Supplementary Material File: Assessing predicted age-specific breast cancer mortality rates in 27 European countries by 2020.

Ramon Clèries1,2,*, Rosie Rooney3, Mireia Vilardell4, Josep A. Espinàs1, Tadeusz Dyba3,Josep M Borras1,2,

1. Catalan Institute of Oncology – Catalan Cancer Plan. IDIBELL, Av Gran Via 199-203 08908 Hospitalet de Llobregat, Catalonia-Spain.

2. Department of Clinical Sciences. IDIBELL. University of Barcelona, Barcelona 08907, Spain.

3. European Commission, DG Joint Research Centre, Institute for Health and Consumer Protection, Public Health – Cancer Policy Support. 21020 Ispra (Varese) –Italy.

4. Section Statistics from the Department of Genetics, Micobiology and Statistics, Biology Faculty . University of Barcelona 08028, Spain.

Key words: breast cancer, Europe, mortality, projections, time- trends, screening

*Address of the corresponding author:

Plan for Oncology of the Catalan Government.

IDIBELL, Hospital Duran i Reynals. Av. Gran Via de l’Hospitalet, 199-203 – 1ª planta. 08908 – L’Hospitalet de Llobregat , Catalonia-Spain

e-mail:

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Age Group 50-69: Predictions 2020 / Age Group >69: Predictions 2020
Northern-Western and Southern / (N) / ASMR / SMR / (N) / ASMR / SMR
Finland / 340 / 36.1 / 0.94 / 430 / 98.7 / 0.91
Ireland / 252 / 49.7 / 0.99 / 369 / 147.3 / 0.97
Luxembourg / 21 / 41.3 / 0.67 / 49 / 125.1 / 0.83
The Netherlands / 1201 / 57.2 / 0.92 / 1601 / 118.2 / 0.93
Sweden / 491 / 37.3 / 0.94 / 830 / 91.7 / 0.98
UK / 3502 / 48.1 / 0.89 / 6521 / 123.3 / 0.91
Denmark / 406 / 55.9 / 0.83 / 609 / 145.8 / 0.85
France* / 3291 / 43.5 / 0.77 / 6702 / 112.1 / 0.93
Austria / 349 / 39.0 / 0.72 / 908 / 116.2 / 0.95
Belgium / 731 / 55.1 / 0.85 / 1394 / 137.2 / 0.94
Germany / 5161 / 47.1 / 0.88 / 11373 / 128.2 / 0.99
Estonia / 71 / 43.2 / 0.77 / 146 / 110.8 / 1.16
Latvia / 174 / 55.7 / 0.90 / 241 / 120.9 / 1.15
Lithuania / 184 / 49.2 / 0.81 / 259 / 105.4 / 1.03
Southern Europe
Spain / 1997 / 37.7 / 0.98 / 3681 / 78.1 / 0.94
Italy / 3126 / 44.6 / 0.80 / 6995 / 107.1 / 0.91
Portugal / 492 / 37.1 / 0.79 / 779 / 85.2 / 0.91
Greece / 612 / 44.5 / 1.02 / 1235 / 121.1 / 0.99
Malta / 21 / 35.2 / 0.67 / 37 / 155.2 / 0.91
Croatia / 308 / 52.8 / 0.91 / 582 / 142.4 / 1.02
Slovenia / 107 / 45.1 / 0.81 / 287 / 129.1 / 0.95
Eastern Europe
Czech Rep. / 571 / 36.4 / 0.86 / 997 / 112.1 / 0.95
Hungary / 825 / 58.1 / 1.04 / 1131 / 131.2 / 0.97
Bulgaria / 551 / 51.1 / 1.02 / 596 / 99.3 / 1.13
Poland / 2421 / 49.1 / 1.04 / 2694 / 103.7 / 1.14
Romania / 1439 / 54.1 / 1.03 / 1653 / 107.1 / 1.13
Slovakia / 342 / 55.3 / 1.00 / 407 / 132.6 / 1.06

N: Predicted number of BC deaths by 2020 (Median); ASMR:Predicted age-standardized mortality rates from Breast Cancer by 2020 (Median);

SMR: N/E*, where E are the expected number of deaths from BC applying the BC mortality rates of 2010 to the population at risk in 2020.

The base period for predictions comprised the years between 2006 and 2012 in all countries.

Table S1. Results of the predictions in 2020: predicted number of deaths from breast cancer, predicted age-standardized mortality rates from Breast Cancer and estimates of the standardized mortality ratios of BC in 2020 with respect to 2010.

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Situation of BC screening programmes in the European countries considered in this study

The situation of BC screening programmes in the European countries considered in this study is presented in Table S2. Age of target population is based on Eurostat Breast Cancer Statistics (1) and updated from literature review. Note: In the text below, rates refer to “BC mortality rates”. Percentages presented refer to annual percent change of rates.

Austria: In was implemented in Austria the BC screening program offered to all women aged 40 years and older (1, 2, 3). This program runs the “opportunistic” screening, i.e. screening is made by non-dedicated mammography screening centres and has no active invitation system. An organized and controlled breast-cancer screening programme is planned for women 50-69 years aged (1-5). In Tyrol, an organized programme targeting age groups 40-69 is active since 2007 (4). Pattern: A clearly decrease in ASRs has been observed since 1990s, age-specific rates for ages 40-69 in 2006-2010 are below to those in 2000-2004, and a plateau in the decrease of BC mortality rates in 2020 is expected.

Belgium: A national program started in 2001 with a target age-group comprised between 50 and 69 years (1, 2, 5-7). Opportunistic screening is widespread, with 80% of the diagnostic mammography examinations related to spontaneous screening (6, 7). Pattern: A clearly decrease in ASRs has been observed since 1990s, age-specific rates for ages 50-69 in 2006-2010 are below to those in 2000-2004, and plateau in the decrease of BC mortality rates in 2020 is expected for women aged 60 and over.

Bulgaria: no active national program had been implemented, although certain private centers have been conducting screening examinations since 2011 (2,8). Pattern: Rise of 1.1% of ASRs among women aged 69 and older during 1990-2000. Age-specific rates for ages 55 and older were similar between periods 2000-2004 and 2006-2010. There is predicted a rise of age-specific rates by 2020 for ages 69 and older.

Croatia: A national program was implemented in 2006 covering a target population aged 50-69 (2, 9, 10). Pattern: Marked rise of ASRs among women aged 50-69 during 1990-2000, followed by a decreasing trend during 2000-2010. Age-specific rates for ages 50-69 were similar between periods 2000-2004 and 2006-2010. A decrease of rates in this age group is predicted by 2020.

Czech Republic: Two independent pilot projects were launched in 1996-2000 and 2000-2001 at a national level but does not have a centralized population-based screening program (2, 11, 12).All eligible women received an individual invitation letter,except in the Czech Republic, where women were referredby general practitioners or gynaecologists. Personal invitationswere introduced in the Czech Republic on a pilotbasis in 2007.Pattern: A clearly decrease in ASRs has been observed since 1990s, age-specific rates for women aged 45 and older in 2006-2010 are below to those in 2000-2004, and a decrease in BC mortality rates is expected in all age groups by 2020.

Denmark: By the beginning of the 1990s, screening programs started in few areas of Denmark, offering mammograms to women aged 50-69 years, and Nationwide coverage has been reached between 2007-2010 (1, 2, 12-14). Pattern: A decrease in ASRs has been observed since 2000s, age-specific rates for women aged 50-69 in 2006-2010 are below to those in 2000-2004, and BC mortality rates in 2020 are expected to remain below to those of 2010 among women in that target age-group.

Estonia: The organized screening program started in 2002 covering ages 50-69 (1, 2, 12, 15), but in 1996 pilot programs were also carried out (1). Pattern: A rise of ASRs was observed during the years 1990-2000 (2.2% among women aged 50-69 and 2.1% among women older than 69), but a decrease of ASRs was detected beyond 2000s. Age-specific rates between 50-64 years decreased during 2006-2010 compared to 2000-2004, and a decrease in BC mortality rates among women aged 50-64 is expected by 2020.

Finland: The BC screening activities started in 1987 covering ages 50-69 years, reaching national coverage by 1989 (2, 12, 16). Pattern: A slight increase of ASRs during 1990-2000 for women older than 69 years, followed by a decrease since the beginning of 2000s in all age groups. Age-specific rates between 50-64 years decreased during 2006-2010 compared to 2000-2004, and the decrease of BC mortality rates in this age group is also expected to continue by 2020.

France: Screening activities started with regional screening by 1989 (1, 2, 17). A national program is offered to women aged 50-74 (17). Pattern: Age-specific rates between 50-74 years decreased during 2006-2010 compared to 2000-2004, and a continuous decrease of BC mortality rates in the age group 50-64 is expected by 2020.

Germany: Pilot studies, starting in 2001, were followed by 2005 at a national level (1,12). The national program invites women aged 50-69 years (1, 2, 12, 18). Pattern: : Age-specific rates between 50-69 years clearly decreased during 2006-2010 compared to 2000-2004, and a continuous decrease of BC mortality rates in the age group 50-64 is expected by 2020.

Greece: Sporadic pilot projects have been active since 1990s (1, 2, 19) with target age groups comprised between 40 and 64 years. Pattern: Rise of ASRs among women aged 69 and older during the whole study period (ASR 1990-2000: 2.8%; ASR 2000-2010: 0.3%). In this age group, BC mortality rates are predicted to level-off by 2020.

Hungary: The organized programme was implemented in 2001-2002 with target age groups comprised between 45-65 years (1, 2, 20). Pattern: During 1990-2000 ASR rose by 0.3% among women aged 50-69, but decrease beyond year 2000. Age-specific rates between 50-64 years clearly decreased during 2006-2010 compared to 2000-2004, and a continuous decrease of BC mortality rates in the age group 50-64 is expected by 2020.

Ireland: There was introduced organized screening in 2000 with a target population aged 50-69 years (1, 2, 21). Pattern: During 1990-2000 ASR rose by 0.7% among women aged 50-69, but decrease beyond year 2000. Age-specific rates between 50-64 years clearly decreased during 2006-2010 compared to 2000-2004, and a decrease of BC mortality rates in the age group 55-64 is expected by 2020.

Italy: Population-based screening began in 1990 but national coverage was attained by 2007, with a target population aged 50-69 (1, 2, 22). Pattern: Age-specific rates between 50-64 years clearly decreased during 2006-2010 compared to 2000-2004, and a decrease of BC mortality rates in that age group is expected by 2020.

Latvia: Screening program was activated by 2009 and in Lithuania in 2005, both comprising age groups 50-69 (1, 2). In both countries, ASRs rose during 1990-2000. In Latvia, ASRs rose among women older than 69 beyond 2000 (1.1% per year). In both countries, age-specific rates between 50-69 years did not clearly decrease during 2006-2010 compared with 2000-2004. However, in Lithuania, a slight decrease of BC mortality rates is expected by 2020 among women aged 50-59, but in both countries, a rise of BC mortality rates is expected among women aged 69 and older.

Luxembourg: the screening program started by 1992 (1, 2,23) with target age groups 50-69 years. Age-specific rates between 50-64 years clearly decreased during 2006-2010 compared to 2000-2004, and leveling-off of BC mortality rates is expected by 2020.

Malta: Screening program was implemented in 2009 (1, 2) with target age groups 50-69 years. Age-specific rates among women aged 35-79 years clearly decreased during 2006-2010 compared to 2000-2004, and leveling-off of BC mortality rates is expected by 2020.

The Netherlands: The screening program started in 1988, where women aged 50-69 is screened at 2-year intervals (1, 2, 12). Age-specific rates among women aged 35 and older clearly decreased during 2006-2010 compared to 2000-2004, and a decrease of BC mortality rates among women aged 45-64 is expected by 2020.

Poland: In 2007, started a screening program offering digital mammograms to women aged 50-69 (1, 2, 24). ASRs rose during the whole study period among women older than 69 years by 0.5% during 1990-2000 and 0.3% during 2000-2010. Age-specific rates among women aged 50-59 decreased during 2006-2010 compared to 2000-2004, and an increase of BC mortality rates among women older than 69 is expected by 2020.

Portugal: It was implemented the first region-based screening in 1990 but nationwide screening was achieved by 2005 covering ages 45-69 (1, 2, 12, 25).Among women older than 69 years, a slight rise of ASRs during 1990-2000 was found, followed by a decrease beyond the year 2000. Age-specific rates among women aged 45-69 did not decreased during 2006-2010 compared to 2000-2004, and a level-off is expected in all age groups by 2020.

Romania and Slovakia do not have organized screening program (1, 2, 26, 27). ASRs in Romania rose during the whole study period in all age groups. In this country, age-specific rates did not decrease among women older than 55 during 2006-2010 compared to 2000-2004. However, in Slovakia, ASRs rose only among women older than 69 years during 1990-2000, and age-specific ratres decreased among women aged 35-65 during 2006-2010 compared to 2000-2004. In Romania, by 2020, BC mortality rates are expected to level-off and even decrease among women younger than 69, but rise among women older than 69 years. In Slovakia, a level-off of BC mortality rates is expected by 2020.

In Slovenia a nationwide screening program was introduced in 2008 (1, 2) with target age groups comprised between ages 50-69 years.Age-specific ratres decreased among women aged 50-74 during 2006-2010 compared to 2000-2004. A decrease of BC mortality rates is expected by 2020 among women aged 45-74 years.

Spain: The first screening programs started at the beginning of the 1990s (1, 2,12, 28) covering ages 45-69 years. Age-specific ratres decreased among women aged 45-79 during 2006-2010 compared to 2000-2004. A level off of BC mortality rates is expected by 2020.

Sweden: Breast cancer screening program started in 1986 with target age groups 40-69 and 40-74 depending on the area (1, 2, 12). Age-specific ratres decreased in all age groups during 2006-2010 compared to 2000-2004. A decrease of BC mortality rates is expected among age groups 45-69 and a level off among women older than 69 years.

Finally, in the United Kingdom screening programs started by 1988 covering ages comprised between 50-69 years (1, 2, 12). Age-specific rates decreased in all age groups during 2006-2010 compared to 2000-2004. A decrease of BC mortality rates is expected among age groups 45-79 and a level off among women older than 79 years.

Target
Country / Type / Year * / Age-Groups
Austria / National/Local / 1974 / 2007 / 40+/40-69
Belgium / National / 2001 / 50-69
Bulgaria / Local / **
Croatia / National / 2006 / 50-69
Czech Republic / National / 2002 / 45-69
Denmark / National / 1992 / 2003 / 50-69
Estonia / National / 1996 / 2002 / 50-69
Finland / National / 1987/1989 / 50-69
France / National / 2003 / 50-74
Germany / National / 2005 / 50-69
Greece / Pilot / * / 40-50/64
Hungary / National / 2002 / 45-65
Ireland / National / 2000 / 50-64
Italy / National / 1990 / 50-69
Latvia / National / 2008 / 50-69
Lithuania / National / 2005 / 50-69
Luxembourg / National / 1992 / 50-69
Malta / National / 2008 / 50-69
The Netherlands / National / 1988 / 50-74
Poland / National / 2006 / 50-69
Portugal / National / 1990 / 45-69
Romania / **
Slovakia / **
Slovenia / National / 2008 / 50-69
Spain / National / 1990 / 45-69
Sweden / National / 1986 / 40-74
United Kingdom / National / 1988 / 50-69

(*) First year with national/regional screening activities in the corresponding country;

(**) Data not available; (***) In Greece some sporadic pilot projects have been active since 1990s covering age groups comprised between 40-64 years.

Table S2. Situation of the BC screening programs in the countries considered in the Study.

References

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