title: Dutch digital breast cancer screening: implications for breast cancer care.
abstract: BACKGROUND
  In comparison to other European population-based breast cancer screening programmes, the Dutch programme has a low referral rate, similar breast cancer detection and a high breast cancer mortality reduction. The referral rate in the Netherlands has increased over time and is expected to rise further, mainly following nationwide introduction of digital mammography, completed in 2010. This study explores the consequences of the introduction of digital mammography on the balance between referral rate, detection of breast cancer, diagnostic work-up and associated costs.
  
  
  METHODS
  Detailed information on diagnostic work-up (chart review) was obtained from referred women (n = 988) in 2000-06 (100% analogue mammography) and 2007 (75% digital mammography) in Nijmegen, the Netherlands.
  
  
  RESULTS
  The average referral rate increased from 15 (2000-06) to 34 (2007) per 1000 women screened. The number of breast cancers detected increased from 5.5 to 7.8 per 1000 screens, whereas the positive predictive value fell from 37% to 23%. A sharp rise in diagnostic work-up procedures and total diagnostic costs was seen. On the other hand, costs of a single work-up slightly decreased, as less surgical biopsies were performed.
  
  
  CONCLUSIONS
  Our study shows that a low referral rate in combination with the introduction of digital mammography affects the balance between referral rate and detection rate and can substantially influence breast cancer care and associated costs. Referral rates in the Netherlands are now more comparable to other countries. This effect is therefore of value in countries where implementation of digital breast cancer screening has just started or is still under discussion.
authors.affiliation: Department of Epidemiology, Radboud University Nijmegen Medical Centre, The Netherlands. j.timmers@lrcb.nl
authors.forename: Johanna M
authors.initials: JM
authors.lastname: Timmers
authors.forename: Gerard J
authors.initials: GJ
authors.lastname: den Heeten
authors.forename: Eddy M
authors.initials: EM
authors.lastname: Adang
authors.forename: Johannes D
authors.initials: JD
authors.lastname: Otten
authors.forename: André L
authors.initials: AL
authors.lastname: Verbeek
authors.forename: Mireille J
authors.initials: MJ
authors.lastname: Broeders
mesh_terms: D000368:Aged; D001706:Biopsy; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000401:mortality; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics*; D055088:Early Detection of Cancer / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008327:Mammography / Q000191:economics / Q000379:methods*; D008403:Mass Screening / Q000191:economics / Q000706:statistics & numerical data; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D015397:Program Evaluation; D012017:Referral and Consultation / Q000191:economics / Q000706:statistics & numerical data* / Q000639:trends; D015996:Survival Rate