Results from the randomized trial underway in the Health Insurance Plan of Greater New York to determine the efficacy of periodic screening with mammography and palpation of the breast have been examined to determine the effect of screening on racial differences in breast cancer survival rates. Consistent with experience in general populations, the control group showed a lower five-year survival rate among non-White women with breast cancer than among White women. In the study group, 65 per centIn this paper, information from the randomized control trial to test the efficacy of screening for breast cancer* being conducted by the Health Insurance Plan of Greater New York (HIP) is utilized to examine differentials in survival rates among non-White women compared with White following diagnosis of breast cancer.Briefly, the situation in the general population is that Black women with breast cancer have a markedly poorer fiveyear relative survival rate** from breast cancer than White women as exemplified in Several explanations might be advanced for the relatively poor survival rates from breast cancer among Black women: e.g., differentials in diagnostic delay because of variations in recognition of signs and symptoms and care seeking behavior; quality of care; or the underlying biological course of breast cancer due to genetic or other host factors. Results from the HIP study discussed below suggest that secondary prevention programs may be an effective approach to changing the poor survival rate of Blacks. The HIP StudyThe HIP study's design, methodology, and findings for all races combined have been reported extensively in the literature.4 The investigation was initiated toward the end of 1%3 to determine whether periodic screening with clinical examination and mammography results in reduced breast cancer mortality among women aged 40-64 years at time of entry. Women in this age group who were members of the Plan, a comprehensive prepaid group practice with a wide spectrum of socioeconomic groups of enrollees, were allocated through a stratified random procedure to study and control groups, each consisting of 31,000 individuals. Study women were offered screening examinations; the 65 per cent who appeared for the initial examination were offered three additional examinations at annual intervals unless earlier follow-up or biopsy was indicated; all but a small proportion (12 per cent) had at least one additional annual examination. Control women received their usual medical care which during the 1960s did not emphasize other early detection methods, e.g., breast self-examination.Screening ended in 1970 and follow-up of the tested cohorts of the study and control women, including those who are no longer enrolled in HIP, has continued to date to
This paper deals with a long-term prospective study of breast cancer to determine the value of periodic screening for this condition, which also incorporates epidemiologic objectives. The methodology of the study, the variables included, and preliminary observations based on detected cases are presented. THE difficulties in conducting prospective studies on comparatively low incidence diseases are so severe that they are rarely undertaken for a specific condition. This holds for breast cancer despite the fact that an estimated 6 per cent of the women develop the disease during their lifetime and about one in five of the deaths from cancer among women is attributable to this condition. However, an opportunity has recently presented itself to incorporate epidemiological objectives related to breast cancer in a long-term prospective study whose main purpose is to investigate the value of periodic breast cancer screening. This paper presents the methodology of the study, the variables included, and preliminary observations based on the breast cancer cases detected in the early stages of the investigation. Before proceeding to this discussion, a brief review of where we are in understanding the epidemiology of breast cancer is in order. THE SEARCH FOR RISK FACTORS IN BREAST CANCERThe outstanding characteristic of the search for risk factors in female breast cancer is the lack of success in identifying specific parameters that are strongly associated with the incidence of the disease. The unifying element in these efforts is a hormonal hypothesis, whether the investigation is concerned with socio-
Periodic screening for cancer of the breast using mammography as well as clinical examination is being conducted by the Health Insurance Plan in a large random sample of women aged 40 to 64 years. A similar group of women has been assigned as controls. The long term objective is to determine whether the screening program results in lowering of mortality from mammary cancer. From the first screening examination among 20,211 women, the following observations can be made: 1. Screening has resulted in substantial detection of cancer; mammary cancer is detectable through screening an average of 21 months sooner than usual. 2. A higher proportion of cancers has been detected in the screened group (65%) in an early stage (as shown by the absence of axillary node involvement) than in the control group (41%). 3. Both mammography and clinical examination contribute to the early detection of cancer in mass screening. 4. Mammography and clinical examination are complimentary in detection. 5. Under different conditions of age, breast type and lesion characteristics, the two procedures have different rates of accuracy. 6. Mammography does comparatively well when the woman is older than 50, when the breasts are mostly fatty in type and when the lesion is in the lower half of the breast; clinical examinations do comparatively well when the woman is younger than 50, when the breasts are small and when the breasts are of the glandular type.
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