A randomised trial of weekend and evening breast screening appointments.

BACKGROUND: There is a need to research interventions that improve access to and convenience of breast cancer screening services. METHODS: We conducted a randomised trial comparing invitations to out-of-hours appointments with standard office hour appointments. Women who were to be invited for routine breast screening were randomised (3 : 1 : 1 : 1) to one of these screening invitations: standard office hour appointment, office hour appointment with the option to change to an out-of-hours appointment, weekday evening appointment, or weekend appointment. RESULTS: A total of 9410 women were invited to an office hour, 3519 to an office hour with the option to change, 3271 to a weekday evening, and 3162 to a weekend appointment. The offer of an initial out-of-hours appointment was associated with a non-significant decrease in attendance rates (73.7% vs 74.1%). The highest attendance was observed in the group offered an initial office hour appointment with the option to change to out-of-hours (76.1% vs 73.3% for standard office hour, P=0.001), with 7% of invitees exercising the option to change. CONCLUSION: The optimum strategy for improving attendance at breast screening is to offer a traditional office hour appointment and including in the letter of invitation an option to change to an evening or weekend appointment if wished.

Pathological and mammographic prognostic factors for screen detected cancers in a multi-centre randomised, controlled trial of mammographic screening in women from age 40 to 48 years.

AIM: To assess pathological and radiological prognostic factors for cancers detected by screening within a multi-centre RCT trial of mammographic screening of younger women. METHOD: The survival of 232 women with screen detected invasive cancer was ascertained. Data on invasive cancer size, histological grade, nodal status, vascular invasion, mammographic spiculation, comedo calcification and mammographic background were assessed. Kaplan-Meier and Cox proportional hazards methods were used to examine survival. RESULTS: Univariate analysis indicated that women with cancers with the following features had poorer survival; ≥ 30 mm, histologically grade 3, heavily node positive (4 or more positive nodes), vascular invasion positive and displaying mammographic comedo calcification. In a multivariate model survival remained poorer in women with four or more nodes positive (HR 8.36, 95% CI 2.31, 30.17) and in those with comedo calcification (HR 3.00,95% CI 1.13, 7.99). CONCLUSION: Nodal status and the presence of mammographic comedo calcification have independent prognostic significance in young women with screen detected cancer.

Radiological and pathological findings of interval cancers in a multi-centre, randomized, controlled trial of mammographic screening in women from age 40-41 years.

AIM: The aim of this study was to analyse the radiographic findings of the screening mammograms of women with interval cancer who participated in a multi-centre, randomized, controlled trial of mammographic screening in women from age 40-48 years. MATERIALS AND METHODS: The screening and diagnostic mammograms of 208 women with interval cancers were reviewed. Abnormalities were classified as malignant, subtle and non-specific. RESULTS: Eighty-seven (42%) of women had true, 66 (32%) occult and 55 (26%) false-negative interval cancers. The features most frequently missed or misinterpreted were granular microcalcification (38%), asymmetric density (27%) and distortion (22%). Thirty-seven percent of abnormal previous screens were classified as malignant, 39% subtle change and 21% as non-specific. Granular calcifications were significantly more common on the diagnostic mammograms of false-negative interval cancers than those of true interval cancers (28 versus 14%, p=0.04). Occult interval cancers were more likely to be <10 mm and <15 mm in invasive pathological size than other interval cancers (p=0.03 and 0.005, respectively). True interval cancers were more likely to be histologically grade 3 than other interval cancers (p=0.04). Women who developed true and false-negative interval cancers had similar background patterns, but women with occult cancers had a higher proportion of dense patterns (p<0.05). CONCLUSION: Interval cancers in a young screening population have a high proportion of occult lesions that are small and occur in dense background patterns. The proportion of interval cancers that are false negative is similar that seen in older populations and granular microcalcification is the commonest missed mammographic feature.

Radiological findings of screen-detected cancers in a multi-centre randomized, controlled trial of mammographic screening in women from age 40 to 48 years.

AIM: To elucidate the mammographic findings of screen-detected cancers in women screened between 40-48 years, and to establish the frequency and nature of abnormal findings on previous mammograms in women with screen-detected cancers. METHODS: A radiology review panel consisting of three experienced breast radiologists viewed the screening mammograms in chronological order, confirming that any abnormalities detected corresponded to the cancers detected at later screens. An analysis correlating mammographic features with median invasive size and the proportion measuring less than 10 and 15mm was performed. RESULTS: Two hundred and thirty-two women had screen-detected invasive cancers with mammograms available for review. The most frequent features seen at diagnosis were spiculate mass, ill-defined mass, granular calcification, deformity and comedo calcification. Thirty-four percent of mammograms showed calcification. The mammographic sign associated with smallest median size was calcification. Calcification was also the mammographic abnormality most frequently associated with cancers <10mm in size. In total there were 147 abnormal previous screens of 87 women. The most commonly missed features were granular microcalcification, deformity and ill-defined mass. Of the missed abnormalities 20% were classified as malignant, 43% as subtle change and 32% as non-specific. CONCLUSION: Compared with older women, screen-detected cancer in younger women more commonly manifests as calcification and less frequently a spiculate mass. Calcification is the sign most frequently associated with invasive cancers <10mm in size. Calcification and deformity are the signs most frequently seen on the previous mammograms of women with screen-detected cancer.

Imprint cytology from ultrasound-guided core biopsies: accurate and immediate diagnosis in a one-stop breast clinic.

AIM: To investigate whether imprint cytology from ultrasound-guided core biopsy specimens was adequate for the National Health Service Breast Screening Programme (NHSBSP) guidelines. METHODS: We prospectively audited imprint cytology from ultrasound-guided core biopsy specimens. The performance indicators for imprint cytology specimens from 111 consecutive ultrasound-guided core biopsy were compared with standards set by the NHSBSP for fine-needle aspiration cytology (FNAC). RESULTS: Imprint cytology fulfilled the "preferred" targets for absolute and complete sensitivity, specificity, positive predictive value, false-positive and false-negative rates, inadequate rate and inadequate rate from cancers. It also satisfied the minimum target for suspicious rate. The complete sensitivity was 97%, full specificity 78%, with 100% positive predictive value for C5 cytology and an inadequate rate from cancers of 1.5%. CONCLUSION: Imprint cytology from ultrasound-guided core biopsy allows same-day diagnosis and the collection of data regarding the grade of the carcinoma for treatment decisions from a single needle test.

Predictors of outcome of mammography in the National Health Service Breast Screening Programme.

BACKGROUND: Little is known about the factors influencing the risk of recall for assessment, invasive diagnostic procedures, and early rescreening after screening mammography. METHODS: From June 1996 to March 1998 women attending screening at 10 National Health Service Breast Screening Programme (NHSBSP) centres completed a self administered questionnaire and were followed up for their screening outcome. RESULTS: 1969 (3.3%) out of 60 443 women aged 50-64 who had never used hormone replacement therapy (HRT) were recalled for assessment but were not diagnosed with breast cancer (defined here as false positive recall). After adjustment for the variation between centres, false positive recall was decreased significantly among women who were likely to have had a previous NHSBSP mammogram (odds ratio (OR) 0.49, 95% confidence interval (95% CI) 0.38 to 0.63 for likely versus unlikely), who were postmenopausal (OR 0.65, 95% CI 0.56 to 0.76 for postmenopausal v premenopausal) and increased significantly for women reporting previous breast surgery (OR 1.64, 95% CI 1.42 to 1.89). Although false positive recall decreased significantly with parity and increasing body mass index, these effects were not large and no significant variation was found with age, education, family history of breast cancer, oral contraceptive use, sterilisation, exercise, smoking, or alcohol consumption. Altogether 655 (1.1%) women had an invasive diagnostic procedure; no personal characteristics were predictive of this outcome, 286(0.5%) were referred for early rescreening, and this was increased significantly by nulliparity and a family history of breast cancer. INTERPRETATION: Premenopausal women, those without a previous NHSBSP mammogram, and women with previous breast surgery have an increased risk of false positive recall by the NHSBSP.

A comparative audit of prevalent, incident and interval cancers in the Avon breast screening programme.

The 4th year of the Avon breast screening programme comprises two distinct groups: those called for screening for the first time (prevalent group) and those who were initially screened 3 years earlier (incident group). The cancer detection rate, stage of disease and rate of interval cancers in these patients have been compared. For the prevalent groups of year 1 and year 4 there was no statistically significant difference in the cancer detection rate, proportion of small tumours or node positivity. For the prevalent and incident groups of year 4, there was no statistically significant difference in the cancer detection rate or proportion of small tumours. There were significantly fewer node-positive tumours in the incident group (5/45 vs 8/23; P < 0.05). Fifty-six interval cancers presented in the 3-year period between years 1 and 4 of screening; 28 (50%) after 24 months. The screening programme may result in tumours being detected at an earlier stage, but this may be offset by the high rate of interval cancers. This suggests that the time between screens may need to be reduced to 2 years.

Rate and classification of interval cancers in the breast screening programme.

There has been concern about the number of interval cancers which have been detected within the National Breast Screening Programme. A series of 134 women presenting with interval cancers was studied by prospective audit and the rate and radiological classification of the tumours determined. The cancers were classified as true (67), false-negative (22), unclassifiable (28), occult (12), and minimal sign (5). The interval cancer rate did not achieve the new National Guidelines in either the first 2 years or the 3rd interval year. The false-negative cancers presented mainly in the 1st interval year, whereas the true cancers were predominantly confined to the 2nd and 3rd years. These data suggest that alterations to the screening programme may be beneficial. It may be, however, that the programme is still on the learning curve and this should be taken into account when interpreting these data.

Concentrations of magnesium and ionized calcium in umbilical cord blood in distressed term newborn infants with hypoxic-ischemic encephalopathy.

Magnesium and ionized calcium in mixed umbilical cord blood was assessed colorimetrically in 38 distressed and 21 healthy term newborn infants. Distressed infants with a severe or moderate degree of hypoxic-ischemic encephalopathy (HIE) (n = 8) had significantly lower (p < 0.001) concentrations of magnesium (0.52 +/- 0.08 mmol/L) compared to the control group (0.69 +/- 0.06 mmol/L). No differences in concentrations of ionized calcium between distressed and control infants were detected.

Markers of oxidative stress before and after exchange transfusion for neonatal sepsis.

Oxidative status before and after ET was assessed in eight septic newborns who received exchange transfusion (ET). Short-term elevations of conjugated dienes (CDs) and thiobarbituric acid reactive substances (TBARSs) (p < 0.05) and increased serum antioxidant capacity (AOC) (p = 0.06) were noted. Chromatographic migration of the red blood cells (CM RBCs), a measure of RBC deformability, also improved after ET. ET for neonatal sepsis does not cause significant oxidative stress; rather, it may help to restore the antioxidant depots and improve RBC deformability and microcirculation.

Barium enemas are a headache.

The frequency of headache after Picolax (sodium picosulphate, Nordic Ltd) preparation for barium enema was investigated and its association with dehydration, as assessed by haemoconcentration, was determined. Eleven out of 41 patients (26.8%) complained specifically of headaches. Although patients with and without headaches developed significant increases in haemoglobin concentration after Picolax preparation, the rise in haemoglobin in those with headaches was significantly greater than in those without (P less than 0.05). In both groups the haemoglobin concentration returned to normal after a bowel washout. These results suggest an association between dehydration and headache developing after a Picolax regimen. It may be possible to prevent this symptom by advising on the intake of specific volumes of fluid during preparation for barium enema.

Report on a biochemical red tide repressive agent.

Organisms were isolated from the November 1973 red tide outbreak in a search for a naturally occurring predator organism. Two organisms were found which look promising as a means of biocontrol: a Tintinnideae spp., ciliate and Gomphosphaeria aponina Kutzing, a blue-green algae. This report characterizes a blue-green algal toxin found to be lethal to the Florida red tide organism Gymnodinium breve Davis.