The effect of mammographic screening on invasive breast cancer in Western Australia.

OBJECTIVE: To determine whether mammographic screening has affected the presentation of invasive breast cancer in Western Australia. DESIGN: Population-based reviews of the presentation of all invasive breast cancers diagnosed in Western Australia in 1989 and 1994. SETTING: Western Australia (population 1.8 million). Active recruitment of women aged 50-69 years for mammographic screening began in 1989. MAIN OUTCOME MEASURES: Size and stage of invasive breast cancers at diagnosis. RESULTS: From 1989 to 1994, the age-standardised incidence rose from 109 to 123 per 100,000 woman-years, based on 584 and 750 cases, respectively. The proportion of all invasive breast cancers detected as a result of a mammogram increased from 9.2% in 1989 to 34.5% in 1994. Among the cases where relevant information was recorded, the proportion of "impalpable" tumours increased from 7.7% in 1989 to 27.6% in 1994, and the average size of palpable tumours fell. There was an unexpected increase in the proportion of tumors that were negative on assays for oestrogen and progesterone receptors. CONCLUSIONS: A relatively simple and inexpensive clinical review has boosted confidence that the outlay of public monies required to establish and conduct screening in Australia appears likely to yield the reductions in mortality from breast cancer that would be predicted on the basis of the earlier controlled trials of mammography.

Breast cancer in Western Australia in 1989: IV. Summary of histopathological assessment in 655 cases.

This study was part of a population-based survey of all cases of breast cancer diagnosed in Western Australia in 1989. The paper concerns histopathology reporting by pathologists in 655 cases of carcinoma of the breast in that year, before the introduction of mammographic screening programmes. Pathological features of the neoplasms are documented, and the extent to which information known to be of clinical or prognostic importance was included in the reports is analysed. 96.5% of all pathology reports included information on breast cancer subtype and, in 98.6% of cases with axillary dissection, the number of lymph nodes dissected, and the number containing metastatic tumor was stated. In 83.7% of cases of invasive carcinoma exact tumor dimensions were recorded. In 44.9% of cases histological grade was recorded, and information about excision margins was present in 60% of reports overall. The reporting of pathological features in many instances was limited by the way in which the specimen was handled prior to reception. At the time of the study, views about the importance of many aspects of histological assessment were still evolving. Even now, for example, consensus is still being reached on the value of histological grading in predicting prognosis and whether reliable histological assessment of such factors as extent of DCIS and completeness of excision of DCIS is possible. The introduction of mammographic screening since 1989 has provided a focus for wider discussion about the value of histological information in prognostication and patient management. A case is made to support the use of "check lists" for surgical pathology reports in cases of breast cancer.

Breast cancer in Western Australia in 1989: III. Accuracy of FNA cytology in diagnosis.

A population-based study of all cases of breast cancer diagnosed in Western Australia (WA) in 1989 revealed 701 cases of cancer in 692 women. Three hundred and ninety-six (56.5%) of these cancers had fine needle aspiration (FNA) cytology. Forty-three cases were managed non-surgically, on the basis of an FNA diagnosis and without histologic follow up. Of the cases with histological follow-up, 73% received an unequivocal diagnosis of malignancy by FNA, and abnormal cells (atypical, suspicious or malignant diagnoses) were reported in 94.2%. Of the cases, 3.2% were reported as benign and in 2.6% the samples taken were unsatisfactory. There were no false positive cytological diagnoses of malignancy. This study is the first to examine the results of FNA diagnosis of breast cancer from a medical community as a whole, rather than for individual or specialist units; the accuracy of diagnosis was similar for different pathology practices including public and private sector laboratories. Lower absolute sensitivity (the proportion of cases given an unequivocal diagnosis of malignancy) was seen in very small and very large tumours, pure duct carcinoma in situ (DCIS), and invasive lobular carcinoma. False negative rates (the proportion of cases given a benign cytological diagnosis) were very low for all laboratories (0-4.5%) and for all types of carcinoma, and the proportion of unsatisfactory samples was exceptionally low for all laboratories (0-4.5%). The overall figures for accuracy are similar to those reported from other centres in Australasia and overseas, and confirm the effective use of FNA cytology throughout the clinical and pathology community in WA.

Breast cancer in Western Australia in 1989. I. Presentation.

This study was designed as a population-based study of all cases of breast cancer diagnosed in Western Australia (WA) in 1989. Cases were identified from the State Cancer Registry and from computerized hospital inpatient records. Data were obtained from the records of surgeons and oncologists managing the patients, hospital medical records, and pathology and cytology reports. A total of 701 histologically proven tumours were documented in 692 women. Of these 6.8% were not known to the State Cancer Registry. Two-thirds (68%) of tumours were first detected by the woman herself, 11% were found by a doctor and 11% were detected by mammographic screening. Stage I tumours accounted for 40% of tumours and Stage II 39%. The estimated lifetime risk of a WA woman developing at least one malignant breast tumour is 10%. Passive surveillance based upon a legal obligation on doctors to notify cases of cancer may be resulting in a significant under-estimation of the incidence of cancer in WA. Mammographic screening played only a small role in the detection of breast cancer in WA in 1989, but its contribution and the proportion of stage I tumours should both increase as a population-based mammographic screening programme is established. This survey will provide a yardstick against which changes can be measured. Eighty-four per cent of tumours presently occur in women who would have access to mammographic screening although only 44% occur in the 50-69 age bracket that is to be actively recruited. The lifetime risk of breast cancer in WA women is greater than has been appreciated previously.

Breast cancer in Western Australia in 1989. II. Diagnosis and primary management.

This study was designed as a population-based study of all cases of breast cancer diagnosed in Western Australia (WA) in 1989. Cases were identified from the State Cancer Registry and from computerized hospital inpatient records. Data were obtained from the records of surgeons and oncologists managing the patients, hospital medical records and pathology and cytology reports. A total of 701 tumours in 692 women were treated by 105 different surgeons of whom 25 saw 10 or more cases. Over 70% were proven by cytology or biopsy within 2 weeks of presentation to a doctor. The first diagnostic investigation was fine needle aspiration in 45%, open biopsy in 28% and diagnostic mammogram in 24.4%. A definitive procedure involving breast conservation was performed in 31.3% of patients with operable tumours; 35.6% of those under 50 years of age. If axillary dissection or sampling was part of such treatment, 93.5% of those under 50 years and 75% of those 50 years and over had radiotherapy to the residual breast. Although less than one-third of patients were referred to a medical oncologist almost a half had adjuvant systemic therapy (92% of node positive and 23% of node negative patients). Tamoxifen was prescribed as part of adjuvant therapy in 93% of those over 50 years and cyclophosphamide, methotrexate and 5-fluorouracil in 71% of those under 50 years. Less than 10% of patients treated with mastectomy and axillary dissection had postoperative radiotherapy to the chest wall and drainage areas. The patterns of care of patients with breast cancer in WA prior to the introduction of population-based mammographic screening have been established.(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal cancer in a young woman after treatment for osteosarcoma.

Five years after completing adjuvant chemotherapy for osteosarcoma of the fibula, a 20-year-old woman developed an esophageal carcinoma. The association between prior chemotherapy and radiation exposure, and the significance of genetic factors and family history are discussed. This case exemplifies the importance of continued follow-up of the long-term survivors of tumor management.

Interstitial pneumonitis due to leukaemic cell necrosis.

Pulmonary complications are common in patients with acute leukaemia. Infection is the usual cause of these. A case of acute leukaemia is described in which diffuse interstitial pneumonitis developed during remission induction therapy. This occurred during a very rapid fall in the leukaemic blast population following the start of chemotherapy. Open lung biopsy showed necrotic leukaemic cells filling the lung interstitium. The patient made an uneventful recovery from this complication.

Metastatic astrocytoma.

Two women, treated with surgery and radiotherapy for cerebral astrocytoma, developed metastases. In one case a metastasis in a craniotomy scar was probably implanted at the time of surgery; at first this was sensitive to chemotherapy and radiotherapy, but it later recurred and became resistant to treatment, with resistant tumour spreading extensively through the scalp and the cervical lymphatic chain. In the other case tumour disseminated hematogenously to the bone marrow. Both patients died of metastatic disease with primary tumours apparently well controlled. The syndrome of metastatic astrocytoma may be under-diagnosed.

High dose melphalan with autologous marrow rescue in cancer treatment.

Autologous bone marrow rescue circumvents the major toxicity of most cancer chemotherapeutic agents. Melphalan is a particularly well suited agent for use with autologous bone marrow rescue and produces response in chemo-resistant tumours. Thirteen patients have been treated with high dose melphalan with autologous bone marrow rescue in this department. The aims of treatment were palliation, debulking of non-resectable tumours and curative adjuvant therapy. Three patients died of melphalan related toxicity. Of the remaining ten patients there were five partial remissions, one objective response, one complete remission, one with no response and two patients in whom the response is not yet assessable (adjuvant therapy). In our experience high dose melphalan is an effective means of killing tumour cells which are not sensitive to chemotherapy at conventional doses. It is recommended in young patients who have not had extensive previous radio- or chemotherapy, in the early stages of disease, with cure or prolonged remission the aim. High dose melphalan is not recommended in the older patient or in those with massive diseases and is no longer used with palliative intent.

Acute renal failure following near drowning in salt water.

Two young men swallowed and inhaled salt water, suffered cold exposure and an undertermined degree of body trauma, in separate incidents. Severe acute oliguric renal failure followed in both, requiring dialytic therapy. Single needle subclavian intermittent haemodialysis allowed ambulatory outpatient management. The risk of acute renal failure following even brief sea water immersion is emphasised and the value of ambulant subclavian haemodialysis in the management of acute renal failure illustrated.