Attending the breast screening programme after breast cancer treatment: A population-based study

IntroductionIn the Netherlands, breast cancer patients are treated and followed at least 5 years after diagnosis. Furthermore, all women aged 50–74 are invited biennially for mammography by the nationwide screening programme. The relation between the outpatient follow-up (follow-up visits in the outpatient clinic for 5 years after treatment) and the screening programme is not well established and attending the screening programme as well as outpatient follow-up is considered undesirable. This study evaluates potential factors influencing women to attend the screening programme during their outpatient follow-up (overlap) and the (re-)attendance to the screening programme after 5 years of outpatient follow-up.MethodsData of breast cancer patients aged 50–74 years, treated for primary breast cancer between 1996 and 2007 were selected from the Netherlands Cancer Registry and linked to the National Breast Cancer Screening Programme in the Northern region. Cox regression analyses were used to study women (re-)attending the screening programme over time, possible overlap with the outpatient follow-up and factors influencing this.ResultsIn total 11 227 breast cancer patients were included, of whom 19% attended the screening programme after breast cancer treatment, 4.4% within 5 years and 15.4% after more than 5 years. Factors that independently influenced attendance within 5 years as well as more than 5 years after treatment were: interval tumours (HR 0.77; 95%CI 0.61–0.97 and HR 0.69; 95%CI 0.53–0.88, ref: screen-detected tumours), receiving adjuvant radiotherapy (HR 0.65; 95%CI 0.47–0.90 and HR 0.66; 95%CI 0.47–0.93; ref: none) and diagnosis of in situ tumours (HR 1.67; 95%CI 1.25–2.23 and HR 1.39; 95%CI 1.05–1.85; ref: stage I tumours). Non-screen related tumours (HR 0.41; 95%CI 0.29–0.58) and recent diagnosis (HR 0.89 per year; 95%CI 0.86–0.92) were only associated with attendance within 5 years after treatment.ConclusionThe interrelation between outpatient follow-up and screening should be improved to avoid overlap and low attendance to the screening programme after outpatient follow-up. Breast cancer patients should be informed that attending the screening programme during the outpatient follow-up is not necessary.     

Cervical cancer screening programme in Finland with an example on implementing alternative screening methods

In Finland (population 5 million) the organised Pap screening programme for preventing cervical cancer has been in action already for 45 years. Women aged 30 to 64 are targeted (N 1.25 million) and the screening interval is five years. The programme invites women seven times in a lifetime; the attendance rate per one screening invitational round is 73%. The programme has affected markedly the cervical cancer rates in our country. During the decennia of its action there has been about 80% decrease in the age-adjusted cervical cancer incidence and mortality rates. The current age-standardised incidence rate is 4 and mortality rate 1 per 100,000 woman-years. In the current article we describe the organisational aspects of the programme; and pay attention to renovation of the programme taken place during the last decade when novel technological alternatives have been started to be used as the screening tests. By expanding the coverage and compliance of screening we still expect to increase the impact of the programme. Same time, efforts are needed to avoid overuse of services due to spontaneous screening, in order to decrease potential adverse effects and improve overall cost-effectiveness. A large-scale public health policy trial on Human papillomavirus (HPV) screening is on-going. Cross-sectional information available thus far suggests promising results. Follow-up of cancer rates after screening episodes are still required to evaluate optimal screening policies (e.g., screening intervals by age groups, and starting and stopping ages). We propose speeding up the use of modern technological alternatives in organised screening programmes.     

Audit of practice based cervical smear programme: completion of the cycle.

OBJECTIVES--To determine the effectiveness of a practice based cervical screening programme and the changing pattern of abnormal smear results and to improve the quality of care provided for patients. DESIGN--Audit of practice held data on cervical screening from 1980 to 1990. Changes in the programme were made after analysis of first five years'' data. SETTING--Mixed urban and rural practice of 10,900 patients in Northumberland. SUBJECTS--Women aged 20-65 who had not had a hysterectomy. RESULTS--2356 (85.1%) of the 2767 targeted women had a test during 1980-5 and 2498 (89.5%) of the 2790 women had a test during 1985-90. Inviting women aged 20-25 to attend for a test increased coverage from 45.8% (146/319) in 1980-5 to 82.5% (282/342) in 1985-90. The proportion of women with abnormalities requiring hospital referral rose in the second half of the study, especially among younger women (from 17/39 (44%) to 45/64 (70%) in women aged 25-34). CONCLUSIONS--Practice based cervical screening programmes can be highly effective. Cytological abnormalities affect patients psychologically as well as physically and practices should provide support and explanation for patients with abnormal results. Data from individual practices should be aggregated to allow health authorities to plan secondary care effectively.     

Detecting hypertension: screening versus case finding in Norway.

OBJECTIVE--Evaluation of detection of hypertension in adults in the county of Nord-Trøndelag, Norway. DESIGN--Cross sectional survey with clinical follow up examinations. SETTING--Health survey by screening teams from the national health screening service, and examinations by all 106 general practitioners in the county. SUBJECTS--During 1984-6, 74,977 persons (88.1% of those aged 20 years and over) participated in the health survey. MAIN OUTCOME MEASURES--Hypertension (when assessed by standardised recording and by questionnaires on drug treatment for hypertension) according to the blood pressure thresholds used in the Norwegian treatment programme. Subjects positive on screening were grouped after clinical examination into treatment groups. RESULTS--In all, 2399 subjects were positive for hypertension. Before screening 6210 (8.3%) patients reported taking antihypertensive drugs and another 3849 (5.1%) had their blood pressure monitored regularly. All who screened positive were referred to their general practitioner and evaluated according to a standard programme. As a result, drug treatment was started in 406 (0.5%) participants screened and blood pressure monitoring in another 1007 (1.3%). Of all patients taking antihypertensive drugs after the screening, 6399 (94.0%) had been diagnosed before screening, and of those whose blood pressure was monitored after the screening, 79.3% had been diagnosed before screening. CONCLUSIONS--At the blood pressure screening thresholds used, and when hypertension is defined by an overall clinical diagnosis, the results indicate that general practitioners can find and diagnose hypertensive patients with the case finding strategy.     

Cancer prevention in primary care. Screening for cervical cancer.

Cervical screening has been shown to be effective in several countries, although not by means of randomised controlled trials. A screening programme has been in operation in the United Kingdom since 1964, but it has, in the past, been beset with problems of organisation, accountability, and commitment. The introduction in 1988 of a systematic call and recall introduction in 1988 of a systematic call and recall system and the setting up of an NHS cervical screening programme national coordinating network has brought a greater sense of coherence. Coverage of the target population in England between 1989-90 and 1992-3 increased from 61% to 83%, and there is a strong indication that cervical screening is now beginning to reach those most at risk--namely, older women from lower social classes. Primary care is central to the overall success of the cervical screening programme. General practitioners are in a unique position to invite women for a smear test, to take smears, to ensure that abnormal smear test results are followed up, and to check on reasons for non-attendance. Numerous studies have looked at the involvement of general practice in cervical screening, identifying many ways in which the programme can be improved. Many practices are now running well organised and effective programmes.     

Population screening for congenital hypothyroidism.

A pilot screening programme for congenital hypothyroidism covering most of North London, Essex, Bedfordshire, and Hertfordshire entailed carrying out an assay of thyroid-stimulating hormone on single Guthrie dried blood spots. During one year 87 444 babies were screened and 26 cases of primary congenital hypothyroidism detected, giving an incidence of 1:3363. Only two cases (7.7%) had already been diagnosed on clinical grounds before the results of screening became available. In two other babies the diagnosis was delayed. The programme thus resulted in the early treatment of 22 babies, eight of whom already had pronounced features of hypothyroidism that had not been detected on routine clinical examinations. Although definitive evidence will not be available for some years, the results suggest that the prognosis for most of these babies is likely to be improved by early diagnosis; thus the introduction of national screening should be delayed no longer.     

Experience with screening newborns for Duchenne muscular dystrophy in Wales.

OBJECTIVES--To assess the acceptability of screening newborn boys for Duchenne muscular dystrophy. DESIGN--Screening is offered on the basis of informed consent in response to an information sheet entitled "A new test for baby boys--Do you want it?" The programme includes a prospective long term evaluation of family responses to early diagnosis and a comparison of their experiences and perceptions with those families who have undergone the later traditional clinical diagnosis. SETTING--All maternity units throughout Wales. Samples obtained through screening programme for phenylketonuria and congenital hypothyroidism. SUBJECTS--Those families whose son had a positive screening test. MAIN OUTCOME MEASURES--Creatine kinase activity. Venous blood test to confirm positive result. Molecular genetic mutation analysis. Muscle biopsy and dystrophin analysis. Qualitative measure of satisfaction among affected families. RESULTS--34,219 Boys have been screened and nine affected families have been identified. Eight families were very positive about the programme. Three chose not to complete the diagnostic process. CONCLUSION--The programme should continue to permit a full evaluation of the issues involved and should serve as a model for other initiatives within the community for genetic disease.     

Implementation of liquid-based cytology in the screening programme against cervical cancer in the County of Funen, Denmark, and status for the first year

As one of the first laboratories in Denmark (and Scandinavia), we have gradually implemented liquid-based cytology into the screening programme against cervical cancer in the County of Funen since 1 June 2001. This paper describes the course of the implementation period in the different steps in the screening programme, and the preliminary results obtained after the first year. We conclude that the new technique has improved the specimen and diagnostic quality. As a result of the reduction of the screening time, the workload in the laboratory is in balance although we have introduced a rapid review as a quality control. Besides, the reduction in the number of repeated cytological tests and follow-up visits at the gynaecologist means a saving for the screening programme as a whole. From our point of view the implementation of ThinPrep method is economically neutral.     

Effective serological and molecular screening of deceased tissue donors

A comprehensive and effective screening programme is essential to support the banking of tissues from deceased donors. However, the overall quality of the samples obtained from deceased donors, quantity and condition, is often not ideal, and this may lead to problems in achieving accurate and reliable results. Additionally a significant percentage of referrals are still rejected upon receipt as unsuitable for screening. We are actively involved in improving the overall quality of deceased donor screening outcomes, and have specifically evaluated and validated both serological and molecular assays for this purpose, as well as developing a specific screening strategy to minimise the specificity issues associated with serological screening. Here we review the nature and effectiveness of the deceased donor screening programme implemented by National Health Service Blood and Transplant (NHSBT), the organisation with overall responsibility for the supply of tissue products within England. Deceased donor screening data, serological and molecular, from August 2007 until May 2012 have been collated and analysed. Of 10,225 samples referred for serology screening, 5.5 % were reported as reactive; of 2,862 samples referred for molecular screening, 0.1 % were reported as reactive/inhibitory. Overall 20 % of the serological and 100 % of the molecular screen reactivity was confirmed as reflecting true infection. The use of a sequential serology screening algorithm has resulted in a marked reduction of tissues lost unnecessarily due to non-specific screen reactivity. The approach taken by NHSBT has resulted in the development of an effective and specific approach to the screening of deceased tissue donors.     

Cervical screening: how often should women be screened?

Introduction
As a result of major improvements that have been made to cervical screening during the last 15 years, and implementation of call and recall to invite all women aged 20–64 for screening, the incidence of cervical carcinoma has fallen by 42% since 1990¹. Cervical cancer is now a rare disease, largely thanks to the widespread uptake of screening by the women at risk. Despite the manifest success of the NHS Cervical Screening Programme (NHSCSP), there is pressure on one hand to improve its sensitivity by the introduction of new technology, including human papillomavirus (HPV) testing², and on the other hand to reduce the cost of the programme, which is more than £130m per year. The main method suggested to reduce costs is the restriction of routine screening to an interval of 5 years^3–5.     

Use of antidepressants among people committing suicide in Sweden.

OBJECTIVE--To analyse the outcome of depression in the Swedish population as reflected by the detection of antidepressants in a national forensic toxicological screening programme of unnatural deaths. DESIGN--Antidepressants detected by the National Laboratory of Forensic Chemistry were related to data on use expressed in person years of exposure. SUBJECTS--All 7000 cases of unnatural death with results from forensic toxicological screening in 1990-1; this included 3400 (85%) of the 4000 cases of suicide in Sweden. MAIN OUTCOME MEASURES--Number of findings of antidepressants in the screening programme and number of findings of different antidepressants in relation to their use. RESULTS--Antidepressants were found in 585 screening tests, corresponding to 542 subjects or less than 16% of the 3400 cases of suicide. Newer, less toxic antidepressants were found more often than the older compounds. Toxic concentrations of antidepressants were found in only 190 cases (5.6%). CONCLUSION--A consistent finding in surveys of suicide is that about half of the patients who commit suicide are depressed. The current data suggest that most depressed patients who commit suicide are not taking antidepressants immediately before death. Therapeutic failure may be a greater problem with antidepressants than toxicity as the results did not indicate any advantage of the newer, less toxic antidepressants. All causes of death should be included in risk analyses, thereby providing an estimate of effectiveness as well as toxicity of antidepressants.     

Computer assisted screening: effect on the patient and his consultation.

The initial impact of computer assisted preventive screening in general practice consultations has been monitored. The technology has not been found stressful by patients, and the power of the consultation to alleviate low arousal has been increased by computer use. No appreciable increase in the durations of consultation was detected, despite an average computer initiated input of two minutes eight seconds. The computer has successfully prompted preventive screening and health education with a sixfold increase in the number of potentially relevant procedures being mentioned. The actual information presented by the computer has been shown to be crucial, with the terminal''s mere presence an ineffective reminder. The computer terminal was used in 65% of the consultations for which it was available, which, if sustained, represents an effective screening programme for attending patients.     

An economic view of high compliance as a screening objective.

Accepted wisdom holds that high compliance is essential for a screening programme to be successful. Indeed, a reason that the national breast screening programme is not routinely offered to women aged 65 or more is on the grounds of predicted poor compliance by older women. Increasing compliance is often associated with increased costs. These costs represent a lost opportunity for screening alternative target populations. We question the need for screening programmes to achieve high compliance, and we argue that a screening programme can be efficient with very low levels of compliance. Adopting compliance as a screening objective and as a measure of the success of screening may be detrimental to the efficiency of a screening programme.     

An Economic Evaluation of Neonatal Screening for Inborn Errors of Metabolism Using Tandem Mass Spectrometry in Thailand

Background

Inborn errors of metabolism (IEM) are a rare group of genetic diseases which can lead to several serious long-term complications in newborns. In order to address these issues as early as possible, a process called tandem mass spectrometry (MS/MS) can be used as it allows for rapid and simultaneous detection of the diseases. This analysis was performed to determine whether newborn screening by MS/MS is cost-effective in Thailand.

Method

A cost-utility analysis comprising a decision-tree and Markov model was used to estimate the cost in Thai baht (THB) and health outcomes in life-years (LYs) and quality-adjusted life year (QALYs) presented as an incremental cost-effectiveness ratio (ICER). The results were also adjusted to international dollars (I$) using purchasing power parities (PPP) (1 I$ = 17.79 THB for the year 2013). The comparisons were between 1) an expanded neonatal screening programme using MS/MS screening for six prioritised diseases: phenylketonuria (PKU); isovaleric acidemia (IVA); methylmalonic acidemia (MMA); propionic acidemia (PA); maple syrup urine disease (MSUD); and multiple carboxylase deficiency (MCD); and 2) the current practice that is existing PKU screening. A comparison of the outcome and cost of treatment before and after clinical presentations were also analysed to illustrate the potential benefit of early treatment for affected children. A budget impact analysis was conducted to illustrate the cost of implementing the programme for 10 years.

Results

The ICER of neonatal screening using MS/MS amounted to 1,043,331 THB per QALY gained (58,647 I$ per QALY gained). The potential benefits of early detection compared with late detection yielded significant results for PKU, IVA, MSUD, and MCD patients. The budget impact analysis indicated that the implementation cost of the programme was expected at approximately 2,700 million THB (152 million I$) over 10 years.

Conclusion

At the current ceiling threshold, neonatal screening using MS/MS in the Thai context is not cost-effective. However, the treatment of patients who were detected early for PKU, IVA, MSUD, and MCD, are considered favourable. The budget impact analysis suggests that the implementation of the programme will incur considerable expenses under limited resources. A long-term epidemiological study on the incidence of IEM in Thailand is strongly recommended to ascertain the magnitude of problem.     

Review of neonatal screening programme for phenylketonuria.

OBJECTIVE--To review the neonatal screening programme during 1984-8. DESIGN--Analysis of data from screening laboratories and paediatricians. SUBJECTS--All live births in United Kingdom. MAIN OUTCOME MEASURES--Structure of programme; number of infants tested and number with phenylketonuria; number of infants missed; ages at testing and treatment. RESULTS--The proportion of infants tested approached 100%. The incidence of phenylketonuria was 11.7/100,000 births (445 subjects): 273 had classic phenylketonuria and three had defects of cofactor metabolism. One child with phenylketonuria was known to have been missed compared with three in 1979-83 and six in 1974-8. Seven subjects had been missed over the 15 years due to negative test results. All seven had been tested with the bacterial inhibition assay, although only 53% of infants had been so tested; the difference between the expected and observed proportion was significant (Fisher''s exact test, p = 0.017). Eleven infants with classic phenylketonuria were not tested by 14 days of age and 23 (8%) did not start treatment until after 20 days, an improvement compared with 36 (15%) in 1979-83. There were, however, wide regional variations (0% to 27% treated after 20 days). CONCLUSION--The screening programme achieves high coverage and effectiveness, although some children are still missed. A national practice for screening may help reduce regional variations.     

Screening for congenital hypothyroidism in the Republic of Ireland.

A national pilot study for detecting congenital hypothyroidism by radioimmunoassay of thyroid-stimulating hormone concentrations in dried blood was incorporated into the newborn screening programme in Ireland on 1 August 1979. The programme has been monitored by a steering committee and follows the guidelines set by the European Society of Paediatric Endocrinologists. During the first 12 months 76 224 infants were screened and 19 cases confirmed, giving an incidence of 1:4012. Fifty infants (0.07%) were recalled for a serum sample, though most of the recalls (31; 0.04%) occurred during the first three months, before the methodology had become established. No case was detected clinically. At recall only three of the 19 affected infants had obvious features, and nine inconspicuous features. Organisation was directed at early diagnosis and treatment, the mean age at beginning treatment being 15 days. These results confirm the efficacy of screening for congenital hypothyroidism and suggest that capital and running costs will be offset by savings in maintenance treatment of untreated patients. Screening does not, however, remove the need for continued vigilance, and clinicians should request thyroid-function tests in any suspected case.     

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.     

Should homosexuals be vaccinated against hepatitis B virus? Cost and benefit assessment.

The recent introduction of a vaccine against hepatitis B has raised the questions of who should be offered it and what the cost would be of a vaccination programme. An analysis was performed of the financial costs and benefits of such a programme designed to prevent acute hepatitis B in male homosexuals in the United Kingdom. Under various assumptions the total costs of screening and vaccination ranged from 2.2m pounds to 3m pounds for a five year programme and from 3.3m pounds to 4.8m pounds for a 10 year programme. The benefits over the same two periods for the programme, depending on two different assumptions of mortality prevented, ranged 3.9m pounds to 13.7m pounds and from 7m pounds to 24.4m pounds. Thus considerable savings may be made to the national economy by offering vaccination to homosexuals. These savings are obtained after consideration of only the acute aspects of hepatitis B. Had it been possible to determine the costs of the chronic sequelae of this disease the savings, compared with the costs, would have been greatly increased.     

The English national risk-reduction programme for preservation of sight in diabetes

This paper discusses the new national guidelines for a systematic screening programme to detect sight-threatening diabetic retinopathy in the population of people with diabetes in England. A review of the literature examines the evidence base to support screening interventions and effective management and treatments in diabetic retinopathy. The current evidence supports the establishment of a digital retinal photography system using pupil dilation. A Policy Advisory Group has been formulated by the National Screening Committee to guide the meeting of this target in England. A conclusion is made that with increased effort and organisation, health care professionals can ensure that the screening programme is successfully implemented and rates of visual impairment and blindness caused by diabetic retinopathy can be reduced significantly. (Mol Cell Biochem 261: 183–185, 2004)     

Regret on Choice of Colorectal Cancer Screening Modality Was Associated with Poorer Screening Compliance: A 4-Year Prospective Cohort Study

Purpose

Very few studies examined the issue of regret on choosing colorectal cancer (CRC) screening tests. We evaluated the determinants of regret and tested the hypothesis that regret over screening choices was associated with poorer screening compliance.

Methods

A bowel cancer screening centre invited all Hong Kong citizens aged 50-70 years who were asymptomatic of CRC to participate in free-of-charge screening programmes. Upon attendance they attended health seminars on CRC and its screening, and were offered an option to choose yearly faecal immunochemical test (FIT) for up to four years vs. one direct colonoscopy. They were not allowed to switch the screening option after decision. A self-administered, four-item validated survey was used to assess whether they regretted over their choice (> 2 = regretful from a scale of 0 [no regret]-5 [extreme regret]). A binary logistic regression model evaluated if initial regret over their choice was associated with poorer programme compliance.

Results

From 4,341 screening participants who have chosen FIT or colonoscopy, 120 (2.8%) regretted over their decision and 1,029 (23.7%) were non-compliant with the screening programme. Younger subjects and people who felt pressure when making their decision were associated with regret. People who regretted their decision were 2.189 (95% C.I. 1.361-3.521, p = 0.001) times more likely to be non-compliant with the programme.

Conclusions

This study is the first to show that regret over the initial CRC screening choice was associated with later non-compliance. Screening participants who expressed regret over their choice should receive additional reminders to improve their programmatic compliance.