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Mammography in Breast Cancer Screening. a Radiographic Analysis

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Mammography in Breast Cancer Screening. a Radiographic Analysis MAMMOGRAPHY IN BREASTCANCERSCREENING. A RADIOGRAPHIC ANALYSIS OF THE CARCINOMAS FOUND AT UTRECHT, NIJMEGEN AND KOPPARBERG COUNTY Mammography in breastcancerscreening A radiographic analysis of the carcinomas found at Utrecht, Nijmegen and Kopparberg county Mammografie als opsporingsmethodiek bij het bevolkingsonderzoek op mammacarcinoom. Een radiodiagnostische analyse van de carcinomen gevonden bij de screening in Utrecht, Nijmegen en in de provincie Kopparberg (met een samenvatting in het Nederlands) PROEFSCHRIFT TER VERKRIJGING VAN DE GRAAD VAN DOCTOR IN DE GENEESKUNDE AAN DE RIJKSUNIVERSITEIT TE UTRECHT, OP GEZAG VAN DE RECTOR MAGNIFICUS PROF. DR. O.J. DE JONG, VOLGENS BESLUIT VAN HET COLLEGE VAN DEK ANEN IN HET OPENBAAR TE VERDEDIGEN OP DINSDAG 12 NOVEMBER 1985 DES NAMIDDAGS TE 4.15 UUR door JACOBUS WILHELMUS THEODORUS MULLER geboren 8 maart 1942 te Bergambacht PRGMOTORES: Prof. dr. C.B.A.J. Puylaert Prof. dr. A.C. Klinkhamer CO-REFERENT: Dr. J.H.C.L. Hendriks Aan: Lia Machteld Michiel Mijn ouders "These standards of objective truth and criticism may teach him (the individual man) to try again and to think again; to challenge his own conclusions, and to use his imagination in trying to find whether and where his own conclusions are at fault. They may teach him to apply the method of trial and error in every field, and especially in science; and thus they may teach him how to item from his mistakes, and how to search for them. These standards may help him to discover how little he knows and how much there is he does not know. They may help him to grow in knowledge, and also to realise that he is growing. They may help him to become aware of the fact that he owes his growth to other people's criticism and that reasonableness is readiness to listen to criticism." Karl Popper, 1978 The challenge for the radiologists is to have the opportunity to offer women meaningful respite from breast cancer McLelland 1984 The medio-lateral oblique projection. Dit proefschrift kwam tot stand met financiële steun van de Röntgenstichting Utrecht. © 1985 J.W.Th. Muller Niets uit deze uitgave mag worden verveelvoudigd en/of openbaar gemaakt door middel van druk, fotocopie, microfilm of op welke andere wijze ook, zonder voorafgaande schriftelijke toestemming van de auteur. Voorwoord Dit proefschrift, geschreven met de bedoeling een bijdrage te leveren tot de vroege opsporing van het mammacarcinoom, is tot stand gekomen dankzij de medewerking van velen. Allen die eraan hebben bijgedragen wil ik hartelijk danken. Ik noem in de eerste plaats mijn promotoren Prof. dr. C.B. A. J. Puylaert en Prof. dr. A.C. Klinkhamer. Dankzij hun vriendschappelijke stimulansen is de mammografie in het AZU tot ontplooiing gekomen. Het idee en de uiteinde- lijke realisatie van dit proefschrift ligt hieraan mede ten grondslag. Met her. en anderen is vele uren aan dit proefschrift gewerkt. Met name noem ik mijn goede vrienden Dr. J.H.CL. Hendriks en Dr. L. Tabar uit Zweden, want zonder hun inbreng en hulp zou deze dissertatie niet geschreven zijn. Vooral Dr. J.H.CL. Hendriks heeft bijzonder geholpen bij de talloze keren dat het manuscript aan een kritische beschouwing onderworpen moest worden. Bijzonder dankbaar ben ik Dr. M.A.J. Eykman, Dr. W.P.Th.M. Mali, mevrouw S. Mali-Brinkman en Dr. J.W.R. Nortier, die mij geholpen hebben bij het tot stand komen van het definitieve manuscript. Tot slot dank ik Prof. dr. F. de Waard, mevrouw Dr. H.J.A. Collette, Dr. J.J. Rombach en me- vrouw Drs. C Zuur voor hun hulp en hun kritische opmerkingen op be- paalde onderdelen. Dit proefschrift zou verder niet tot stand gekomen zijn zonder de nimmer aflatende steun en hulp van de projectleiders van de screening in Utrecht, Nijmegen en de provincie Kopparberg, die mij hun materiaal ter beschikking hebben gesteld. De dames H. Rijken en A. Staal hebben al het te bewerken materiaal opgezocht. Mevrouw T. van Berkel heeft de ponskaarten getypt voor de computer van het Academisch Computer Centrum Utrecht (ACCU). De heer B. J. Slotboom zorgde hierna voor de benodigde informatie. Het manuscript werd herhaaldelijk door de dames J. Metselaar, Y. Huygen, M. de Jongh, C. Holtzer, M. Klemkerk en R. van Emmerik uitgetypt. De heer J. de Groot hoofd van de afdeling Medische Fotografie, Röntgendiagnostiek AZU en zijn medewerkers zorgden met enorme inzet voor een zo goed mogelijk fotografisch resultaat. De heren D. Eykel, R. Ruygrok en R. Toorenvliet hebben daadwerkelijke steun verleend. Dr. Ir. J.A.J. Faber, medewerker van het Mathematisch Instituut, verzorgde de statistische onderbouwing. Me- vrouw Seeger-Wolf vertaalde het manuscript in het Engels. Ik dank de laboranten, vooral de dames S. van de Grift, A. Savenije, M.A.C. Evelein en W. Scheepmaker, van het AZU, het St. Joseph Ziekenhuis te Eindhoven, het Diakonessenhuis te Utrecht en van de drie projecten voor hun samenwerking bij het maken van foto's van hoge kwaliteit. Mijn voormalige associés, prof. dr. C.B.A.J. Puylaert, Prof. dr. A.C. Klinkhamer, Prof. dr. J.H.J. Ruys, Prof. dr. P.F.G.M. van Waes, H. Dams- ma, P.P.G. Kramer, Dr. M.A.M. Feldberg en Dr. W.P.Th.M. Mali dank ik voor de vele jaren van prettige samenwerking, de behulpzaamheid en de vriendschap ondervonden op onze afdeling in het AZU. Ditzelfde geldt eveneens voor mijn voormalige associés A.Ph. Booy, H. van der Borne, O.S. Derksen, Mw. S.N. Kho en Th.C.M. van Rhijn voorde tijd dat ik werkzaam was in de Röntgenafdeling van het St. Joseph Ziekenhuis te Eindhoven. Door hun plezierige medewerking was het mogelijk tijd en gelegenheid te vinden om aan het manuscript te kunnen werken. Mijn huidige associés P. Denijs, Dr. A. Krivka en T. Weits dank ik eveneens voor hun steun en medewerking. Tot slot dank ik Lia voor haar morele en daadwerkelijke steun bij het schrijven van deze dissertatie en vraag mijn kinderen vergiffenis voor het tekort aan aandacht in deze periode. List of abbreviations T.I.D. = Tumour density ill-defined. T.S.D. = Tumour density sharply defined. M.W.T. = Microcalcifications without tumour density. T.A.M. = Tumour density and microcalcifications. Misc. = Miscellaneous. A.Z.U. = Academisch Ziekenhuis Utrecht (Utrecht University Hos- pital). T.A.S.D. = Tumour density almost sharply defined. T.W.M. = Tumour density without microcalcifications. S.L. = Stellate lesion (tumour with spicules). Exam. = Examination. T.N.M. = Tumour Nodule Metastasis. B.C.D.D.P. = Breast Cancer Detection Demonstration Project. H.I.P. = Health Insurance Plan of Greater New-York. D.C.I.S. = Duct carcinoma in-situ. HVL = Half-Value Layer. Kopparberg = Kopparberg county (several Tables). Contents Chapter I Introduction 1 Chapter II The value of early diagnosis of breast carcinoma 3 Chapter III Population screening by mammography 5 Chapter IV The screening programs in Utrecht, Nijmegen en Kopparberg county 13 Chapter V The mammographic signs of carcinoma of the breast 23 Chapter VI The frequency of occurrence of the various mammographic signs 39 Chapter VII The present study 45 Chapter VIII Summary and general discussion 79 Samenvatting en algemene discussie 83 Appendices A. Xeromammography 87 B. The medio-lateral oblique projection 89 C. Radiation dose 91 D. Localization of non-palpable lesions 97 E. Epidemiological aspects and concepts. 99 CHAPTER I Introduction Since 1975, population-based screening for carcinoma of the breast by mam- mography has been carried out in the cities of Utrecht and Nijmegen in The Netherlands and since 1977 in Kopparberg county in Sweden. This screening has yielded an abundance of data, not all of which have been processed yet, the mammographic (radiographic) data in particular. The present sindy concerns an analysis of the mammographic signs in the histologically proven carcinomas (invasive and intraductal) detected by these three screening programs. The radiographic signs of the screened carcinomas were compared with those of the clinical carcinomas diagnosed in the Utrecht University Hospital (to be called AZU carcinomas). These AZU carcinomas were taken as reference material, and were therefore analysed in the same way as the screening material. In this study we will attempt to answer the following questions: 1. What are the mammographic signs of the carcinomas found in the first screening? 2. Do these signs differ from those found in a clinical situation? \ 3. What are the mammographic signs of the carcinomas found in the subse- \ quent screenings? 4. Do the mammographic signs differ between the various age-groups? 5. Which mammographic signs are characteristic for the carcinomas found between screenings (interval carcinomas)? On the basis of our findings an additional question was raised: 6. What is the relevance of this study for the diagnosis of breast carcinoma by mammography in population-based screening program? This retrospective investigation into the radiographic signs found of the carcinomas detected during the screening yielded some supplementary data which will also be discussed. Population screening by mammography reveals other abnormalities be- sides carcinoma. The policy to be followed when such lesions are found will not be discussed in this thesis except where differential diagnosis is concer- ned. In the following chapters, the term carcinoma (or tumour) will refer to carcinoma of the breast unless otherwise mentioned. CHAPTER II The value of early diagnosis of breast carcinoma II. 1. INTRODUCTION Carcinoma of the breast is a major health problem (Seidman 1983). In the Netherlands and many other countries breast cancer is the most frequently occurring type of tumour in women. The incidence is still rising (Strax 1980). In the Netherlands the diagnosis is made at an annual rate of more than 6,000 women, of whom more than 2,500 die of the disease (Collette 1983).
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