No abstract

Objectives-To investigate observed stage distributions at first and repeat screenings. To compare the observed outcomes with expected values based on simulation modelling, varying the assumptions about the natural history of the disease. Methods-An overview is made of observed data on stage distribution at first and repeat screenings and the diVerence between those distributions is summarised in a Gini coeYcient. Four possible explanations for the observations are considered, two of these are worked out as Miscan simulation models, and the outcomes are compared with observations. Results-Often the reported stage distributions at repeat screenings are not or only slightly more favourable than at first screenings and, in the ones that are more favourable, the diVerence is relatively small. If, in the Miscan model, it is assumed that there is no correlation between the duration of preclinical breast cancer in consecutive tumour size categories and that there is a strong influence of latent cancers, it is not possible to reproduce the observed outcomes. Conclusions-The two modelled explanations are not suYcient. Decreasing sensitivity seems an unlikely explanation for the discrepancy in many screening programmes. The possibility that the observations may be explained because false reassurance has been given should be seriously considered and investigated. (J Med Screen 1999;6:132-138)

Abstract:The purpose of this research was to estimate the cost-effectiveness of mammographic screening to supplement the results of the National Evaluation of Breast Cancer Screening which identified the mortality benefit as the most sensitive parameter. This appraisal used a different computer model, MISCAN, which models the effects of introducing a national screening program into a previously unscreened population, rather than basing estimates on the assumption of a fully established program. For the 40 to 49 age group a mortality reduction of 8 per cent was assumed, rather than the 30 per cent estimate utilised in the National Evaluation. The revised estimate is based on the two Swedish trials (Malmo and WE). New estimates for treatment costs were also incorporated into the MISCAN model. The costeffectiveness of the policy recommended in the National Evaluation Report, $1 1 000 per life year saved with two-yearly screening of women over 40, is estimated by the MISCAN model to be $20 300. These differences arise partly from the difference in mortality,effects for the 40 to 49 age group, but also from differences inherent in the steady-state and dynamic population approaches to modelling premature deaths averted. The MISCAN results confirm that screening for women over 50 is more cost-effective than screening women under 50. Screening all women aged 50 to 69 every two to three years is reasonable value for money. For women aged 40 to 49 the mortality benefit and cost-effectiveness is less clear, and it would be prudent to allow screening in this group until further evidence is available. ( A w t J Public Health 1993; 17: 42-50) reast cancer is the most common cause of cancer death among Australian women: in 1989

An exercise test showed normal working capacity and no signs of coronary artery disease. Standard 12-lead ECG was still normal.Haemoglobin returned to normal within 2 weeks. After follow-up for 9 months, he has had no further signs or symptoms of heart failure.This patient had an acute febrile illness followed by a rash, slight haemoglobin fall, and temporary heart failure. Recent