Natural history of breast cancers detected in the Swedish mammography screening programme: a cohort study

Abstract

Background: The natural history of screen-detected breast cancers is not well understood. A previous analysis of the incidence change during the introduction of the Norwegian screening programme in the late 1990s suggested that the natural history of many screen-detected invasive breast cancers is to regress spontaneously but the study was possibly confounded by use of hormone replacement therapy in the population. We did a similar analysis of data collected during an earlier period when few women were exposed to hormone replacement therapy.

Methods: We compared cumulative breast cancer incidence in age-matched cohorts of women living in seven Swedish counties before and after the initiation of public mammography screening between 1986 and 1990. Women aged 40-49 years were invited to screening every year and women aged 50-74 years were invited every 2 years. A screened group including all women aged 40-69 years (n=328,927) was followed-up for 6 years after the first invitation to the programme. A control group including all women in the same age range (n=317,404) was also followed-up for 6 years--4 years without screening and 2 years when they entered the screening programme. Screening attendance was much the same in both groups (close to 80%). Counts of incident invasive breast cancers were obtained from the Swedish Cancer Registry (in-situ cancers were excluded).

Findings: Before the age-matched controls were invited to be screened at the end of their follow-up period, the 4-year cumulative incidence of invasive breast cancer was significantly higher in the screened group (982 per 100,000) than it was in the control group (658 per 100,000) (relative risk [RR] 1·49, 95% CI 1·41-1·58). Even after prevalence screening in the control group, the screened group had higher 6-year cumulative incidence of invasive breast cancer (1443 per 100,000 vs 1269 per 100,000; RR 1·14, 1·10-1·18).

Interpretation: Because the cumulative incidence among controls did not reach that of the screened group, we believe that many invasive breast cancers detected by repeated mammography screening do not persist to be detected by screening at the end of 6 years, suggesting that the natural course of many of the screen-detected invasive breast cancers is to spontaneously regress.

Funding: None.