For PSA values of 0-3.9 ng/mL, the positive predictive value and sensitivity of DRE, tumor volume, and tumor grade were strongly dependent on PSA level. DRE has a poor performance in low PSA ranges.

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Objective-To assess the impact of the national breast cancer screening programme on breast cancer mortality in the first years after its introduction. Setting-The Netherlands and United Kingdom. Methods-MISCAN models, incorporating demographic, epidemiological, and screening characteristics of the region under study, were used to assess the mortality in the presence and absence of screening. Results-Breast cancer mortality decreased in women aged 55-74 as the Dutch nationwide screening programme built up, and was 5% lower in 1996 than before the start of the programme. The mortality reduction due to screening in the age group 55-74 is expected to increase gradually to 18% in 1999, 10 years after the introduction of screening, and to 29% in the long term. In the United Kingdom screening was expected to achieve a mortality reduction of 5% and 18% in the age group 55-69 five and 10 years respectively after screening was started. A maximum mortality reduction of 24% in this age group is predicted. Conclusions-The eVects of screening will be small in the first years after the start of the programme. Accordingly, it was expected that the reduction in breast cancer mortality due to the Dutch nationwide breast screening programme, which started around 1989, would be statistically significant from 1997 onwards, the point at which the target population of women was completely covered; 70% of the reported 12% mortality reduction in England and Wales in 1994 is expected to be attributed to screening. (J Med Screen 1999;6:30-34)

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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)