Cancer Screening Programs And Health Insurance In Europe – Breast cancer, a major cause of female morbidity and mortality, is a global health problem; Data from 2008 show an incidence of ~450,000 new cases and 140,000 deaths (mean incidence rate 70.7 and mortality rate 16.7, worldwide standardized rate per 100,000 women) in the member states of the European Union. Incidence rates in Western Europe are among the highest in the world. We review the state of BC screening programs in the European Union. Up-to-date information on active BC screening programs was obtained from a literature review and a search of national ministries of health and cancer service websites. Although BC screening programs have been established in almost all countries of the European Union, there are still significant differences in the coverage of the target population and age and in the techniques used. Screening is the mainstay of early detection of BC whose main weakness is the participation rate of the target population. National policies and health care planning should aim to maximize participation in controlled organized screening programs by identifying and reducing any barriers to adherence, also with the aim of reducing health care costs.
Breast cancer (BC) is a global health problem and one of the main causes of morbidity and mortality in women (1–3). Its distribution (incidence, prevalence) and the economic burden it imposes on national health services make it a major public health problem in both developed and developing countries (4).
Cancer Screening Programs And Health Insurance In Europe
BC is the most common neoplasm affecting women under the age of 45 and is even more common in the 45-65 age group. BC is the leading cause of cancer death in women worldwide.
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In 2008, ~1.4 million new BC diagnoses were made worldwide and 446,000 women died from BC; in the same year, the incidence in EU member states (EU28) was ~450,000 new cases with 140,000 deaths, representing a mean incidence rate of 70.7 and a mean mortality rate of 16.7 per 100,000 women (World Age-Standardized Rate, ASR-W) (5).
Different incidence, mortality and survival rates are due to different risk factors, availability of organized screening programs and access to effective treatment (1). Despite the fact that mortality is higher in less prosperous countries (Figure 1) (6), the incidence of BC in Western Europe is among the highest in the world (5), and prevention of BC is a major public health goal in the EU as well.
Retrospective studies of causes of death among women over the last 30 years based on WHO data in most European countries have reported different situations with significant changes in BC death rates, including a ~40% decrease in Ireland and a 17% increase in Romania . All the most developed countries of Northwestern Europe experienced a decrease, while an increase was recorded in Central European countries (Table I). The largest reductions included women over 50, also in areas lacking active screening programs; decreases were less pronounced in 50- to 69-year-olds, and greater variability, even including large increases, was found among women older than 70 years (7-10).
Table I Standardized mortality and incidence rates from breast cancer in the Member States of the European Union and changes in mortality rates from 1989 to 2006.
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Breast cancer standardized mortality and incidence rates in European Union member states and changes in mortality rates from 1989 to 2006.
The increasing incidence of BC and peaking in the 1980s in all countries has been accompanied by a decrease in BC mortality, both in countries that have adopted screening programs and in those that have not, probably due to advances in surgical techniques and treatments in all countries (11, 12 ) (Table I).
The beneficial effects of organized screening are, however, well established. Numerous trials have shown a large reduction in mortality (13–17) which actually reached 70% in a study conducted in the Netherlands (18); despite some possible bias in reporting mortality reduction, all have consistently demonstrated the effectiveness of screening in reducing BC mortality (19).
In 2003, the European Council recommended the implementation of cancer screening programs based on European best practice guidelines (20).
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According to the International Agency for Research on Cancer, participants in organized screening programs, in which women aged 50 to 69 are referred for mammography at 2-year intervals, have a 35% lower chance of dying from BC (21). According to a more recent review of more methodologically rigorous studies, the likely impact of screening programs in the EU28 on women invited for screening is a 26% reduction in mortality (95% confidence interval, CI, 13–36%) over a period of 6–11 years. – above (22).
Despite widespread agreement among EU member states on the important role of population-based screening (PB) in cancer control, a 2007 EU report reviewing compliance with the Council’s recommendations found that several states still do not have a BC screening program. We review the progress of the EU28 screening program since March 2014.
A clinical breast examination (CBE) is a basic physical examination of the breasts, especially in symptomatic women. In the French program, it is an integral part of the first-level screening (23), which leads in its execution and interpretation. Although it is performed by experienced specialists, integration with other tests is required in the presence of a suspicious finding or sign.
Mammography is the only screening method recognized by the European Commission for women aged 50 to 69. It is a morphological method that allows the examination of the breast in its entirety and offers the highest sensitivity even for tumors in the early stage, especially in women with predominantly dense breasts. Its specificity is influenced by breast density and reporting technique.
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A review of the European literature examining the impact of mammography screening on BC mortality found a reduction of 25–31% among women invited and of 38–48% among those actually screened (24). According to the authors, the reason for the BC screening debate is the adoption of analytical methods unsuitable for capturing the true effects of screening.
An independent British study confirmed these data and found a ~20% reduction in BC mortality among screened women, with ~1% overdiagnosis (25). However, further analysis of the data led the authors to conclude that overdiagnosis rates could not be precisely quantified. Opinions on how to estimate the risk of overdiagnosis vary, resulting in estimates that can range from 0 to 50% depending on the method used (26).
Overdiagnosis is attracting increasing interest; the problem is closely related to the availability of sensitive diagnostic tests and the high probability of detecting slow-growing or non-aggressive lesions. It is a useful parameter for assessing the impact of screening on women’s overall health and is estimated by comparing the incidence of tumors in women who have been screened over a period of time and in women who have never been screened.
An Italian study based on data from a cancer registry evaluated the effect of BC screening in reducing diagnoses of highly invasive lesions. Organized programs that have been active for several years have been associated with a significant, stable decrease in the incidence of pT4 lesions and an increase in pT2 lesions beginning at 3-4. year of the program, with the incidence ratio decreasing from 0.81 (95% CI, 0.75–0.88) to 0.71 (95% CI, 0.64–0.79) in Years 7–8. year (27).
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Finally, a large number of diagnostic centers adopted digital mammography, which improved diagnosis and allowed better management and storage of scans. The image is displayed in real time on high resolution monitors and later archived in electronic image archiving systems. The adoption of digital mammography in 2007 quickly resulted in a doubling of referral rates to the Dutch screening program (28); moreover, the improved sensitivity of the equipment resulted in a reduction in false positives. Computer-assisted techniques combined with digital mammography also improve lesion detection (29).
In 2003, the European Commission recommended BP screening for women aged 50-69; in 2007, programs based on the Council’s indications were active or being organized in 22 countries.
Alternatives to organized screening, proposed in order to achieve earlier diagnosis, encourage self-referral to breast units interconnected online, also in order to monitor the quality of examinations. These models exploit and improve existing diagnostic resources and facilities and aim to adapt diagnostic and clinical protocols according to the risk profile and clinical condition of each subject; moreover, they are useful in environments where it is difficult to use classical screening methods with individual calls. However, several national and European experiences show that screening by invitation achieves a high level of coverage faster and that the costs of organized programs are more limited (30–33).
The current situation with screening programs in the EU28 is described below and shown in Table II and shown in Figure 2. This study is based on the latest data available from PubMed-indexed journals, the websites of each member country’s ministries of health. and websites of national cancer observatories; in the absence of these sources, information was sought in scientific journals published in the local language.
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Figure 2 Distribution of breast cancer screening programs in the EU28 and coverage rates. Participation data is divided into five classes from 0 to 100%. Participation rates are those listed in Table II. Member States for which attendance data were not available are marked with NA.
PB, population-based; NPB, non-population; Natw, throughout the country; Reg, regional; Local, limited to some municipalities; Fm, screen-film mammography; Dm, digital mammography; CBE, clinical breast examination; NA, data not available.
In 1974, Austria was the first
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