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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Note: Separate PDQ summaries on Breast Cancer Prevention, Breast Cancer Treatment, Male Breast Cancer Treatment, and Breast Cancer Treatment and Pregnancy are also available.
This summary covers the topic of breast cancer screening and includes information about breast cancer incidence and mortality, risk factors for breast cancer, the process of breast cancer diagnosis, and the benefits and harms of various breast cancer screening modalities. This summary also includes information about screening among special populations.
Mammography is the most widely used screening modality, with solid evidence of benefit for women aged 40 to 74 years. Clinical breast examination and breast self-exam have also been evaluated but are of uncertain benefit. Technologies such as ultrasound, magnetic resonance imaging, tomosynthesis, and molecular breast imaging are being evaluated, usually as adjuncts to mammography.
Screening With Mammography
Based on solid evidence, screening mammography may lead to the following benefit:
Based on solid evidence, screening mammography may lead to the following harms:
For all these potential harms of screening mammography, internal validity, consistency and external validity are good.
Clinical Breast Examination
Clinical breast examination (CBE) has not been tested independently; it was used in conjunction with mammography in one Canadian trial, and was the comparator modality versus mammography in another trial. Thus, it is not possible to assess the efficacy of CBE as a screening modality when it is used alone versus usual care (no screening activity).
Screening by CBE may lead to the following harms:
Breast Self-examination
Breast self-examination (BSE) has been compared to usual care (no screening activity) but has not been shown to reduce breast cancer mortality.
Based on solid evidence, formal instruction and encouragement to perform BSE leads to more breast biopsies and diagnosis of more benign breast lesions.
Breast cancer incidence and mortality
Breast cancer is the most common noncutaneous cancer in U.S. women, with an estimated 63,300 cases of in situ disease, 226,870 new cases of invasive disease, and 39,510 deaths in 2012.[1] Thus, fewer than 1 of 6 women diagnosed with breast cancer die of the disease. By comparison, about 72,590 American women are estimated to die of lung cancer in 2012. Males account for 1% of breast cancer cases and breast cancer deaths (refer to the Special Populations section of this summary for more information).
Widespread adoption of screening increases breast cancer incidence in a given population and changes the characteristics of cancers detected, with increased incidence of lower-risk cancers, premalignant lesions, and ductal carcinoma in situ (DCIS). (Refer to the Ductal Carcinoma In Situ section in the Breast Cancer Diagnosis and Pathology section of this summary for more information.) Ecologic studies from the United States [2] and the United Kingdom [3] demonstrate an increase in DCIS and invasive breast cancer incidence since the 1970s, attributable to the widespread adoption of both postmenopausal hormone therapy and screening mammography. In the last decade, women have refrained from using postmenopausal hormones, and breast cancer incidence has declined, but not to the levels seen prior to the widespread use of screening mammography.[4]
One might expect that if screening identifies cancers before they cause clinical symptoms, then the period of screening will be followed by a period of compensatory decline in cancer rates, either in annual population incidence rates or in incidence rates in older women. However, no compensatory drop in incidence rates has ever been seen following the adoption of screening, suggesting that screening leads to overdiagnosis—the identification of clinically insignificant cancers (refer to the Overdiagnosis section in the Harms of Screening Mammography section of this summary for more information).
Breast cancer incidence and mortality risk also vary according to geography, culture, race, ethnicity, and socioeconomic status (refer to the Special Populations section of this summary for more information).
Risk Factors for Breast Cancer
Breast cancer risk is affected by many factors besides participation in screening activities. Understanding and quantifying these risks is important to a woman, to her physicians, and to public policy makers.
The incidence of breast cancer increases with a woman's age. As shown in Table 1, a 60-year-old woman has a higher risk of being diagnosed with breast cancer in the next 10 years than does a 40-year-old woman.
The cumulative lifetime incidence decreases with advancing age because the longer a woman lives without a breast cancer diagnosis, the lower her lifetime risk compared to a younger woman who might develop breast cancer at a younger or older age. The commonly quoted risk of one in eight women who will be diagnosed with breast cancer is based on lifetime risk of a diagnosis (not death) starting from birth and does not account for the woman's current age.[2]
Breast cancer mortality increases with age. For a 40-year-old woman without a breast cancer diagnosis, the chance of dying from breast cancer within the next 10 years is extremely small, but for a woman older than 65, it is about 1%. For a woman older than 70, the risk of dying of breast cancer is even higher, but the risk of dying of any cause is higher yet.[5]
Personal history of breast cancer
Women with a personal history of invasive breast cancer, DCIS, or lobular carcinoma in situ also have an increased risk of being diagnosed with a new primary breast cancer.[6] Recommendations for subsequent mammograms vary, but evidence for various strategies is scant.
Prior radiation therapy
Women treated with thoracic radiation before the age of 30 years have a 1% annual risk of breast cancer, starting 8 years after the irradiation and for the rest of their lives.[7,8] Annual screening with magnetic resonance imaging has been proposed in such women, beginning 8 years after treatment or by age 25 years, whichever is later.[9] Because this population is small, there are no studies to confirm the benefit of this recommendation.
Dense breast tissue
Women with radiologically dense breasts (heterogeneously dense or extremely dense in the terminology of the Breast Imaging Reporting and Data System [BI-RADS]) [10,11,12,13] have a threefold to sixfold increased risk of breast cancer compared with women who have fatty breasts.[14]
Other risk factors and risk prediction models
Other risk factors for breast cancer include an inherited predisposition (BRCA1 or BRCA2, and others); early age at menarche and late age at first birth; and previous breast biopsies showing benign proliferative breast disease.[15,16,17] Menopausal hormone use, obesity, lack of physical activity, and alcohol intake are associated with an increased risk of breast cancer. (Refer to the PDQ summaries on Cancer Prevention Overview and Breast Cancer Prevention for more information.) Several models estimate an individual woman's risk based on these and other factors.[18,19,20,21]
Evaluation of Breast Symptoms
Women with breast symptoms are not candidates for screening because they require a diagnostic evaluation. During a 10-year period, 16% of 2,400 women aged 40 to 69 years sought medical attention for breast symptoms at their health maintenance organization.[1] Women younger than 50 years were twice as likely to seek evaluation. Additional testing was performed in 66% of these women, including invasive procedures performed in 27%. Cancer was diagnosed in 6.2%, most often stage II or III. Of the breast symptoms prompting medical attention, a mass was most likely to lead to a cancer diagnosis (10.7%) and pain was least likely (1.8%) to do so.
Pathologic Diagnosis of Breast Cancer
Breast cancer is most often diagnosed by pathologic review of a fixed specimen of breast tissue. The breast tissue can be obtained from a symptomatic area or from an area identified by an imaging test. A palpable lesion can be biopsied with core needle biopsy or, less often, fine-needle aspiration biopsy or surgical excision; image guidance improves accuracy. Nonpalpable lesions can be sampled by core needle biopsy using stereotactic x-ray or ultrasound guidance or can be surgically excised after image-guided localization. In a retrospective study of 939 patients with 1,042 mammographically detected lesions who underwent core needle biopsy or surgical needle localization under x-ray guidance, sensitivity for malignancy was greater than 95% and the specificity was greater than 90%. Compared with surgical needle localization under x-ray guidance, core needle biopsy resulted in fewer surgical procedures for definitive treatment, with a higher likelihood of clear surgical margins at the initial excision.[2]
Ductal CarcinomaIn Situ
Ductal carcinoma in situ (DCIS) is a noninvasive condition that can evolve to invasive cancer, with variable frequency and time course.[3] Some authors include DCIS with invasive breast cancer statistics, but others argue that the term be replaced by ductal intraepithelial neoplasia, similar to the terminology used for cervical and prostate precursor lesions, and that breast cancer statistics exclude these DCIS cases.
DCIS is most often diagnosed by mammography. In the United States, only 4,900 women were diagnosed with DCIS in 1983, compared with approximately 63,000 women who are expected to be diagnosed in 2012, when mammographic screening has been widely adopted.[3,4,5] The Canadian National Breast Screening Study-2 of women aged 50 to 59 years found a fourfold increase in DCIS cases in women screened by clinical breast examination (CBE) plus mammography compared with those screened by CBE alone, with no difference in breast cancer mortality.[6] (Refer to the PDQ summary on Breast Cancer Treatment for more information.)
The natural history of DCIS is poorly understood because nearly all DCIS cases are treated. A single retrospective review of 11,760 breast biopsies performed between 1952 and 1968 identified 28 cases of DCIS,[7,8] which were detected by physical examination, biopsied without resection, and then followed for 30 years. Nine women developed invasive breast cancer and four women died of the disease. These findings are interesting but probably not relevant to women with screen-detected DCIS in an era of improved cancer care.
Development of breast cancer after treatment of DCIS depends on the characteristics of the lesion but also on the delivered treatment. One large randomized trial found that 13.4% of women treated by lumpectomy alone developed ipsilateral invasive breast cancer within 90 months, compared with 3.9% of those treated by lumpectomy and radiation.[9] The best evidence indicates that most DCIS lesions will not evolve to invasive cancer and that those that do can still usually be managed successfully, even after that transition. Thus, the detection and treatment of nonpalpable DCIS often represents overdiagnosis and overtreatment.
Among women diagnosed with (and treated for) DCIS between 1984 and 1989, only 1.9% died of breast cancer within 10 years,[10] which was a lower mortality rate than for the age-matched population at large. This favorable outcome may reflect the benign nature of the condition, the benefits of treatment, or the volunteer effect (women undergoing breast cancer screening are generally healthier than those who do not).
Attempts to define low-risk DCIS cases that can be managed with less therapies are important. One such effort analyzed a series of 706 DCIS patients who were monitored to develop the University of Southern California/Van Nuys Prognostic Scoring Index, which defines the risk of recurrent DCIS and invasive cancer among women with DCIS based on age, margin width, tumor size, and grade.[11] The low-risk group, comprising a third of the cases, experienced only 1% DCIS recurrences and no invasive cancers, independent of the use of postoperative radiation therapy. The moderate- and high-risk groups had higher recurrence rates, and they benefited from postlumpectomy radiation. Overall, only approximately 1% died of breast cancer. In a separate study, adjuvant tamoxifen therapy was shown to reduce the incidence of invasive breast cancer.[12]
Numerous uncontrolled trials and retrospective series have documented the ability of mammography to diagnose small, early-stage breast cancers, which have a favorable clinical course.[1] Although several trials also show better cancer-related survival in screened versus nonscreened women, a number of important biases may explain that finding:
Because the extent of these biases is never clear in any particular study, most groups rely on randomized controlled trials to assess the benefits of screening. (Refer to the Cancer Screening Summary Overview for more information.)
Assessment of Performance and Accuracy
Performance benchmarks for screening mammography in the United States are described on the Breast Cancer Surveillance Consortium (BCSC) Web site.
The sensitivity of mammography is the percentage of breast cancers detected in a given population, when breast cancer is present. Sensitivity depends on tumor size, conspicuity, and hormone sensitivity as well as breast tissue density, patient age, timing within the menstrual cycle, overall image quality, and interpretive skill of the radiologist. Overall sensitivity is approximately 79% but is lower in younger women and in those with dense breast tissue (see the BCSC Web site).[2,3,4] Delay in diagnosis of breast cancer is the most common cause of medical malpractice litigation and half of the cases resulting in payment to the claimant involve false-negative mammograms.[5]
Specificity and false-positive rate
The specificity of mammography is the likelihood of the test being normal when cancer is absent, whereas the false-positive rate is the likelihood of the test being abnormal when cancer is absent. If specificity is low, many false-positive examinations result in unnecessary follow-up examinations and procedures. (Refer to the subsection on Harms in the Screening With Mammography section of the Overview section of this summary for more information.)
Interval cancers
Interval cancers are cancers that are diagnosed in the interval after a normal screening examination and before the subsequent screen. Some of these cancers were present at the time of mammography (false-negatives), and others grew rapidly in the interval between mammography and detection. As a general rule, interval cancers have characteristics of rapid growth [6,7] and are frequently of advanced stage at the time of discovery/diagnosis.[8]
One study of 576 women with interval cancers reported that interval cancers are more prevalent in women aged 40 to 49 years. Interval cancers appearing within 12 months of a negative screening mammogram appear to be related to decreased mammographic sensitivity, attributable to greater breast density in 68% of cases. Those appearing within a 24-month interval appear to be related both to decreased mammographic sensitivity due to greater breast density in 37.6% and to rapid tumor growth in 30.6%.[9]
Another study that compared the characteristics of 279 screen-detected cancers with those of 150 interval cancers found that interval cancers were much more likely to occur in women younger than 50 years and to be of mucinous or lobular histology; or to have high histologic grade, high proliferative activity, relatively benign features mammographically and/or to lack calcifications. Screen-detected cancers were more likely to have tubular histology; to be smaller, low stage, and hormone sensitive; and to have a major component of ductal carcinoma in situ.[6]
Mammography Description and Background
Mammography utilizes ionizing radiation to image breast tissue. The examination is performed by compressing the breast firmly between two plates. Such compression spreads out overlapping tissues and reduces the amount of radiation needed to image the breast. For routine screening in the United States, examinations are taken in both mediolateral oblique and craniocaudal projections. Both views should include breast tissue from the nipple to the pectoral muscle. Radiation exposure is 4 to 24 mSv per standard two-view screening examination. Two-view examinations are associated with a lower recall rate than are single-view examinations because they eliminate concern about abnormalities due to superimposition of normal breast structures.[1]
Under the Mammography Quality Standards Act (MQSA) enacted by Congress in 1992, all U.S. facilities that perform mammography must be certified by the U.S. Food and Drug Administration (FDA) to ensure the use of standardized training for personnel and a standardized mammography technique utilizing a low radiation dose.[2] (Refer to the FDA's Web page on Mammography Facility Surveys, Mammography Equipment Evaluations, and Medical Physicist Qualification Requirement under MQSA.) The 1998 MQSA Reauthorization Act requires that patients receive a written lay-language summary of mammography results.
On screening, the following BI-RADS assessments are used: 1, negative; 2, benign; or 0, incomplete with additional evaluation needed.
About 10% of women screened will be recalled for additional evaluation; more than 80% of these will be considered normal or benign after a full diagnostic workup, which may include additional mammographic views, ultrasound, or both. About 15% of women recalled will be recommended for biopsy, with 30% of cases assessed as BI-RADS 4, suspicious, yielding cancer; and 95% of cases assessed as BI-RADS 5, highly suggestive of malignancy, yielding cancer. About 2% of women screened will be recommended for short-interval follow-up, assessed as BI-RADS 3, probably benign, with fewer than 2% of such women ultimately found to have cancer.[3]
Benefit of Mammography
Randomized controlled trials
Randomized controlled trials (RCTs), with participation by nearly half a million women from four countries, examined the breast cancer mortality rates of women who were offered regular screening. One trial, the Canadian National Breast Screening Study (NBSS)-2, compared mammogram plus clinical breast examination (CBE) with CBE alone; the other eight trials compared screening mammogram with or without CBE to a control consisting of usual care.
The trials differed in design, recruitment of participants, interventions (both screening and treatment), management of the control group, compliance with assignment to screening and control groups, and analysis of outcomes. Some trials used individual randomization, while others used cluster randomization in which cohorts were identified and then offered screening; one trial used nonrandomized allocation by day of birth in any given month. Cluster randomization sometimes led to imbalances between the intervention and control groups. Age differences have been identified in several trials, although the differences were probably too small to have a major effect on the trial outcome.[4] In the Edinburgh Trial, socioeconomic status, which correlates with the risk of breast cancer mortality, differed markedly between the intervention and control groups, so it is difficult, if not impossible, to interpret the results.
Breast cancer mortality is the major outcome parameter for each of these trials, so the methods used to determine cause of death are critically important. Efforts to reduce bias in the attribution of mortality cause have been made, including the use of a blinded monitoring committee (New York) and a linkage to independent data sources, such as national mortality registries (Swedish trials). Unfortunately, these attempts could not ensure a lack of knowledge of women's assignments to screening or control arms. Evidence of possible misclassification of breast cancer deaths in the Two-County Trial with possible bias in favor of screening has been analyzed.[5]
There were also differences in the methodology used to analyze the results of these trials. Four of the five Swedish trials were designed to include a single screening mammogram in the control group, timed to correspond with the end of the series of screening mammograms in the study group. The initial analysis of these trials used an 'evaluation' analysis, tallying only the breast cancer deaths that occurred in women whose cancer was discovered at or before the last study mammogram. In some of the trials a delay occurred in the performance of the end-of-study mammogram, resulting in more time for members of the control group to develop or be diagnosed with breast cancer. Other trials used a 'follow-up' analysis, which counts all deaths attributed to breast cancer, regardless of the time of diagnosis. This type of analysis was used in a meta-analysis of four of the five Swedish trials in response to concerns about the evaluation analyses.[5]
The accessibility of the data for international audits and verification also varies, with formal audit having been undertaken only in the Canadian trials. Other trials have been audited to varying degrees, usually with less rigor.[6]
All of these studies are designed to study breast cancer mortality rather than all-cause mortality because of the infrequency of breast cancer deaths relative to the total number of deaths. When all-cause mortality in these trials was examined retrospectively, only the Edinburgh Trial showed a significant difference, which could be attributed to socioeconomic differences. The meta-analysis (follow-up methods) of the four Swedish trials also showed a small but significant improvement of all-cause mortality.
The trials are described in detail in the Appendix of Randomized Controlled Trials section of this summary.
Summary of RCTs
Screening for breast cancer does not affect overall mortality, and the absolute benefit for breast cancer mortality is small.
A way to view the potential benefit of breast cancer screening is to estimate the number of lives extended because of early breast cancer detection.[7,8] The outcomes of 10,000 women aged 50 to 70 years who undergo a single screen.[9] Mammograms will be normal (true-negatives and false-negatives) in 9,500 women. Of the 500 abnormal screens, 466 to 479 will be false-positives, and 100 to 200 of these women will undergo invasive procedures. The remaining 21 to 34 abnormal screens will be true-positives, indicating breast cancer. Some of these women will die of breast cancer in spite of mammographic detection and optimal therapy, and some may live long enough to die of other causes even if the cancer had not been screen detected. The number of extended lives attributable to mammographic detection is between two and six. Another expression of this analysis is that one life may be extended per 1,700 to 5,000 women screened and followed for 15 years. The same analysis for 10,000 women aged 40 to 49 years, assuming the same 500 abnormal examinations, results in an estimate that 488 of these will be false-positives, and 12 will be breast cancer. Of these 12, there will probably be only one or two lives extended. Thus, for women aged 40 to 49 years, it is estimated that one or two lives may be extended per 5,000 to 10,000 mammograms.
While the numbers discussed above are from a single mammography exam, women undergo screening throughout their lifetimes, which can include 20 to 30 years of screening activity. A meta-analysis of RCTs conducted for the U.S. Preventive Services Task Force in 2009 (including the AGE Trial) found that the number needed to invite to screen for 10 years to avoid or delay one death from breast cancer was 1,904 for women in their 40s, 1,339 for women in their 50s, and 377 for women in their 60s.[10] A 2009 combined analysis by six Cancer Intervention and Surveillance Modeling Network modeling groups found that screening every 2 years maintained an average of 81% of the benefit of annual screening with almost half the false-positive results. Screening biennially from age 50 to 69 years achieved a median 16.5% reduction in breast cancer deaths versus no screening. Initiating biennial screening at age 40 years (vs. age 50 years) reduced breast cancer mortality by an additional 3%, consumed more resources, and yielded more false-positive results.[11]
Effectiveness of Population-Based Screening Programs
Although the RCTs of screening have addressed the issue of screening efficacy (i.e., the extent to which screening reduces breast cancer mortality under the ideal conditions of an RCT), they do not provide information about the effectiveness of screening (i.e., the extent to which screening is reducing breast cancer mortality in the U.S. population). Studies that provide information about this issue include nonrandomized controlled studies of screened versus nonscreened populations, case-control studies of screening in real communities, and modeling studies that examine the impact of screening on large populations. An important issue in all of these studies is the extent to which they can control for additional effects on breast cancer mortality such as improved treatment and heightened awareness of breast cancer in the community.
Two population-based, observational studies from Sweden compared breast cancer mortality in the presence and absence of screening mammography programs. One study compared two adjacent time periods in 7 of the 25 counties in Sweden and concluded a statistically significant breast cancer mortality reduction of 18% to 32% attributable to screening.[12] The most important bias in this study is that the advent of screening in these counties occurred over a period during which dramatic improvements in the effectiveness of adjuvant breast cancer therapy were being made, changes which were not addressed by the study authors. The second study considered an 11-year period comparing seven counties with screening programs to five counties without them.[13] There was a trend in favor of screening, but again, the authors did not consider the effect of adjuvant therapy or differences in geography (urban vs. rural) that might affect treatment practices.
In Nijmegen, the Netherlands, where a population-based screening program was undertaken in 1975, a case-cohort study showed that screened women have decreased mortality (odds ratio [OR] = 0.48).[14] However, a subsequent study comparing Nijmegen breast cancer mortality rates with neighboring Arnhem in the Netherlands, which had no screening program, showed no difference in breast cancer mortality.[15]
A community-based case-control study of screening as practiced in excellent U.S. health care systems between 1983 and 1998 found no association between previous screening and reduced breast cancer mortality. Mammography screening rates, however, were generally low.[16] The association among women at increased risk due to a family history of breast cancer or a previous breast biopsy (OR = 0.74; 95% confidence interval [CI], 0.50–1.03) was stronger than that among women at average risk (OR = 0.96; 95% CI, 0.80–1.14), but the difference was not statistically significant (P = .17).[16]
A well-conducted ecologic study compared three pairs of neighboring European countries, matched on similarity in health care systems and population structure, one of which had started a national screening program some years earlier than the others. The investigators found that each country had experienced a reduction in breast cancer mortality, with no difference between matched pairs that could be attributed to screening. The authors suggested that improvements in breast cancer treatment and/or health care organizations were more likely responsible for the reduction in mortality than was screening.[17]
A systematic review of ecologic and large cohort studies published through March 2011 compared breast cancer mortality in large populations of women aged 50 to 69 years who started breast cancer screening at different times. Seventeen studies met inclusion criteria. All studies had methodological problems, including control group dissimilarities, insufficient adjustment for differences between areas in breast cancer risk and breast cancer treatment, and problems with similar measurement of breast cancer mortality between compared areas. There was great variation in results among the studies, with four studies finding a relative reduction in breast cancer mortality of 33% or more (with wide confidence intervals) and five studies finding no reduction in breast cancer mortality. Because only a part of the overall reduction in breast cancer mortality could possibly be attributed to screening, the review concluded that any relative reduction in breast cancer mortality due to screening would likely be no more than 10%, less than predicted by the RCTs.[18]
Statistical Modeling of Breast Cancer Incidence and Mortality in the United States
The optimal screening interval has been addressed by modelers. Modeling makes assumptions that may not be correct; however, the credibility of modeling is greater when the model produces overall results that are consistent with randomized trials overall and when the model is used to interpolate or extrapolate. For example, if a model's output agrees with RCT outcomes for annual screening, then it has greater credibility in comparing the relative effectiveness of biennial versus annual screening.
In 2000, the National Cancer Institute formed a consortium of modeling groups (Cancer Intervention and Surveillance Modeling [CISNET]) to address the relative contribution of screening and adjuvant therapy to the observed decline in breast cancer mortality in the United States.[19] (Refer to the Randomized controlled trials section of this summary for more information.) These models gave reductions in breast cancer mortality similar to those expected in the circumstances of the RCTs but updated to the use of modern adjuvant therapy. In 2009, CISNET modelers addressed several questions related to the harms and benefits of mammography, including comparing annual versus biennial screening.[11] The proportion of reduction in breast cancer mortality maintained in moving from annual to biennial screening for women aged 50 to 74 years ranged across the six models from 72% to 95%, with a median of 80%.
Several studies have shown that the method of cancer detection is a powerful predictor of patient outcome,[1] which is useful for prognostication and treatment decisions. All of the studies accounted for stage, nodal status, and tumor size.
A 10-year follow-up study of 1,983 Finnish women with invasive breast cancer demonstrated that the method of cancer detection is an independent prognostic variable. When controlled for age, nodal status, and tumor size, screen-detected cancers had a lower risk of relapse and better overall survival. For women whose cancers were detected outside screening, the hazard ratio (HR) for death was 1.90 (95% confidence interval [CI], 1.15–3.11), even though they were more likely to receive adjuvant systemic therapy.[2]
Similarly, an examination of the breast cancers found in three randomized screening trials (Health Insurance Plan, National Breast Screening Study [NBSS]-1, and NBSS-2) accounted for stage, nodal status, and tumor size and determined that patients whose cancer was found via screening have a more favorable prognosis. The relative risks for death were 1.53 (95% CI, 1.17–2.00) for interval and incident cancers, compared with screen-detected cancers; and 1.36 (95% CI, 1.10–1.68) for cancers in the control group, compared with screen-detected cancers.[3]
A third study compared the outcomes of 5,604 English women with screen-detected cancers to those with symptomatic breast cancers diagnosed between 1998 and 2003. After controlling for tumor size, nodal status, grade, and patient age, researchers found that the women with screen-detected cancers fared better than their symptomatic counterparts. The HR for survival of the symptomatic women was 0.79 (95% CI, 0.63–0.99).[4] Thus, method of cancer detection is a powerful predictor of patient outcome,[2] which is useful for prognostication and treatment decisions. The findings of this study are also consistent with the evidence that some screen-detected cancers are low risk and represent overdiagnosis.
Mammography screening may be effective in reducing breast cancer mortality in certain populations, but it can pose harm to women who participate. The limitations are best described as discomfort associated with the test, false-positives (related to the specificity of the test), false-negatives (related to the sensitivity of the test), radiation risk and overdiagnosis (true-positives that will not become clinically significant).
Compression of the breast is important during a mammogram to reduce motion artifact and improve image quality. Positioning of the woman is important. One study that evaluated how often pain and discomfort are felt during mammography reported that 90% of women undergoing mammography had discomfort, and 12% rated the sensation as intense or intolerable.[1]
False-Positives Leading to Possible Additional Interventions and Anxiety
The specificity of mammography (refer to the Breast Cancer Screening Concepts section of this summary for more information) affects the number of additional interventions due to false-positive results. Even though breast cancer is the most common noncutaneous cancer in women, fewer than 5 per 1,000 women actually have the disease when they are screened. Therefore, even with a specificity of 90%, most abnormal mammograms are false-positives.[2] Women with abnormal screening mammograms undergo additional mammographic imaging to magnify the area of concern, ultrasound, magnetic resonance imaging, and tissue sampling (by fine-needle aspiration, core biopsy, or excisional biopsy).
A study of breast cancer screening in 2,400 women enrolled in a health maintenance organization found that over a 10-year period, 88 cancers were diagnosed, 58 of which were identified by mammography. During that period, one-third of the women had an abnormal mammogram result that required additional testing, including 539 additional mammograms, 186 ultrasound examinations, and 188 biopsies. The cumulative biopsy rate (the rate of true-positives) due to mammographic findings was approximately 1 in 4 (23.6%). The positive predictive value (PPV) of an abnormal screening mammogram in this population was 6.3% for women aged 40 to 49 years, 6.6% for women aged 50 to 59 years, and 7.8% for women aged 60 to 69 years.[3] A subsequent analysis and modeling of data from the same cohort of women, all of whom were continuously enrolled in the Harvard Pilgrim Health Care plan from July 1983 through June 1995, estimated that the risk of having at least one false-positive mammogram was 7.4% (95% confidence interval [CI], 6.4%–8.5%) at the first mammogram, 26.0% (95% CI, 24.0%–28.2%) by the fifth mammogram, and 43.1% (95% CI, 36.6%–53.6%) by the ninth mammogram.[4] Cumulative risk of at least one false-positive by the ninth mammogram varied from 5% to 100%, depending on four patient variables (younger age, higher number of previous breast biopsies, family history of breast cancer, and current estrogen use) and three radiologic variables (longer time between screenings, failure to compare the current and previous mammograms, and the individual radiologist's tendency to interpret mammograms as abnormal). Overall, the biggest risk factor for having a false-positive mammogram was the individual radiologist's tendency to read mammograms as abnormal.
By reviewing Medicare claims following mammographic screening in 23,172 women older than 65 years, one study [5] found that, per 1,000 women, 85 had follow-up testing, 23 had biopsies, and 7 had cancer. Thus, the PPV for an abnormal mammogram was 8%. For women older than 70 years, the PPV was 14%.
An audit of mammograms performed in 1998 at a single institution revealed that 14.7% of examinations resulted in a recommendation for additional testing (Breast Imaging Reporting and Data System category 0), 1.8% resulted in a recommendation for biopsy (categories 4 and 5), and 5.7% resulted in a recommendation for short-term interval mammography (category 3). Cancer was diagnosed in 0.5% of the cases referred for additional testing.[6]
Because large numbers of women have false-positive tests, the issue of psychological distress—which may be provoked by the additional testing—has been studied. A telephone survey of 308 women performed 3 months after screening mammography revealed that about one-fourth of the 68 women with a "suspicious" result were still experiencing worry that affected their mood or functioning, even though subsequent testing had ruled out a cancer diagnosis.[7] Several studies,[8,9,10] however, show that the anxiety following evaluation of a false-positive test leads to increased participation in future screening examinations.[11]
False-Negatives Leading to Possible False Sense of Security
The sensitivity of mammography (refer to the Breast Cancer Screening Concepts section of this summary for more information) ranges from 70% to 90%, depending on a woman's age and the density of her breasts, which is affected by her genetic predisposition, hormone status, and diet. Assuming an average sensitivity of 80%, mammograms will miss approximately 20% of the breast cancers that are present at the time of screening (false-negatives). Many of these missed cancers are high risk, with adverse biologic characteristics (refer to the Interval cancers section in the Breast Cancer Screening Concepts section of this summary for more information ). If a 'normal' mammogram dissuades or postpones a woman or her doctor from evaluating breast symptoms, she may suffer adverse consequences. Thus, a negative mammogram should never prevent work-up of breast symptoms.
Radiation Exposure
The major predictors of radiation risk are young age at exposure and dose. For women older than 40 years, the benefits of annual mammograms probably outweigh the potential risk,[12] but certain subpopulations of women may have an inherited susceptibility to ionizing radiation damage.[13,14] In the United States, the mean glandular dose for screening mammography is 1 mGy to 2 mGy (100–200 mrad) per view or 2 mGy to 4 mGy (200–400 mrad) per standard two-view exam.[15,16]
Overdiagnosed disease is a neoplasm that would never become clinically apparent without screening before a patient's death. The prevalence of cancer in women who died of noncancer causes is surprisingly high. In an overview of seven autopsy studies, the median prevalence of occult invasive breast cancer was 1.3% (range, 0%–1.8%) and of ductal carcinoma in situ was 8.9% (range, 0%–14.7%).[17,18] A "perfect" screening test would identify approximately 10% of "normal" women as having breast cancer, even though most of those cancers would probably not result in illness or death. Treatment of these cancers would constitute overtreatment.
Currently, cancers that will cause illness and/or death cannot be confidently distinguished from those that will remain occult, so all cancers are treated.
To determine the number of screen-detected cancers that are overdiagnosed, one can compare breast cancer incidence over time in a screened population with that of an unscreened population.
Population-based studies could demonstrate the extent of overdiagnosis if the screened and nonscreened populations were the same except for screening. Unfortunately, the populations may differ in time, geography, culture, and the use of postmenopausal hormone therapy. Investigators also differ in their calculation of overdiagnosis as they adjust for characteristics such as lead-time bias.[19,20] As a consequence, the magnitude of overdiagnosis due to mammographic screening is controversial, with estimates ranging from 0% to 54%.[19,20,21,22]
Several observational population-based comparisons consider breast cancer incidence before and after adoption of screening.[23,24,25,26,27] If there were no overdiagnosis—and other aspects of screening were unchanged—there would be a rise in incidence followed by a decrease to below the prescreening level, and the cumulative incidence would be similar. Such results have not been observed. Breast cancer incidence rates increase at the initiation of screening without a compensatory drop in later years. One study in 11 rural Swedish counties showed a persistent increase in breast cancer incidence following the advent of screening.[24] A population-based study showed increases in invasive breast cancer incidence of 54% in Norway and 45% in Sweden in women aged 50 to 69 years, following the introduction of nationwide screening programs. No corresponding decline in incidence in women older than 69 years was ever seen.[28] Similar findings suggestive of overdiagnosis have been reported from the United Kingdom [25] and the United States.[26,27]
Patient Characteristics
Several characteristics of women being screened that are associated with the accuracy of mammography include age, breast density, whether it is the first or subsequent exam, and time since last mammogram. Younger women have lower sensitivity and higher false-positive rates on screening mammography than do older women (refer to the Breast Cancer Surveillance Consortium performance measures by age for more information).
For women of all ages, high breast density is associated with 10% to 29% lower sensitivity.[1] High breast density is an inherent trait, which can be familial [2,3] but also may be affected by age, endogenous [4] and exogenous [5,6] hormones,[7] selective estrogen receptor modulators such as tamoxifen,[8] and diet.[9] Hormone therapy is associated with increased breast density and is associated not only with lower sensitivity but also with an increased rate of interval cancers.[10]
The Million Women Study in the United Kingdom revealed three patient characteristics that were associated with decreased sensitivity and specificity of screening mammograms in women aged 50 to 64 years: use of postmenopausal hormone therapy, prior breast surgery, and body mass index below 25.[11] In addition, a longer interval since the last mammogram increases sensitivity, recall rate, and cancer detection rate and decreases specificity.[12]
Strategies have been proposed to improve mammographic sensitivity by altering diet, timing mammograms with menstrual cycles, interrupting hormone therapy before the examination, or using digital mammography machines.[13] Obese women have more than a 20% increased risk of having false-positive mammography results compared with underweight and normal weight women, although sensitivity is unchanged.[14]
Tumor Characteristics
Some cancers are more easily detected by mammography than other cancers are. In particular, mucinous, lobular, and rapidly growing cancers can be missed because their appearance on x-rays is similar to that of normal breast tissue.[15] Medullary carcinomas may be similarly missed.[16] Some cancers, particularly those associated with BRCA 1/2 mutations, masquerade as benign tumors.[17,18]
Physician Characteristics
Radiologist performance is critical to assessing mammographic interpretive performance, yet there is substantial, well-documented variability among radiologists. Factors that influence radiologists' performance include their level of experience and the volume of mammograms they interpret.[19] There is often a trade-off between sensitivity and specificity, such that higher sensitivity may be associated with lower specificity. Radiologists in academic settings have a higher positive predictive value (PPV) of their recommendations to undergo biopsy than do community radiologists.[20] Fellowship training in breast imaging may lead to improved cancer detection, but it is associated with higher false-positive rates.[13]
Facility Characteristics
After controlling for patient and radiologist characteristics, screening mammography interpretive performance (specificity, PPV, area under the curve [AUC]) varies by facility and is associated with facility-level characteristics. Higher interpretive accuracy of screening mammography was seen at facilities that offered screening examinations alone, included a breast imaging specialist on staff, did single as opposed to double readings, and reviewed interpretive audits two or more times each year.[21]
False-positive rates vary significantly between facilities performing diagnostic mammography and are higher at facilities where concern about malpractice is high.[22] False-positive rates are also higher at facilities serving vulnerable women (women of racial or ethnic minorities and women with lower educational attainment, limited household income, or rural residence) than at facilities serving nonvulnerable women, perhaps because of poorer compliance with recommendations for follow-up examinations.[23] Analyses that do not adjust for important patient characteristics may falsely conclude that there is more facility variation in overall accuracy than actually exists.[22]
International Comparisons
International comparisons of screening mammography have found higher specificity in countries with more highly centralized screening systems and national quality assurance programs.[24,25] For example, one study reported that the recall rate is twice as high in the United States as it is in the United Kingdom, yet there is no difference in the rate of cancers detected. Such comparisons may be confounded by social, cultural, and economic factors.[25]
Prevalent Versus Subsequent Examination and the Interval Between Exams
The likelihood of diagnosing cancer is highest with the prevalent (first) screening examination, ranging from 9 to 26 cancers per 1,000 screens, depending on the woman's age. The likelihood decreases for follow-up examinations, ranging from 1 to 3 cancers per 1,000 screens.[26] The optimal interval between screening mammograms is unknown. In particular, the breast cancer mortality-focused, randomized, controlled trials (RCTs) used single screening intervals with little variability across the trials. A prospective United Kingdom trial randomly assigned women aged 50 to 62 years to receive mammograms annually or at the standard 3-year interval. Although the grade and node status were similar in both groups, more cancers of slightly smaller size were detected in the annual screening group, with a lead time of approximately 7 months in comparison with triennial screening.[27]
A large observational study found a slightly increased risk of late-stage disease at diagnosis for women in their 40s who were adhering to a 2-year versus a 1-year schedule (28% vs. 21%; odds ratio = 1.35; 95% confidence interval [CI], 1.01–1.81), but no difference was seen for women in their 50s or 60s.[28,29]
A Finnish study of 14,765 women aged 40 to 49 years assigned women born in even-numbered years to annual screens and women born in odd-numbered years to triennial screens. The study was small in terms of number of deaths, with low power to discriminate breast cancer mortality between the two groups. There were 18 deaths from breast cancer in 100,738 life-years in the triennial screening group and 18 deaths from breast cancer in 88,780 life-years in the annual screening group (hazard ratio, 0.88; 95% CI, 0.59–1.27).[30]
Digital Mammography
Digital mammography is more expensive than screen-film mammography (SFM) but is more amenable to data storage and sharing. Performance of both technologies has been compared directly in several trials yielding similar results.
A large cohort of women undergoing both types of mammography was evaluated at 33 U.S. centers in the Digital Mammographic Imaging Screening Trial (DMIST), showing no differences in mammographic sensitivity and specificity. Digital mammography had a higher sensitivity in premenopausal and perimenopausal women, in women younger than 50 years, and in women with dense breasts, according to a planned subset analysis.[13] Digital mammography was associated with lower sensitivity among women older than 65 years.
An Italian trial of parallel cohorts of 14,385 women matched for age and interpreting radiologist were screened by either full-field digital or SFM. Recall rate and cancer detection rate, especially for clustered microcalcifications, were higher for digital mammography, whereas the recall rate for poor technical quality was higher for SFM. PPV—the probability that an individual with a positive screening result has the disease—was the same.[31]
The Oslo II Study randomly assigned women to screening by digital mammography (n = 6,944) or SFM (n = 16,985) with soft-copy double reading by experienced radiologists. Recall and cancer detection rates were higher for digital mammography, but there was no difference in PPV or incidence of interval cancers.[32]
A study of a single-center population-based screening program in the Netherlands compared women aged 50 to 75 years screened by full-field digital mammography (FFDM) that included computer-aided detection (CAD) with women screened by SFM. In 5 years, 311,082 screening examinations were done by SFM and 56,518 by FFDM. The groups were assembled without obvious bias but without randomization. The recall rate was higher in the FFDM group, but there was no difference in detection of invasive breast cancer. There was higher detection of ductal carcinoma in situ (DCIS) in the FFDM group related to increased detection of clustered microcalcifications.[33]
A review of ten controlled studies of various designs found that, overall, digital mammography increases breast cancer detection (combining invasive cancer and DCIS) and that recall rates are not consistently better with either technology.[34]
Mammography and CAD
CAD systems are designed to help radiologists read mammograms by highlighting suspicious regions such as clustered microcalcifications and masses.[35] Generally, CAD systems increase sensitivity and decrease specificity [36] and increase detection of DCIS.[37] Several CAD systems are in use. One large population-based study comparing recall rates and breast cancer detection rates before and after the introduction of CAD systems found no change in either rate.[35,38] Another large study noted an increase in recall rate and increased DCIS detection but no improvement in cancer detection rate.[37]
No randomized trials of clinical breast examination (CBE) as a sole screening modality have yet been reported. The Canadian National Breast Screening Study (NBSS) compared high-quality CBE plus mammography to CBE alone in women aged 50 to 59 years (refer to the Clinical Breast Examination section in the Overview section of this summary for more information). CBE, lasting 5 to 10 minutes per breast, was conducted by trained health professionals, with periodic evaluations of performance quality. The frequency of cancer diagnosis, stage, interval cancers, and breast cancer mortality were similar in the two groups and compared favorably with other trials of mammography alone, perhaps because of the careful training and supervision of the health professionals performing CBE.[1] Breast cancer mortality with follow-up 11 to 16 years after entry (mean = 13 years) was similar in the two screening arms (mortality rate ratio, 1.02 [95% confidence interval [CI], 0.78–1.33]).[2] The investigators estimated the operating characteristics for CBE alone; for 19,965 women aged 50 to 59 years, sensitivity was 83%, 71%, 57%, 83%, and 77% for years 1, 2, 3, 4, and 5 of the trial, respectively; specificity ranged between 88% and 96%. Positive predictive value (PPV), which is the proportion of cancers detected per abnormal examination, was estimated to be 3% to 4%. For 25,620 women aged 40 to 49 years who were examined only at entry, the estimated sensitivity was 71%, specificity was 84%, and PPV was 1.5%.[3]
Among community clinicians, screening CBE has higher specificity (97%–99%) [4] and lower sensitivity (22%–36%) compared with examiners in clinical trials of breast cancer screening.[5,6,7,8] A study of screening in women with a positive family history of breast cancer showed that, after a normal initial evaluation, the patient herself or her clinician performing a CBE identified more cancers than did mammography.[9] Another study examined the usefulness of adding CBE to screening mammography; among 61,688 women older than 40 years and screened by mammography and CBE, sensitivity for mammography was 78%, and combined mammography-CBE sensitivity was 82%. Specificity was lower for women undergoing both screening modalities than it was for women undergoing mammography alone (97% vs. 99%).[10] Two international trials of CBE are under way in India and Egypt.
Monthly breast self-examination (BSE) has been promoted, but there is no solid evidence that it is effective in reducing breast cancer mortality.[11,12] The only large, well-conducted, randomized clinical trial of BSE randomly assigned 266,064 women factory workers in Shanghai to receive either BSE instruction with reinforcement and encouragement, or instruction on the prevention of lower back pain. Neither group received any other breast cancer screening. After 10 to 11 years of follow-up, 135 breast cancer deaths occurred in the instruction group, and 131 cancer deaths occurred in the control group (relative risk [RR] = 1.04; 95% CI, 0.82–1.33). Although the number of invasive breast cancers diagnosed in the two groups was about the same, women in the instruction group had more breast biopsies and more benign lesions diagnosed than did women in the control group.[13]
Other research on BSE is limited. First, Leningrad investigators cluster-randomized more than 100,000 women to BSE training or control. The group that received BSE training had more breast biopsies but no improvements in breast cancer mortality.[14] Second, in the U.K. Trial of Early Detection of Breast Cancer, two districts invited more than 63,500 women aged 45 to 64 years to educational sessions about BSE. After 10 years of follow-up, there was no difference in breast cancer mortality rates compared to those in women from centers without organized BSE education (RR = 1.07; 95% CI, 0.93–1.22).[15] Third, and last, a case-control study nested within the Canadian NBSS compared self-reported BSE frequency before enrollment with breast cancer mortality. Women who examined their breasts visually, used their finger pads for palpation, and used their three middle fingers had a lower breast cancer mortality rates.[16]
The primary role of ultrasound is the diagnostic evaluation of palpable or mammographically identified masses, rather than serving as a primary screening modality. A review of the literature and expert opinion by the European Group for Breast Cancer Screening concluded that "there is little evidence to support the use of ultrasound in population breast cancer screening at any age."[17] In the setting of normal mammography and ultrasonography, less than 3% of women who have a lump will ultimately be found to have breast cancer.[18,19,20,21]
Magnetic Resonance Imaging
Breast magnetic resonance imaging (MRI) may be used in women for diagnostic evaluation, including evaluating the integrity of silicone breast implants, assessing palpable masses following surgery or radiation therapy, detecting mammographically and sonographically occult breast cancer in patients with axillary nodal metastasis, and preoperative planning for some patients with known breast cancer. There is no ionizing radiation exposure with this procedure. It has been promoted as a screening test for breast cancer among women at elevated risk of breast cancer based on BRCA 1/2 mutation carriers, a strong family history of breast cancer, or several genetic syndromes such as Li-Fraumeni or Cowden disease.[22,23,24] Breast MRI is more sensitive but less specific than screening mammography [25,26] and is more expensive.
Direct comparisons of breast MRI and mammography in young high-risk women report MRI sensitivities of 71% to100% versus mammography sensitivities of 20% to 50%. Contrast-enhancing foci are seen frequently in healthy breasts, so false-positive results are common.[27,28] In these studies, MRI specificities range from 37% to 97%, with threefold to fivefold higher recall rates and substantially lower PPVs. Thus, women who are screened with MRI have more negative surgical biopsies.[25]
Because all studies of MRI screening are observational, none can assess morbidity, survival, or mortality, compared with other screening modalities,[29] though it is likely that MRI screening results in overdiagnosis (refer to the Overdiagnosis section in the Harms of Screening Mammography section of this summary for more information).
Using infrared imaging techniques, thermography of the breast identifies temperature changes in the skin as an indicator of an underlying tumor, displaying these changes in color patterns. Thermographic devices have been approved by the FDA under the 510(k) process, which does not require evidence of clinical effectiveness. There have been no randomized trials of thermography to evaluate the impact on breast cancer mortality or the ability to detect breast cancer. Small cohort studies do not suggest any additional benefit for the use of thermography as an adjunct modality for breast cancer screening.[30,31]
Tissue Sampling (Fine-Needle Aspiration, Nipple Aspirate, Ductal Lavage)
Various methods to analyze breast tissue for malignancy have been proposed as screening methods for breast cancer.
Random periareolar fine-needle aspirates were performed in 480 women at high risk for breast cancer, and the women were monitored for a median of 45 months.[32] Twenty women developed breast neoplasms (13 invasive and 7 ductal carcinoma in situ[DCIS]). Using multiple logistic regression and Cox proportional hazards analysis, a diagnosis of hyperplasia with atypia was found to be associated with the subsequent development of DCIS and invasive breast cancer.
Nipple aspirate fluid cytology was studied in 2,701 women who were monitored for subsequent incidence of breast cancer, with an average of 12.7 years of follow-up.[33] Breast cancer incidence overall was 4.4%, including 11 cases of DCIS and 93 cases of invasive cancer, and was associated with abnormal nipple aspirate fluid cytology. Whereas the breast neoplasm rate was only 2.6% for 352 women in whom no fluid could be aspirated, it was 5.5% for 327 women with epithelial hyperplasia and 10.3% for 58 women with atypical hyperplasia.
One study reported results of nipple aspiration followed by ductal lavage in 507 women at high risk for breast cancer.[34] Nipple aspirate fluid was obtained from 417 women, but only 111 (27%) were adequate samples. A total of 383 ductal lavage samples were evaluated, 299 (78%) of which were adequate for diagnosis. Abnormal cells were found in 92 (24%) ductal lavage samples, including 88 (17%) with mild atypia, 23 (6%) with marked atypia, and 1 (<1%) malignant. The corresponding numbers and percentages for nipple aspiration fluid were 16 (6%), 8 (3%), and 1 (<1%). Discomfort with the ductal lavage procedure was judged by participants to be comparable to mammography. Because ductal lavage screening has not been compared to mammography and there is no evidence of efficacy or mortality reduction, its use as a screening or diagnostic tool remains investigational.
Individuals With Little to Gain from Screening
Women with limited life expectancy
Achieving balance between the benefits and harms of screening is especially important for women with a life expectancy of 5 years or less. Such women might have end-stage renal disease, severe dementia, terminal cancer, or severe comorbid disease with functional dependencies in activities of daily living. Early cancer detection and prompt treatment are unlikely to reduce morbidity or mortality within a woman's 5 years of expected survival, but the negative consequences of screening will occur immediately. Abnormal screening may trigger additional testing, with the attendant anxiety. In particular, the detection of a low-risk malignancy would probably result in a recommendation for treatment, which could impair rather than improve quality of life, without improving survival. Despite these considerations, many women with poor life expectancy due to age or health status often undergo screening mammography.[1] A sizable proportion of patients with advanced cancer continue to undergo cancer screening tests that do not have a meaningful likelihood of providing benefit. For example, among women with advanced cancer compared with controls, at least 1 screening mammogram was received by 8.9% (95% confidence interval [CI], 8.6%–9.1%) versus 22.0% (95% CI, 21.7%–22.5%).[2]
Elderly women
Screening mammography in women older than 65 years often results in additional diagnostic testing in 85 per 1,000 women, with cancer diagnosed in 9 women. The testing is often accomplished over many months, which may cause anxiety.[3] While screening mammography may yield cancer diagnoses in approximately 1% of elderly women, many of these cancers are low risk. A study of California Medicare beneficiaries aged 65 to 79 years demonstrated this clearly. The relative risk (RR) of detecting localized breast cancer was 3.3 (95% CI, 3.1–3.5) among screened women. Diagnosis of metastatic cancer was reduced among screened women (RR = 0.57), suggesting a benefit of mammography screening in elderly women, though it comes with an increased risk of overdiagnosis.[4]
Screening women in their 80s and 90s should be performed on a case-by-case basis, with comorbid diseases and life expectancy taken into consideration when making this decision.
Young women
There is no evidence for performing screening mammography in average-risk women younger than 40 years.
Approximately 1% of all breast cancers occur in men. Most cases are diagnosed during the evaluation of palpable lesions, which are generally easy to detect. Treatment consists of surgery, radiation, and systemic adjuvant hormone therapy or chemotherapy. Because of the rarity of the disease, it is extremely unlikely that any screening modality would be useful.
Individuals at Increased Risk of Breast Cancer and Thus Possibly With More to Gain From Screening
Women who have received thoracic radiation
Screening for breast cancer has been recommended for women exposed to therapeutic radiation to the chest, especially if they were exposed at an early age. One systematic review of observational studies of women exposed to large doses (≥20 Gy) of chest radiation before age 30 years found standardized incidence ratios of 13.3 to 55.5 for breast cancer, with no plateau with increasing age.[5] Screening mammography and magnetic resonance imaging can identify early-stage cancers in these women, but the benefits and risks have not been clearly defined.
Although age-adjusted breast cancer incidence rates are higher in white women than in black women, mortality rates are higher in black women. Among breast cancer cases diagnosed from 2001 to 2007, 61% of white women and only 51% of black women had localized disease. The 5-year relative survival rate for localized disease was 99.3% for white women and 92.6% for black women; for regional disease, it was 85.2% for white women and 72% for black women; and for distant disease, it was 24.7% for white women and 14.8% for black women.[6] Both breast cancer incidence and mortality are lower among Hispanic and Asian/Pacific Islander women than among white and black women.[6] Survival in black women may be worse than in white women at least in part because of a higher frequency of adverse histologic features, such as a triple-negative phenotype.[7]
Several explanations for these findings have been proposed, including lower socioeconomic status, lower level of education, and less access to screening and treatment services. Population-based studies demonstrate that, compared with other groups, Medicaid recipients and uninsured patients of all races have later-stage breast cancer diagnosis, and survival from the time of diagnosis is shorter. These differences are associated with socioeconomic status and may reflect lack of participation in screening activities.[8,9] Black women older than 65 years are less likely to undergo mammogram screening. Among regular users of mammography, however, cancer was diagnosed in black and white women at similar stages.[10]
Similar studies of Hispanic populations have been conducted. Breast cancer stage at diagnosis in San Diego County, California, was more advanced for Hispanic women than for white women, especially for those younger than 50 years. Low-income whites were more likely to have late-stage diagnosis than high-income whites. Among Hispanic women, there was no difference according to income, but all the Hispanic groups were at or below the lowest white income level.[11] In New Mexico, a population-based case-control study examined the reproductive histories of 719 Hispanic and 836 white breast cancer patients, with half of each group having breast cancer. The Hispanic women had higher body mass index, higher parity, and earlier pregnancies.[12] Whereas reproductive factors such as age at first full-term birth, parity, and duration of lactation accounted for some of the ethnic differences in breast cancer incidence for postmenopausal women, there was no evidence that these factors played a role in the differences for premenopausal patients. A study of mammography screening in an Albuquerque health maintenance organization found that Hispanic women had consistently lower rates of screening than did whites (50.6% vs. 65.5% in 1989, and 62.7% vs. 71.6% in 1996).[13] Predictors of more advanced stage at diagnosis included Hispanic race (odds ratio, 2.12) and younger age.
Health Insurance Plan, United States 1963 [1,2]
Malmo, Sweden 1976[3,4]
Ostergotland (County E of Two-County Trial), Sweden 1977[6,7,8]
Kopparberg (County W of Two-County Trial), Sweden 1977 [6,7,8]
Edinburgh, United Kingdom 1976 [10]
The study design and conduct make these results difficult to assess or combine with the results of other trials.
NBSS-1, Canada 1980 [11]
NBSS-2, Canada 1980 [15]
Stockholm, Sweden 1981 [16]
Gothenberg, Sweden 1982
AGE Trial[17]
This summary was comprehensively reviewed and extensively revised.
This summary is written and maintained by the PDQ Screening and Prevention Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
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This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about breast cancer screening. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
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This summary is reviewed regularly and updated as necessary by the PDQ Screening and Prevention Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
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National Cancer Institute: PDQ® Breast Cancer Screening. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional. Accessed <MM/DD/YYYY>.
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text:
Camel and Horsehair Canvas from Gilt Edge Suitings
Posted 28 February 2010 - 12:25 AM
According to Antonio Argentino, even some of the better know Italian firms selling canvas may be having their canvasses made up in China and other faraway places. However, this is not for them, and all of their offerings are all made in Italy
In this review, we will be looking mainly at the camel hair based body canvasses from this firm. However, there are one or two horse hair chest canvasses amongst the selection, which would be worthwhile including. They feel that the main strength of their canvas selection is that they are woven to be balanced. This means that if you wet them and then allow then to dry out they will undulate but never curl up. I take it this means that the amount of shrinkage in warp and weft remains balanced.
Their contact details for all of those interested in purchasing from them is as follows:
Gilt Edge Suiting
Tel: 0044 1254 831311
79 Bolton Rd,
Abbey Village,
Lancashire PR6 8DP
Antonio Argentino: email@example.com
The first one has a fairly solid weight of 320 gr.mtq. WARP 100% WOOL weft 80%wool 20%hair.
The next one feels weightier, and a bit springier, but is in fact less at 303 gr.mtq. WOOL 43% HAIR 10% VISCOSE WOOL 47%.
Next is a nice medium weight option with camel hair at 240 gr.mtq. WOOL 43% HAIR13% VISCOSE WOOL RAYON 44%
The Nocetta 2018 is a body canvas that weighs 243 gr.mtq. Viscose wool 47% wool 53%
The NASA 00140 is softer and weighs 210 gr.mtq. Viscose wool 40% wool 60%.
The AO 210 is more stoutly woven at 295 gr.mtq. WOOL 35% 15% HAIR 50% VISCOSE WOOL RAYON.
The AO 210/2003 is its softer cousin. 240 gr.mtq. WOOL43% HAIR13% VISCOSE WOLL RAYON44%.
The AO 2005 feels very similar but a tad lighter and softer still. I haven't been given the exact weight and composition for this one.
ISO 3016 feels very similar to the previous one. 225gr.mtq. WOOL36% VISCOSE WOOL RAYON52% HAIR12%
Pegaso 1630 is another similar weave and composition, except it is a bit lighter and softer. 215 gr.mtq WOOL36% VISCOSE WOOL RAYON52% HAIR 12%
SI R BLU is another medium weight variation at 222gr.mtq. WOOL36% VISCOSEWOOLRAYON52% HAIR 12%
Cristallo 228 is a soft and of feather light tropical weight at only 150gr.mtq with some cotton in it. WOOL30% VISCOSE60% COTTON10%.
SO 228 is extremely soft and of feather light tropical weight at 155 gr.mtq but feels even softer in the weave that the Cristallo version. WOOL30% VISCOSE60% COTTON10%.
SE SA 503 is another canvas that will give a more structure feel to a coat. It also has a very slightly bristly finish to help it grip the cloth. 275gr.mtq. PURE COTTON30% RAYONVISCOSE56% HAIR14%.
There is also a light version of the same weave. 205 gr.mtq. 30%PURECOTTON 60%RAYONVISCOSE 10%HAIR.
AA.NO 00518 is 260gr.mtq. 30%purecotton 56%rayonviscose 14%hair.
A softer version is AA 00150. 203 gr.mtq. 30%purecotton 60%rayonviscose 10%hair
CO 625 is another much ultra soft and feather weight canvas. 145 gr.mtq. 42%pure cotton 56%viscose wool 2%hair.
The Monterosa remains soft and light but still has some body to it. 160 gr.mtq. 42%pure cotton 56% viscose wool 2% hair.
The Mont Blanc is another ultra light canvas. 145gr.mtq. 40%pure cotton 58% viscosewool 2%hair.
The CO.NO 625/N is another variation on the soft canvas, but dyed black. 155 gr.mtq. 42% purecotton 56%viscose wool 2%hair.
The Violetta is has just a touch more hair and less cotton to give it tag more spring while remaining ultra soft. 145 gr.mtq. 30%pure cotton55%viscose 5%hair10%rayon.
The Viola Black is the softest and lightest of them all at 125 gr.mtq. 40% pure cotton 57%viscosewool 3%hair.
It also comes in a white version called Violetta Bianco. 125 gr.mtq. 40% pure cotton 57%viscose wool 3%hair.
The Lilla' is a bit more substantial at 175gr.mtq, but with a lot more hair content to give it spring. 40%pure cotton 46%rayonviscose 14%hair.
The Crinone AZ 85 feels like it is probably meant to be used as chest canvas, although available in widths suggestive of heavy body canvas. It has a weight reminiscent of Hänsel Orange or Laptair. However it has a totally different weave and is much more impressively springy . Unfortunately, I have not been given the exact weight or fibre content. However, the springiness of the canvas suggests a high hair content.
Last comes the type of chest canvas that in German is called Fachrosshaar (specialty horsehair). This is one of the most impressively springiest and meatiest of this type of chest canvas currently available. 140 gr.mtq, cotton 57% horse hair 43%.
All in all the wide selection and variety is impressive. There should be something here to keep everyone happy.
Another thread on linen canvasses will shortly follow as well as another thread on their linings.
Posted 28 February 2010 - 12:28 AM
Art. flyng horse / puro crine animale/horse hair
Composistion :cotton 57% horse hair 43%
Puro CRINE SANREMO M cm 46/47 gr.mtq 140
Peli cammello/camel hair
Composition: PURE WOOL
CAMEL HAIR PURE WOOL 80 cm 80 gr.mtq 320 WARP 100%WOOLweft 80%wool20%hair
Composition : MIXED WOOL-HAIR WOOL RAYON
CAMEL HAIR IE 0016 balanced cm 70 gr.mtq 240 WOOL43%HAIR13%VISCOSE WOOLRAYON44%
CAMEL HAIR NOCETTA2018 cm 70 gr.mtq 243 viscosewool 47% wool53%
Camel hair IE D 0010 cm 70 gr.mtq 303 WOOL43%HAIR 10% VISCOSE WOOL47%
CAMEL HAIR NASA 00140 cm 70 gr.mtq 210 viscosewool 40% wool60%
CAMEL HAIR AO 210 balanced cm 70 gr.mtq 295WOOL35%15%HAIR50%VISCOSEWOLLRAYON
CAMEL HAIR AO 210/ 2003 balanced cm 70 gr.mtq 240WOOL43%HAIR13%VISCOSEWOLLRAYON44%
CAMEL HAIR SI 3016 balanced cm 70 gr.mtq 225WOOL36%VISCOSE WOOLRAYON52%HAIR12%
CAMEL HAIR PEGASO 1630 balanced cm 70 gr.mtq 215WOOL36%VISCOSEWOOLRAYON52%HAIR 12%
CAMEL HAIR SI R BLU cm 70 gr.mtq 222WOOL36%VISCOSEWOOLRAYON52%HAIR 12%
CAMEL HAIR SO 228 cm 70 gr.mtq 155 WOOL30%VISCOSE60%COTTON10%
CAMEL HAIR CRISTALLO 228 cm 70 gr.mtq 150 WOOL30%VISCOSE60%COTTON10%
CAMEL HAIR SE SA 503 balanced cm 75/150 gr.mtq 275 PURE COTTON30%RAYONVISCOSE56%HAIR14%
CAMEL HAIR SE SA LIGHT 503 cm 75/150 gr.mtq 205 30%PURECOTTON60%RAYONVISCOSE10%HAIR
CAMEL HAIR AA 00150 cm 75/150 gr.mtq 203 30%purecotton60%rayonviscose10%hair
CAMEL HAIR AA.NO 00518 cm 75/150 gr.mtq 260 30%purecotton56%rayonviscose14%hair
CAMEL HAIR CO.NO 625/N cm 70 gr.mtq 155 42%purecotton56%viscose wool2%hair
CAMEL HAIR CO 625 cm 70 gr.mtq 145 42%pure cotton 56%viscose wool2%hair
CAMEL HAIR MONT BLANC cm 70 gr.mtq 145 40%pure cotton 58%viscosewool2%hair
CAMEL HAIR MONTEROSA cm 70 gr.mtq 160 42%pure cotton 56%viscose wool 2%hair
CAMEL HAIR VIOLETTA cm 70 gr.mtq 145 30%pure cotton55%viscose 5%hair10%rayon
CAMEL HAIR VIOLA BLACK 3W cm 70 gr.mtq 125 40%pure cotton57%viscosewool 3%hair
CAMEL HAIR VIOLETTA BIANCO cm 70 gr.mtq 125 40%pure cotton57%viscose wool 3%hair
CAMEL HAIR LILLA cm 75/150 gr.mtq 175 40%pure cotton46%rayonviscose14%hair
Posted 28 February 2010 - 04:13 AM
Some of the canvasses resemble those offered by the Orag, Munich, so I would be able to compare.
- checkvilMuh, Ridgelap, BrantHoda and 10 others like this
"Nur der ist Meister seiner Kunst, der immer sucht, das Gute zu verbessern und niemals glaubt, das Beste schon zu haben."
"Only he is a master of his art who always seeks to improve the good and never believes to have the best already"
Posted 28 February 2010 - 09:58 AM
Posted 28 February 2010 - 03:52 PM
Some of the canvasses resemble those offered by the Orag, Munich, so I would be able to compare.
BTW one more thing, the horsehair chest canvas (Fachrosshaar type of weave) offered by Gilt Edge Suitings is much springier and heavier than the very soft and light version offered by Orag. I am also not aware of any haircloth elsewhere with as high a hair content as 48%, which is very impressive. The Orag version probably has a similar hair content to the softers ones from Richard James Weldon, which have a hair content around 30%. I also understand that Gilt Edge Suitings are also the makers of everything they sell, rather than just being sellers.
Posted 17 June 2010 - 07:48 PM
its this one i can tell by looking at it
sator as always you are a star
Posted 18 June 2010 - 10:44 AM
Posted 21 August 2010 - 12:06 PM
According to him, his firm is about the only one left still weaving canvas in Italy. All of the other firms have long gone out to places such as Rumania or China. Although this is common knowledge already, manufacturers in China often use chemicals that have been banned in the EU and traces of what are classified as toxic compounds can be found on the finished products. I have heard that some of these are classified as carcinogens. In many cases, "Italian canvas" these days too often means that the firm is Italian but has moved its mills overseas.
The downside of weaving in Italy is expense. As a result very few merchants stocks their products, because once they add on their own mark up, it becomes expensive enough that most regard the pricing to be uncompetitive. However, when buying from Gilt Edge you are buying directly from the makers. Most of the stuff stocked by well known trimming merchants comes from places like China.
Apparently, the particular strength of the Italian woven canvasses from Gilt Edge is that it is woven to be balanced. This means that every yarn that is woven with a twist to the right is balanced out with one given a twist to the left. The canvasses are further soaked in water and sun dried. The shrinking process that the canvas undergoes is rigorous enough that tailors reportedly find little shrinkage. This, in combination with the balance weaving process, ensures that you don't encounter the problem of crinkled warping in the canvas from unequal shrinkage in warp and weft.
We rarely scrutinise the weave and origin of our lining products such as canvas in the same way that we do cloth. Given that the canvas forms the scaffolding and foundations of a garment, there is every reason to be even just as particular, if not more so, about where our canvas comes from and how it is woven. Certainly those tailors who are looking to only use the finest products for their suits should definitely take a look at the canvasses from Gilt Edge. The range of canvasses are excellent, and there is bound to be something in there that will peak your interest. After having thumbed through the above swatch book on quite a number of occasions, I am finding the products extremely promising.
I should mention that I have not yet used anything from Gilt Edge yet but I have just put in an order for several different canvasses in varying weights to try out. I will certainly report back in due course.
I know there are also fusers amongst us ( ) and for those I will probably put out a scan of their fusibles at some point. They also have a nice selection of waist banding canvas, cupro Bemberg inner linings (which they weave themselves from the buds of cotton after the cotton has bee removed from them) and domette. The choice of Bemberg linings is few, and expensive, but high quality.
Posted 14 November 2010 - 12:26 PM
Gilt Edge Suiting sells canvas and trimming from the Italian firm Tessillino Zorloni Bruno. Founded 1880. Tessitura Meccanica Lino. 20034 Giussano (MI) - Via Rossini 13 - 15. Tel 032 850 110 Fax 0362 354 418 email firstname.lastname@example.com
The wool blend camel canvasses hardly shrink at all, as would be expected from a canvas that has been well pre-shrunk in the sun in the old fashioned way. The wool/camel canvasses are very nice, as are the wool-linen blend ones and can recommend them highly. I am starting to preferentially use Tessillino Zorloni Bruno canvas to those from other sources.
I have ordered several lengths of a selection of different canvasses from them. One opinion expressed about the canvasses containing cotton is that they do shrink and warp a little when you wet and steam iron them. I purchased some cotton blend canvas and found that I could get it to easily shrink, so I wetted it and then steam ironed thoroughly for future use. I guess this is just the nature of cotton.
Posted 14 November 2010 - 12:31 PM
Some of this looks off-bais. It is probably just the photgraphing that gives it that appearance. Cloth or canvas that is truely off-bais is to be avoided.
None of the cut lengths I have so far received are woven off bias (nor for that matter are the samples). A small sample can easily twist as it is being scanned (it tends to get squashed on the scanner).
BTW I pay full price for everything I receive. I am not paid to say anything nice about this company. All reviews are fully independent.
In future I will post more feedback from experienced gained by using more this canvas.
Posted 27 February 2014 - 06:47 AM
I wanted to order Lilla 175g from Gilt Edge, but shipping up to 5kg from UK to Europe or USA cost about 74Euro, ridicolous.
Posted 27 February 2014 - 07:02 AM
Shipping is from Italy, and I paid between 20 to 35,- Euro to Germany, depending on the weight of the parcel.
Even with high(er) shipping costs it's still cheaper than buying something similar from the ORAG in Munich, Bavaria.
Just ask the main office in Italy if there is an agent in the USA.
"Nur der ist Meister seiner Kunst, der immer sucht, das Gute zu verbessern und niemals glaubt, das Beste schon zu haben."
"Only he is a master of his art who always seeks to improve the good and never believes to have the best already"
Posted 27 February 2014 - 11:18 AM
I was talking to Antonio, going to buy there.
Edited by Der Zuschneider, 28 February 2014 - 03:40 PM.
Posted 07 March 2014 - 12:33 AM
Have you purchased yet? I've got a project I want to start soon and I wonder what the costs are like.
Posted 08 March 2014 - 06:29 AM
Got big samples, could share them here in USA only...
CAMEL HAIR SO 228 cm 70 gr.mtq 155 WOOL30%VISCOSE60%COTTON10%
CAMEL HAIR CRISTALLO 228 cm 70 gr.mtq 150 WOOL30%VISCOSE60%COTTON10%
CAMEL HAIR LILLA' cm 75/150 gr.mtq 175 40%pure cotton46%rayonviscose14%hair
Looks like Lilla could be the best, is substantial, but I like it more strucktured.
Now I know how the English tailors work so soft that lapels flutter in the wind like a handkerchief.
Edited by Der Zuschneider, 01 April 2014 - 07:02 AM.
Posted 03 April 2014 - 01:46 PM
Is there a US agent? Do they send small samples of their ranges? What are the prices like? Thanks for the answers.
Posted 09 April 2014 - 10:35 PM
Terrible shipping costs:
5kg from UK is 80 Euro and from Italy 145 Euro and from Germany 10kg for 40 Euro.
Edited by Der Zuschneider, 02 May 2014 - 03:05 AM.
Posted 10 April 2014 - 12:33 AM
^ ^ ^
Yeah, I sent an email too and never heard from them. A website would be invaluable to them if they wanted to expand their presence/business. Maybe they don't choose to or don't need to expand. Oh well. . .
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text:
|photo credit : charles richard photography
The Banana Pecan Pancakes were the star of my Christmas Breakfast Party... they are a very simple show-stopper. I use Jiffy Baking Mix - it is by far my favorite for easy pancakes and biscuits.
|photo : charles richard
Banana Pecan Pancakes
4 bananas (2 bananas diced for the batter, 2 sliced for garnishing)
1/2 cup of pecans, toasted
1 cup of maple syrup
2 cups of Jiffy Baking Mix
1 1/4 cup of milk
1 teaspoon of sugar
1/2 teaspoon of salt
2 tablespoons of vegetable oil
Before beginning the pancake batter, be sure to have the bananas sliced and diced and pecans toasted. Place the pecans in a microwave safe bowl with the syrup. Heat them for 40 seconds in the microwave.
Heat oven to 250 degrees.
Prepare pancake batter by whisking together Jiffy Baking Mix, milk, sugar and salt. On a griddle or cast-iron pan, heat oil on medium (about 1 minute). Pour batter into the pan to form 4-5 inch pancakes. Sprinkle 1 tablespoon of bananas on each pancake before flipping. Flip after 2-3 minutes, or when bubbles begin to form and the edges slightly brown. Cook on medium for 2-3 more minutes. Keep pancakes on a baking sheet in the oven until ready to serve.
Serve topped with sliced bananas and hot pecan syrup.
Get the recipes for the Christmas Breakfast Party here : Herbed Scrambled Eggs | Maple Glazed Thick-cut Bacon


text:
By Clay Waters | May 26, 2010 2:56 PM EDT
In Wednesday's "Bill Puts Scrutiny on Detainees' Lawyers," New York Times legal reporter Charlie Savage sank his teeth into a Republican proposal that would crack down on lawyers for Guantanamo Bay detainees suspected of taking actions to harm the military.
But Savage went off the rails in the last two paragraphs:
As for the tradition of lawyers representing unpopular clients, these groups go far beyond standard courtroom advocacy.
A provision tucked into a defense bill before Congress would direct the Pentagon's inspector general to investigate any suspected misconduct by lawyers for Guantánamo Bay detainees, opening a new chapter in a recurrent political controversy over legal ethics and the representation of terrorism suspects.So far unobjectionable, though we could have learned more about those photographs: Were researchers trying to make targets out of interrogators?
The provision would require the Pentagon inspector general to investigate instances in which there was "reasonable suspicion" that lawyers for detainees violated a Pentagon policy, generated "any material risk" to a member of the armed forces, violated a law under the inspector general's exclusive jurisdiction, or otherwise "interfered with the operations" of the military prison at Guantánamo.
In introducing the proposal last week, Representative Jeff Miller, Republican of Florida, focused on the John Adams Project, a joint enterprise of the American Civil Liberties Union and the National Association of Criminal Defense Lawyers. It provides research and legal assistance to the uniformed lawyers defending detainees who are facing prosecution before a military commission.
Mr. Miller characterized the John Adams Project as a "treacherous enterprise," referring to accusations that its researchers took pictures of interrogators and gave them to military defense lawyers, who in turn showed them to detainees.
The lawyers have defended the legality and propriety of their efforts. They contend that the detainees were illegally tortured in the custody of the Central Intelligence Agency, and they want to raise that issue at trial. To do so, they need to identify potential witnesses to the interrogation sessions.
But Savage went off the rails in the last two paragraphs:
The legislation is the latest attack on lawyers representing detainees. Although such lawyers have tended to espouse civil libertarian views, some conservative critics have imputed to them a lack of patriotism and sympathy for the cause of Islamist terrorism.While making conservatives out as attack dogs questioning the patriotism of noble apolitical lawyers, Savage ignores that the main group of lawyers representing Guantanamo detainees is the Center for Constitutional Rights. It may think of itself as "civil libertarian" (and so does the Times) but it's a hard-left group whose president Michael Ratner said in a December 2005 press release (during the Bush administration): "Every American should be in political rebellion against the criminals now running this country." The Weekly Standard recently called Ratner, who wrote an admiring book about Che Guevara, the "lead terrorist defender" at Gitmo.
Such attacks have also prompted a strong reaction, including by other conservatives who have defended the tradition in the American legal system of lawyers representing unpopular clients.
As for the tradition of lawyers representing unpopular clients, these groups go far beyond standard courtroom advocacy.


text:
Enterprise Storage, HCI, High Availability, Hyperconverged Infrastructure, Hyperconvergence, SDS, Software-defined storage, Storage Virtualization, SvSAN, Synchronous Mirroring
Bristol, Bristol
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$1 to $5 million
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text:
Purple Cleatus Cooler, Aquaholic Anchor
Cleatus Cups
Unique. An Original. World's Coolest Cleat.
The Cleatus Cooler features a 3mm neoprene zippered bottle cooler and a 6" nylon dock cleat re-purposed as the cooler handle. Printed with an approximate 3" wide x 3" high logo.
Patented black dock cleat handle.
Zipper on the back.
Holds most standard 2.5 inch diameter bottles, both long and short neck.
Assembled in the USA.