A comparison of two digital mammography systems: are there any differences?

AIM: To compare the performance of two newly introduced digital mammography technologies (Sectra and Hologic) to the Welsh breast-screening service; specifically, whether there are differences in the number, type, size, and grade of tumour identified. MATERIALS AND METHODS: This was a retrospective study of a prospectively collected database of 50,000 consecutive screening episodes from 2012; clients were aged 49-88 years (mean 61.9 years). All studies were double-blind read by two readers. All tumours identified in the two arms of the study were detailed and compared specifically with regards to type (ductal or lobular) size, grade, and whether invasive or non-invasive. Performance was analysed for any statistically significant differences. RESULTS: Twenty-five thousand consecutive women were screened with Hologic (recall rate 5.9% of which 18% were cancer) and 25,000 were screened with Sectra digital mammography (recall rate 4.3% and 22% were cancer). Five hundred tumours were found with no significant difference in invasive cancer detection or between ductal or lobular subtypes. The Hologic system detected 267 tumours; of which 81 (30.33%) were non-invasive (3.24 per 1000), compared to the Sectra system with 233 cancers overall including 36 non-invasive (15.45%, 1.44 per 1000). The difference in non-invasive lesions (mainly ductal carcinoma in situ [DCIS]) detection was significant (p<0.001); 38% of which were high nuclear grade (HNG) using Hologic and 50% HNG lesions using Sectra. There was no significant difference in non-invasive size between the two technologies. The mean glandular dose received using the Sectra system was significantly less (0.7 mGy) compared to the Hologic system (1.6 mGy) for a 50-60 mm breast thickness. CONCLUSIONS: Population breast screening is frequently criticised for identifying lesions irrelevant to long-term outcomes or life expectancy and although the two systems seem comparable in terms of invasive cancer detection, a statistically significant difference in the detection of non-invasive lesions was seen, not reported in previous studies. This is a contentious issue, as identifying more DCIS has the potential to over-diagnose screened women leading to increased morbidity, higher "cancer detection rates", longer cancer waiting times, and reduced patient psychological wellbeing. The Sectra system is able to deliver a similar invasive detection cancer delivering a much lower dose mammogram, which is important in limiting overall population radiation dose. Further study as to whether the differences in tumour detection rates are clinically significant long term are now required.

The Nottingham Prognostic Index: five- and ten-year data for all-cause survival within a screened population.

INTRODUCTION: The Nottingham Prognostic Index (NPI) is an established prognostication tool in the management of breast cancers (BCs). Latest ten-year survival data have demonstrated an improved outlook for each NPI category and the latest UK five- and ten-year survival from BC has been reported to be 85% and 77%, respectively. We compared survival of each NPI category for BCs diagnosed within the national breast screening service in Wales (Breast Test Wales (BTW)) to the latest data, and reviewed its validity in unselected cases within a screened population. METHODS: All women screened between 1998 and 2001 within BTW were included. The NPI score for each cancer was calculated using the size, nodal status, and grade of the primary tumour. Survival data (all-cause) were calculated after ten years of follow-up. RESULTS: In the three-year screening period, 199,082 women were screened. A total of 1,712 cancers were diagnosed, and 1,546 had data available for calculating the NPI. Overall five-year and ten-year survival was 94% and 82%, respectively. CONCLUSIONS: Overall five-year and ten-year survival (all-cause) has improved even when compared with UK data for BC-specific survival. We found that the NPI remains valid for BC treatment, and that our data provide a reference for updating the all-cause survival of women diagnosed with BCs within a screened population.

The incidence and 10-year survival of interval breast cancers in Wales.

AIM: To evaluate the number of interval cancers (IC) within one screening cycle and the overall 10-year survival of IC, including its four main classifications, and compare that to screen-detected cancers (SDC). MATERIALS AND METHODS: Within Breast Test Wales (BTW), all SDC between the years 1998 and 2001 were included. IC that occurred between 1998 and 2003 that had undergone screening between the years 1998 and 2001 were also included. These IC were classified into true interval (TI), false negative (FN), occult cancer (OCC), and unclassified cancer (UCC). BTW received notification of all deaths of women that had undergone screening; thus, the 10-year all-cause survival rate was calculated from the date of diagnosis and death. RESULTS: During the study period, 199,082 women attended screening. Of these, 1020 (0.51%) women had SDC and 692 (0.38%) women developed IC. Of the 692 IC, 391 (57.8%) were TI, 120 (17.7%) were FN, 68 (10%) were OCC, and 98 (14.5%) were UCC; 15 (2.2%) were not classified. After a 10-year follow-up period, the 10-year survival rate (all-cause) for SDC was 81.6%, overall for all of IC was 72.4% (OR = 1.67, p < 0.001), TI was 77.5% (OR = 1.00, p = 0.99), FN was 55% (OR = 2.36, p < 0.001), OCC was 54.4% (OR = 3.17, p < 0.001), and UCC was 87.8% (OR = 0.61, p = 0.19). CONCLUSIONS: The overall 10-year survival of IC was significantly different to SDC. However, within this, the prognosis of TI was similar to SDC, whereas FN and OCC had significantly worse long-term survival. Further research is required to identify the underlying cause of poor survival of FN and OCC.

Is primary endocrine therapy effective in treating the elderly, unfit patient with breast cancer?

INTRODUCTION: Elderly patients with oestrogen receptor (ER)-positive breast cancer wishing to avoid surgery or those who are considered unsuitable for a general anaesthetic may be treated with primary endocrine therapy. We have reviewed all patients with ER-positive breast cancer who were initially treated with primary hormone therapy (PHT) at a district general hospital in south Wales and investigated their outcome in order to evaluate the appropriateness of this method of managing breast cancer. MATERIALS AND METHODS: All patients with breast cancer who were initially treated with PHT between January 2002 and December 2008 were identified from a single consultant's prospectively maintained database. For each patient the Charlson co-morbidity index was calculated to give an estimate of ten-year survival. Patients who had died during the study period were identified from hospital and cancer registries. RESULTS: A total of 83 cancers in 82 patients with a median age of 81 years (range: 62-93 years) were included. All cancers were ER-positive. Six patients (7%) had a greater than 50% chance of surviving ten years, calculated using the Charlson index. The median follow-up period was 24 months (range: 6-72 months). Twelve patients (15%) had disease progression while taking PHT. Twenty-three patients (28%) have died (median time from diagnosis to death of 10.5 months, range: 1-77 months). Two patients (2%) experienced disease progression within six months of starting PHT and the number of patients whose cancer progressed increased with increasing length of follow up. Fourteen patients (17%) eventually underwent a wide local excision under local anaesthetic. CONCLUSIONS: PHT can be considered an effective treatment in this elderly, unfit population with the aim of stopping disease progression so that these patients die with their breast cancer, not of it.

Doctors' knowledge of radiation -- a two-centre study and historical comparison.

AIM: To investigate knowledge of the use of ionizing radiation in 2010 and whether there has been any change in this knowledge since the study was first undertaken over 7 years ago. MATERIALS AND METHODS: In both studies a single chest x-ray was classed as one unit of radiation. Doctors from all grades were asked to evaluate the average radiation dose incurred with 13 commonly undertaken radiological procedures, including magnetic resonance imaging (MRI), computed tomography (CT), etc. Answers within 20% of the actual dose were marked as correct. RESULTS: Two hundred and forty-two questionnaires were completed (130 in 2003; 112 in 2010). Equal numbers of juniors, middle grades, and consultants were questioned, and scores were comparable (23.3% in 2003; 29.4% in 2010). The majority of doctors (92% in 2003; 86% in 2010) correctly noted that ultrasound and MRI involve no radiation. Doctors underestimated the radiation doses of all investigations by a smaller margin in 2010 compared to 2003 (i.e., more accurately), with only one exception: CT of the abdomen. CONCLUSION: Despite evidence of some improvement, doctors of all grades still have a very poor knowledge of radiation exposure even with the most common investigations. The worsening appreciation of the radiation involved in CT scanning is especially worrying considering its increasing use in practice today.

A review of needle core biopsy diagnosed radial scars in the Welsh Breast Screening Programme.

INTRODUCTION: Radial scars are benign breast lesions; their appearance on mammography may, however, mimic carcinoma. Needle core biopsy is performed for pre-operative diagnosis and, currently in Wales, all lesions with benign biopsy results are surgically excised. We have reviewed all cases of needle core biopsy-diagnosed radial scars from the Welsh breast screening programme, Breast Test Wales (BTW), and investigated the outcome of radial scars based on histology from surgical excision in order to evaluate the appropriateness of the current management of these lesions in Wales. PATIENTS AND METHODS: All needle core biopsy diagnosed radial scars were identified from the BTW screening database from the start of screening in 1989 until the end of 2007. RESULTS: A total of 118 patients were diagnosed with radial scars on needle core biopsy; two patients had bilateral radial scars. Median patient age was 54 years (range, 49-68 years). Ninety-five lesions (79%) were thought to be pure radial scars on needle core biopsy; however, only 81 pure radial scars were identified on excision biopsy histology. Carcinoma was present in seven patients and ductal carcinoma in situ in nine patients at excision biopsy. In two patients, the cancers occurred in lesions reported as pure radial scars on needle core biopsy. Twenty-two lesions showed atypical ductal or lobular hyperplasia (ADH/ALH) or both on excision biopsy; 14 of these lesions were classed as pure radial scars by needle core biopsy. CONCLUSIONS: All core biopsy diagnosed radial scars, presenting as screen detected abnormalities, should be excised due to their association with premalignant and malignant conditions.

A pilot evaluation of saline sonohysterography for postmenopausal bleeding with thickened endometrium.

The aim of this study was to assess the clinical and cost implications of pilot introduction of saline sonohysterography for postmenopausal bleeding with thickened endometrium (>or= 5 mm), at the Royal Glamorgan Hospital. The investigation was attempted in 48 patients who were found to have a thickened endometrium (>or= 5 mm) on transvaginal ultrasound scanning. The attempt was successful in 45 patients (93.8%). Failures were due to (1) cervical stenosis and (2) leakage of saline from the cervix. Difficult catheterisation of the cervix causing pain was encountered in a minority of cases. Two-thirds of patients were found have focal lesions and were booked for hysteroscopic resection. These patients included 30 with polyps, which were precisely described in all of them. In view of this low complication rate and high accuracy, the technique was integrated as a standard method of investigation for postmenopausal bleeding at the hospital.

Two-view mammography at the incident round has improved the rate of screen-detected breast cancer in Wales.

AIM: To investigate whether pre-invasive and invasive cancer detection rates were improved in Wales after the introduction of two views at incident screens. METHODS: The records of women attending follow-up screening for 2 years before and 2 years after the introduction of two-view incident screening were analysed. Cancer detection rates were compared before and after introduction of two view screening. RESULTS: At the incident round 98,752 women had one and 95,464 had two views. Five hundred and fifty-five cancers were detected with one view and 744 with two, an increased detection rate from 5.6 to 7.8 cancers per 1000 women screened (p=0.01). Two hundred and thirty-nine small cancers were detected with one view and 323 with two, increasing the detection rate from 2.4 to 3.4 per 1000 women screened (p=0.05). CONCLUSIONS: Two-view mammography at incident rounds detects more cancers and more favourable prognosis small cancers than single-view mammograms.

Is general practitioner access to breast imaging safe?

AIM: The aim of this study was to assess the consultant radiologist run open-access breast radiology service (OAR) to investigate whether the system was safe or whether cancers were being missed. METHODS: A retrospective review of the national cancer registry database to identify patients presenting with symptomatic breast cancer in the catchment area of the Royal Glamorgan Hospital (RGH) from April 2000 to April 2002 was performed. Pathology, radiology and outpatient records were reviewed to identify patients previously assessed at the RGH. RESULTS: Fifty-four patients with breast cancer were diagnosed via the OAR and 159 by the breast clinic (BC). Twelve patients with breast cancer were diagnosed after their initial presentation. Eight patients had been previously seen for benign breast lesions. Four patients had missed breast cancers (two were initially seen via the BC and two via the OAR). A significant difference in the number of cancers missed by the two referral routes was not observed (p = 0.221). CONCLUSION: OAR is as accurate a means of diagnosing breast cancer as traditional rapid access BCs. Women presenting with discrete lumps with no radiological abnormality should still undergo assessment with clinical fine core-biopsy.

A case-control study to estimate the impact on breast cancer death of the breast screening programme in Wales.

OBJECTIVES: The aim of this study was to estimate the effect of service screening, as provided by the NHS breast screening programme, on breast cancer mortality in Wales. Furthermore, we wished to ascertain whether a reduction in breast cancer mortality consistent with that observed in the randomised screening trials was being achieved. SETTING: The NHS Breast Screening Programme in Wales, managed by Breast Test Wales, with headquarters in Cardiff. METHODS: A case-control study design with 1:2 matching. The cases were deaths from breast cancer in women aged 50-75 years at diagnosis who were diagnosed after the instigation of screening in 1991 and who died after 1998. The controls were women who had not died of breast cancer or any other condition during the study period. One was from the same GP practice and the other from a different GP practice within the same district, matched by year of birth. RESULTS: Based on 419 cases, the odds ratio for risk of death from breast cancer for women who have attended at least one routine screen compared to those never screened was 0.62 (95% confidence interval [CI] 0.47-0.82, p=0.001). After excluding cases diagnosed prior to 1995 and adjusting for self-selection bias, the estimated mortality reduction was 25% (odds ratio=0.75, 95% CI 0.49-1.14, p=0.09). CONCLUSION: The Breast Test Wales screening programme is achieving a reduction in breast cancer mortality of 25% in women attending for screening, which is consistent with the results of the randomized controlled trials of mammographic screening.

The relevance of reported symptoms in a breast screening programme.

AIM: Although the National Health Service (NHS) Breast Screening Programme is aimed at asymptomatic women, inevitably patients attending screening report symptoms. The study aim was to assess the usefulness of recall based on clinical symptoms. MATERIALS AND METHODS: Information on breast symptoms is recorded at screening and radiologists can make recall decisions based on mammography and symptom history. We identified 1394 women with significant symptoms, between 1991 and 1996. The majority (54%) complained of a lump, 21% had breast distortion, 18% breast pain alone and 6% reported nipple discharge. RESULTS: Of the 1394 women, 262 were recalled because of mammographic suspicion and of these, 45% had breast cancer. The other 1132 women had symptoms and benign mammograms and 44% of these were recalled. Seven breast cancers were diagnosed; all had complained of a breast lump. In two the cancer would have been seen on two-view mammography. Of 638 not recalled, five women went on to develop an interval cancer. CONCLUSION: The results indicate that collecting details on symptoms is useful given the high rate of breast cancer in those with mammographic abnormality. When mammography is benign, however, the low rate of cancer detection means recall should be selective based on only the most relevant symptoms.

Results from 10 years of breast screening in Wales.

OBJECTIVE: To present results from 10 years of breast screening in Wales, including rates of interval cancers. SETTING: All women aged 50-64 years in Wales; approximately 250,000 in each screening round. METHODS: Breast Test Wales (BTW) began mammographic screening in 1989 as part of the National Breast Screening Programme. Two view mammography was introduced at the inception of the Welsh programme for all prevalent screens. Single view mammography was subsequently performed for incident screens. Interval cancers were identified by matching details from the BTW administrative screening database with the BTW database of all incident breast cancers for residents in Wales. RESULTS: For the first and second round prevalent screens, the cancer detection rate was 8.6 per 1000 and 7.4 per 1000 screened, respectively. The interval cancer rates following round one were 4.9 per 10,000 in the first 12 months, 9.0 per 10,000 between 12 and 24 months, and 11.6 per 10,000 between 24 and 36 months after screening. For the second round incident screens the detection rate was 4.6 per 1000 and the standardised detection ratio was 0.89, but the interval cancer rates in the first year after incident screens were not statistically different from those following prevalent screens. There was no change in the proportion of invasive breast cancers which were < 15 mm in diameter, or in the grades of invasive cancer between the first and second rounds, prevalent or incident screens. CONCLUSIONS: Breast Test Wales has achieved the standards set by the National Health Service Breast Screening Programme. Taking two views at the prevalent screen gave high sensitivity and may have resulted in the low standardised detection ratio at subsequent incident screens.

Randomized trial of a specialist genetic assessment service for familial breast cancer.

BACKGROUND: Because of the growing demand for genetic assessment, there is an urgent need for information about what services are appropriate for women with a family history of breast cancer. Our purpose was to compare the psychologic impact and costs of a multidisciplinary genetic and surgical assessment service with those of current service provisions. METHODS: We carried out a prospective randomized trial of surgical consultation with (the trial group) and without (the control group) genetic assessment in 1000 women with a family history of breast cancer. All P: values are from two-sided tests. RESULTS: Although statistically significantly greater improvement in knowledge about breast cancer was found in the trial group (P: =.05), differences between groups in other psychologic outcomes were not statistically significant. Women in both groups experienced statistically significant reductions in anxiety and found attending the clinics to be highly satisfying. An initial specialist genetic assessment cost pound 14.27 (U.S. $22.55) more than a consultation with a breast surgeon. Counseling and genetic testing of affected relatives, plus subsequent testing of family members of affected relatives identified as mutation carriers, raised the total extra direct and indirect costs per woman in the trial group to pound 60.98 (U.S. $96.35) over costs for the control subjects. CONCLUSIONS: There may be little benefit in providing specialist genetics services to all women with a family history of breast cancer. Further investigation of factors that may mediate the impact of genetic assessment is in progress and may reveal subgroups of women who would benefit from specialist genetics services.