Olive Kearins

Objective To evaluate the long term risks of invasive breast cancer and death from breast cancer after ductal carcinoma in situ (DCIS) diagnosed through breast screening. Design Population based observational cohort study. Setting Data from the NHS Breast Screening Programme and the National Cancer Registration and Analysis Service. Participants All 35 024 women in England diagnosed as having DCIS by the NHS Breast Screening Programme from its start in 1988 until March 2014. Main outcome measures Incident invasive breast cancer and death from breast cancer. Results By December 2014, 13 606 women had been followed for up to five years, 10 998 for five to nine years, 6861 for 10-14 years, 2620 for 15-19 years, and 939 for at least 20 years. Among these women, 2076 developed invasive breast cancer, corresponding to an incidence rate of 8.82 (95% confidence interval 8.45 to 9.21) per 1000 women per year and more than double that expected from national cancer incidence rates (ratio of observed rate to expected rate 2.52, 95% confidence interval 2.41 to 2.63). The increase started in the second year after diagnosis of DCIS and continued until the end of follow-up. In the same group of women, 310 died from breast cancer, corresponding to a death rate of 1.26 (1.13 to 1.41) per 1000 women per year and 70% higher than that expected from national breast cancer mortality rates (observed:expected ratio 1.70, 1.52 to 1.90). During the first five years after diagnosis of DCIS, the breast cancer death rate was similar to that expected from national mortality rates (observed:expected ratio 0.87, 0.69 to 1.10), but it then increased, with values of 1.98 (1.65 to 2.37), 2.99 (2.41 to 3.70), and 2.77 (2.01 to 3.80) in years five to nine, 10-14, and 15 or more after DCIS diagnosis. Among 29 044 women with unilateral DCIS undergoing surgery, those who had more intensive treatment (mastectomy, radiotherapy for women who had breast conserving surgery, and endocrine treatment in oestrogen receptor positive disease) and those with larger final surgical margins had lower rates of invasive breast cancer. Conclusions To date, women with DCIS detected by screening have, on average, experienced higher long term risks of invasive breast cancer and death from breast cancer than women in the general population during a period of at least two decades after their diagnosis. More intensive treatment and larger final surgical margins were associated with lower risks of invasive breast cancer.

Objective: To record how breast screening centres in England deliver all biopsy results (cancer/non-cancer) from the breast assessment visit. Design: Online survey of 63 of 79 breast screening centres in England from all regions (East Midlands, East of England, London, North East Yorkshire & Humber, North West, South East, South West, West Midlands). The survey contained quantitative measures of frequency for telephoning biopsy results (routinely, occasionally or never) and optional qualitative free-text responses. Surveys were completed by a staff member from each centre. Results: There were no regional trends in the use of telephone results services, ( X ² (14, n=63)=11.55, p=0.64), Centres who telephoned results routinely did not deliver results sooner than centres who deliver results in-person ( X ² (16, n=63)=12.76, p=0.69). When delivering cancer results, 76.2% of centres never telephone results and 23.8% of centres occasionally telephone results. No centres reported delivering cancer results routinely by telephone. Qualitative content analysis suggests that cancer results are only telephoned at the patient request and under exceptional circumstances. When delivering non-cancer results, 12.7% of centres never telephoned results, 38.1% occasionally telephoned results and 49.2% routinely telephoned results. Qualitative content analysis revealed different processes for delivering telephone results, including patient choice and scheduling an in-person results appointment for all women attending breast assessment, then ringing non-cancer results unexpectedly ahead of this prebooked appointment. Conclusions: In the National Health Service Breast Screening Programme, breast assessment results that are cancer are routinely delivered in-person. However, non-cancer breast assessment results are often routinely delivered by telephone, despite breast screening policy recommendations. More research is needed to understand the impact of telephoning results on women attending breast assessment, particularly women who receive a non-cancer result. Future research should also consider how women themselves might prefer to receive their results.

Introduction One of the main harms from breast cancer screening is the anxiety caused by false positive results. Various factors may be associated with false-positive anxiety. One modifiable factor may be the method of communication used to deliver results. The aim of this study is to measure the effect on anxiety of receiving benign biopsy results in-person or by telephone. Methods and analysis This is a multi-centre cluster randomised crossover trial in the English National Health Service Breast Screening Programme (NHSBSP) involving repeated survey measures at four time points. Participants will be women of screening age who have a biopsy following a suspicious mammography result, who ultimately receive a benign or normal (B1) result. Centres will trial both telephone and in-person results on a month-by-month basis, being randomised to which communication method will be trialled first. Women will be blinded to the method of communication they will receive. The analysis will compare women who have received telephone results and women who have received in-person results. The primary outcome measure will be anxiety (measured by the Psychological Consequences Questionnaire) after receiving results, while controlling for baseline anxiety. Secondary outcome measures will include anxiety at 3 and 6 months post-results, understanding of results and patient preferences for how results are communicated. Qualitative telephone interviews will also be conducted to further explore women’s reasons for communication preferences. Qualitative and quantitative data will be integrated after initial separate analysis using the pillar integration process. Ethics and dissemination This study has been approved by the Public Health England Breast Screening Programme Research Advisory Committee, (BSPRAC_0013, ODR1718_040) and the National Health Service Health Research Authority (HRA) West Midlands—Coventry & Warwickshire Research Ethics Committee (17/WM/0313). The findings from this study will be disseminated to key stakeholders within the NHSBSP and via academic publications. Trial registration number ISRCTN36997684 Trial sponsor This research is part of a PhD award and is funded by the Economic and Social Research Council Doctoral Training Centre at the University of Warwick and Public Health England. The sponsor for this research is Jane Prewett (sponsorship@warwick.ac.uk).

The overall cancer detection rate was 14% greater with digital mammography compared with screen-film mammography, with substantially higher detection of grade 1 and grade 2 invasive cancers but no change in the detection of grade 3 invasive cancers. PurposeTo report the impact of changing from screen-film mammography to digital mammography (DM) in a large organized national screening program.Materials and MethodsA retrospective analysis of prospectively collected annual screening data from 2009–2010 to 2015–2016 for the 80 facilities of the English National Health Service Breast Cancer Screening Program, together with estimates of DM usage for three time periods, enabled the effect of DM to be measured in a study of 11.3 million screening episodes in women aged 45–70 years (mean age, 59 years). Regression models were used to estimate percentage and absolute change in detection rates due to DM.ResultsThe overall cancer detection rate was 14% greater with DM (P < .001). There were higher rates of detection of grade 1 and 2 invasive cancers (both ductal and lobular), but no change in the detection of grade 3 invasive cancers. The recall rate was almost unchanged by the introduction of DM. At prevalent (first) screening episodes for women aged 45–52 year...

1570 Background: The degree of over-diagnosis and over-treatment for ductal carcinoma in situ (DCIS) remains contentious. Hypotheses from retrospective data were tested in a prospective, population-based study. Methods: A prospective longitudinal cohort of 12,838 women diagnosed through a population-based national breast screening program accrued 2003-2012 with proforma for imaging, surgery, pathology and adjuvant therapy. Follow-up was linked to national databases and case note review to analyse patterns of care, recurrence and mortality. Results: Data was complete for 9,972/12,838 (78%) women (mean age 60 years; range 46-87) with median follow up 62 months (range 6-116). Breast conservation (BCS) was definitive surgery for 7,028 (70.5%) women; use increased with older age (CHI² 380, 6 df p < 0.001). Mastectomy (Mx; n = 2,944) was associated with higher grade DCIS (CHI² 19.31, 2 df P < 0.001), larger size (CHI² 203.9, 5 df P < 0.001) and comedo necrosis (CHI² 9.1, 1 df P = 0.003). For patients undergoing BCS, use of radiotherapy was associated with high grade (CHI² 199.9, 2 df P < 0.001), comedo necrosis (CHI² 62.3, 1 df P = 0.001), larger size (CHI² 57.5, 5 df P < 0.001), microinvasion (CHI² 49.9, 1 df P = < 0.001), and use of endocrine therapy (CHI² 16.47, 3 df P < 0.001), but not close ( < 1mm) or involved margin(s). In women who underwent BCS, ipsilateral in-breast recurrence (n = 368; CHI² 27.14, 5 df P < 0.001) and ipsilateral invasive cancer (n = 182; CHI² 32.62, 5 df P < 0.001) were significantly reduced by radiotherapy, independent of margins. Endocrine therapy reduced local recurrence by 1.52%, independent of radiotherapy. Among 324 deaths (3.3% of the cohort), 47 were from invasive breast cancer. There was no difference in overall mortality by type of surgery (3.16% BCS vs 3.5% Mx; CHI² 0.017, 3 1f, P = 0.90), use of radiotherapy (2.48% or not 3.84%; CHI² 0.30, 1 df, P = 0.59) or endocrine therapy (3.88% or not 3.14%; CHI² 0.077, 1 df, P = 0.78). Conclusions: This prospective cohort of contemporary, screen-detected DCIS demonstrates ipsilateral recurrence, but not mortality, is reduced by radiotherapy and endocrine therapy. Death due to breast cancer was rare, outnumbered 5:1 by death from other causes.