The aim of this study was to assess changes in the trends in breast cancer mortality and incidence from 1975 to 2006 among Dutch women, in relation to the implementation of the national breast cancer screening programme. Screening started in 1989 for women aged 50-69 and was extended to women aged 70-75 years in 1998 (attendance rate approximately >80%). A joinpoint Poisson regression analysis was used to identify significant changes in rates over time. Breast cancer mortality rates increased until 1994 (age group 35-84), but thereafter showed a marked decline of 2.3-2.8% per annum for the age groups 55-64 and 65-74 years, respectively. For the age group of 75-84 years, a decrease started in the year 2001. In women aged 45-54, an early decline in breast cancer mortality rates was noted (1971)(1972)(1973)(1974)(1975)(1976)(1977)(1978)(1979)(1980), which is ongoing from 1992. For all ages, breast cancer incidence rates showed an increase between 1989 and 1993, mainly caused by the age group 50-69, and thereafter, a moderate increase caused by age group 70-74 years. This increase can partly be explained by the introduction of screening. The results indicate an impressive decrease in breast cancer mortality in the age group invited for breast cancer screening, starting to show quite soon after implementation. ' 2008 Wiley-Liss, Inc.Key words: breast cancer screening; trends; mortality; incidence Worldwide, breast cancer is the most common cancer and the leading cause of death among women with cancer. In Europe, the average age-adjusted (European standard population, ESR) incidence and mortality rates were 94 and 26 per 100,000 women, respectively, in 2006. 1 In The Netherlands, these figures were much higher, with an incidence rate of 128 and a mortality rate of 30 per 100,000 women.The efficacy of mammographic screening in reduction of breast cancer mortality has been shown in randomized controlled trials. 2,3 Screening also improves outcomes for diagnosed cancers, which are detected earlier and probably treated more effectively. 4,5 If a screening program is indeed effective, breast cancer mortality in population statistics will be declining for the age groups invited for screening probably about 7-10 years after the start of the program. 6 Furthermore, breast cancer incidence rates are highly sensitive to mass screening, resulting in a transient increase in incidence and a stage shift to earlier stages, microinvasive and in situ cancers in the steady state situation. 7 This study was performed to analyze the changes in breast cancer mortality and incidence over the last 3 decades among Dutch women, taking account of the implementation of the Dutch breast cancer screening program for different age groups.
Material and methods
The Dutch screening programIn 1989, a breast cancer screening program was gradually implemented in The Netherlands, inviting all women aged 50-69 years (formally 49-68; women will be invited for the first time in the year that they become 50, but for evaluation, we considered the age they ha...