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Papers by Vivian van Breest Smallenburg

Research paper thumbnail of Improving the Sensitivity of Screening Mammography in the South of the Netherlands

Overdiagnosis is the diagnosis of cancer that will never cause symtoms or death during a woman's ... more Overdiagnosis is the diagnosis of cancer that will never cause symtoms or death during a woman's lifetime. Without screening these cancers would not have been detected and treated. In a systematic review of countries with organised screening programmes, Jørgensen et al. found an overdiagnosis rate of 52%. 38 Several other studies also report high overdiagnosis rates, ranging between 15 and 42%. 39,40 On the other hand, a study from the UK estimated that at least two lives are saved for every overdiagnosed case and that the benefits thus outweight the harms. 41 Also the European Screening Network working group Table 2. Determinants of the sensitivity of screening mammography.

Research paper thumbnail of Trends in breast biopsies for abnormalities detected at screening mammography: a population-based study in the Netherlands

British journal of cancer, Jan 9, 2013

Diagnostic surgical breast biopsies have several disadvantages, therefore, they should be used wi... more Diagnostic surgical breast biopsies have several disadvantages, therefore, they should be used with hesitation. We determined time trends in types of breast biopsies for the workup of abnormalities detected at screening mammography. We also examined diagnostic delays. In a Dutch breast cancer screening region 6230 women were referred for an abnormal screening mammogram between 1 January 1997 and 1 January 2011. During two year follow-up clinical data, breast imaging-, biopsy-, surgery- and pathology-reports were collected of these women. Furthermore, breast cancers diagnosed >3 months after referral (delays) were examined, this included review of mammograms and pathology specimens to determine the cause of the delays. In 41.1% (1997-1998) and in 44.8% (2009-2010) of referred women imaging was sufficient for making the diagnosis (P<0.0001). Fine-needle aspiration cytology decreased from 12.7% (1997-1998) to 4.7% (2009-2010) (P<0.0001), percutaneous core-needle biopsies (CBs)...

Research paper thumbnail of Lower sensitivity of screening mammography after previous benign breast surgery

International Journal of Cancer, 2012

Few data are available on the effect of previous benign breast surgery on screening mammography a... more Few data are available on the effect of previous benign breast surgery on screening mammography accuracy. We determined whether sensitivity of screening mammography and tumor characteristics are different for women with and without previous benign breast surgery. We included a consecutive series of 317,398 screening mammograms of women screened between 1997 and 2008. During 2-year follow-up, clinical data, breast imaging, biopsy and surgery reports were collected from women with screen-detected or interval breast cancers. Screening sensitivity, tumor biology and tumor stages were compared between 168 women with breast cancer and prior ipsilateral benign breast surgery and 2,039 women with breast cancer but without previous ipsilateral, benign breast surgery. The sensitivity of screening mammography was significantly lower for women with prior surgery [64.3% (108/168) versus 73.4% (1,496/2,039), p = 0.01]. The concomitant increased interval cancer risk remained significant after logistic regression adjustment for age and breast density (OR = 1.5, 95% CI: 1.1-2.1). Comparing screen-detected cancers in women with and without prior breast surgery, no significant differences in estrogen receptor status (p = 0.56), mitotic activity (p = 0.17), proportions of large (T2+) tumors (p = 0.6) or lymph node positive tumors (p = 0.4) were found. Also for interval cancers, no differences were found in estrogen receptor status (p = 0.41), mitotic activity (p = 0.39), proportions of large tumors (p = 0.9) and lymph node positive tumors (p = 0.5) between women with and without prior breast surgery. We conclude that sensitivity of screening mammography is significantly lower in women with previous benign breast surgery than without, but tumor characteristics are comparable both for screen detected cancers and interval cancers.

Research paper thumbnail of Malpractice claims following screening mammography in The Netherlands

International Journal of Cancer, 2012

Although malpractice lawsuits are frequently related to a delayed breast cancer diagnosis in symp... more Although malpractice lawsuits are frequently related to a delayed breast cancer diagnosis in symptomatic patients, information on claims at European screening mammography programs is lacking. We determined the type and frequency of malpractice claims at a Dutch breast cancer screening region. We included all 85,274 women (351,009 screens) who underwent biennial screening mammography at a southern breast screening region in The Netherlands between 1997 and 2009. Two screening radiologists reviewed the screening mammograms of all screen detected cancers and interval cancers and determined whether the cancer had been missed at the previous screen or at the latest screen, respectively. We analyzed all correspondence between the screening organization, clinicians and screened women, and collected complaints and claims until September 2011. At review, 20.9% (308/1,475) of screen detected cancers and 24.3% (163/670) of interval cancers were considered to be missed at a previous screen. A total of 19 women (of which 2, 6 and 11 women had been screened between 1997 and 2001 (102,439 screens), 2001 and 2005 (114,740 screens) and 2005 and 2009 (133,830 screens), respectively) had contacted the screening organization for additional information about their screen detected cancer or interval cancer, but filed no claim. Three other women directly initiated an insurance claim for financial compensation of their interval cancer without previously having contacted the screening organization. We conclude that screening-related claims were rarely encountered, although many screen detected cancers and interval cancers had been missed at a previous screen. A small but increasing proportion of women sought additional information about their breast cancer from the screening organization.

Research paper thumbnail of Mammographic changes resulting from benign breast surgery impair breast cancer detection at screening mammography

European Journal of Cancer, 2012

Screening mammography Sensitivity Breast surgery Breast cancer Breast density Abstract Purpose: T... more Screening mammography Sensitivity Breast surgery Breast cancer Breast density Abstract Purpose: To study possible explanations for lower screening performance after previous benign breast surgery. Patients and methods: We included a consecutive series of 351,009 screening examinations in 85,274 women, obtained between January 1, 1997 and January 1, 2009. The examinations of women with screen detected cancers (SDC) or interval cancers (IC), diagnosed after previous benign breast surgery, were reviewed by two screening radiologists. They determined the presence and degree of post surgical changes, classified breast density and determined whether mammographic interpretation was hampered by tissue characteristics. They also assessed whether the cancer had already been visible at a previous screen. Results: Screening sensitivity was lower in women with prior benign breast surgery than without (63.5% (115/181) versus 73.5% (1643/2236), p = 0.004). A total of 115 SDCs and 66 ICs were diagnosed in breasts after previous benign breast surgery. Post surgical mammographic alterations in the breast segment where cancer was diagnosed were more distinct in ICs than in SDCs (p = 0.001). Women with post surgical mammographic changes at the location of the breast cancer had an increased interval cancer risk (OR = 2.12, 95% confidence interval (CI) = 1.05-4.26). Limited mammographic interpretation due to tissue characteristics was mentioned, only in three SDCs and one IC. The proportions of SDCs and ICS that were already visible at a previous screen were comparable for women with and without prior surgery (SDC: 47.5% versus 43.8%, p = 0.3, IC: 50.0% versus 48.4%, p = 0.8). Conclusion: Previous benign breast surgery decreases screening sensitivity and this is likely due to postoperative mammographic changes.

Research paper thumbnail of Two-view versus single-view mammography at subsequent screening in a region of the Dutch breast screening programme

European Journal of Radiology, 2012

We retrospectively determined the effect of analogue two-view mammography versus single-view mamm... more We retrospectively determined the effect of analogue two-view mammography versus single-view mammography at subsequent screens on breast cancer detection and determined financial consequences for a current digital mammography setting. Two screening radiologists reviewed the mammograms of 536 screen detected cancers (SDCs) and 171 interval cancers (ICs) with single-view mammography (mediolateral-oblique view) at the last but one screen (SDCs) or latest screen (ICs). They determined whether two-view mammography at the last (but one) screen could have increased the cancer detection rate at that screening round. For subsequent screens, the radiologists also assessed the percentage of SDCs and ICs that had been missed at previous two-view screening mammography (SDC) or latest two-view screening (IC), respectively. Additional personnel and digital storage costs for standard two-view mammography at subsequent screening were calculated for digital screening. Two-view mammography could have facilitated earlier cancer detection in 40.9% (219/536) of SDCs and 39.8% (68/171) of ICs. For twoview screens, 24.4% of SDCs (213/871) were missed at previous two-view screening and 29.3% of ICs (110/375) were missed at the latest screen. Overall costs increase D 1.03/screen after implementation of digital two-view mammography. Standard two-view mammography at subsequent screening may modestly increase cancer detection at an earlier stage, whereas additional screening costs are limited.

Research paper thumbnail of Improving the Sensitivity of Screening Mammography in the South of the Netherlands

Overdiagnosis is the diagnosis of cancer that will never cause symtoms or death during a woman's ... more Overdiagnosis is the diagnosis of cancer that will never cause symtoms or death during a woman's lifetime. Without screening these cancers would not have been detected and treated. In a systematic review of countries with organised screening programmes, Jørgensen et al. found an overdiagnosis rate of 52%. 38 Several other studies also report high overdiagnosis rates, ranging between 15 and 42%. 39,40 On the other hand, a study from the UK estimated that at least two lives are saved for every overdiagnosed case and that the benefits thus outweight the harms. 41 Also the European Screening Network working group Table 2. Determinants of the sensitivity of screening mammography.

Research paper thumbnail of Trends in breast biopsies for abnormalities detected at screening mammography: a population-based study in the Netherlands

British journal of cancer, Jan 9, 2013

Diagnostic surgical breast biopsies have several disadvantages, therefore, they should be used wi... more Diagnostic surgical breast biopsies have several disadvantages, therefore, they should be used with hesitation. We determined time trends in types of breast biopsies for the workup of abnormalities detected at screening mammography. We also examined diagnostic delays. In a Dutch breast cancer screening region 6230 women were referred for an abnormal screening mammogram between 1 January 1997 and 1 January 2011. During two year follow-up clinical data, breast imaging-, biopsy-, surgery- and pathology-reports were collected of these women. Furthermore, breast cancers diagnosed >3 months after referral (delays) were examined, this included review of mammograms and pathology specimens to determine the cause of the delays. In 41.1% (1997-1998) and in 44.8% (2009-2010) of referred women imaging was sufficient for making the diagnosis (P<0.0001). Fine-needle aspiration cytology decreased from 12.7% (1997-1998) to 4.7% (2009-2010) (P<0.0001), percutaneous core-needle biopsies (CBs)...

Research paper thumbnail of Lower sensitivity of screening mammography after previous benign breast surgery

International Journal of Cancer, 2012

Few data are available on the effect of previous benign breast surgery on screening mammography a... more Few data are available on the effect of previous benign breast surgery on screening mammography accuracy. We determined whether sensitivity of screening mammography and tumor characteristics are different for women with and without previous benign breast surgery. We included a consecutive series of 317,398 screening mammograms of women screened between 1997 and 2008. During 2-year follow-up, clinical data, breast imaging, biopsy and surgery reports were collected from women with screen-detected or interval breast cancers. Screening sensitivity, tumor biology and tumor stages were compared between 168 women with breast cancer and prior ipsilateral benign breast surgery and 2,039 women with breast cancer but without previous ipsilateral, benign breast surgery. The sensitivity of screening mammography was significantly lower for women with prior surgery [64.3% (108/168) versus 73.4% (1,496/2,039), p = 0.01]. The concomitant increased interval cancer risk remained significant after logistic regression adjustment for age and breast density (OR = 1.5, 95% CI: 1.1-2.1). Comparing screen-detected cancers in women with and without prior breast surgery, no significant differences in estrogen receptor status (p = 0.56), mitotic activity (p = 0.17), proportions of large (T2+) tumors (p = 0.6) or lymph node positive tumors (p = 0.4) were found. Also for interval cancers, no differences were found in estrogen receptor status (p = 0.41), mitotic activity (p = 0.39), proportions of large tumors (p = 0.9) and lymph node positive tumors (p = 0.5) between women with and without prior breast surgery. We conclude that sensitivity of screening mammography is significantly lower in women with previous benign breast surgery than without, but tumor characteristics are comparable both for screen detected cancers and interval cancers.

Research paper thumbnail of Malpractice claims following screening mammography in The Netherlands

International Journal of Cancer, 2012

Although malpractice lawsuits are frequently related to a delayed breast cancer diagnosis in symp... more Although malpractice lawsuits are frequently related to a delayed breast cancer diagnosis in symptomatic patients, information on claims at European screening mammography programs is lacking. We determined the type and frequency of malpractice claims at a Dutch breast cancer screening region. We included all 85,274 women (351,009 screens) who underwent biennial screening mammography at a southern breast screening region in The Netherlands between 1997 and 2009. Two screening radiologists reviewed the screening mammograms of all screen detected cancers and interval cancers and determined whether the cancer had been missed at the previous screen or at the latest screen, respectively. We analyzed all correspondence between the screening organization, clinicians and screened women, and collected complaints and claims until September 2011. At review, 20.9% (308/1,475) of screen detected cancers and 24.3% (163/670) of interval cancers were considered to be missed at a previous screen. A total of 19 women (of which 2, 6 and 11 women had been screened between 1997 and 2001 (102,439 screens), 2001 and 2005 (114,740 screens) and 2005 and 2009 (133,830 screens), respectively) had contacted the screening organization for additional information about their screen detected cancer or interval cancer, but filed no claim. Three other women directly initiated an insurance claim for financial compensation of their interval cancer without previously having contacted the screening organization. We conclude that screening-related claims were rarely encountered, although many screen detected cancers and interval cancers had been missed at a previous screen. A small but increasing proportion of women sought additional information about their breast cancer from the screening organization.

Research paper thumbnail of Mammographic changes resulting from benign breast surgery impair breast cancer detection at screening mammography

European Journal of Cancer, 2012

Screening mammography Sensitivity Breast surgery Breast cancer Breast density Abstract Purpose: T... more Screening mammography Sensitivity Breast surgery Breast cancer Breast density Abstract Purpose: To study possible explanations for lower screening performance after previous benign breast surgery. Patients and methods: We included a consecutive series of 351,009 screening examinations in 85,274 women, obtained between January 1, 1997 and January 1, 2009. The examinations of women with screen detected cancers (SDC) or interval cancers (IC), diagnosed after previous benign breast surgery, were reviewed by two screening radiologists. They determined the presence and degree of post surgical changes, classified breast density and determined whether mammographic interpretation was hampered by tissue characteristics. They also assessed whether the cancer had already been visible at a previous screen. Results: Screening sensitivity was lower in women with prior benign breast surgery than without (63.5% (115/181) versus 73.5% (1643/2236), p = 0.004). A total of 115 SDCs and 66 ICs were diagnosed in breasts after previous benign breast surgery. Post surgical mammographic alterations in the breast segment where cancer was diagnosed were more distinct in ICs than in SDCs (p = 0.001). Women with post surgical mammographic changes at the location of the breast cancer had an increased interval cancer risk (OR = 2.12, 95% confidence interval (CI) = 1.05-4.26). Limited mammographic interpretation due to tissue characteristics was mentioned, only in three SDCs and one IC. The proportions of SDCs and ICS that were already visible at a previous screen were comparable for women with and without prior surgery (SDC: 47.5% versus 43.8%, p = 0.3, IC: 50.0% versus 48.4%, p = 0.8). Conclusion: Previous benign breast surgery decreases screening sensitivity and this is likely due to postoperative mammographic changes.

Research paper thumbnail of Two-view versus single-view mammography at subsequent screening in a region of the Dutch breast screening programme

European Journal of Radiology, 2012

We retrospectively determined the effect of analogue two-view mammography versus single-view mamm... more We retrospectively determined the effect of analogue two-view mammography versus single-view mammography at subsequent screens on breast cancer detection and determined financial consequences for a current digital mammography setting. Two screening radiologists reviewed the mammograms of 536 screen detected cancers (SDCs) and 171 interval cancers (ICs) with single-view mammography (mediolateral-oblique view) at the last but one screen (SDCs) or latest screen (ICs). They determined whether two-view mammography at the last (but one) screen could have increased the cancer detection rate at that screening round. For subsequent screens, the radiologists also assessed the percentage of SDCs and ICs that had been missed at previous two-view screening mammography (SDC) or latest two-view screening (IC), respectively. Additional personnel and digital storage costs for standard two-view mammography at subsequent screening were calculated for digital screening. Two-view mammography could have facilitated earlier cancer detection in 40.9% (219/536) of SDCs and 39.8% (68/171) of ICs. For twoview screens, 24.4% of SDCs (213/871) were missed at previous two-view screening and 29.3% of ICs (110/375) were missed at the latest screen. Overall costs increase D 1.03/screen after implementation of digital two-view mammography. Standard two-view mammography at subsequent screening may modestly increase cancer detection at an earlier stage, whereas additional screening costs are limited.