBJECTIVES--To assess the experiences of obstetricians in England and Wales of serum screening for Down''s syndrome. DESIGN--Postal questionnaire survey. SUBJECTS--Questionnaires were sent to all practising obstetricians in England and Wales with nonacademic appointments who had not participated in an earlier (randomly sampled) survey of obstetricians'' attitudes (n = 555). Responses were received from 393 (71%), of which 351 were analysed. The data represent about one third of obstetric consultants in England and Wales. MAIN OUTCOME MEASURES--The extent of use of serum screening for Down''s syndrome, and the problems encountered. RESULTS--Serum screening for Down''s syndrome was being offered on some basis by virtually all obstetricians in the survey. Nearly half the sample said that they did not have adequate resources for counselling all the women to whom screening was offered. Many problems were reported, which in all cases were more common than equivalent problems encountered with serum screening for neural tube defects. Over 80% (289) said that women not understanding the test was a problem. CONCLUSIONS--There is considerable confusion associated with serum screening for Down''s syndrome. The precedent of serum screening for neural tube defects does not seem to have lessened the problems experienced, rather the contrary. Many obstetricians report inadequate resources for counselling, which is consistent with the high prevalence of problems associated with women not understanding the test. There is an urgent need to consider what counselling should consist of and who should undertake it and to ensure that necessary resources are available.