The aim of this study was to evaluate the usefulness of combined screening with conventional procedure and screening mammography by comparing a number and detection rate of breast cancers between conventional procedure without (CP group) and with screening mammography (MMG group) performed in Kumamoto prefecture from 1999 to 2005

Fukuyama Miki

Kigo Rie

Kihara Shinichi

Kukinaka Chieko

Murakami Mika

Oyama Misako

Taniguchi Mariko

Tsuchikame Naotoshi

Umeki Shoko

まり子 谷口

信市 木原

公子 福山

彰子 梅木

智恵子 柊中

直俊 土亀

美佐子 小山

美華 村上

莉瑛 木子

Kumamoto University Repository

熊本大学学術リポジトリUsefulness of Combined Screening withConventional Procedure and ScreeningMammography in the Detection of Breast Cancer: Results from the Mass Survey for BreastCancer in Kumamoto Prefecturejournal orpublication title熊本大学医学部保健学科紀要volume 5page range 19-25year 2009-02-27URL http://hdl.handle.net/2298/11270Usefulness of Combined Screening with Conventional Procedure and Screening Mammography in the Detection of Breast Cancer-Results from the Mass Survey for Breast Cancer in Kumamoto Prefecture-Usefulness of Combined Screening with Conventional Procedure andScreening Mammography in the Detection of Breast Cancer— Results from the Mass Survey for Breast Cancer in Kumamoto Prefecture —Shinichi Kihara n, Misako Oyama 2>, Naotoshi Tsuchikame 2), Mika Murakami n,Shoko Umeki n, Chieko Kukinaka n, Miki Fukuyama n, Mariko Taniguchi1' and Rie KigonAbstractPurpose ! The aim of this study was to evaluate the usefulness of combined screening withconventional procedure and screening mammography by comparing a number and detectionrate of breast cancers between conventional procedure without (CP group) and with screening mammography (MMG group) performed in Kumamoto prefecture from 1999 to 2005.Materials and method: A total of 225,509 cases were enrolled in this study. They were124,239 in CP group and 101,270 in MMG group, respectively. Conventional procedurewas performed by inspection and palpation of the breast. MMG group included the cases ofsuspected or suggestive of breast cancer by conventional procedure. Final diagnosis ofbreast cancer was obtained by the fine or core needle biopsies. The detection rate of breastcancer was compared between two groups and further evaluation was performed in MMGgroup of the breast cancer screening on 2005.Results ! The breast cancer was detected in 73 (0.06%) cases of CP group and 198(0.2%) of MMG group during 7 years' screening, respectively. Detection rate of the breastcancer was significantly higher in MMG group than that in CP group (p<0.01). Furthermore, early breast cancer was obtained in 50 (83.3%) of 65 cases in MMG group of thebreast cancer screening on 2005.Conclusion : Breast cancer screening using mammography is more useful procedure in thedetection of early breast cancer than the conventional procedure alone. Combined breastcancer screening with mammography and conventional procedure is recommended for themass survey of breast cancer. For women in age of under 40 years, a MRI or ultrasonographyis, however, necessary for the screening in addition to combined screening with mammography.IntroductionIncidence and mortality of the breast cancer have been increasing recent years in Japan n.Annual increase in the number of cases with breast cancer reaches approximately 40,000 n.Moreover, higher mortality rate has been observed especially in breast cancer as comparedwith other primary cancers occurred in Japanese women in their prime n. Therefore, the mass1) School of Health Sciences, Kumamoto University2 ) Kumamoto General Health Center-19-(2009) Shinichi Kihara et al.survey for breast cancer has started to decrease its mortality rate in accordance with thelegislative action in 1987. The conventional procedure including the inspection and palpation ofbreast was firstly introduced into the breast cancer survey. Various strategies for the breastcancer screening have been recommended for increase in screening accuracy since then. A combined screening with conventional procedure and biennial mammography had been performedin women of 50 years or older in 1995-1996. The combined screening has been extended towomen of 40 years or older on 2004.The breast cancer screening for most women residents in Kumamoto prefecture has been carried out for many years at Kumamoto General Health Center. The conventional procedure andscreening mammography (Combined screening) were used for the breast cancer survey at thisinstitution. The aim of this study was to obviate the usefulness of combined screening withmammography in the breast cancer survey.Materials and MethodsThe breast cancer survey was performed in 225,509 cases from 1999 to 2005 at the KumamotoGeneral Health Center. All of them were enrolled in this study. They were 124,239 with onlyconventional procedure (CP group) and 101,270 with conventional procedure and screeningmammography (MMG group), respectively. Conventional procedure was performed by inspectionand palpation of the breast. MMG group included the cases of suspected or suggestive ofbreast cancer by conventional procedure. The method for the survey was selected by each caseafter giving an informed consent. Final diagnosis of breast cancer was obtained by the fine orcore needle biopsy. The detection rate of breast cancer was compared between the groups withor without screening mammography in cases underwent breast cancer survey from 1999 to2005. The further analysis was performed in MMG group on 2005.Statistical analysis was performed using a Med Calc software. Type I error was used forthe comparison of detection rate between two groups. Significant difference was defined asp<0.05.Results1 . Breast cancer survey from 1999 to 2005The number of cases surveyed in each year from 1999 to 2005 is summarized in Table 1. Thenumber of cases with screening mammography increased every year with decrease in thatwith conventional procedure. The number of cases with screening mammography increased to10 times from 1999 to 2005. There was not a significant difference in age distribution betweenCP and MMG groups. They ranged from 30 to 90 years. Highest incidence of the number ofcases was observed in ages from 50 to 74 years.-20-Usefulness of Combined Screening with Conventional Procedure and Screening Mammography in the Detection of Breast Cancer-Results from the Mass Survey for Breast Cancer in Kumamoto Prefecture-Table 1 Number of Surveyed Cases from 1999 to 2005Year ^^\^1999200020012002200320042005TotalScreening Case (N)CP35,75530,96119,74715,10312,8118,5251,337124,239MMG2,3145,45713,05416,76319,57720,64323,462101,270CP, conventional procedure; MMG, combainedscreening with conventional procedure and mammographyThe number and detection rate of the breast cancer from 1999 to 2005 are demonstrated inTable 2. The breast cancer was observed in 73 (0.06%) of CP group and 198 (0.2%) of MMGgroup, respectively. The number of cases with breast cancer in CP group decreased every year,while that in MMG group increased. The detection rate of breast cancer in each year rangedfrom 0.04 to 0.11%, although the number of screening cases decreased in CP group. Remarkablechange in the detection rate of each year was not found in CP group excluding that of 2004.On the other hand, the detection rate of breast cancer in each year increased from 0.04 to0.28% in MMG group. The number and detection rate of breast cancer in each year wereremarkably higher on 2004 and 2005 in MMG group. The detection rate of breast cancer wassignificantly higher in MMG group than in CP group (p<0.01).Seven-thousand nine-hundred eighteen (7.8%) of 101,270 cases in MMG group were suspectedof breast cancer (Table 3). The rate of suspected breast cancer in each year ranged from 6.1%Table 2 Number of Detected Breast Cancer and DetectionRate from 1999 to 2005Year ^"^-\^1999200020012002200320042005TotalDetected Breast Cancer (N)IP20198979173MMG321731275365198Detection Rate (%) *IP0.060.060.040.060.050.110.070.06MMG0.130.040.140.190.140.260.280.2breast cancers / all screening cases-21-(2009) Shinichi Kihara et al.to 8.4% (Table 3). One-hundred ninety eight biopsy-proven breast cancers were discovered,which corresponded to 0.2% of all screening cases and 2.5% of suspected cases in MMG group.Table 3 Summary of Breast Cancer Survey in MMG from 1999 to 2005Year^\^1999200020012002200320042005TotalScreeningCase(N)2,3145,45713,05416,76319,57720,64323,462101,270Suspected Case(N)1953321,0971,3851,5831,5811,7457,918Rate ofSuspectedCase (%)8.46.18.48.38.07.77.47.8Detected Case(N)321731275365198DetectionRate(%)*0.130.040.140.190.140.260.280.2DetectionRate (96)"1.50.61.62.21.73.43.72.5breast cancers / all screening cases ** breast cancers / suspected cases2. MMG group on 2005The number of screening cases in MMG group was 23,462 cases, which were obviouslygreater than 13,337 cases in CP group (Table 1). They were classified into three groups bytheir ages as follows; ages of 30 to 34 years, 35 to 85 years and over 85 years. The numberof screening cases increased in order of their ages of sixties, fifties, forties and seventies (Table 4).The breast cancer was suspected in 1,745 (7.4%) of 23,462 cases. The rate of suspected breastcancer was 5.2% in their ages of 30 to 34 years, 11.3% in 35 to 85 years and 4.2% in over 85years, respectively. In ages of 35 to 85 years, it increased in order with ages of 45 to 49 years,50 to 54 years and 35 to 39 years (Table 4). 65 breast cancers were diagnosed by the fine orcore needle biopsy. The detection rate of breast cancer was 0.28% of all screening cases and3.7% of suspected cases, respectively (Table 4). The highest detection rate of breast cancerwas obtained in MMG group on 2005 in mass screenings from 1999 to 2005 (Table 3). Theirages ranged from 44 to 84 years. The detection rate of breast cancer in respective ages rangedfrom 0.2% to 0.7%. The highest detection rate of 0.7% was observed in ages of 80 to 84 years.In the suspected cases, the detection rate of breast cancer ranged from 0 to 8.8% with itshighest value in ages of 75 to 79 years.-22-Usefulness of Combined Screening with Conventional Procedure and Screening Mammography in the Detection of Breast Cancer-Results from the Mass Survey for Breast Cancer in Kumamoto Prefecture-Table 4 Summary of Breast Cancer Survey in MMG on 2005Age ^\30-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-TotalScreening Case(N)1582202,1432,3153,0563,6903,3783,6213,0311,3954074823,462Suspected Case(N)818210262286278215208166682421,745Rate-of-SuspectedCase (96)5.18.29.811.39.47.56.45.75.54.95.94.27.4DetectedCase (N)0041279108663065DetectionRate (%)*000.20.50.20.20.30.20.20.40.700.28DetectionRate (%)**001.94.62.53.24.73.93.68.80.703.7* breast cancers / all screening cases ** breast cancers / suspected casesClinical stages of 65 breast cancers in their respective ages are summarized in Table 5. Surgicalresection was appropriately performed in all cases with breast cancer. There were 37 cases instage 1, 13 in stage II and 2 in stage III, respectively. As a result, the early breast cancerof stage I or stage II was obtained in 50 (83.3%) of 65 detected breast cancers. Except forages of 70 to 74 years, the stage I breast cancer was most frequently observed in the respectiveages.Table 5 Stage^\StageAge ^\30-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-Totaland Age Distribution of Detected Breast Cancer in MMG onStage 0122232113Stage I25366625237Stage n141111413Stage HI1122005Stage IV Total4127910965365-23-(2009) Shinichi Kihara et al.DiscussionIt is difficult for all municipalities to employ the ideal screening for breast cancer because ofhigh cost for introducing the devices of mammography and idiosyncratic circumstances behindindividual screening cases. In Kumamoto prefecture, combined screening with conventional procedure and screening mammography has started in 1999. The number of screening cases inMMG group increased annually from 2,314 in 1999 to 23,462 in 2005 owing to the effort of themunicipality. As combined screening increased, screening with conventional procedure aloneremarkably decreased from 35,755 in 1999 to 1,333 in 2005. However, there were still suchcases surveyed alone with the conventional procedure present in 2004 and 2005. They rejectedthe screening mammography because of pain during the positioning of mammography, economicburden and poor understanding of the value of screening mammography. Combined screeningis the best method for early detection of breast cancer 2>4>5). Therefore, public education isimportant to increase combined screening for breast cancer.Seventy three breast cancers were found in CP group and 198 in MMG group from 1999 to2005, respectively. The detection rate of breast cancer in MMG group was 0.2%, which was 3.3times higher than 0.06% in CP group. In MMG group, the detection rate of breast cancer was2.5 % in breast cancer suspected cases. The detection rate in MMG group is compatible withthose reported by others 6). Furthermore, the detection rate of breast cancer remarkablyincreased on 2004 and 2005. Improvement in diagnostic technique associated with mammographyprobably results in increase in the detection rate on 2004 and 2005.On 2005, the number of screening cases was mainly distributed from forties to sixties. Manywomen at high risk of breast cancer tended to complain a discomfort. They were observed inthe same ages from forties to sixties. Therefore, breast cancer screening is better to be morefrequently performed in these ages than the other ages. However, false-positive result in thebreast cancer screening is higher in an relatively younger women because of their dense breast7>8).In this study, the rate of suspected breast cancer increased in order of 45-49 year-old ages, 40-44, 50-55 and 35-39. Breast cancer was found only in 65 cases of 1,745 suspected cases on 2005.Then, 1,680 cases (96.2%) of suspected women were diagnosed as false-positive. These false-positive cases are suggestive of high risk cases of subsequent interval cancers 7). Althoughfalse-positive cases are less likely to receive the same subsequent screening than those assessedas negative, breast cancer screening should be performed annually. On the other hand, highestrate of diagnosed cancers in the suspected cases was observed in ages of 75-79 years. Womenwith low-dense breast are suggested to exhibit a higher detection rate by breast cancer screening. In this study, more breast cancers were obtained by the combined screening than that byconventional procedure. In combined screening on 2005, 83.3% of them were diagnosed as earlybreast cancer. Combined screening with mammography may be more powerful in detectingearly breast cancer than the conventional procedure.On the basis of these results, mammography is recommended to be employed in breast cancerscreening for women aged over 40 years, as has been found in other countries49*. Screeningmammography is better to be performed once a year rather than biennially. On the otherhand, screening mammography without conventional procedure is being carried out in many-24-Usefulness of Combined Screening with Conventional Procedure and Screening Mammography in the Detection of Breast Cancer-Results from the Mass Survey for Breast Cancer in Kumamoto Prefecture -municipalities. However, conventional procedure is an important in the diagnosis of particularcancers such as inflammatory carcinoma and Paget disease of breast. Furthermore, conventionalprocedure seems to bring a sense of relief or familiarity on the subject from the examiner.Ultrasonography has been reported to be powerful particularly in the detection of breast cancerin dense breasts of younger than 40 years of age. A study employing ultrasonography intothe combined screening for Japanese women of 40 ages started in 200610) . Magnetic resonanceimaging (MRI) is reported to be another useful modality in screening women at high risk forbreast cancer 21112). MRI for the breast also provides accurate information on patientmanagement10. They include the assessment of response to treatment and decision of appropriate surgery. MRI has been utilized as an additional modality for young women at highrisk for breast cancer because of poor sensitivity of their screening mammography 13). Therefore, it is necessary to employ ultrasonography or MRI to the combined screening in case ofscreening for the young women 313).In conclusions, breast cancer screening using mammography is more useful procedure in thedetection of early breast cancer than the conventional procedure alone. Combined breast cancerscreening with mammography and conventional procedure is recommended for the mass survey of breast cancer. For women in age of under 40 years, a MRI or ultrasonography is, however, necessary for the screening in addition to combined screening with mammography.References1 ) VITAL STATISTICS OF JAPAN 1958-2004 : the Ministry of Health, Labor and Welfare.2) Wujcik, D. Fair, AM. ! Barriers to diagnostic resolution after abnormal mammography : a review of the literature.J Cancer Nurs 31 ! 16-30, 2008.3 ) Honjo, S. et al. ! Relative and combined performance of mammography and ultrasonography for breast cancer screening in the general population '. a pilot study in Tochigi Prefecture, Japan. Jpn J Clin Oncol 37 I 715-720, 2007.4 ) Armstrong, K. et al. ! Screening mammography in women 40 to 49 years of age ! a systematic review for the American College of Physicians. Ann Intern Med 146 : 516-526, 2007.5) Morimoto.T. et al. ! A comparison of Mass Screening for Breast Canser Using Mammography and Physical Examination Alone in Japan. Breast Cancer 30 : 19-25, 1995.6) Japan Cancer Society in 2006 '. The detection Rate of Breast Cancer by Screening. 2006.7 ) McCann, J. et al. ! Impact of false-positive mammography on subsequent screening attendance and risk of cancer.Breast Cancer Res 4 : 11-16, 2002.8) Lehman, CD. et al. ! Effect of age and breast density on screening mammograms with false positive findings. Am JRoentgenol 173 : 1651-1655, 1999.9) Ringash, J. et al. ! Preventive health care, 2001 update ! screening mammography among women aged 40-49 years ataverage risk of breast cancer. CMAJ 164 : 469-76, 2001.10) Tactic outcome research I Japan strategic anti-cancer randomized trial; J-START, 2006.11) Singh, V. et al. I New diagnostic techniques for breast cancer detection. Future Oncol 4 : 501-513, 2008.12) Lord, SJ. Et al. ' A systematic review of the effectiveness of magnetic resonance imaging (MRI) as an addition tomammography and ultrasound in screening young women at high risk of breast cancer. Eur J Cancer 43 ! 1905-1917,2007.13) Warner, E. et al. '. Systematic review ! using magnetic resonance imaging to screen women at high risk for breastcancer. Ann Intern Med 148 ! 671-679.-25-

Usefulness of Combined Screening with Conventional Procedure and Screening Mammography in the Detection of Breast Cancer : Results from the Mass Survey for Breast Cancer in Kumamoto Prefecture

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Usefulness of Combined Screening with Conventional Procedure and Screening Mammography in the Detection of Breast Cancer : Results from the Mass Survey for Breast Cancer in Kumamoto Prefecture

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