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  • 1. Ancelle-Park, R.
    et al.
    Armaroli, P.
    Ascunce, N.
    Bisanti, L.
    Bellisario, C.
    Broeders, M.
    Cogo, C.
    de Koning, H.
    Duffy, S. W.
    Frigerio, A.
    Giordano, L.
    Hofvind, S.
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Lynge, E.
    Massat, N.
    Miccinesi, G.
    Moss, S.
    Naldoni, C.
    Njor, S.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Paap, E.
    Paci, E.
    Patnick, J.
    Ponti, A.
    Puliti, D.
    Segnan, N.
    Von Karsa, L.
    Tornberg, S.
    Zappa, M.
    Zorzi, M.
    Summary of the evidence of breast cancer service screening outcomes in Europe and first estimate of the benefit and harm balance sheet2012Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, s. 5-13Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives To construct a European 'balance sheet' of key outcomes of population-based mammographic breast cancer screening, to inform policy-makers, stakeholders and invited women. Methods From the studies reviewed, the primary benefit of screening, breast cancer mortality reduction, was compared with the main harms, over-diagnosis and false-positive screening results (FPRs). Results Pooled estimates of breast cancer mortality reduction among invited women were 25% in incidence-based mortality studies and 31% in case-control studies (38% and 48% among women actually screened). Estimates of over-diagnosis ranged from 1% to 10% of the expected incidence in the absence of screening. The combined estimate of over-diagnosis for screened women, from European studies correctly adjusted for lead time and underlying trend, was 6.5%. For women undergoing 10 biennial screening tests, the estimated cumulative risk of a FPR followed by non-invasive assessment was 17%, and 3% having an invasive assessment. For every 1000 women screened biennially from age 50-51 until age 68-69 and followed up to age 79, an estimated seven to nine lives are saved, four cases are over-diagnosed, 170 women have at least one recall followed by non-invasive assessment with a negative result and 30 women have at least one recall followed by invasive procedures yielding a negative result. Conclusions The chance of saving a woman's life by population-based mammographic screening of appropriate quality is greater than that of over-diagnosis. Service screening in Europe achieves a mortality benefit at least as great as the randomized controlled trials. These outcomes should be communicated to women offered service screening in Europe.

  • 2.
    Bordás, Pál
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Lenner, Per
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Interval cancer incidence and episode sensitivity in the Norrbotten mammography screening programme, Sweden2009Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 16, nr 1, s. 39-45Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To estimate the interval cancer incidence, its determinants and the episode sensitivity in the Norrbotten Mammography Screening Programme (NMSP).

    SETTING: Since 1989, women aged 40-74 years (n = 55,000) have been invited to biennial screening by the NMSP, Norrbotten county, Sweden.

    METHODS: Data on 1047 invasive breast cancers from six screening rounds of the NMSP (1989-2002) were collected. We estimated the invasive interval cancer rates, rate ratios and the episode sensitivity using the detection and incidence methods. A linear Poisson-model was used to analyse association between interval cancer incidence and sensitivity.

    RESULTS: 768 screen-detected and 279 interval cancer cases were identified. The rate ratio of interval cancer decreased with age. The 50-59 year age group showed the highest rate ratio (RR = 0.52, 95% CI 0.41-0.65) and the 70-74 year age group the lowest (RR = 0.23, 95% CI 0.15-0.36). The rate ratios for the early (0-12 months) and late (13-24 months) interval cancers were similar (RR = 0.18, 95% CI 0.15-0.22 and 0.20, 95% CI 0.17-0.24). There was a significantly lower interval cancer incidence in the prevalence round as compared with the incidence rounds. According to the detection method the episode sensitivity increased with age from 57% in the age group 40-49 years to 84% in the age group 70-74 years. The corresponding figures for the incidence method were 50% and 77%, respectively.

    CONCLUSION: Our study showed an interval cancer incidence of 38% and the episode sensitivity of 62-73%, depending on the method of calculation. Our results are of clinically acceptable level and concert with the reference values of the European guidelines.

  • 3. Broeders, Mireille
    et al.
    Moss, Sue
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Njor, Sisse
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Poop, Ellen
    Massat, Nathalie
    Duffy, Stephen
    Lynge, Elsebeth
    Paci, Eugenio
    The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies2012Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, s. 14-25Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives To assess the impact of population-based mammographic screening on breast cancer mortality in Europe, considering different methodologies and limitations of the data. Methods We conducted a systematic literature review of European trend studies (n = 17), incidence-based mortality (IBM) studies (n = 20) and case-control (CC) studies (n = 8). Estimates of the reduction in breast cancer mortality for women invited versus not invited and/or for women screened versus not screened were obtained. The results of IBM studies and CC studies were each pooled using a random effects meta-analysis. Results Twelve of the 17 trend studies quantified the impact of population-based screening on breast cancer mortality. The estimated breast cancer mortality reductions ranged from 1% to 9% per year in studies reporting an annual percentage change, and from 28% to 36% in those comparing post- and prescreening periods. In the IBM studies, the pooled mortality reduction was 25% (relative risk [RR] 0.75, 95% confidence interval [CI] 0.69-0.81) among invited women and 38% (RR 0.62, 95% CI 0.56-0.69) among those actually screened. The corresponding pooled estimates from the CC studies were 31% (odds ratio [OR] 0.69, 95% CI 0.57-0.83), and 48% (OR 0.52, 95% CI 0.42-0.65) adjusted for self-selection. Conclusions Valid observational designs are those where sufficient longitudinal individual data are available, directly linking a woman's screening history to her cause of death. From such studies, the best 'European' estimate of breast cancer mortality reduction is 25-31% for women invited for screening, and 38-48% for women actually screened. Much of the current controversy on breast cancer screening is due to the use of inappropriate methodological approaches that are unable to capture the true effect of mammographic screening.

  • 4. Giordano, Livia
    et al.
    von Karsa, Lawrence
    Tomatis, Mariano
    Majek, Ondrej
    de Wolf, Chris
    Lancucki, Lesz
    Hofvind, Solveig
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Segnan, Nereo
    Ponti, Antonio
    Mammographic screening programmes in Europe: organization, coverage and participation2012Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, s. 72-82Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives To summarize participation and coverage rates in population mammographic screening programmes for breast cancer in Europe. Methods We used the European Network for Information on Cancer (EUNICE), a web-based data warehouse (EUNICE Breast Cancer Screening Monitoring, EBCSM) for breast cancer screening, to obtain information on programme characteristics, coverage and participation from its initial application in 10 national and 16 regional programmes in 18 European countries. Results The total population targeted by the screening programme services covered in the report comprised 26.9 million women predominantly aged 50-69. Most of the collected data relates to 2005, 2006 and/or 2007. The average participation rate across all programmes was 53.4% (range 19.4-88.9% of personally invited); or 66.4% excluding Poland, a large programme that initiated personal invitations in 2007. Thirteen of the 26 programmes achieved the European Union benchmark of acceptable participation (>70%), nine achieved the desirable level (>75%). Despite considerable invitation coverage across all programmes (79.3%, range 50.9-115.2%) only 48.2% (range 28.4-92.1%) of the target population were actually screened. The overall invitation and examination coverage excluding Poland was 70.9% and 50.3%, respectively. Conclusions The results demonstrate the feasibility of European-wide screening monitoring using the EBCSM data warehouse, although further efforts to refine the system and to harmonize standards and data collection practices will be required, to fully integrate all European countries. The more than threefold difference in the examination coverage should be taken into account in the evaluation of service screening programmes.

  • 5. Holmberg, L
    et al.
    Duffy, SW
    Yen, AMF
    Tabár, L
    Vitak, B
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Frisell, J
    Differences in endpoints between the Swedish W-E (two county) trial of mammographic screening and the Swedish overview: methodological consequences.2009Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 16, nr 2, s. 73-80Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To characterize and quantify the differences in the number of cases and breast cancer deaths in the Swedish W-E Trial compared with the Swedish Overview Committee (OVC) summaries and to study methodological issues related to trials in secondary prevention.

    SETTING: The study population of the W-E Trial of mammography screening was included in the first (W and E county) and the second (E-county) OVC summary of all Swedish randomized mammography screening trials. The OVC and the W-E Trial used different criteria for case definition and causes of death determination.

    METHOD: A Review Committee compared the original data files from W and E county and the first and second OVC. The reason for a discrepancy was determined individually for all non-concordant cases or breast cancer deaths.

    RESULTS: Of the 2615 cases included by the W-E Trial or the OVC, there were 478 (18%) disagreements. Of the disagreements 82% were due to inclusion/exclusion criteria, and 18% to disagreement with respect to cause of death or vital status at ascertainment. For E-County, the OVC inclusion rules and register based determination of cause of death (second OVC) rather than individual case review (W-E Trial and 1st OVC) resulted in a reduction of the estimate of the effect of screening, but for W-County the difference between the original trial and the OVC was modest.

    CONCLUSIONS: The conclusion that invitation to mammography screening reduces breast cancer mortality remains robust. Disagreements were mainly due to study design issues, while disagreements about cause of death were a minority. When secondary research does not adhere to the protocols of the primary research projects, the consequences of such design differences should be investigated and reported. Register linkage of trials can add follow-up information. The precision of trials with modest size is enhanced by individual monitoring of case status and outcome status such as determination of cause of death.

  • 6.
    Jonsson, Håkan
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Andersson, Anne
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Mao, Zheng
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Age-specific differences in tumour characteristics between screen-detected and non-screen-detected breast cancers in women aged 40–74 at diagnosis in Sweden from 2008 to 20172024Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective:  To analyze differences between screen-detected and non-screen-detected invasive breast cancers by tumour characteristics and age at diagnosis in the nationwide population-based mammography screening program in Sweden.

    Methods:  Data were retrieved from the National Quality Register for Breast Cancer for 2008-2017. Logistic regression analysis was used to estimate the likelihood for a tumour to be screen-detected by tumour characteristics and age group at diagnosis.

    Results:  In total there were 51,429 invasive breast cancers in the target age group for mammography screening of 40-74 years. Likelihood of screen detection decreased with larger tumour size, lymph node metastases, higher histological grade and distant metastasis. Odds ratios (ORs) for negative oestrogen (ER) and progesterone (PgR) were 0.41 and 0.57; for positive HER2, 0.62; for Ki-67 high versus low, 0.49. Molecular sub-types had OR of 0.56, 0.40 and 0.28, respectively, for luminal B-like, HER2-positive and triple negative versus luminal A-like. Adjusting for tumour size (T), lymph node status (N), age, year and county at diagnosis slightly elevated the ORs. Statistically significant interactions between tumour characteristics and age were found (p < 0.05) except for ER and PgR. The age group 40-49 deviated most from the other age groups.

    Conclusions:  Our study demonstrates that screen-detected invasive breast cancers had more favourable tumour characteristics than non-screen-detected after adjusting for age, year and county of diagnosis, and even after adjusting for T and N. The trend towards favourable tumour characteristics was less pronounced in the 40-49 age group compared to the other age groups, except for ER and PgR.

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  • 7.
    Jonsson, Håkan
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Bordás, Pál
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Wallin, Hans
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Lenner, Per
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Service screening with mammography in Northern Sweden: effects on breast cancer mortality - an update.2007Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 14, nr 2, s. 87-93Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To study the effectiveness of service screening with mammography in Northern Sweden.

    SETTING: Two counties which invited women aged 40-74 years to service screening with mammography were compared with two counties where service screening started 5-7 years later. There were 109,000 and 77,000 women in the study and control counties, respectively.

    METHODS: Cohorts in the study group were defined to include only breast cancer cases diagnosed after their first invitation to screening. Two outcome measures for breast cancer mortality were used; excess mortality and underlying cause of death (UCD). Detection mode was used to estimate the efficacy of screening for those women who actually attended screening. The cohorts were followed for 11 years.

    RESULTS: The relative rate (RR) of breast cancer death as excess mortality and UCD for women aged 40-74 years invited to screening, compared with women not yet invited, was 0.70 (95% confidence interval [CI] 0.56-0.87) and 0.74 (95% CI 0.62-0.88), respectively. The largest effect was seen in women aged 40-49 years (RR = 0.64 and RR = 0.62 for excess mortality and UCD, respectively). RR in age 40-74 years for women actually screened was 0.65 (95% CI 0.51-0.84) and 0.70 (95% CI 0.57-0.86) for excess mortality and UCD, respectively. The number of women needed to screen to save one life was 912 after 11 years of follow-up.

    CONCLUSIONS: This study confirms previous findings in the earlier follow-up and indicates a long-term reduction of breast cancer mortality by 26-30%. The efficacy among those who actually attended screening was about 5% larger.

  • 8.
    Jonsson, Håkan
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Törnberg, S.
    Oncologic Centre, Karolinska Hospital, Stockholm, Sweden.
    Lenner, Per
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Service screening with mammography of women aged 50–69 years in Sweden: effects on mortality from breast cancer2001Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 8, nr 3, s. 152-160Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES:To estimate the effect of the population based service screening programme in Sweden on mortality from breast cancer among women aged 50–69. SETTING:In 1986, population based service screening with mammography started in Sweden, and by 1997 screening had been introduced in all counties. Half of the counties invite women from 40 years of age whereas women 50 and older are invited in the other counties. The upper age limit was either 69 or 74. Women in the age group 50–69 years are thus invited to screening in all counties.

    METHODS:The counties which started with mammographic screening in 1986–87 constituted the study group and were compared with the counties which started in 1993 or later. In 1987 the mean number of women aged 50–69 was 161 986 and 98 608 in the study and control groups, respectively. Refined excess mortality (smoothed with the Lowess method) from breast cancer and refined cause specific mortality from breast cancer were used as effect measures. To adjust for geographical differences in mortality from breast cancer a reference period was used. Allowance was made for two potential biases: (a) inclusion bias implying the inclusion of cases diagnosed before invitation to screening in the first screening round, and (b) lead time bias.

    RESULTS:After a mean follow up time of 10.6 years since the start of screening and a mean individual follow up time of 8.4 years, a non-significant reduction in refined excess mortality for breast cancer was estimated as relative risk (RR) 0.84 (95% confidence interval (95% CI) 0.67 to 1.05). After adjustment for inclusion and lead time biases the RR was 0.80 (20% reduction). Only 27% of the deaths from breast cancer in the total mortality for women aged 50–79 at death consisted of women aged 50–69 at diagnosis who were diagnosed after the start of screening. This figure has important implications for judgement of the impact of screening on age specific national breast cancer mortalities.

    CONCLUSIONS:A non-significant reduction in mortality from breast cancer was found in counties performing service screening with mammography in Sweden. Adjustment for possible biases changed the result towards a larger effect of screening. The results do not contradict the effects found in the Swedish randomised mammography trials.

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  • 9.
    Lenner, Per
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Excess Mortality from Breast Cancer in Relation to Mammograpy Screening in Northern Sweden1997Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 4, nr 1, s. 6-9Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives—Previous randomised studies of mammography screening have shown a significant effect on breast cancer mortality, particularly in women aged 50–Q69 at randomisation. Breast cancer mortality has traditionally been studied by judgments on causes of death, either from cause of death registers or from medical records. In this study an alternative method was used, estimating the excess mortality associated with breast cancer.

    Setting—In 1990 two counties of northern Sweden started population based mammography screening of women aged 40–74. The unscreened population in the two other counties of the same region were selected as controls.

    Results—Excess mortality associated with breast cancer was lower in the screened population, and was discernible three to four years after the start of screening. The relative risk estimate, based on the cumulative excess number of deaths from breast cancer during 1990–95 in the screened versus the control population aged 40–74 (at diagnosis of breast cancer), was 0.72 (95% confidence interval (CI) 0.53 to 0.99). For women aged 50–69 it was 0.67 (95% CI 0.46 to 0.99). In the 50–69 age group the estimated excess number of deaths from breast cancer during 1995 was 17.0 per 100 000 women (95% CI 5.0 to 29.0) in the screened counties and 51.1 per 100 000 (95% CI 30.2 to 71.9) in the unscreened counties.

    Conclusions—Population based routine screening has substantial effects on breast cancer mortality in women aged 50–69. Estimation of excess mortality can be used in future studies to evaluate the effects of mammography screening on breast cancer mortality.

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  • 10.
    Mao, Zheng
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi. Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Breast cancer screening with mammography in women aged 40-49 years: impact of length of screening interval on effectiveness of the program2021Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 28, nr 2, s. 200-206, artikel-id 0969141320918283Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To estimate the impact on the effectiveness of Swedish breast cancer screening program in women aged 40-49 years of shortening the screening interval from 21 months to 18 or 12 months.

    Methods: The reduction in breast cancer mortality among participants in screening with mammography was previously estimated in the Swedish SCReening of Young women (SCRY) study to be 29%. The expected increased effectiveness with a hypothetical shorter screening interval than the average of 21 months in SCRY was calculated using data about the women who died from breast cancer even though they participated in the SCRY program.

    Results: During the study period, 547 women who participated in the index screening round died from breast cancer. Shortening the screening interval to 18 months led to an improved effectiveness of 0.7-3.9% considering interval cancers only and of 1.3-7.6% considering screening-detected cancers only, and for both interval and screening-detected cancers the improvement was 1.9-11.5% when the assumed mortality reduction for the deceased cases varied from 5% to 30%. Shortening the screening interval to 12 months increased the effectiveness by 1.6-9.8% for interval cancers and by 2.9-17.4% for both interval and screening-detected cancers.

    Conclusion: Shortening the screening interval for women aged 40-49 years to 18 or 12 months might further reduce the breast cancer mortality rate.

  • 11. Moss, S. M.
    et al.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Paci, E.
    Lynge, E.
    Njor, S.
    Broeders, M.
    The impact of mammographic screening on breast cancer mortality in Europe: a review of trend studies2012Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, s. 26-32Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Objective Analysing trends in population breast cancer mortality statistics appears a simple method of estimating the effectiveness of mammographic screening programmes. We reviewed such studies of population-based screening in Europe to assess their value. Methods A literature review identified 17 papers, of which 12 provided quantitative estimates of the impact of screening. Due to differences in comparisons and outcome measures, no pooled estimate of effectiveness was calculated. Results Comparisons included breast cancer mortality before and after the introduction of screening, trends in early and late starting areas and trends in age groups affected and unaffected by screening. Studies that calculated the percentage annual change after the start of screening found reductions of 1-9% per year (1%, 2.3-2.8% and 9% for those with adequate follow-up). Of studies that compared mortality in time periods before and after introduction of screening, three single country studies all had adequate follow-up and estimated mortality reductions ranging from 28% to 36%. Limitations of studies of population mortality rates include the inability to exclude deaths in women with breast cancer diagnosed before invitation to screening, diluting any observable impact of screening, and the gradual implementation of screening in a country or region. Conclusions Although analysing population breast cancer mortality rates over time can be a first step in examining changes following the introduction of screening, this method is of limited value for assessment of screening impact. Other methods and individual data are necessary to properly quantify the effect.

  • 12. Njor, Sisse
    et al.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Moss, Sue
    Paci, Eugenio
    Broeders, Mireille
    Segnan, Nereo
    Lynge, Elsebeth
    Breast cancer mortality in mammographic screening in Europe: a review of incidence-based mortality studies2012Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, s. 33-41Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Objectives To estimate the impact of service mammography screening on breast cancer mortality using European incidence-based mortality (IBM) studies (or refined mortality studies). IBM studies include only breast cancer deaths occurring in women with breast cancer diagnosed after their first invitation to screening. Methods We conducted a literature review and identified 20 publications based on IBM studies. They were classified according to the method used for estimating the expected breast cancer mortality in the absence of screening: (1) women not yet invited; (2) historical data from the same region as well as from historical and current data from a region without screening; and (3) historical comparison group combined with data for non-participants. Results The estimated effect of mammography screening on breast cancer mortality varied across studies. The relative risks were 0.76-0.81 in group 1; 0.75-0.90 in group 2; and 0.52-0.89 in group 3. Study databases overlapped in both Swedish and Finnish studies, adjustment for lead time was not optimal in all studies, and some studies had other methodological limitations. There was less variability in the relative risks after allowing for the methodological shortcomings. Conclusions Based on evidence from the most methodologically sound IBM studies, the most likely impact of European service mammography screening programmes was a breast cancer mortality reduction of 26% (95% confidence interval 13-36%) among women invited for screening and followed up for 6-11 years.

  • 13.
    Nordyke, Katrina
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Norström, Fredrik
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Carlsson, Annelie
    Danielsson, Lars
    Emmelin, Maria
    Department of Clinical Sciences, Lund University, Lund, Sweden .
    Högberg, Lotta
    Karlsson, Eva
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health-related quality-of-life in children with coeliac disease, measured prior to receiving their diagnosis through screening2011Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 18, nr 4, s. 187-192Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To compare the health-related quality-of-life (HRQoL) of children with screening-detected coeliac disease (CD), before they learned of their diagnosis, with that of children without CD and in those previously diagnosed with CD.

    METHODS: In a cross-sectional CD screening study ('ETICS': Exploring the Iceberg of Coeliacs in Sweden), of 10,041 Swedish 12-year-olds invited, 7567 (75%) consented to participate, and 7208 (72%) children without previously diagnosed CD had serological markers analysed. Before the screening results were known, 7218 children (72%) and 6524 of their parents (65%) answered questionnaires. Questionnaires included the Swedish child-friendly pilot version of the EQ-5D instrument and proxy version of the EQ-5D instrument, which are generic tools used to describe HRQoL.

    RESULTS: We found no significant difference in HRQoL between the groups of children with screening-detected CD, without CD, and those previously diagnosed with CD.

    CONCLUSION: The HRQoL reported by 12-year-olds with screening-detected CD, before they learned of their diagnosis, was not worse than that of the children without CD or those previously diagnosed with CD. Thus, mass screening for CD should not be justified on the basis that children with unrecognized CD have a poor HRQoL. However, because these children rated their HRQoL before diagnosis and treatment, they may not have recognized or perceived symptoms as severe enough to seek medical attention which demonstrates how difficult clinical/active case finding can be. Mass screening may still, therefore, be considered if the aim is early detection and prevention of future complications.

  • 14.
    Numan Hellquist, Barbro
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Duffy, Stephen W
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Overdiagnosis in the population-based service screening programme with mammography for women aged 40 to 49 years in Sweden2012Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, nr 1, s. 14-19Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To estimate the level of overdiagnosis of all breast cancers and of invasive breast cancers in women aged 40–49 invited to the subsequent screening rounds in the Swedish service-screening programme 1986–2005.

    Methods: To estimate the level of overdiagnosis in subsequent screening, the rate ratios (RR) of the breast cancer incidence in the study group (women in areas with screening in ages 40–49) and the control group (women in areas with no screening in ages 40–49) were calculated for all breast cancers and for invasive breast cancers. The RR estimates were adjusted for the prescreening difference in incidence between study and control group and for lead time.

    Results: The prescreening incidence rate ratio was estimated at 0.92 (95% confidence interval [CI]: 0.88–0.97). The number of breast cancer cases and person-years were 6047 and 3.8 million, and 7790 and 5.2 million, in the study group and control group respectively during the study period. The RR estimate for all cancers was 1.01 (95% CI: 0.94–1.08) when adjusted for prescreening difference and a lead time of 1.2 years. The corresponding estimate for invasive breast cancers was 0.95 (95% CI: 0.88–1.02).

    Conclusions: We found no significant overdiagnosis for women aged 40–49 in the Swedish service screening programme with mammography.

  • 15.
    Nyström, Lennarth
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Bjurstam, Nils
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper.
    Zackrisson, Sophia
    Frisell, Jan
    Reduced breast cancer mortality after 20+years of follow-up in the Swedish randomized controlled mammography trials in Malmo, Stockholm, and Goteborg2017Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 24, nr 1, s. 34-42Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To analyze the age- and trial-specific effects of the breast cancer screening trials with mammography in Malmo , Stockholm, and Goteborg.

    Methods: The original trial files were linked to the Swedish Cancer and Cause of Death Registers to obtain date of breast cancer diagnosis and date and cause of death. Relative risks and 95% confidence intervals were calculated using the evaluation model (only breast cancers diagnosed between date of randomization and date when the first screening round of the control group was completed were included in the analysis).

    Results: Women aged 40-70 at randomization in the Malmo I and II, Stockholm, and Goteborg trials were followed-up for an average of 30, 22, 25, and 24 years, respectively. The overview of all trials resulted in a significant decrease of 15% in breast cancer mortality. The variation by consecutive 10-year age group at randomization was small-from 21% in the age group 40-49 to 11% in the age group 50-59. After adjustment for age, there was a significant reduction in breast cancer mortality in the Goteborg trial (26%), and a non-significant reduction in the Malmo I and II and Stockholm trials (12%, 15%, and 5.8%, respectively).

    Conclusions: The overview showed a 15% significant relative reduction in breast cancer mortality due to invitation to mammography screening. Heterogeneity in age, trial time, attendance rates, and length of screening intervals may have contributed to the variation in effect between the trials.

  • 16. Tabar, Laszlo
    et al.
    Chen, Tony Hsiu-Hsi
    Yen, Amy Ming-Fang
    Dean, Peter B.
    Smith, Robert A.
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Törnberg, Sven
    Chen, Sam Li-Sheng
    Chiu, Sherry Yueh-Hsia
    Fann, Jean Ching-Yuan
    Ku, May Mei-Sheng
    Wu, Wendy Yi-Ying
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Hsu, Chen-Yang
    Chen, Yu-Ching
    Svane, Gunilla
    Azavedo, Edward
    Grundström, Helene
    Sundén, Per
    Leifland, Karin
    Frodis, Ewa
    Ramos, Joakim
    Epstein, Birgitta
    Åkerlund, Anders
    Sundbom, Ann
    Bordás, Pál
    Wallin, Hans
    Starck, Leena
    Björkgren, Annika
    Carlson, Stina
    Fredriksson, Irma
    Ahlgren, Johan
    Öhman, Daniel
    Holmberg, Lars
    Duffy, Stephen W.
    Early detection of breast cancer rectifies inequality of breast cancer outcomes2020Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 28, nr 1, s. 34-38Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To explain apparent differences among mammography screening services in Sweden using individual data on participation in screening and with breast cancer-specific survival as an outcome.

    Methods: We analysed breast cancer survival data from the Swedish Cancer Register on breast cancer cases from nine Swedish counties diagnosed in women eligible for screening. Data were available on 38,278 breast cancers diagnosed and 4312 breast cancer deaths. Survival to death from breast cancer was estimated using the Kaplan-Meier estimate, for all cases in each county, and separately for cases of women participating and not participating in their last invitation to screening. Formal statistical comparisons of survival were made using proportional hazards regression.

    Results: All counties showed a reduction in the hazard of breast cancer death with participation in screening, but the reductions for individual counties varied substantially, ranging from 51% (95% confidence interval 46-55%) to 81% (95% confidence interval 74-85%). Survival rates in nonparticipating women ranged from 53% (95% confidence interval 40-65%) to 74% (95% confidence interval 72-77%), while the corresponding survival in women participating in screening varied from 80% (95% confidence interval 77-84%) to 86% (95% confidence interval 83-88%), a considerably narrower range.

    Conclusions: Differences among counties in the effect of screening on breast cancer outcomes were mainly due to variation in survival in women not participating in screening. Screening conferred similarly high survival rates in all counties. This indicates that the performance of screening services was similar across counties and that detection and treatment of breast cancer in early-stage reduces inequalities in breast cancer outcome.

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  • 17.
    Wu, Wendy Y-Y
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Nyström, Lennarth
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Jonsson, Håkan
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Estimation of overdiagnosis in breast cancer screening using a non-homogeneous multi-state model: a simulation study2018Ingår i: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 25, nr 4, s. 183-190Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: Overdiagnosis is regarded as a harm of screening. We aimed to develop a non-homogeneous multi-state model to consider the age-specific transition rates for estimation of overdiagnosis, to validate the model by a simulation study where the true frequency of overdiagnosis can be calculated, and to compare our estimate with the cumulative incidence method. Methods: We constructed a four-state model to describe the natural history of breast cancer. The latent disease progression and the observed states for each individual were simulated in a trial with biennial screening of women aged 51-69 and a control group of the same size without screening. We performed 100 repetitions of the simulation with one million women to evaluate the performance of estimates. A sensitivity analysis with reduced number of controls was performed to imitate the data from the service screening programme. Results Based on the 100 repetitions, the mean value of the true frequency of overdiagnosis was 12.5% and the average estimates by the cumulative incidence method and the multi-state model were 12.9% (interquartile range: 2.46%) and 13.4% (interquartile range: 2.16%), respectively. The multi-state model had a greater bias of overdiagnosis than the cumulative incidence method, but the variation in the estimates was smaller. When the number of unscreened group was reduced, the variation of multi-state model estimates increased. Conclusions: The multi-state model produces a proper estimate of overdiagnosis and the results are comparable with the cumulative incidence method. The multi-state model can be used in the estimation of overdiagnosis, and might be useful for the ongoing service screening programmes.

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