Impact of use of hormone replacement therapy on false positive recall in the NHS breast screening programme: results from the million women
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《英国医生杂志》
1 Cancer Research UK Epidemiology Unit, Gibson Building, Radcliffe Infirmary, Oxford OX2 6HE, 2 Breast Screening Service, Princess of Wales Community Hospital, Bromsgrove B61 0BB, 3 West of London Breast Screening Service, Charing Cross Hospital, London W6 8RF, 4 Gloucestershire Breast Screening Service, Cheltenham GL53 7AS, 5 Breast Care Unit, Oxford Radcliffe Hospital NHS Trust, Churchill Hospital, Oxford OX3 7JH, 6 Patricia Massey Breast Screening Unit, Queen Alexandra Hospital, Portsmouth PO6 3LY, 7 Avon Breast Screening, Central Health Clinic, Bristol BS2 0JD, 8 North Lancashire Breast Screening Service, Royal Lancaster Infirmary, Lancaster LA1 4GG, 9 West Sussex Breast Screening Service, Worthing Hospital, Worthing BN11 2DH, 10 Breast Screening Unit, Coventry and Warwick Hospital, Coventry CV1 4FH, 11 Greater Manchester Breast Screening Service, Nightingale Centre, Withington Hospital, Manchester M20 0PT, 12 NHS Breast Screening Programme, Sheffield S11 9PS
Correspondence to: E Banks mailto:emily.banks@anu.edu.au
Introduction
About half of the women attending the NHS breast screening programme have used hormone replacement therapy.1 Although previous studies have reported that use of hormone replacement therapy increases the risk of being recalled after mammography for further assessment, with no subsequent diagnosis of breast cancer ("false positive recall"), the effect of different patterns of use is unclear.2
Relative risk of false positive recall in postmenopausal women in relation to time since last use of hormone replacement therapy. (Relative risk compared with never users (1057/44 427 recalled) stratified by screening centre, age, previous screening, body mass index, previous breast operation, and time since menopause in: current users of hormone replacement therapy (relative risk 1.64, 95% confidence interval 1.50 to 1.80; 1157/28 634 recalled); past users ceasing use <1 year ago (1.42, 1.08 to 1.86; 63/1758 recalled), 1-4 years ago (1.23, 1.04 to 1.46; 176/5910 recalled), and 5 years ago (1.07, 0.85 to 1.34; 92/3800 recalled)). Results are plotted according to the median number of years since last use of hormone replacement therapy in each of these categories
Participants, methods, and results
The risk of false positive recall is significantly and substantially increased in current and recent users of hormone replacement therapy; this effect persists for several years after use ceases and, in current users, is accompanied by an increased risk of having a biopsy performed.
False positive mammography is important, because of the anxiety, extra investigations, and inconvenience recalled women experience and its resource implications.2 Moreover, recalled women are less likely to accept subsequent invitations for screening, despite having a higher incidence of breast cancer than women who have not been recalled.5 An increased risk of false positive recall can be justified if it improves cancer detection, but current use of hormone replacement therapy reduces the ability of mammographic screening to detect breast cancer,2 such that the increase in false positive recall is not offset by improved cancer detection.
Our finding that the effect of hormone replacement therapy takes several years to wear off does not support suggestions that the high rates of false positive recall in current users could be largely reversed if women ceased use of hormones weeks or months before mammography.
We thank the many women who completed questionnaires for this study. We are grateful to the staff at the collaborating breast screening units and at the Million Women Study coordinating centre for their valuable contribution to the study and to Adrian Goodill for producing the figure.
Contributors: Emily Banks, Gillian Reeves, Valerie Beral, and Julietta Patnick had the original idea for the study, with important input on practical aspects of study design from Barbara Crossley, Elizabeth Hilton, and Moya Simmonds. Diana Bull analysed the data; Emily Banks, Gillian Reeves, Valerie Beral, Julietta Patnick, and Matthew Wallis interpreted the data. Stephen Bailey, Nigel Barrett, Peter Briers, Ruth English, Alan Jackson, Elizabeth Kutt, Janet Lavelle, Linda Rockall, Matthew Wallis, and Mary Wilson contributed to local study design and conduct. All of the authors participated in drafting the paper and gave final approval of the version to be published. Emily Banks, Gillian Reeves, and Valerie Beral are guarantors.
Funding: The Million Women Study is supported by Cancer Research UK, the Medical Research Council, and the NHS Breast Screening Programme.
Competing interests: None declared.
Ethical approval: The study was approved by the Anglia and Oxford Multi-Centre Research Ethics Committee.
References
Million Women Study Collaborators. Patterns of use of hormone replacement therapy in one million women in Britain, 1996-2000. Br J Obstet Gynaecol 2002;109: 1319-1330.
Banks E. Hormone replacement therapy and the sensitivity and specificity of breast cancer screening: a review. J Med Screen 2001;8: 29-35.
The Million Women Study Collaborative Group. The million women study: design and characteristics of the study population. Breast Cancer Res 1999;1: 73-80.
Patnick J. 2002 NHS breast screening programme review. Sheffield, UK: NHS Breast Screening Programme, 2002.
McCann J, Stockton D, Godward S. Impact of false positive mammography on subsequent screening attendance and risk of cancer. Breast Cancer Res 2002;4: R11.(Emily Banks, deputy direc)
Correspondence to: E Banks mailto:emily.banks@anu.edu.au
Introduction
About half of the women attending the NHS breast screening programme have used hormone replacement therapy.1 Although previous studies have reported that use of hormone replacement therapy increases the risk of being recalled after mammography for further assessment, with no subsequent diagnosis of breast cancer ("false positive recall"), the effect of different patterns of use is unclear.2
Relative risk of false positive recall in postmenopausal women in relation to time since last use of hormone replacement therapy. (Relative risk compared with never users (1057/44 427 recalled) stratified by screening centre, age, previous screening, body mass index, previous breast operation, and time since menopause in: current users of hormone replacement therapy (relative risk 1.64, 95% confidence interval 1.50 to 1.80; 1157/28 634 recalled); past users ceasing use <1 year ago (1.42, 1.08 to 1.86; 63/1758 recalled), 1-4 years ago (1.23, 1.04 to 1.46; 176/5910 recalled), and 5 years ago (1.07, 0.85 to 1.34; 92/3800 recalled)). Results are plotted according to the median number of years since last use of hormone replacement therapy in each of these categories
Participants, methods, and results
The risk of false positive recall is significantly and substantially increased in current and recent users of hormone replacement therapy; this effect persists for several years after use ceases and, in current users, is accompanied by an increased risk of having a biopsy performed.
False positive mammography is important, because of the anxiety, extra investigations, and inconvenience recalled women experience and its resource implications.2 Moreover, recalled women are less likely to accept subsequent invitations for screening, despite having a higher incidence of breast cancer than women who have not been recalled.5 An increased risk of false positive recall can be justified if it improves cancer detection, but current use of hormone replacement therapy reduces the ability of mammographic screening to detect breast cancer,2 such that the increase in false positive recall is not offset by improved cancer detection.
Our finding that the effect of hormone replacement therapy takes several years to wear off does not support suggestions that the high rates of false positive recall in current users could be largely reversed if women ceased use of hormones weeks or months before mammography.
We thank the many women who completed questionnaires for this study. We are grateful to the staff at the collaborating breast screening units and at the Million Women Study coordinating centre for their valuable contribution to the study and to Adrian Goodill for producing the figure.
Contributors: Emily Banks, Gillian Reeves, Valerie Beral, and Julietta Patnick had the original idea for the study, with important input on practical aspects of study design from Barbara Crossley, Elizabeth Hilton, and Moya Simmonds. Diana Bull analysed the data; Emily Banks, Gillian Reeves, Valerie Beral, Julietta Patnick, and Matthew Wallis interpreted the data. Stephen Bailey, Nigel Barrett, Peter Briers, Ruth English, Alan Jackson, Elizabeth Kutt, Janet Lavelle, Linda Rockall, Matthew Wallis, and Mary Wilson contributed to local study design and conduct. All of the authors participated in drafting the paper and gave final approval of the version to be published. Emily Banks, Gillian Reeves, and Valerie Beral are guarantors.
Funding: The Million Women Study is supported by Cancer Research UK, the Medical Research Council, and the NHS Breast Screening Programme.
Competing interests: None declared.
Ethical approval: The study was approved by the Anglia and Oxford Multi-Centre Research Ethics Committee.
References
Million Women Study Collaborators. Patterns of use of hormone replacement therapy in one million women in Britain, 1996-2000. Br J Obstet Gynaecol 2002;109: 1319-1330.
Banks E. Hormone replacement therapy and the sensitivity and specificity of breast cancer screening: a review. J Med Screen 2001;8: 29-35.
The Million Women Study Collaborative Group. The million women study: design and characteristics of the study population. Breast Cancer Res 1999;1: 73-80.
Patnick J. 2002 NHS breast screening programme review. Sheffield, UK: NHS Breast Screening Programme, 2002.
McCann J, Stockton D, Godward S. Impact of false positive mammography on subsequent screening attendance and risk of cancer. Breast Cancer Res 2002;4: R11.(Emily Banks, deputy direc)