Background The debate regarding the lower age limit for mammography service screening is old and lively; a product in part of the lower breast cancer risk in younger ages as well as the limited data available for studies of the younger age group. Recently the idea of inviting only high risk groups has gained momentum, however high risk might not be equivalent to greater benefit from screening. Therefore, there is a need for information on effectiveness of screening as it relates to young women and to specific risk groups. To this end, this thesis evaluates mammography screening for the age group – 40 to 49 year old women – in terms of breast cancer mortality reduction in total and in subgroups based on breast cancer risk factors. Overdiagnosis of mammography screening is also evaluated for women 40 to 49 years old. In addition, this thesis presents a statistical method to estimate this effectiveness and to test for differences in effectiveness between subgroups adjusted for non-compliance and contamination. Methods The studies of this thesis are based on data from the Screening of Young Women (SCRY) database. The SCRY database consists of detailed information on diagnosis, death, screening exposure and risk factors for breast cancer cases and population size by year (between 1986 and 2005) and municipality for women in Sweden between 40 and 49 years old. The material was divided into a study group consisting of the counties that invited women in the age group 40-49 years to mammography screening, and a contemporaneous control group consisting of the counties that did not. Effectiveness was estimated in terms of rate ratios for two different exposures (invitation to and participation in screening), and overdiagnosis for subsequent screening was estimated adjusting for lead time bias. Defining a reference period enabled adjustment for possible underlying differences in breast cancer mortality and incidence. A statistical model for adjusting for non-compliance and contamination in randomised controlled trials was further developed to allow for adjustment in cohort studies using a Poisson model with log-linear structure for exposure and background risk. Results During the study period (1986-2005), there were 619 and 1205 breast cancer deaths and 6047 and 7790 breast cancer cases in the study group and the control groups, respectively. For women between 40 and 49 years old, the breast cancer mortality reduction was estimated at 26% [95% CI, 17 to 34%] for invited to screening and 29% [95% CI, 20 to 38%] for attending screening. The RR estimates for the high-risk groups based on the risk factors parity, age at birth of first child, and socio-economic status were equal to or higher than that of the low risk groups. The new statistical method showed that the decrease in effectiveness with parity was not a statistically significant trend. The overdiagnosis from subsequent screening for 40 to 49 year old women was estimated at 1% [95 % CI, -6 to 8 %] (i.e., not statistically significant). Conclusion Subgroup specific effectiveness was also estimated. The relative effectiveness of screening for breast cancer with mammography for women age 40 to 49 years appears to be comparable to that for older women. These findings and the fact that there was no statistically significant overdiagnosis from subsequent screening speak for inviting women 40 to 49 years old to screening. High-risk screening for nulliparous women aged 40 to 49 years, for example, might be an alternative in countries where population-based screening for all women between 40 and 49 years old is not possible. However, the matter of risk factors and the effect of their combinations is complex and risk group screening presents ethical and practical difficulties. The new statistical model is a useful tool for analysing cohorts with exposed and non-exposed populations where non-compliance and contamination is a potential source of bias.

Breast cancer is the most common form of cancer in female population in the Czech Republic. In 2002 the Czech Republic joined most European countries and launched nation-wide mammography screening, enabling women to attend regular preventive examinations when they reach 45 years of age. In January 2014 they started to address women to invite them for preventive breast cancer examinations, as part of a nationwide information campaign. Mortality of this cancer has been decreasing in recent years, which can be explained by the increasing quality of treatment and earlier detection of the disease. Therefore, knowledge of primary and secondary prevention is very important. The theoretical part briefly describes the anatomy of female breasts, defines a malignant tumor, as well as epidemiological aspects of breast cancer. Another chapter is about prevention itself. In the secondary prevention I describe self-examination of breasts and the history and nature of mammography screening. I also present organizations implementing preventive programs aimed at breast cancer. The practical part includes research results, which were obtained through quantitative research questionnaires. The research group consisted of women who live in the Ústí region. The questionnaire consisted of 27 questions and was answered by a group of 150 women between 18 and 44 years old and 150 women over 45 years. I handed out these questionnaires in Ústí healthcare center and I also created an electronic questionnaire which I sent across social networks. Out of the 150 (100 %) questionnaires distributed in Ústí healthcare center, I got only 60 back and 58 of them were sufficiently completed for the needs of the research, the return was only 38.7 %. I received the remaining 242 questionnaires electronically. The aim of the study was to explore the awareness of risk factors of breast cancer of women in the Ústí Region and also to find out whether women in the Ústí region carried out self-examination of breasts and if women over 45 attended regular mammography screening. Based on my research aim I set out four hypotheses. Hypothesis 1: Women in the Ústí region are informed about the risk factors of breast cancer. Hypothesis 2: Women at the age of 18 to 44 in the Usti region are more informed about the risk factors of breast cancer than women in the age group over 45. Hypothesis 3: The difference in the frequency of breast self-examination among women in the age group 18 to 44 is statistically more significant than in women in the over 45 age group. Hypothesis 4: Attending mammography examination of women over 45 in the Ústí region rises according to their level of education. The results of testing my hypotheses show that women in the Ústí region are not informed about the risk factors of breast cancer. I assumed that awareness is higher among women in the 18 to 44 age group, but even this hypothesis wasn't proven. Awareness of risk factors is on the same level in category of 18 to 44 years as in women over 45 years of age. Regarding breast self-examination, women in the above 45 years old age group carry out self-examination more often than women 18 to 44 years old. Even the last hypothesis was not confirmed, attendance of mammography doesn't appear to depend on the education of women. Awareness of women needs to increase, especially in case of risk factors of breast cancer. Awareness increase could be achieved by greater information campaign on television, in newspapers, in businesses with high numbers of working women, or in secondary and higher education through various public lectures. Over 90% of women attend Mammography screening according to my research, which are laudable results. The fact that the actual self-examination of breasts isn't carried out at all by more than half of the women in the age group 18 to 44 is serious. This work could serve as teaching or study material to improve general knowledge of this topic.

Contexte : Les inégalités sociales de santé représentent un problème de santé publique considérable. Dans le cadre du cancer du sein, la précarité est associée au pronostic. En effet, une relation entre précarité géographique et stade au diagnostic a été établie dans la littérature. Cependant, à ce jour, aucune étude n'a encore analysé l'association de ce dernier à la précarité individuelle.Objectifs : Les objectifs de ce travail de recherche sont (1) d'estimer le risque de cancer du sein de stade avancé associé à la précarité individuelle, (2) d'étudier l'impact des facteurs pouvant modifier ce risque, (3) d'évaluer la robustesse de l'association face au choix de la mesure de précarité.Population et méthode : Les données sont issues d'une étude cas-témoins. Les Cas et les Témoins de l'étude ont été recrutés parmi les patientes de l'Hérault atteintes de cancers du sein invasifs diagnostiqués entre 2011 et 2012. Les Cas correspondent aux patientes présentant un cancer du sein de mauvais pronostic (taille de tumeur supérieure à 5cm, ou atteinte ganglionnaire ou atteinte métastatique) et les Témoins aux patientes présentant des cancers de bon pronostic (taille de tumeur inférieure à 5cm et aucune atteinte ganglionnaire et aucune atteinte métastatique). Au total 604 patientes ont été incluses : 173 Cas et 431 Témoins. L'exposition à la précarité a été recueillie par un questionnaire standardisé.Résultats : Les patientes précaires ont, toutes variables égales par ailleurs, 2 fois plus de risque d'avoir un cancer de stade avancé comparée aux patientes non précaires. La précarité n'est associée à aucun autre facteur biologique (grade SBR, types histologique et moléculaire). Chez les patientes asymptomatiques (diagnostiquées suite à un dépistage) les patientes précaires ont plus de risque d'avoir des cancers de stade avancé. Chez les femmes avec un antécédent familial de cancer du sein tout comme chez les femmes vivant dans une zone géographique favorisée, les patientes précaires et non-précaires ont le même risque de cancer de stade avancé. Comparé aux autres mesures de l'environnement socio-économique (classe sociale, précarité géographique…), le score EPICES semble la méthode de mesure la plus adaptée pour étudier l'association entre précarité et stade au diagnostic.Conclusion : Nos résultats suggèrent que les écarts observés entre les patientes précaires et les patientes non-précaire semblent être plutôt liés à retard au diagnostic plutôt qu'à des différences biologiques entre les tumeurs. Ce retard au diagnostic semble dépendre de composantes individuelles mais aussi collectives. De plus, une meilleure connaissance du cancer du sein pourrait permettre de réduire les barrières supplémentaires vécues par les précaires. / Context: Socio-economic inequalities in health represent a significant public health problem. In the breast cancer context, socio-economic deprivation is associated with prognosis. Indeed, a relationship between area-based deprivation and diagnostic stages was already described in the international literature. However, the association between individual deprivation and diagnostic stages was not study so far.Objectives: Our aim was to (1) estimate the risk of advanced breast cancer associated with individual socio-economic deprivation, (2) study the impact of modifying factors, (3) evaluate the strength of this association according to the method used to measure deprivation.Population and methods: Data were collected from a Case-Control study. Cases and Controls were recruited among invasive breast cancer patients diagnosed between 2011 and 2012 in the Hérault. Cases were defined as patients with poor prognosis breast cancer (with tumor size over 5cm, or with lymph node involvement, or with metastasis). Controls were defined as patients with good prognosis breast cancer (with tumor size under 5cm, and without lymph node involvement, and without metastasis). A total number of 604 patients were included: 173 Cases and 431 Controls. The exposition to deprivation was measured by a standardized questionnaire.Results: Deprived patients, with all other variables remaining constant, have a two-fold risk of having advanced breast cancer compared to non-deprived patients. Deprivation was not associated with the other biological factors (SBR grade, histologic and molecular type). Among asymptomatic patients (diagnosed after a mammographic screening), deprived patients have a higher risk of advanced breast cancer. Among women with family history of breast cancer so as women living in affluent geographic areas, deprived and non-deprived patients have the same risk of advanced breast cancer. Compared to other measures of socio-economic environment (social class, area-based deprivation…), EPICES score seems to be the most adapted method to study the association between deprivation and breast cancer diagnostic stages.Conclusion: Our results suggest that the gap observed between deprived and non-deprived patients seem to be associated with delayed diagnosis more than biological differences between tumors. This delayed diagnosis seems depend on individual and geographic components. Moreover, a better knowledge of breast cancer could allow a reduction of the barrier experienced by deprived women.

Bakgrund: Bröstcancer är den vanligaste cancerformen hos kvinnor. Mammografiscreening har minskat antalet dödsfall i bröstcancer. Kvinnor upplever undersökningen som ångestfylld, besvärlig och smärtsam, vilket orsakar minskat deltagande. För ökat välbefinnande är det viktigt med förståelse för kvinnors erfarenheter.  Syfte: Syftet med litteraturstudien var att belysa kvinnors erfarenheter av mammografiscreening.  Metod: En litteraturstudie med resultat från tio kvalitativa studier. Sökningar genomfördes i PubMed och CINAHL. Artiklarna kvalitetsgranskades sedan analyserades och sammanställdes studiernas resultat.  Resultat: Analysen resulterade i tre kategorier och nio underkategorier. Huvudkategorierna var oro och rädsla, känsla av utsatthet samt behov av trygghet. Resultatet visar att erfarenheterna varierade men det upplevdes främst som fyllt av ångest, oro och smärta. Dessa känslor kunde lugnas med tiden, genom adekvat information eller om röntgensjuksköterskan var omtänksam och gav god omvårdnad.  Konklusion: Röntgensjuksköterskan har stort inflytande på undersökningen och kan med små medel förbättra kvinnors erfarenheter. Den kliniska verksamheten och röntgensjuksköterskan uppmuntras anpassa arbetssättet mot en mer personcentrerad omvårdnad. Då genomförs undersökningen på ett smidigare sätt och bilderna blir bättre vilket genererar ett minskat behov av omtag, och därmed kostnad, samt minskad psykisk påfrestning för kvinnorna. / Background: Breast cancer is the most common form of cancer among women. Mammography screening has reduced the number of deaths from breast cancer, but women experience the examination as anxiety-ridden and painful.  Aim: The purpose of the literature study was to illuminate women's experiences of mammography screening.  Methods: A literature study with results from ten qualitative studies. Searches were conducted in PubMed and CINAHL. The quality of the articles was reviewed, then the results of the articles were analyzed and compiled.  Results: The analysis resulted in three main categories and nine subcategories. The main categories were anxiety and fear, feelings of vulnerability and the need for safety. Although results varied, the examination was mainly described as worrisome and painful. Time, information, or good care provided by the radiographer could improve the experience.  Conclusion: The radiographer has a great influence on the examination and can with small means improve women's experiences. The clinical practice and the radiographer are encouraged to apply a more person-centered care. The examination is then performed more easily and the image quality increases, which reduces the need for recalls as well as the mental strain for women.

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This dissertation is focused on medical care field, introduces common issues of oncology illnesses. Presents the system and particularity of women's breast cancer care and looks into patient's rights and importace of foreknowledge. Also presents activities of non-state nonprofit organization focused on this sphere. The aim of this dissertation is to map involved organizations and analysis of their work. Investigates foreknowledge of patients about knowing of them and also finds topics of their intersect. Key words oncology diagnosis, breast cancer, patients organizations, prevention, second opinion, health service, non-profit non-govermental organizations, information asymmetry, mammography screening, informační asymetrie, mamografický screening