Evidence-informed recommendations on managing breast screening atypia: perspectives from an expert panel consensus meeting reviewing results from the Sloane atypia project.

Evidence-based clinical guidelines are essential to maximize patient benefit and to reduce clinical uncertainty and inconsistency in clinical practice. Gaps in the evidence base can be addressed by data acquired in routine practice. At present, there is no international consensus on management of women diagnosed with atypical lesions in breast screening programmes. Here, we describe how routine NHS breast screening data collected by the Sloane atypia project was used to inform a management pathway that maximizes early detection of cancer and minimizes over-investigation of lesions with uncertain malignant potential. A half-day consensus meeting with 11 clinical experts, 1 representative from Independent Cancer Patients' Voice, 6 representatives from NHS England (NHSE) including from Commissioning, and 2 researchers was held to facilitate discussions of findings from an analysis of the Sloane atypia project. Key considerations of the expert group in terms of the management of women with screen detected atypia were: (1) frequency and purpose of follow-up; (2) communication to patients; (3) generalizability of study results; and (4) workforce challenges. The group concurred that the new evidence does not support annual surveillance mammography for women with atypia, irrespective of type of lesion, or woman's age. Continued data collection is paramount to monitor and audit the change in recommendations.

The patterns and position of snacking in children in aged 2-12 years: A scoping review.

BACKGROUND: Childhood obesity is associated with serious comorbidities during childhood and into adulthood. One potential risk factor for childhood obesity is consumption of unhealthy, energy-dense foods. This scoping review examines evidence on snacking in children aged 2-12 years of age and presents the patterns and position of snacking in children's diets. METHODS: A search of electronic databases (MEDLINE, Web of Science, PubMed, Embase) for articles published from March 2011 to November 2022 was conducted. Articles providing insight into the position of snacking (e.g., energy contribution), or patterns (e.g., location, timing), in children aged 2-12 years were included. A quality assessment was conducted and data was synthesised according to data source (nationally representative or other). RESULTS: Twenty-one articles were included, most (n = 13) reporting nationally representative data. The average number of daily snacks was 3, with 92.9-100.0% of children consuming snacks. Most were consumed in the afternoon (75.2-84.0%) and at home (46.5-67.3%). Snacks frequently consumed were 'fruits and vegetables', 'baked desserts', 'sweets, candy and confectionery', and 'dairy products'. Snacks contributed 231-565 kcal daily, up to a third of daily carbohydrate intake, a quarter of fat intake, and a fifth of protein intake. Snacks provided up to one third of vitamin C intake, one quarter of vitamin E, potassium and magnesium intake, and a fifth of calcium, folic acid, vitamins D and B12, iron and sodium intake. DISCUSSION: This scoping review provides insight into patterns and position of snacking within children's diets. Snacking plays a significant role in children's diets with multiple snacking occasions occurring throughout a child's day, the overconsumption of which has the potential to increase risk of childhood obesity. Further research is required into the role of snacking, particularly specific foods playing a role in micronutrient intake, and clear guidance for snacking intake in children.

Fresh Beef and Lamb Consumption in Relation to Nutrient Intakes and Markers of Nutrition and Health Status among the Population Aged 5-90 Years in Ireland.

The dietary role of meat is under scrutiny for health and environmental reasons, yet a growing body of evidence proposes that advice to limit red meat consumption is unnecessarily restrictive. The aim of this study was to investigate the role of 'fresh beef and lamb' in the diet of the population (5-90 years) in Ireland and its association with markers of nutrition and health status. Analyses are based on data from three nationally representative dietary surveys in the Republic of Ireland. Dietary intake data were estimated using food records, and nutrient intakes were estimated based on UK and Irish food composition tables. Biochemical samples were collected and analysed using standard procedures. 'Fresh beef and lamb' (defined as beef/lamb that had not undergone any preserving process other than chilling/freezing/quick-freezing) was consumed by 68-84% of the population and intakes ranged from 19 to 43 g/d across age groups. It made important contributions to intakes of protein, monounsaturated fat, vitamins D, B12, niacin, iron and zinc while also contributing relatively small proportions of total fat, saturated fat and salt. Higher consumption of 'fresh beef and lamb' was associated with higher intakes of protein, niacin, vitamins B6, B12, zinc and potassium (but also total fat) and lower intakes of carbohydrate and total sugars (but also dietary fibre). In adults, older adults and WCBA, higher consumption of 'fresh beef and lamb' was not associated with increased risk factors of cardio-metabolic diseases nor was it associated with better or poorer nutritional status for vitamins D, B12 or iron. This study adds to the evidence base on the contribution of 'fresh beef and lamb' in the diet and may be useful to policymakers updating guidance for healthy diets from sustainable food systems.

Impact of COVID-19 on the practice of breast pathologists: a survey of breast pathologists in the UK and Ireland.

AIMS: There is little information on the impact of COVID-19 on breast pathologists. This survey assessed the effect of the COVID-19 pandemic on UK and Ireland-based breast pathologists to optimise working environments and ensure preparedness for potential future pandemics. METHODS: A 35-question survey during the first wave of COVID-19 infections in the UK including questions on workload, working practices, professional development, training, health and safety and well-being was distributed to consultant breast pathologists and responses collected anonymously. RESULTS: There were 135 responses from breast pathologists based in the UK and Ireland. Most participants (75.6%) stated that their workload had decreased and their productivity dropped. 86/135 (63.7%) were given the option of working from home and 36% of those who did reported improved efficiency. Multidisciplinary team meetings largely moved to virtual platforms (77.8%) with fewer members present (41.5%). Online education, including webinars and courses, was utilised by 92.6%. 16.3% of pathologists reported shortages of masks, visors or gowns as the the most common health and safety concern. COVID-19 had a significant negative impact on the physical and mental health of 33.3% of respondents. A small number of pathologists (10.4%) were redeployed and/or retrained. CONCLUSION: The UK and Ireland breast pathologists adapted to the rapid change and maintained service delivery despite the significant impact of the pandemic on their working practices and mental health. It is important to apply flexible working patterns and environments that improve productivity and well-being. The changes suggested should be considered for long-term shaping of breast pathology services.

The effects of a UK review of Breast Cancer Screening on Uptake: an observational before/after study.

OBJECTIVES: To measure whether uptake of breast cancer screening was affected by the publication of the Marmot Review and associated press coverage. SETTING: Eight NHS breast screening centres in the West Midlands of the UK. METHODS: Uptake of breast cancer screening invitations was compared in the week before and after the Marmot review publication. All 12,023 women invited for screening between 23 October 2012 and 5 November 2012 were included. A mixed effects model of the predictors of screening uptake (on date invited, or within 21 days) was created. Predictors considered for inclusion were whether the allocated screening appointment was before or after publication of the review, population factors (age, index of multiple deprivation income domain by quintile, previous attendance), and interaction terms. RESULTS: Uptake decreased after publication of the review from 65% to 62% (OR = 0.87 95%CI = 0.80-0.94), but a similar decrease was seen for the same dates on the previous year (OR = 0.85 95%CI = 0.78-0.93). Odds of attending screening were lower for women in the most deprived (uptake = 49%, OR = 0.54, 95%CI = 0.46-0.62) in comparison with the least deprived quintile (uptake = 71%). Odds of attendance also increased if the woman had ever previously attended (OR 3.9 95% CI 3.5-4.4), and decreased with each year of increasing age (OR 0.96 95% CI 0.96-0.97). There were no interactions between any of the other predictors and whether the appointment was before or after publication of the Marmot review. CONCLUSION: No change in uptake of breast cancer screening above normal seasonal variation was detected after publication of the Marmot review.

Patient satisfaction with clinical nurse specialists' practice.

A co-ordinated approach was adopted to monitor practice standards among clinical nurse specialists (CNSs) in West Midlands breast screening assessment nursing teams. A regional working party was assembled and a patient satisfaction survey was produced. Results of the survey show that for women attending for breast screening assessment, interaction with a CNS is perceived to be highly beneficial. Contact points vary with local practice, but the majority of women had contact with a CNS at some point during the assessment process for support and information. The results of the survey are used as an integral part of the quality assurance process in relation to CNS provision in the West Midlands. Services should aim to ensure that sufficient CNSs are available for women attending breast screening assessment centres.

Invitation management initiative to improve uptake of breast cancer screening in an urban UK Primary Care Trust.

OBJECTIVES: In an attempt to improve breast cancer screening uptake and coverage, persistent non-attenders in the Heart of Birmingham Teaching Primary Care Trust were included in an invitation management initiative. METHODS: Persistent non-attenders were identified in routine screening lists. Phone contact was attempted or a home visit was made. If the case was not resolved, a second appointment was made and further phone calls and home visits were attempted. RESULTS: Of 548 persistent non-attenders identified, 228 (42%) declined screening, 171 (31%) attended, 72 (13%) had moved away or died, 11 (2%) were recently screened or under care for other conditions. Sixty-six cases (12%) remained unresolved. Fourteen women opted to be permanently withdrawn from the National Health Service Breast Screening Programme (NHSBSP). Twenty-four women had a negative experience of breast cancer screening (defaulted, recalled for assessment, recalled for technical reasons). No malignancies were found. A total of 1375 phone calls and 230 home visits were attempted. Uptake would have been 62.2% if none of the persistent non-attenders included in the initiative had attended for screening. With the initiative, uptake of breast cancer screening was increased to 65.3%. CONCLUSIONS: Phone calls and home visits resulted in only a moderate increase in breast cancer screening uptake. The initiative encouraged nervous attenders who were reassured about the screening process. However, more women declined screening than were screened and the initiative made it easier for women to request to be permanently withdrawn from the NHSBSP.

Screening histories of invasive breast cancers diagnosed 1989-2006 in the West Midlands, UK: variation with time and impact on 10-year survival.

OBJECTIVES: To examine variations in screening status category with time for 20,862 invasive breast cancers diagnosed in the West Midlands between 1989 and 2006, and to provide 10-year relative survival rates for each category. METHOD: Population-based breast screening was introduced in the West Midlands from 1988. Primary invasive breast cancers diagnosed from 1 April 1989 to 31 March 2006 in women eligible for breast screening were identified from the West Midlands Cancer Intelligence Unit's cancer registration database. A screening status was determined for each case using previously published methodology. RESULTS: Screening status rates are affected initially by the gradual rollout of the screening programme and more recently by the need to wait for three years before interval cancers and cancers in lapsed and non-attenders can be identified. In the steady-state period 1994-2003, 40.6% of invasive breast cancers were screen-detected, 36.3% were interval cancers and 11.2% were cancers in non-attenders (NA). Ten-year relative survival was 89.6% for screen-detected breast cancers, 73.3% for interval cancers and 51.9% for cancers in NA. CONCLUSION: The detection of invasive breast cancers by screening has improved over time, with an equivalent reduction in the numbers of interval cancers. This, together with a stable rate of cancers in NA and an improvement in the survival of women with interval cancers, suggests that further improvements in breast cancer mortality can be predicted. International comparisons of interval cancer rates are difficult due to interprogramme differences in the time between screens.

Population estimates of survival in women with screen-detected and symptomatic breast cancer taking account of lead time and length bias.

BACKGROUND: Evidence of the impact of breast screening is limited by biases inherent in non-randomised studies and often by lack of complete population data. We address this by estimating the effect of screen detection on cause-specific fatality in breast cancer, corrected for all potential biases, using population cancer registry data. METHODS: Subjects (N = 26,766) comprised all breast cancers notified to the West Midlands Cancer Intelligence Unit and diagnosed in women aged 50-74, from 1988 to 2004. These included 10,100 screen-detected and 15,862 symptomatic breast cancers (6,009 women with interval cancers and 9,853 who had not attended screening). Our endpoint was survival to death from breast cancer. We estimated the relative risk (RR) of 10-year cause-specific fatality (screen-detected compared to symptomatic cancers) correcting for lead time bias and performing sensitivity analyses for length bias. To exclude self-selection bias, survival analyses were also performed with interval cancers as the comparator symptomatic women. FINDINGS: Uncorrected RR associated with screen-detection was 0.34 (95% CI 0.31-0.37). Correcting for lead time, RR was 0.49 (95% CI 0.45-0.53); length bias analyses gave a range of RR corrected for both phenomena of 0.49-0.59, with a median of 0.51. Self-selection bias-corrected estimates yielded a median RR of 0.68. INTERPRETATION: After adjusting for various potential biases, women with screen-detected breast cancer have a substantial survival advantage over those with symptomatic breast cancer.

Correcting for lead time and length bias in estimating the effect of screen detection on cancer survival.

Determination of survival time among persons with screen-detected cancer is subject to lead time and length biases. The authors propose a simple correction for lead time, assuming an exponential distribution of the preclinical screen-detectable period. Assuming two latent categories of tumors, one of which is more prone to screen detection and correspondingly less prone to death from the cancer in question, the authors have developed a strategy of sensitivity analysis for various magnitudes of length bias. Here they demonstrate these methods using a series of 25,962 breast cancer cases (1988-2004) from the West Midlands, United Kingdom.

The West Midlands breast cancer screening status algorithm - methodology and use as an audit tool.

OBJECTIVES: To illustrate the ability of the West Midlands breast screening status algorithm to assign a screening status to women with malignant breast cancer, and its uses as a quality assurance and audit tool. METHODS: Breast cancers diagnosed between the introduction of the National Health Service [NHS] Breast Screening Programme and 31 March 2001 were obtained from the West Midlands Cancer Intelligence Unit (WMCIU). Screen-detected tumours were identified via breast screening units, and the remaining cancers were assigned to one of eight screening status categories. Multiple primaries and recurrences were excluded. RESULTS: A screening status was assigned to 14,680 women (96% of the cohort examined), 110 cancers were not registered at the WMCIU and the cohort included 120 screen-detected recurrences. CONCLUSIONS: The West Midlands breast screening status algorithm is a robust simple tool which can be used to derive data to evaluate the efficacy and impact of the NHS Breast Screening Programme.