Systematic review and meta-analysis of prognostic characteristics for breast cancers in populations with digital versus film mammography indicate the transition may have increased both early detection and overdiagnosis.

OBJECTIVE: Film mammography has replaced digital mammography in breast screening programs globally. This led to a small increase in the rate of detection, but whether the detection of clinically important cancers increased is uncertain. We aimed to assess the impact on tumour characteristics of screen-detected and interval breast cancers. STUDY DESIGN AND SETTING: We searched seven databases from inception to 08 October 2023 for publications comparing film and digital mammography within the same population of asymptomatic women at population (average) risk of breast cancer. We recorded reported tumour characteristics and assessed risk of bias using the ROBINS-I tool. We synthesized results using meta-analyses of random effects. RESULTS: Eighteen studies were included in the analysis from 8 countries, including 11,592,225 screening examinations (8,117,781 film; 3,474,444 digital). There were no differences in tumour size, morphology, grade, node status, receptor status, or stage in the pooled differences for screen-detected and interval invasive cancer tumour characteristics. There were statistically significant increases in screen-detected DCIS across all grades: 0.05 (0.00-0.11), 0.14 (0.05-0.22), and 0.19 (0.05-0.33) per 1,000 screens for low, intermediate, and high grade DCIS respectively. There were similar (non-statistically significant) increases in screen-detected invasive cancer across all grades. CONCLUSION: The increased detection of all grades of DCIS and invasive cancer may indicate both increased early detection of more aggressive disease and increased overdiagnosis. FUNDING: Australian National Health and Medical Research Council and the National Breast Cancer Foundation. REGISTRATION: PROSPERO 2017:CRD42017070601.

Breast Cancer Stage and Size Detected with Film versus Digital Mammography in New South Wales, Australia: A Population-Based Study Using Routinely Collected Data.

BACKGROUND: Digital mammography has replaced film mammography in breast-screening programs globally, including Australia. This led to an increase in the rate of detection, but whether there was increased detection of clinically important cancers is uncertain. METHODS: In this population-wide retrospective cohort study in New South Wales, Australia spanning 2004 to 2016 and including 4,631,656 screens, there were 22,965 cancers in women screened with film (n = 11,040) or digital mammography (n = 11,925). We examined the change in tumor characteristics overall and how these rates changed over time, accounting for changes in background rates using an interrupted time-series. Comparisons were made with unscreened women (n = 26,326) during this time. RESULTS: We found increased detection of in situ cancer (3.36 per 10,000 screens), localized invasive, and smaller-sized breast cancers attributable to the change in mammography technology, whereas screen-detected intermediate-sized and metastatic breast cancers decreased. Rates of early-stage and intermediate-sized interval cancers increased, and late-stage (-1.62 per 10,000 screens) and large interval cancers decreased. In unscreened women, there were small increases in the temporal trends of cancers across all stages. CONCLUSIONS: At least some of the increased detection of smaller early-stage cancers may have translated into a reduction in larger and late-stage cancers, indicating beneficial detection of cancers that would have otherwise progressed. However, the increased detection of smaller early-stage and small cancers may also have increased over-diagnosis of lesions that would otherwise have not caused harm. IMPACT: Robust evaluation of potential benefits and harms is needed after changes to screening programs. See related In the Spotlight, p. 638.

The impact of cross-jurisdictional patient flows on ascertainment of hospitalisations and cardiac procedures for ST-segment-elevation myocardial infarction in an Australian population.

Introduction: The patient journey for residents of New South Wales (NSW) Australia with ST-elevation myocardial infarction (STEMI) often involves transfer between hospitals and these can include stays in hospitals in other jurisdictions. Objective: To estimate the change in enumeration of STEMI hospitalisations and time to subsequent cardiac procedures for NSW residents using cross-jurisdictional linkage of administrative health data. Methods: Records for NSW residents aged 20 years and over admitted to hospitals in NSW and four adjacent jurisdictions (Australian Capital Territory, Queensland, South Australia, and Victoria) between 1 July 2013 and 30 June 2018 with a principal diagnosis of STEMI were linked with records of the Australian Government Medicare Benefits Schedule (MBS). The number of STEMI hospitalisations, and rates of angiography, percutaneous coronary intervention and coronary artery bypass graft were compared for residents of different local health districts within NSW with and without inclusion of cross-jurisdictional data. Results: Inclusion of cross-jurisdictional hospital and MBS data increased the enumeration of STEMI hospitalisations for NSW residents by 8% (from 15,420 to 16,659) and procedure rates from 85.6% to 88.2%. For NSW residents who lived adjacent to a jurisdictional border, hospitalisation counts increased by up to 210% and procedure rates by up to 70 percentage points. Conclusions: Cross-jurisdictional linked hospital data is essential to understand patient journeys of NSW residents who live in border areas and to evaluate adherence to treatment guidelines for STEMI. MBS data are useful where hospital data are not available and for procedures that may be conducted in out-patient settings.

The financial implications of investigating false-positive and true-positive mammograms in a national breast cancer screening program.

Objectives To determine the total annual screening and further-investigation costs of investigating false-positive and true-positive mammograms in the Australian population breast-screening program. Methods This economic analysis used aggregate-level retrospective cohort data of women screened at a breast-screening clinic. Counts and frequencies of each diagnostic workup-sequence recorded were scaled up to national figures and costed by estimating per-patient costs of procedures using screening clinic cost data. Main outcomes and measures estimated were percentage share of total annual screening and further-investigation costs for the Australian population breast-screening program of investigating false-positive and true-positive mammograms. Secondary outcomes determined were average costs of investigating each false-positive and true-positive mammogram. Sensitivity analyses involved recalculating results excluding subgroups of patients below and above the screening age range of 50-74 years. Results Of 8235 patients, the median age was 60.35 years with interquartile range of 54.17-67.17 years. A total of 15.4% (ranging from 13.4 to 15.4% under different scenarios) of total annual screening and further-investigation costs were from investigating false-positive mammograms. This exceeded the share of costs from investigating true-positives (13%). Conclusions We have developed a transparent and non-onerous approach for estimating the costs of false-positive and true-positive mammograms associated with the national breast-screening program. While determining an optimal balance between false-positives and true-positive rates must rely primarily on health outcomes, costs are an important consideration. We recommend that future research adopts and refines similar approaches to facilitate better monitoring of these costs, benchmark against estimates from other screening programs, and support optimal policy development.

Considerations for Evaluating the Introduction of New Cancer Screening Technology: Use of Interval Cancers to Assess Potential Benefits and Harms.

This framework focuses on the importance of the consideration of the downstream intermediate and long-term health outcomes when a change to a screening program is introduced. The authors present a methodology for utilising the relationship between screen-detected and interval cancer rates to infer the benefits and harms associated with a change to the program. A review of the previous use of these measures in the literature is presented. The framework presents other aspects to consider when utilizing this methodology, and builds upon an existing framework that helps researchers, clinicians, and policy makers to consider the impacts of changes to screening programs on health outcomes. It is hoped that this research will inform future evaluative studies to assess the benefits and harms of changes to screening programs.

The management of women with ductal carcinoma in situ of the breast in Australia and New Zealand between 2007 and 2016.

BACKGROUND: The incidence of detected ductal carcinoma in situ (DCIS) continues to increase and now accounts for 14% of all breast cancer, and 20%-25% of screen-detected cases. Treatment trends of DCIS are important in order to inform the ongoing debate about possible overdiagnosis and overtreatment, but have not been investigated for over a decade in Australia and New Zealand. Against this background, we aimed to describe the temporal trends in management of DCIS in Australian and New Zealander women. METHODS: Using the BreastSurgANZ Quality Audit (BQA) database, we conducted a descriptive study of the trends of management of DCIS in Australia and New Zealand from 2007 to 2016. We assessed the frequency of surgical treatments, adjuvant therapies, and axillary surgery conducted in women with pure DCIS. RESULTS: There were 17 883 cases of pure DCIS in 2007-2016 in Australia and New Zealand recorded in the BQA database. The treatment patterns were consistent with no changes over time. The most common surgical treatment was breast-conserving surgery (66%), followed by mastectomy (37%), and 36% of women with DCIS received sentinel node biopsy (SNB). CONCLUSION: The clinical management of women diagnosed with DCIS in Australia and New Zealand, appears stable over time. A substantial proportion of women with DCIS receive SNB and this aspect of surgical care warrants further exploration to determine whether it represents appropriate care. These results, alongside the outcomes of the ongoing clinical trials on the management of DCIS, will help inform if any changes to best practice treatment are required.

Breast Density Notification: A Systematic Review of the Impact on Primary Care Practitioners.

Background: In the last decade, there has been an unprecedented amount of advocacy and attention surrounding the issue of breast density (BD) in relation to mammography screening. It is largely unknown what impact notifying women of their BD has had on clinical practice for PCPs. This systematic review aimed to synthesize evidence from existing studies to understand the impact of BD notification on primary care practitioners' (PCPs) knowledge, attitudes, and practice implications. Methods: Empirical studies were identified through relevant database searches (database inception to May 2020). Two authors evaluated the eligibility of studies, extracted and crosschecked data, and assessed the risk of bias. Results were synthesized in a narrative form. Results: Six studies of the 232 titles identified and screened were included. All studies were undertaken in the United States, with five conducted postlegislation in their respective states, and one study conducted in states that were both prelegislation and postlegislation. Five studies were quantitative, including four cross-sectional surveys, and one study was qualitative. Findings consistently demonstrated PCPs' overall lack of knowledge about BD, low level of comfort in discussing and managing patients in relation to dense breasts, and limited consensus on the most appropriate approach for managing women with dense breasts, particularly in relation to supplemental screening. Conclusions: This review highlights important gaps in PCPs' understanding of BD and confidence in having discussions with women about the implications of dense breasts. It identifies the need for high-quality research and the development of evidence-based guidelines to better support PCPs.

The Impact of Breast Density Information or Notification on Women's Cognitive, Psychological, and Behavioral Outcomes: A Systematic Review.

BACKGROUND: Breast density (BD) is an independent risk factor for breast cancer and reduces the sensitivity of mammography. This systematic review aims to synthesize evidence from existing studies to understand the impact of BD information and/or notification on women's cognitive, psychological, and behavioral outcomes. METHODS: Studies were identified via relevant database searches up to March 2020. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias. RESULTS: Of the 1134 titles identified, 29 studies were included. Twenty-three studies were quantitative, including only 1 randomized controlled trial of women receiving BD information, and 6 were qualitative. Twenty-seven studies were conducted in the United States, with 19 conducted post-BD legislation. The overall results in terms of BD awareness, knowledge, attitudes, perceptions, and intentions were heterogeneous across included studies, with the strongest consistency demonstrated regarding the importance of communication with and involvement of health-care professionals. Together, the studies did, however, highlight that there is still limited awareness of BD in the community, especially in more socioeconomic disadvantaged communities, and limited knowledge about what BD means and the implications for women. Importantly, BD information in the context of overall breast cancer risk has not yet been studied. CONCLUSIONS: There are important gaps in the understanding of the impact of BD information or notification on women and how best to communicate BD information to women. More high-quality evidence to inform both current and future practice related to BD is still needed.

Impact of Full-Field Digital Mammography Versus Film-Screen Mammography in Population Screening: A Meta-Analysis.

BACKGROUND: Breast screening programs replaced film mammography with digital mammography, and the effects of this practice shift in population screening on health outcomes can be measured through examination of cancer detection and interval cancer rates. METHODS: A systematic review and random effects meta-analysis were undertaken. Seven databases were searched for publications that compared film with digital mammography within the same population of asymptomatic women and reported cancer detection and/or interval cancer rates. RESULTS: The analysis included 24 studies with 16 583 743 screening examinations (10 968 843 film and 5 614 900 digital). The pooled difference in the cancer detection rate showed an increase of 0.51 per 1000 screens (95% confidence interval [CI] = 0.19 to 0.83), greater relative increase for ductal carcinoma in situ (25.2%, 95% CI = 17.4% to 33.5%) than invasive (4%, 95% CI = -3% to 13%), and a recall rate increase of 6.95 (95% CI = 3.47 to 10.42) per 1000 screens after the transition from film to digital mammography. Seven studies (80.8% of screens) reported interval cancers: the pooled difference showed no change in the interval cancer rate with -0.02 per 1000 screens (95% CI = -0.06 to 0.03). Restricting analysis to studies at low risk of bias resulted in findings consistent with the overall pooled results for all outcomes. CONCLUSIONS: The increase in cancer detection following the practice shift to digital mammography did not translate into a reduction in the interval cancer rate. Recall rates were increased. These results suggest the transition from film to digital mammography did not result in health benefits for screened women. This analysis reinforces the need to carefully evaluate effects of future changes in technology, such as tomosynthesis, to ensure new technology leads to improved health outcomes and beyond technical gains.

The influence of maternal obesity on pregnancy intention: A cross-sectional analysis.

This prospective cross-sectional study of 1498 pregnant women in early pregnancy sought to investigate the prevalence of pregnancy intention between women of differing body mass index (BMI) categories. There was no difference in the risk of unintended pregnancy between women who were in the healthy weight, overweight or obesity BMI categories. The study identifies and highlights the potential missed opportunities for all women to engage in healthy reproductive life planning behaviours to support health in pregnancy and beyond.

Population attributable fractions of perinatal outcomes for nulliparous women associated with overweight and obesity, 1990-2014.

OBJECTIVE: To examine the prevalence across 25 years of overweight and obesity among nulliparous Australian women during early pregnancy; to estimate the proportions of adverse perinatal outcomes attributable to overweight and obesity in this population. DESIGN: Cohort study; retrospective analysis of electronic maternity data. Setting, participants: 42 582 nulliparous women with singleton pregnancies giving birth at the Royal Prince Alfred Hospital, an urban teaching hospital in Sydney, January 1990 - December 2014. MAIN OUTCOME MEASURES: Maternal body mass index (BMI), socio-demographic characteristics, and selected maternal, birth and neonatal outcomes; the proportion of adverse perinatal outcomes that could be averted by reducing the prevalence of overweight and obesity in women prior to first pregnancies (population attributable fraction, PAF). RESULTS: The prevalence of overweight among nulliparous pregnant women increased from 12.7% (1990-1994) to 16.4% (2010-2014); the prevalence of obesity rose from 4.8% to 7.3% in the same period, while the proportion with normal range BMIs fell from 73.5% to 68.2%. The PAFs for key adverse maternal and neonatal outcomes increased across the study period; during 2010-2014, 23.8% of pre-eclampsia, 23.4% of fetal macrosomia, and 17.0% of gestational diabetes were attributable to overweight and obesity. Were overweight and obese women to have moved down one BMI category during 2010-2014, 19% of pre-eclampsia, 15.9% of macrosomia, 14.2% of gestational diabetes, 8.5% of caesarean deliveries, 7.1% of low for gestational age birthweight, 6.8% of post partum haemorrhage, 6.5% of admissions to special care nursery, 5.8% of prematurity, and 3.8% of fetal abnormality could have been averted. CONCLUSIONS: Over the past 25 years, the proportions of adverse perinatal outcomes attributable to overweight and obesity have risen with the increasing prevalence of maternal overweight and obesity. A substantial proportion of these outcomes might be averted with obesity prevention strategies that reduce pre-pregnancy maternal weight.

Reducing overselective stimulus control with differential observing responses.

Overselective stimulus control refers to discriminative control in which the number of controlling stimuli is too limited for effective behavior. Experiment 1 included 22 special-education students who exhibited overselective stimulus control on a two-sample delayed matching task. An intervention added a compound identity matching opportunity within the sample observation period of the matching trials. The compound matching functioned as a differential observing response (DOR) in that high accuracy verified observation and discrimination of both sample stimuli. Nineteen participants learned to perform the DOR and two-sample delayed matching accuracy increased substantially for 16 of them. When the DOR was completely withdrawn after 10 sessions, accuracy declined. In Experiment 2, a more gradual withdrawal of DOR requirements showed that highly accurate performance could be maintained with the DOR on only a proportion of trials for most participants. The results show that DOR training may lead to a general improvement in observing behavior.

Stimulus Overselectivity in Autism, Down Syndrome, and Typical Development.

Stimulus overselectivity refers to maladaptive narrow attending that is a common learning problem among children with intellectual disabilities and frequently associated with autism. The present study contrasted overselectivity among groups of children with autism, Down syndrome, and typical development. The groups with autism and Down syndrome were matched for intellectual level, and all three groups were matched for developmental levels on tests of nonverbal reasoning and receptive vocabulary. Delayed matching-to-sample tests presented color/form compounds, printed words, photographs of faces, Mayer-Johnson Picture Communication Symbols, and unfamiliar black forms. No significant differences among groups emerged for test accuracy scores. Overselectivity was not statistically overrepresented among individuals with autism in contrast to those with Down syndrome or typically developing children.

A sorting-to-matching method to teach compound matching to sample.

Individuals with developmental disabilities may fail to attend to multiple features in compound stimuli (e.g., arrays of pictures, letters within words) with detrimental effects on learning. Participants were 5 children with autism spectrum disorder who had low to intermediate accuracy scores (35% to 84%) on a computer-presented compound matching task. Sample stimuli were pairs of icons (e.g., chair-tree), the correct comparison was identical to the sample, and each incorrect comparison had one icon in common with the sample (e.g., chair-sun, airplane-tree). A 5-step tabletop sorting-to-matching training procedure was used to teach compound matching. The first step was sorting 3 single pictures; subsequent steps gradually changed the task to compound matching. If progress stalled, tasks were modified temporarily to prompt observing behavior. After tabletop training, participants were retested on the compound matching task; accuracy improved to at least 95% for all children. This procedure illustrates one way to improve attending to multiple features of compound stimuli.

A statewide survey assessing practitioners' use and perceived utility of functional assessment.

The field of applied behavior analysis emphasizes the importance of conducting functional assessment before treatment development for problem behavior. There is, however, little information regarding the extent to which practitioners are using functional assessment in applied settings for individuals with developmental disabilities (DD). The purpose of the current study was to conduct a survey to assess the degree to which various types of functional assessment are implemented in agencies that serve individuals with DD in Massachusetts. Practitioners were asked to indicate their perception about and use of the various categories of functional assessment (e.g., indirect assessment, descriptive assessment, and functional analysis). From the 205 respondents who completed the survey, the most frequently used functional assessment was descriptive assessment. Results indicated that although the majority (67.8%) of practitioners believe functional analysis to be the most informative assessment tool for selecting behavioral treatment, only 34.6% of respondents indicated that they typically use functional analysis to inform the development of a behavior plan.

Thematic Matching as Remedial Teaching for Symbolic Matching for Individuals with Autism Spectrum Disorder.

Matching-to-sample (MTS) is often used to teach symbolic relationships between spoken or printed words and their referents to children with intellectual and developmental disabilities. However, many children have difficulty learning symbolic matching, even though they may demonstrate generalized identity matching. The current study investigated whether training on symbolic MTS tasks in which the stimuli are physically dissimilar but members of familiar categories (i.e., thematic matching) can remediate an individual's difficulty learning symbolic MTS tasks involving non-representative stimuli. Three adolescent males diagnosed with autism spectrum disorder were first trained on symbolic MTS tasks with unfamiliar, non-representative form stimuli. Thematic matching was introduced after the participants failed to learn 0, 2 or 4 symbolic MTS tasks and before additional symbolic MTS tasks were introduced. After exposure to thematic matching, accuracy on symbolic MTS tasks with novel stimuli increased to above chance for all participants. For two participants, high accuracy (> 90%) was achieved on a majority of these sessions. Thus, thematic matching may be an effective intervention for students with limited verbal repertoires and who have difficulty learning symbolic MTS tasks. Possible explanations for the facilitative effect of thematic matching are considered and warrant further investigation.