Predicting the Benefits and Harms of Breast Cancer Screening: Current debates and future directions

Breast cancer is the most common cancer among women in Western countries. Presently, women in the Netherlands have a 1 : 7 chance of developing breast cancer during their lifetime. This means that in 2008, almost 15,000 women were newly diagnosed with the disease. The incidence of breast cancer in the Netherlands is among the highest in Europe.In 2006, for instance, the age-standardized incidence rate was 128 per 100,000 woman-years. As a comparison, the average in Europe was 94.3 per 100,000 woman-years. Although the probability of cure has improved over the last decennia, for a third of all women with breast cancer, the disease will be fatal. This makes breast cancer the most common cause of cancer death in women in Europe. The age-standardized mortality rate in the Netherlands in 2006 was 29.8 per 100,000 woman-years, versus 26.0 per 100,000 woman-years in Europe. Breast cancer develops as a single malignant cell with uncontrolled cell growth to a tumour of several millimeters or centimeters in diameter. At some point in time, the tumour may reach a size at which it becomes symptomatic. The larger the size, the less likely it is that the tumour can be cured. It is therefore thought that by diagnosing cancer at an earlier phase, for instance by screening, the probability of survival can be increased. Several methods for early detection of breast cancer exist: breast self examination, examination by a clinician or a nurse (‘clinical breast examination’), MRI or ultrasonography. Mammography, which involves one or more X-ray images of the breasts, is considered the best tool for examining postmenopausal women with an average risk for the disease, because it can reach a high sensitivity (>70%) and specificity (>95%) when it is applied on a large scale. At the same time, costs are moderate: 50 euro per screening examination in the Netherlands.The effects of breast cancer screening using mammography were therefore studied in several randomized controlled trials (RCTs), with various screening ages and intervals. Screening women aged 50 and older resulted in statistically significant reductions in breast cancer mortality, of between 25%–30% in those women that were randomized in the screening arms of the trials. Soon after the first positive trial outcomes, two pilot projects with large-scale mammography screening were started in the Netherlands, which also showed substantial reductions in breast cancer mortality in screened women. A cost-effectiveness analysis showed a favourable balance between screening costs and potential life years gained.15 Based on these findings, mammography screening was implemented in the Netherlands and other western countries

The Impact of Tobacco Control Policies on Smoking Among Socioeconomic Groups in Nine European Countries, 1990-2007

Background: It is uncertain whether tobacco control policies have contributed to a narrowing or widening of socioeconomic inequalities in smoking in European countries during the past two decades. This paper aims to investigate the impact of price and non-price related population-wide tobacco control policies on smoking by socioeconomic group in nine European countries between 1990 and 2007. Methods: Individual-level education, occupation and smoking status were obtained from nationally representative surveys. Country-level price-related tobacco control policies were measured by the relative price of cheapest cigarettes and of cigarettes in the most popular price category. Country-level non-price policies were measured by a summary score covering four policy domains: smoking bans or restrictions in public places and workplaces, bans on advertising and promotion, health warning labels, and cessation services. The associations between policies and smoking were explored using logistic regressions, stratified by education and occupation, and adjusted for age, Gross Domestic Product, period and country fixed effects. Results: The price of popular cigarettes and non-price policies were negatively associated with smoking among men. The price of the cheapest cigarettes was negatively associated with smoking among women. While these favorable effects were generally in the same direction for all socioeconomic groups, they were larger and statistically significant in lower socioeconomic groups only. Conclusions: Tobacco control policies as implemented in nine European countries, have probably helped to reduce the prevalence of smoking in the total population, particularly in lower socioeconomic groups. Widening inequalities in smoking may be explained by other factors. Policies with larger effects on lower socioeconomic groups are needed to reverse this trend. Implications: Socioeconomic inequalities in smoking widened between the 1990s and the 2000s in Europe. During the same period, there were intensified tobacco control policies in many European countries. It is uncertain whether tobacco control policies have contributed to a narrowing or widening of socioeconomic inequalities in smoking in European countries. This study shows that tobacco control policies as implemented in the available European countries have helped to reduce the prevalence of smoking in the total population, particularly in lower socioeconomic groups. Widening inequalities in smoking may be explained by other factors.Peer reviewe

Breast cancer screening: evidence for false reassurance?

Tumour stage distribution at repeated mammography screening is, unexpectedly, often not more favourable than stage distribution at first screenings. False reassurance, i.e., delayed symptom presentation due to having participated in earlier screening rounds, might be associated with this, and unfavourably affect prognosis. To assess the role of false reassurance in mammography screening, a consecutive group of 155 breast cancer patients visiting a breast clinic in Rotterdam (The Netherlands) completed a questionnaire on screening history and self-observed breast abnormalities. The length of time between the initial discovery of breast abnormalities and first consultation of a general practitioner ("symptom-GP period") was compared between patients with ("screening group") and without a previous screening history ("control group"), using Kaplan-Meier survival curves and log-rank testing. Of the 155 patients, 84 (54%) had participated in the Dutch screening programme at least once before tumour detection; 32 (38%) of whom had noticed symptoms. They did not significantly differ from control patients (n = 42) in symptom-GP period (symptom-GP period > or = 30 days: 31.2% in the symptomatic screened group, 31.0% in the control group; p = 0.9). Only 2 out of 53 patients (3.8%) with screen-detected cancer had noticed symptoms prior to screening, reporting symptom-GP periods of 2.5 and 4 years. The median period between the first GP- and breast clinic visit was 7.0 days (95% C.I. 5.9-

Uncontrolled maternal chronic respiratory diseases in pregnancy: A new potential risk factor suggested to be associated with anorectal malformations in offspring

Background: Chronic respiratory diseases and use of antiasthmatic medication during pregnancy may both play a role in the etiology of congenital anorectal malformations (ARM). However, it is unclear, whether the medication use or the underlying condition would be responsible. Therefore, our aim was to unravel the role of maternal chronic respiratory diseases from that of antiasthmatic medication in the etiology of ARM. Methods: We obtained 412 ARM patients and 2,137 population-based controls from the Dutch AGORA data- and biobank. We used maternal questionnaires and follow-up telephone interviews to obtain information on chronic respiratory diseases, antiasthmatic medication use, and potential confounders. Multivariable logistic regression analyses were performed to estimate odds ratios (ORs) with 95% confidence intervals (95% CI). RESULTS: We observed higher risk estimates among women with chronic respiratory diseases with and without medication use (1.4 [0.8–2.7] and 2.0 [0.8–5.0]), both in comparison to women without a chronic respiratory disease and without medication use. Furthermore, increased ORs of ARM were found for women using rescue medication (2.4 [0.8–7.3]) or a combination of maintenance and rescue medication (2.5 [0.9–6.7]). In addition, increased risk estimates were observed for women having nonallergic triggers (2.5 [1.0–6.3]) or experiencing exacerbations during the periconceptional period (3.5 [1.4–8.6]). CONCLUSIONS: Although the 95% CIs of most associations include the null value, the risk estimates all point towards an association between uncontrolled chronic respiratory disease, instead of antiasthmatic medication use, with ARM in offspring. Further in-depth studies towards mechanisms of this newly identified risk factor are warranted

Uncontrolled maternal chronic respiratory diseases in pregnancy: A new potential risk factor suggested to be associated with anorectal malformations in offspring

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