Minor influence of self-selection bias on the effectiveness of breast cancer screening in case-control studies in the Netherlands

Abstract

Background: Self-selection bias is considered to be a problem when evaluating the effectiveness of breast cancer service screening in case-control studies. Objective: Using the incidence-based mortality method (IBM), a correction factor for the potential influence of self-selection can be derived from a group of non-screened women and a group of notinvited women. Methods: Breast cancer patients, diagnosed in 1990-1995 and between the ages of 50 to 70, were selected from the Netherlands Cancer Registry and five screening regions in the Netherlands. Person-years were calculated for non-screened and not-invited women by using population data available on the number of women invited, the number of women screened and the total population. Incidence-based breast cancer mortality rates according to screening status were calculated for the five screening regions. Results: Between 1990-1995, 15,541 patients were diagnosed with breast cancer. An analysis of ten-year follow-up after diagnosis resulted in 3903 breast cancer deaths, of which 2631 were notinvited and 345 were non-screened. Poisson regression analysis showed heterogeneity between the regions with a range of IBM ratios from 0.64 (95% CI: 0.46-0.90) to 1.08 (95% CI: 0.82-1.43). Conclusions: Heterogeneity between the regions stresses the importance of a country-and/or regionspecific estimate of self-selection. Adjusting for self-selection bias in the regional case-control studies would not change the breast cancer mortality reduction in three regions and would result in an even larger effect in two regions. Looking at the range of IBM ratios the overall influence of selfselection in the Netherlands is minor.