Local Breast Cancer Spatial Patterning: A Tool for Community Health Resource Allocation to Address Local Disparities in Breast Cancer Mortality

Despite available demographic data on the factors that contribute to breast cancer mortality in large population datasets, local patterns are often overlooked. Such local information could provide a valuable metric by which regional community health resources can be allocated to reduce breast cancer mortality. We used national and statewide datasets to assess geographical distribution of breast cancer mortality rates and known risk factors influencing breast cancer mortality in middle Tennessee. Each county in middle Tennessee, and each ZIP code within metropolitan Davidson County, was scored for risk factor prevalence and assigned quartile scores that were used as a metric to identify geographic areas of need. While breast cancer mortality often correlated with age and incidence, geographic areas were identified in which breast cancer mortality rates did not correlate with age and incidence, but correlated with additional risk factors, such as mammography screening and socioeconomic status. Geographical variability in specific risk factors was evident, demonstrating the utility of this approach to identify local areas of risk. This method revealed local patterns in breast cancer mortality that might otherwise be overlooked in a more broadly based analysis. Our data suggest that understanding the geographic distribution of breast cancer mortality, and the distribution of risk factors that contribute to breast cancer mortality, will not only identify communities with the greatest need of support, but will identify the types of resources that would provide the most benefit to reduce breast cancer mortality in the community.     

The effect of the Flemish breast cancer screening program on breast cancer-specific mortality: A case-referent study

BackgroundBreast cancer screening programs were introduced in many countries worldwide following randomized controlled trials in the 1980s showing a reduction in breast cancer-specific mortality. However, their effectiveness remains debated and estimates vary. A breast cancer screening program was introduced in 2001 in Flanders, Belgium where high levels of opportunistic screening practices are observed. The effectiveness of this program was estimated by measuring its effect on breast cancer-specific mortality.MethodsWe performed a case-referent study to investigate the effect of participation in the Flemish population-based mammography screening program (PMSP) on breast cancer-specific mortality from 2005 to 2017. A multiple logistic regression model assessed the association between breast cancer-specific death and screening program participation status in the four years prior to (pseudo)diagnosis (yes/no), with adjustment for potential confounders (individual socio-economic position and calendar year of diagnosis) and stratified for age. In addition, we performed different sensitivity analyses.ResultsWe identified 1571 cases and randomly selected 6284 referents. After adjustment, women who participated in PMSP had a 51 % lower risk of breast cancer-specific mortality compared to those who did not (adjusted odds ratio [aOR] =0.49, 95 % CI: 0.44–0.55). Sensitivity analyses did not markedly change the estimated associations. Correction for self-selection bias reduced the effect size, but the estimate remained significant.ConclusionOur results indicate that in a context of high opportunistic screening rates, participation in breast cancer screening program substantially reduces breast cancer-specific mortality. For policy, these results should be balanced against the potential harms of screening, including overdiagnosis and overtreatment.     

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.     

Urban-Rural Disparity of Breast Cancer and Socioeconomic Risk Factors in China

Breast cancer is one of the most commonly diagnosed cancers worldwide. The primary aim of this work is the study of breast cancer disparity among Chinese women in urban vs. rural regions and its associations with socioeconomic factors. Data on breast cancer incidence were obtained from the Chinese cancer registry annual report (2005–2009). The ten socioeconomic factors considered in this study were obtained from the national population 2000 census and the Chinese city/county statistical yearbooks. Student’s T test was used to assess disparities of female breast cancer and socioeconomic factors in urban vs. rural regions. Pearson correlation and ordinary least squares (OLS) models were employed to analyze the relationships between socioeconomic factors and cancer incidence. It was found that the breast cancer incidence was significantly higher in urban than in rural regions. Moreover, in urban regions, breast cancer incidence remained relatively stable, whereas in rural regions it displayed an annual percentage change (APC) of 8.55. Among the various socioeconomic factors considered, breast cancer incidence exhibited higher positive correlations with population density, percentage of non-agriculture population, and second industry output. On the other hand, the incidence was negatively correlated with the percentage of population employed in primary industry. Overall, it was observed that higher socioeconomic status would lead to a higher breast cancer incidence in China. When studying breast cancer etiology, special attention should be paid to environmental pollutants, especially endocrine disruptors produced during industrial activities. Lastly, the present work’s findings strongly recommend giving high priority to the development of a systematic nationwide breast cancer screening program for women in China; with sufficient participation, mammography screening can considerably reduce mortality among women.     

The breast cancer paradox: A systematic review of the association between area-level deprivation and breast cancer screening uptake in Europe

Breast cancer rates are lower amongst women from more socio-economically deprived areas. However, their mortality rates are higher. One explanation of this breast cancer paradox is that women from more deprived areas are less likely to attend breast cancer screening programmes. This systematic review is the first to examine this issue in Europe. A systematic review of Embase, Medline and PsychINFO (from 2008 to 2019) was undertaken (PROSPERO registration number: CRD42018083703). Observational studies were included if they were based in Europe, measured breast cancer screening uptake, compared at least two areas, included an area-level measure of socio-economic deprivation and were published in the English language. The Joanna Briggs Institute critical appraisal checklist was used to assess study quality and risk of bias. Thirteen studies from seven different European countries met our inclusion criteria and were included in the review. In ten of the thirteen studies, there was a significant negative association between screening uptake and area-level socio-economic deprivation – with women living in more socio-economically deprived neighbourhoods less likely to attend breast cancer screening. Although universal screening programmes were provided in most studies, there were still strong negative associations between screening uptake and area-level socio-economic deprivation. Future breast cancer screening strategies should acknowledge these challenges, and consider developing targeted interventions in more deprived areas to increase screening participation.     

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.     

A close call: the role of screening mammography in the fight against breast cancer: health and medicine for women: a multidisciplinary, evidence-based review of mid-life health concerns

A multidisciplinary panel debated the role of screening mammography in fighting breast cancer during the Health and Medicine for Women continuing medical education (CME) conference at Yale Medical School in September 2010. Different guidelines from professional societies have presented conflicting recommendations for patients regarding both the benefits of mammography and the appropriate age and frequency of screening. In addition, a recent longitudinal study argues that screening mammography may only offer a modest benefit in terms of reducing cancer mortality. In light of these considerations, the panel debated whether mammography should be an informed decision that must be discussed and individualized for each patient based on the context of risk factors such as family history, age, and genetic dispositions.     

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.     

Screening and self examination for breast cancer.

Breast cancer is the major form of cancer in women, with nearly 30,000 new cases and over 15,000 deaths in the United Kingdom each year. Breast screening by mammography has been shown in randomised trials to reduce mortality from breast cancer in women aged 50 and over. An NHS breast screening programme has been in operation in the United Kingdom since 1988. Its aim is to reduce mortality from breast cancer by 25% in the population of women invited to be screened. The uptake of mammography among the eligible population may be the single most important determinant if the programme is to be effective. Primary care teams have an important part to play in encouraging women to attend for screening and in providing information, advice, and reassurance at all stages of the screening process. To date, routine breast self examination has not been shown to be an effective method of screening for breast cancer and should not therefore be promoted as a primary screening procedure. There is, however, a case to be made for women to become more "breast aware."     

Health and social inequality in Europe.

In most European countries health has been shown to be linked to social circumstances--gradients in health status have persisted for decades, despite major changes in the principal causes of death. In central and eastern Europe life expectancy has stagnated since the mid-60s, whereas in the West it has increased; but even in the West it is related to income distribution. Social differences in mortality in men are three times as large in some countries as in others, and are influenced by factors other than conventional risk factors. Substantial declines in mortality and morbidity could result from a narrowing of health inequalities even when differences in health risk between social groups are comparatively small. Policies to reduce health inequalities can be introduced in smaller communities and organisations such as the school and workplace. National policies are variable; factors generating inequalities require action across several policy areas.     

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.     

Changes in incidence of and mortality from breast cancer in England and Wales since introduction of screening. United Kingdom Association of Cancer Registries.

OBJECTIVE--To assess the impact of the NHS breast screening programme on the incidence of and mortality from breast cancer. DESIGN--Comparison of age specific incidence and mortality before and after the introduction of screening in the late 1980s. SETTING--England and Wales. SUBJECTS--Women aged over 30 years. RESULTS--In 1992 the age standardised incidence of breast cancer was 40% higher than in 1979. After the introduction of screening in 1988 recorded incidence rates rose steeply in the screened age group (50-64 year olds) but not in others. In 1992 the rates levelled off at about 25% higher than in 1987. Total mortality from breast cancer has increased steadily since the 1950s; the rates increased earlier in the younger age groups. By the mid-1980s rates had begun to fall in the younger age groups; but total mortality was still among the highest in the world. Age standardised mortality in the 55-69 age group changed little during the first three years of screening but then fell steeply and in 1994 was 12% lower than in 1987. CONCLUSIONS--Since the introduction of screening there have been pronounced increases in recorded incidence in the screened age group. Cancer registries have an essential role in assessing screening programmes and cancer services. The steep decrease in mortality in 55-69 year olds which began three years after screening started is unlikely to be due to screening. The widespread adoption of treatment with tamoxifen during this period may be important. With the reduction in mortality already observed and the expected additional benefits from screening, the Health of the Nation target should be achieved.     

Predictors of Non-Adherence to Breast Cancer Screening among Hospitalized Women

Objective

Disparities in screening mammography use persists among low income women, even those who are insured, despite the proven mortality benefit. A recent study reported that more than a third of hospitalized women were non-adherent with breast cancer screening. The current study explores prevalence of socio-demographic and clinical variables associated with non-adherence to screening mammography recommendations among hospitalized women.

Patients and Methods

A cross sectional bedside survey was conducted to collect socio-demographic and clinical comorbidity data thought to effect breast cancer screening adherence of hospitalized women aged 50–75 years. Logistic regression models were used to assess the association between these factors and non-adherence to screening mammography.

Results

Of 250 enrolled women, 61% were of low income, and 42% reported non-adherence to screening guidelines. After adjustment for socio-demographic and clinical predictors, three variables were found to be independently associated with non-adherence to breast cancer screening: low income (OR = 3.81, 95%CI; 1.84–7.89), current or ex-smoker (OR = 2.29, 95%CI; 1.12–4.67), and history of stroke (OR = 2.83, 95%CI; 1.21–6.60). By contrast, hospitalized women with diabetes were more likely to be compliant with breast cancer screening (OR = 2.70, 95%CI 1.35–5.34).

Conclusion

Because hospitalization creates the scenario wherein patients are in close proximity to healthcare resources, at a time when they may be reflecting upon their health status, strategies could be employed to counsel, educate, and motivate these patients towards health maintenance. Capitalizing on this opportunity would involve offering screening during hospitalization for those who are overdue, particularly for those who are at higher risk of disease.     

Testing the Independence of Two Diagnostic Tests

Consider two diagnostic procedures having binary outcomes. If one of the tests results in a positive finding, a more definitive diagnostic procedure will be administered to establish the presence or absence of a disease. The use of both tests will improve the overall screening sensitivity when the two tests are independent, compared with employing two tests that are positively correlated. We estimate the correlation coefficient of the two tests and derive statistical methods for testing the independence of the two diagnostic procedures conditional on disease status. The statistical tests are used to investigate the independence of mammography and clinical breast exams aimed at establishing the benefit of early detection of breast cancer. The data used in the analysis are obtained from periodic screening examinations of three randomized clinical trials of breast cancer screening. Analysis of each of these trials confirms the independence of the clinical breast and mammography examinations. Based on these three large clinical trials, we conclude that a clinical breast exam considerably increases the overall sensitivity relative to screening with mammography alone and should be routinely included in early breast cancer detection programs.     

Ethnic,racial and socioeconomic disparities in breast cancer survival in two Brazilian capitals between 1996 and 2012

ObjectiveTo study the impact of socio-economic status and ethno-racial strata on excess mortality hazard and net survival of women with breast cancer in two Brazilian state capitals.MethodWe conducted a survival analysis with individual data from population-based cancer registries including women with breast cancer diagnosed between 1996 and 2012 in Aracaju and Curitiba. The main outcomes were the excess mortality hazard (EMH) and net survival. The associations of age, year of diagnosis, disease stage, race/skin colour and socioeconomic status (SES) with the excess mortality hazard and net survival were analysed using multi-level spline regression models, modelled as cubic splines with knots at 1 and 5 years of follow-up.ResultsA total of 2045 women in Aracaju and 7872 in Curitiba were included in the analyses. The EMH was higher for women with lower SES and for black and brown women in both municipalities. The greatest difference in excess mortality was seen between the most deprived women and the most affluent women in Curitiba, hazard ratio (HR) 1.93 (95%CI 1.63–2.28). For race/skin colour, the greatest ratio was found in Curitiba (HR 1.35, 95%CI 1.09–1.66) for black women compared with white women. The most important socio-economic difference in net survival was seen in Aracaju. Age-standardised net survival at five years was 55.7% for the most deprived women and 67.2% for the most affluent. Net survival at eight years was 48.3% and 61.0%, respectively. Net survival in Curitiba was higher than in Aracaju in all SES groups.”ConclusionOur findings suggest the presence of contrasting breast cancer survival expectancy in Aracaju and Curitiba, highlighting regional inequalities in access to health care. Lower survival among brown and black women, and those in lower SES groups indicates that early detection, early diagnosis and timely access to treatment must be prioritized to reduce inequalities in outcome among Brazilian women.     

Estimated benefits and risks of screening for breast cancer.

A controlled randomized trial of breast cancer screening has been initiated in Canada. This paper presents an analysis of the possible benefit from screening relative to the possible radiation risk from mammography for those women who will be screened in the trial. It shows that with modern low-dose mammography, even when a conservative estimate of possible reduction in mortality due to early detection is applied to the data, the estimated benefit substantially exceeds any possible hazard.     

The Prevalence and Factors for Cancer Screening Behavior among People with Severe Mental Illness in Hong Kong

Objectives

Screening is useful in reducing cancer incidence and mortality. People with severe mental illness (PSMI) are vulnerable to cancer as they are exposed to higher levels of cancer risks. Little is known about PSMI''s cancer screening behavior and associated factors. The present study examined the utilization of breast, cervical, prostate, and colorectal cancer screening among PSMI in Hong Kong and to identify factors associated with their screening behaviors.

Method

591 PSMI from community mental health services completed a cross-sectional survey.

Results

The percentage of cancer screening behavior among those who met the criteria for particular screening recommendation was as follows: 20.8% for mammography; 36.5% for clinical breast examination (CBE); 40.5% for pap-smear test; 12.8% for prostate examination; and 21.6% for colorectal cancer screening. Results from logistic regression analyses showed that marital status was a significant factor for mammography, CBE, and pap-smear test; belief that cancer can be healed if found early was a significant factor for pap-smear test and colorectal screening; belief that one can have cancer without having symptoms was a significant factor for CBE and pap-smear test; belief that one will have a higher risk if a family member has had cancer was a significant factor for CBE; and self-efficacy was a significant factor for CBE and pap-smear test behavior.

Conclusions

Cancer screening utilization among PSMI in Hong Kong is low. Beliefs about cancer and self-efficacy are associated with cancer screening behavior. Health care professionals should improve the knowledge and remove the misconceptions about cancer among PSMI; self-efficacy should also be promoted.     

Is mammography indicated for women with defective BRCA genes? Implications of recent scientific advances for the diagnosis, treatment, and prevention of hereditary breast cancer

About 5% of breast cancer patients have inherited their disease because of a mutation in genes encoding either the BRCA-1 or BRCA-2 proteins. Inheriting one of these mutations confers a 50% to 87% risk of breast cancer. Many physicians faced with such a patient would, at a minimum, suggest increased and earlier screening for breast cancer by routine mammography.[1] Normally, regular mammographic screening combined with appropriate and prompt treatment can reduce mortality from breast cancer by 30% in women aged 50-59 years and by about 14%-18% in women aged 40-49. There are no controlled clinical trials for screening young women who have multiple first-degree relatives developing breast cancer before age 45, or those known to carry BRCA-1 or BRCA-2 mutations. In fact, recent advances point out that BRCA-1 and BRCA-2 gene products are needed to repair radiation damage to DNA.[4,5] Based on this finding, I propose that women with defective BRCA genes are likely to have an inordinate sensitivity to radiation, and this raises a question about the advisability of routinely screening these women by frequent mammography.     

Investigating reasons for socioeconomic inequalities in breast cancer survival in New Zealand

Background: This study investigated the role that demographic and tumour factors play in explaining socioeconomic inequalities in breast cancer survival. Methods: Breast cancer cases notified to the New Zealand Cancer Registry (NZCR) from April 2005 to April 2007 were followed up to April 2009. The New Zealand area-based deprivation index (NZDep) was used as a measure of socioeconomic position. Relative survival rates were estimated using sex-, deprivation- and ethnic-specific life tables. Multiple imputation was used to impute missing data. Excess mortality modelling was used to estimate the contribution of demographic and tumour factors to inequalities in survival. Results: There were 2968 breast cancer cases included and 433 recorded deaths. Relative survival rates at 4 years varied across deprivation groups. Using NZDep deciles 1–4 (least deprived) as the reference group, the age- and ethnicity-adjusted hazard ratio (HR) for NZDep deciles 7–8 was 2.03 (CI 1.36–3.04) and for NZDep deciles 9–10 was 1.93 (CI 1.28–2.92). In the fully adjusted model there remained 50% excess mortality for the two most deprived groups compared to the most affluent. Variables which measured timely access to care (extent/size) accounted for more of the survival disparity than breast cancer subtype variables (ER/PR/HER2). Conclusion: Women from deprived areas in New Zealand who are diagnosed with breast cancer are less likely to survive as long as those from affluent areas. A substantial proportion of these socioeconomic disparities can be attributed to differential access to health care although other factors, currently unknown, are also likely to play an important role.