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An analysis of 11.3 million screening tests examining the association between recall and cancer detection rates in the English NHS breast cancer screening programme

  • R. G. BlanksEmail author
  • R. M. Given-Wilson
  • S. L. Cohen
  • J. Patnick
  • R. J. Alison
  • M. G. Wallis
Breast
  • 16 Downloads

Abstract

Objective

To develop methods to model the relationship between cancer detection and recall rates to inform professional standards.

Methods

Annual screening programme information for each of the 80 English NHSBSP units (totalling 11.3 million screening tests) for the seven screening years from 1 April 2009 to 31 March 2016 and some Dutch screening programme information were used to produce linear and non-linear models. The non-linear models estimated the modelled maximum values (MMV) for cancers detected at different grades and estimated how rapidly the MMV was reached (the modelled ‘slope’ (MS)). Main outcomes include the detection rate for combined invasive/micro-invasive and high-grade DCIS (IHG) detection rate and the low/intermediate grade DCIS (LIG) detection rate.

Results

At prevalent screens for IHG cancers, 99% of the MMV was reached at a recall rate of 7.0%. The LIG detection rate had no discernible plateau, increasing linearly at a rate of 0.12 per 1000 for every 1% increase in recall rate. At incident screens, 99% of the MMV for IHG cancer detection was 4.0%. LIG DCIS increased linearly at a rate of 0.18 per 1000 per 1% increase in recall rate.

Conclusions

Our models demonstrate the diminishing returns associated with increasing recall rates. The screening programme in England could use the models to set recall rate ranges, and other countries could explore similar methodology.

Key Points

• Question: How can we determine optimum recall rates in breast cancer screening?

• Findings: In this large observational study, we show that increases in recall rates above defined levels are almost exclusively associated with false positive recalls and a very small increase in low/intermediate grade DCIS.

• Meaning: High recall rates are not associated with increases in detection of life-threatening cancers. The models developed in this paper can be used to help set recall rate ranges that maximise benefit and minimise harm.

Keywords

Breast neoplasms Mass screening Mammography Recall rate 

Abbreviations

AgeX

Trial age extension trial

DCIS

Ductal carcinoma in situ

FPR

False positive (non-cancer) recalls

KC62

Korner return used to collect NHS data (breast screening return is no. 62)

LIG

Low/intermediate grade (DCIS)

MMV

Modelled maximum value

MS

Modelled slope (how rapidly MMV is reached)

NHSBSP

National Health Service Breast Screening Programme

P95

Recall rate at which 95% of MMV is reached

PPV

Positive predictive value

SEER

The Surveillance, Epidemiology and End Results Program of the National Cancer Institute

Notes

Acknowledgments

The work arose from initial discussions at the Clinical Advisory Group for NHSBSP assessment work (members Roger Blanks, Claire Borrelli, Sue Cohen, Alison Duncan, Rosalind Given-Wilson, Jacquie Jenkins, Olive Kearins, Sarah Pinder, Mark Sibbering, Nisha Sharma, Jim Steel, Anne Turnbull and Matthew Wallis).

Funding

Roger Blanks and Rupert Alison receive funding from the Public Health England.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Prof. Julietta Patnick.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was not required for this study because there is no identifiable patient data.

Ethical approval

Institutional Review Board approval was not required because there is no identifiable patient data.

Methodology

• retrospective

• observational

• multicentre

Supplementary material

330_2018_5957_MOESM1_ESM.doc (98 kb)
ESM 1 (DOC 98 kb)

References

  1. 1.
    Consolidated Standards for NHS Breast Screening Programme April 2017 Public Health England https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/589227/Breast_draft_standards_V1.7.pdf accessed 20/7/2017
  2. 2.
    Marmot MG, Altman DG, Cameron DA, Dewar JA, Thompson SG, Wilcox M (2013) The benefits and harms of breast cancer screening: an independent review. Br J Cancer 108:2205–2240Google Scholar
  3. 3.
    http://www.agex.uk/ accessed 1 Jan 2018
  4. 4.
    Tabàr L, Fagerberg G, Duffy SW, Day NE, Gad A, Gröntoft O (1992) Update of the Swedish-two county programme of mammographic screening for breast cancer. Radiol Clin North Am 30:187–210Google Scholar
  5. 5.
    Blanks RG, Day NE, Moss SM (1996) Monitoring the performance of breast screening programmes: use of indirect standardisation in evaluating the invasive cancer detection rate. J Med Screen 3:79–81CrossRefGoogle Scholar
  6. 6.
    Perry N, Broeders M, de Wolf C et al (2006) European guidelines for quality assurance in breast cancer screening and diagnosis. Fourth Edition. Luxembourg: Office for Official Publication of the European communitiesGoogle Scholar
  7. 7.
    Evans AJ, Blanks RG (2002) Should breast screening programmes limit their detection of ductal carcinoma in situ? Clin Radiol 57:1086–1089CrossRefGoogle Scholar
  8. 8.
    Duffy SW, Dibden A, Michalopoulos D et al (2016) Screen detection of ductal carcinoma in situ and subsequent incidence of invasive interval breast cancers: a retrospective population-based study. Lancet Oncol 17:109–114.  https://doi.org/10.1016/S1470-2045(15)00446-5 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Sagara Y, Mallory MA, Wong S et al (2015) Survival benefit of breast surgery for low-grade ductal carcinoma in situ. JAMA Surg 150(8):739–745CrossRefGoogle Scholar
  10. 10.
    Wallis MG, Clements K, Kearins O, Ball G, Macartney J, Lawrence GM (2012) The effect of DCIS grade on rate, type and time to recurrence after 15 years of follow-up of screen-detected DCIS. Br J Cancer 106:1611–1617.  https://doi.org/10.1038/bjc.2012.151 CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Benson JR, Jatoi I, Toi M (2016) Treatment of low risk ductal carcinoma-in-situ: is nothing better than something? Lancet Oncol 17(1):e442–e451CrossRefGoogle Scholar
  12. 12.
    Van Luijt PA, Fracheboud J, Heijnsdijk EAM, den Heeten GJ, de Koning HJ (2013) Nation-wide data on screening performance during the transition to digital mammography: observation in 6 million screens. Eur J Cancer 49:3517–3525CrossRefGoogle Scholar
  13. 13.
    Lehman CD, Arao RF, Sprague BL et al (2017) National performance benchmarks for modern screening digital mammography: update from the Breast Cancer Surveillance Consortium. Radiology 283(1):49–58CrossRefGoogle Scholar
  14. 14.
    NHS Digital, Breast Screening Programme, England - 2015-16 https://digital.nhs.uk/catalogue/PUB23376 accessed 1 Jan 2018
  15. 15.
    Raffle AE, Muir Gray JA (2007) Screening: evidence and practice. Oxford University PressGoogle Scholar
  16. 16.
    Smith-Bindman R, Chu PW, Miglioretti DL et al (2003) Comparison of screening mammography in the United States and United Kingdom. JAMA 290:2129–2138Google Scholar
  17. 17.
    Wallis MG, Lawrence GM, Brenner RJ (2008) Improving quality outcomes in a single-payer system: lessons learnt from the UK Breast Screening Program. J Am Coll Radiol 5:737–743Google Scholar
  18. 18.
    Given-Wilson R, Blanks RG, Moss SM et al (1999) An evaluation of breast cancer screening in South Thames (West) Region of the UK NHS Breast Screening Programme: the first 10 years. Breast 8:66–71Google Scholar
  19. 19.
    Burnside ES, Vulcan D, Blanks RG, Duffy SW (2018) The association between screening mammography recall rate and interval cancers in the UK Breast Cancer Service Screening Programme: a cohort study. Radiology 288(1):47–54CrossRefGoogle Scholar
  20. 20.
    Skaane P, Sebuødegård S, Bandos AI et al (2018) Performance of breast cancer screening using digital breast tomosynthesis: results from the prospective population-based Oslo Tomosynthesis Screening Trial. Breast Cancer Res Treat.  https://doi.org/10.1007/s10549-018-4705-2

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Cancer Epidemiology Unit, Nuffield Department of Population HealthOxford UniversityOxfordUK
  2. 2.Department of RadiologySt Georges University Hospital Foundation TrustLondonUK
  3. 3.Public Health EnglandLondonUK
  4. 4.Cambridge Breast Unit and NIHR Cambridge Biomedical Research CentreCambridge University Hospitals NHS TrustCambridgeUK

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