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Practical problems in breast screening

Practical problems in breast screening concern

• the organisation
• the doctors : general practitionners/gynecologists, radiologists
• the women : informed choice, participation rate
• the results
  • high rate of recall
  • false negatives
  • false positives
• the diagnostic strategies after a positive test.

Organisation

• in Switzerland, « mass screening programmes » exist since less than 10 years for 50-70 y.o women
  • in only three french-speaking cantons (Valais, Vaud, Genève)
  • using private and public radiology departments
  • coordination by a cantonal center
  • with a particular screening for high risk women since 1996
• involves many partners : state, doctors, insurances…
• local variations
  • in the organisation
  • in the number and qualification of the accredited radiologists
  • for the financial participation of the women : 0.- CHF to 10%

The doctors

• the general practitionners and gynecologists
  • problems to inform about the advantages and limitations
  • how to inform about the screening strategies for high-risk women and women with dense breast ?
  • problem of the false reassurance of a negative screening test : may decrease the clinical breast examination (8% of all diagnosed breast cancers are found by the breast examination alone with a negative mammogram).
• radiologists
  • different interest /involment (private or public practice)
  • variable conditions for accreditation
  • problem of the full digital mammography (costs, accreditation)
  • loss of income : reembursement rate of the mammotest is variable (Vaud : 72.-CHF, Valais :112.- CHF, Geneva : 200 CHF).

Women

• problem of the information insufficiency for the 'informed choice'
  • few women are able to take truly informed decisions about screening mammography (benefits and limitations)
  • how to give better the information ?
• how women interpret the mammography screening debate ?
  • 50% report being upset by the public disagreement among screening experts
  • most women suggest that mammography screening should begin before age 40 years, while only 5% suggest a first mammogram should be performed at 50 years or older
  • nearly half (49%) identified costs as the major source of debate
  • women believe the debate is about money rather than the question of benefit
• problem of the low participation rate
  • high rate of spontaneous screeening (opportunistic screening)
  • for a better participation
    • a local, easily accessible breast screening center
    • with free car park facilities
    • a "cosy, nonclinical" atmosphere
    • information before and during screening

Results

• problem of a high rate of recall
  • experience of the radiologists (3-25% of positive tests)
  • pressure of litigation: rates are twice as high in US than in the United Kingdom but cancer detection rates are similar
• false negatives
  • the percentage is low
  • anxiety is very low
  • consequences :
    • medical outcomes (morbidity and mortality)
    • psychological outcomes (distress, false reassurance, loss of confidence in services)
    • legal outcomes (such as litigation)
    • impact on public confidence in screening
    • false reassurance
    • leading to diagnostic delay and subsequent treatment
• false-positive findings = major costs/adverse effects
  • there are 15-40 times as many false positive as true positive mammograms
    • consequences
      • unnecessary surgical biopsies
      • residual scarring
      • anxiety is significantly high 8 weeks after having received a negative diagnosis
        

The goals of the diagnostic strategies after a positive test

• to shorten the time to diagnosis
• to follow the moderns guidelines
  • using the diagnosis procedures of high quality
  • percutanous imaging guided procedures +++
  • sentinel node biopsy
• to raise the high rate positive open surgical biopsies

Conclusion

The main problems are

• monney
  • « Society may decide that it is too expensive to screen women for breast cancer… » *
    • and not to start a screening programm
• information
  • « …women should be provided with the scientific and medical information so that they can participate in the discussion of whether screening is "worthwhile" and decide whether or not to avail themselves of its benefit. » *
    • how to give the optimal information to the women for their 'informed choice' ?
• high opportunistic screeening
  • how to analysis and add the benefits of the three types of « screening « in Switzerland :
    • opportunistic screeening (high)
    • screening for high risk women (since 1996)
    • mass screening programms
  • « …. The economics (and the politics) should not be used to influence the scientific and medical analysis of benefit. » *

* Kopans DB. J Natl Cancer Inst Monogr. 1997;(22):1-3. An overview of the breast cancer screening controversy.