The effects and costs of breast cancer screening

In 1986, the Dutch Ministry of Welfare, Health and Cultural Affairs asked a research group to investigate the expected effect of breast cancer screening on mortality and possibly morbidity, if implemented in the Netherlands. The research group consisted of members from 3 centres, the Dept. of Public Health (Erasmus Universiteit Rotterdam), the Dept. of Public Health and Epidemiology/ Preventicon (Rijksuniversiteit Utrecht) and the Dept. of Epidemiology/ Radiology (Katholieke Universiteit Nijmegen). Data from the two Dutch breast cancer screening projects, the DOM-projects in Utrecht (Rombach, 1980; Collette et a!., 1984; de Waard et a!., 1984) and the Nijmegen project (Hendriks, 1982; Verbeek et a!., 1984; Peeters, 1989) which started in 1974/1975, was made available in order to first establish more precise estimates for the parameters in the above mentioned model for the disease process of breast cancer and screening in the Netherlands. Together with research on the cost, one of the first Dutch cost-effectiveness analyses in health care was started.With the research described in this thesis, both the concept of screening and the underlying model earlier described have been extended to include the impact on almost all aspects after or beyond the screening examination itself: impact on advanced disease late in life, on assessment and primary treatment for women and for health care, on quality of life, impact on financial cost and impact on the situation of the disease in a population outside the invited or screened grou

Mammographic screening: evidence from randomised controlled trials

BACKGROUND: All randomised breast cancer screening trials have shown a reduction in breast cancer mortality in the 'invited for mammography' screening arm compared with the 'control arm' for women aged 50 years and older at randomisation (overall 25%). However, individually published point estimates differ and concern has been raised about methodological quality and outcome measures. Materials and Methods Review of the evidence on breast cancer mortality reduction and discussion of the causes of difference in point estimates in the five Swedish and Canadian trials. A summary of the prerequisites for methodological quality and its available evidence from the trials is given. Data to support breast cancer mortality as a correct outcome measure are presented. RESULTS: There is no reason not to use breast cancer mortality as an outcome measure for trials intended to reduce breast cancer mortality, both from a clinical and a methodological point of view. Everything possible was performed in these trials in order to determine this outcome measure as accurately as possible. The fact that a few of the trials showed a relatively large breast cancer mortality reduction and others far lower reduction rates is irrelevant, if one does not consider the background situation in the region before the trial started, the design of the trial or quality of screening. CONCLUSIONS: There seems no reason to change or halt the current nation-wide population-based screening programmes. Nor is there any justifiable reason for negative reports towards women or professionals

De mysterieuze massa.

... Het leven is een mysterie. En geldt dit niet des te meer voor zijn tegenhanger, de dood? Er zijn talrijke theorieën omtrent de oorsprong van het leven, dan wel het einde van het leven. In dit Darwinjaar is de evolutietheorie, en daarmee de eindigheid van ons bestaan, populairder dan ooit. Er is het scheppingsverhaal met een indicatie van het oneindige van ons bestaan; er is de theorie van een oneindig bewustzijn, geformuleerd op basis van bijna-dood ervaringen van patiënten. Er bestaan Japanse verhalen over shinigami’s, engelen des doods, die met het schrijven van je naam in een zogenaamde ‘death note’ je tijdstip van overlijden bepalen. Deze shinigami’s zouden tegenwoordig, uit verveling of om niet als streber te worden aangemerkt, steeds minder vaak namen noteren. ..

Comparative effectiveness of prostate cancer screening between the ages of 55 and 69 years followed by active surveillance

BACKGROUND: Because of the recent grade C draft recommendation by the US Preventive Services Task Force (USPSTF) for prostate cancer screening between the ages of 55 and 69 years, there is a need to determine whether this could be cost-effective in a US population setting. METHODS: This study used a microsimulation model of screening and active surveillance (AS), based on data from the European Randomized Study of Screening for Prostate Cancer and the Surveillance, Epidemiology, and End Results Program, for the natural history of prostate cancer and Johns Hopkins AS cohort data to inform the probabilities of referral to treatment during AS. A cohort of 10 million men, based on US life tables, was simulated. The lifetime costs and effects of screening between the ages of 55 and 69 years with different screening frequencies and AS protocols were projected, and their cost-effectiveness was determined. RESULTS: Quadrennial screening between the ages of 55 and 69 years (55, 59, 63, and 67 years) with AS for men with low-risk cancers (ie, those with a Gleason score of 6 or lower) and yearly biopsies or triennial biopsies resulted in an incremental cost per quality-adjusted life-year (QALY) of $51,918 or$69,380, respectively. Most policies in which screening was followed by immediate treatment were dominated. In most sensitivity analyses, this study found a policy with which the cost per QALY remained below $100,000. CONCLUSIONS: Prostate-specific antigen–based prostate cancer screening in the United States between the ages of 55 and 69 years, as recommended by the USPSTF, may be cost-effective at a$100,000 threshold but only with a quadrennial screening frequency and with AS offered to all low-risk men. Cancer 2018;124:507-13

Screening for cancers with a good prognosis:The case of testicular germ cell cancer

Background: To determine, using testicular germ cell cancer screening as an example, whether screening can also be effective for cancers with a good prognosis. Methods: Based on the Dutch incidence, stage distribution, and survival and mortality data of testicular germ cell cancer, we developed a microsimulation model. This model simulates screening scenarios varying in screening age, interval, self-examination or screening by the general practitioner (GP), and screening of a defined high-risk group (cryptorchidism). For each scenario, the number of clinically and screen-detected cancers by stage, referrals, testicular germ cell cancer deaths, and life-years gained were projected. Results: Annual self-examination from age 20 to 30 years resulted in 767 cancers detected per 100,000 men followed over life-time, of which 123 (16%) by screening. In this scenario, 19.2 men died from the disease, 4.7 (20%) less than without screening, and 230 life-years were gained. Around 14,000 visits to the GP and 2080 visits to an urologist were required. This scenario resulted in the most favorable ratio between extra visits to the GP or urologist and deaths prevented (1418 and 116 respectively). Monthly screening, or screening until age 40 resulted in less favorable ratios. Self-examination by only the high-risk population prevented 1.0 death per 100,00 men in the general population. In all scenarios, 46–50 life-years were gained for each testicular germ cell cancer death prevented. Conclusion: Despite the good prognosis, self-examination at young ages for testicular germ cell cancer could be considered

Uptake of minimally invasive surgery and stereotactic body radiation therapy for early stage non-small cell lung cancer in the USA

BACKGROUND: We aimed to assess the uptake of minimally invasive surgery (MIS) and stereotactic body radiation therapy (SBRT) among early stage (stage IA-IIB) non-small cell lung cancer (NSCLC) cases in the USA, and the rate of conversions from MIS to open surgery. MATERIALS AND METHODS: Data were obtained from the US National Cancer Database, a nationwide facility-based cancer registry capturing up to 70% of incident cancer cases in the USA. We included cases diagnosed with early stage (clinical stages IA-IIB) NSCLC between 2010 and 2014. In an ecological analysis, we assessed changes in treatment by year of diagnosis. Among surgically treated cases, we assessed the uptake of MIS and whether conversion to open surgery took place. For cases that received thoracic radiotherapy, we assessed the uptake of SBRT. RESULTS: Among 117 370 selected cases, radiotherapy use increased 3.4 percentage points between 2010 and 2014 (p<0.0001). Surgical treatments decreased 3.5 percentage points (p<0.0001). Rates of non-treatment remained stable (range: 10.0%-10.6% (p=0.4066)). Among surgically treated stage IA cases, uptake of MIS increased from 28.7% (95% CI 27.8% to 29.7%) in 2010 to 48.6% (95% CI 47.6% to 49