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Dung Thi Le, M.D.

• Associate Professor of Oncology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0016139/dung-le

Under-5 mortality rate high blood pressure medication and zyrtec order torsemide 10 mg mastercard, both sexes combined blood pressure chart cholesterol purchase torsemide 10 mg visa, 1990-2016Under-5 mortality rate blood pressure newborn torsemide 10 mg generic, both sexes combined hypertension renal failure trusted torsemide 20mg, 1990-2016 Gujarat under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Gujarat 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Haryana under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Haryana 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [8. Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Himachal Pradesh under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Himachal Pradesh 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [6. Himachal Pradesh 117 What risk factors are driving the most death and disability combined? Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Jammu and Kashmir under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Jammu and Kashmir 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [8% of total deaths] 15−39 years [12. How have the leading causes of death and disability combined changed from 1990 to 2016? The percent figure in brackets next to each cause is ‡Sense organ diseases includes mainly hearing and vision loss. Jammu and Kashmir 121 What risk factors are driving the most death and disability combined? Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Jharkhand under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Jharkhand 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [13% of total deaths] 15−39 years [12. Jharkhand 125 What risk factors are driving the most death and disability combined? Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Karnataka under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Karnataka 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [7% of total deaths] 15−39 years [11. Karnataka 129 What risk factors are driving the most death and disability combined? Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Kerala under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Kerala 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [2. Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Madhya Pradesh under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Madhya Pradesh 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [13. Madhya Pradesh 137 What risk factors are driving the most death and disability combined? Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Maharashtra under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Maharashtra 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [6% of total deaths] 15−39 years [10. Maharashtra 141 What risk factors are driving the most death and disability combined? Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Manipur under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Manipur 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [7. Under-5 mortality rate, both sexes combined, 1990-2016Under-5 mortality rate, both sexes combined, 1990-2016 Meghalaya under-5 rate India under-5 rate Comparative average rate globally for similar Socio-demographic Index as Meghalaya 150 100 50 0 1990 1995 2000 2005 2010 2016 Year What caused the most deaths in different age groups in 2016? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [15. Meghalaya 149 What risk factors are driving the most death and disability combined? Percent contribution of top 10 causes of death by age group, both sexes, 2016 0−14 years [11. Under-5 mortality rate, both sexes combined, 1990-2016 Percent contribution of top 10 causes of death by age group, both sexes, 2016What caused the most deaths in different age groups in 2016? However, there was an almost two-fold range of per capita disease burden across the states of India in 2016, adjusting for diferences in age structure between the states, with Kerala and Goa having the lowest rates and Assam, Uttar Pradesh, and Chhattisgarh having the highest rates. Tese fndings highlight major inequalities in disease burden across the states of India, and that neighbouring Sri Lanka, with population 21 million, as well as China, with population 1. The per capita health loss from the individual diseases varies widely between states, with a range of over fve-fold for fve of the 10 leading individual causes, i. The striking health status and disease inequalities between the states of India documented in this report are driven by variations in the exposure to major risk factors as well as broader development factors. The key to reducing these inequalities, and thereby the overall disease burden in India, is to successfully address these risks and determinants in each state of the country in accordance with their magnitude and trajectory. The following major policy-relevant issues arise from the fndings presented in this report. Tese include issues related to specifc risks and disease conditions, as well as broader cross-cutting policy action required to reduce health inequalities between the states. The following sections highlight key issues but are not comprehensive descriptions of each issue. The latter would be more suitable for detailed topic-specifc reports and publications that will be produced subsequently. Addressing the major risk factors Child and maternal malnutrition The very high burden of child and maternal malnutrition in many states of India should be considered an emergency situation, as this is not comIndia: Health of the Nation’s States 199 mensurate with India’s aspirations for further rapid social and economic progress. Besides causing considerable disease burden, malnutrition blunts intellectual growth in children, thereby robbing the country of its future brain power. Several major nutritional enhancement programmes have been in place in India for a long time. Tese include the Integrated Child Development Services since 1975 and the Mid Day Meal Scheme for schoolchildren since 1995. The National Food Security Act was enacted in 2013 for nutritional security of the population. The fact that child and maternal malnutrition continues to be the single largest risk factor for health loss in India in 2016 points to the need for drastic and rapid action on this front. For India as a whole, the per capita disease burden due to child and maternal malnutrition is a striking 12 times higher than in China. Interestingly, even the lowest per capita burden in the Indian state of Kerala is 2. Unsafe water and sanitation The disease burden from unsafe water and sanitation dropped from 13% of the total burden in 1990 to 5% of the total in 2016, but this too is unacceptably high. The Swachh Bharat Abhiyan, launched in India in 2014 with very large investments, could improve this situation. Combining infrastructure development to address this risk with behaviour change would increase the likelihood of benefts, and close monitoring of the impact of the Swachh Bharat Abhiyan versus the disease burden trends in each state over the next few years would enable increasing eforts where they are most needed. Again, for reference the per capita disease burden due to unsafe water and sanitation in India is a massive 40 times higher than in China and 12 times higher than in Sri Lanka. Within India there is a wide variation as well, with the per capita burden ranging 12-fold across the states. The lowest burden is in Goa, although it is seven times higher than in China as a whole, suggesting that huge improvements should be possible across the states of India. Air pollution People living in India have one of the highest levels of exposure to air pollution globally. Continuing eforts to reduce the use of solid fuels, as is being done through the Pradhan Mantri Ujjwala Yojna to enhance access to cooking gas for the poor, will be needed for some time to come. Concerted eforts are needed to curb the sources of this pollution, including power production, industry, vehicles, construction, and open burning. Tese eforts are needed across all states through strategic long-term planning involving the relevant sectors.

In view of our expansive charge heart attack feat sen city generic torsemide 10 mg visa, we tried to address central questions rather than the many details of this complex topic arrhythmia alcohol order torsemide 10 mg with visa. For example pulse pressure 85 generic torsemide 10 mg on-line, we focus on conficts that involve fnancial interests because they are at the heart of concerns and debates about conficts of interest arteria spinalis buy generic torsemide online. The committee expects that many of the recommendations and analyses in our report will also apply more generally to professional and institutional relationships with other commercial entities, such as insurers and vendors of nonmedical products. The committee could not resolve some important issues like harmonizing the different requirements for the disclosure of fnancial relationships because they would require much more time and additional expertise. Instead, to standardize aspects of disclosure policies and procedures, the committee recommended a focused consensus development process that would involve multiple stakeholders on the issue. Our committee was diverse, involving members with different professional backgrounds and areas of expertise. Each of us listened to points of view and information that we had not previously considered. We tried to listen to and understand other viewpoints and be open to new perspectives, even if in the end we did not agree on all issues. Appendix F describes the different views on one issue, a proposal by some committee members for broader requirements for public disclosure. In general, the committee hoped that by explaining our reasoning on diffcult issues our audiences would better appreciate the multiple considerations that a sound confict of interest policy should address. As chair, I want to personally thank the committee members for their hard work and their willingness to engage on diffcult topics. I am deeply grateful to them for the time and effort that they took from their busy schedules to devote to this project. This report is truly a collaborative effort and is much the better, I think, for the back-and-forth discussions. Marilyn Field was unstinting in her background research, drafting and revising of the manuscript, and high standards for our work. And I want to thank Lindsay Parham, my research assistant at the University of California at San Francisco, for her expert help with background research. At the same time, concerns are growing that wide-ranging fnancial ties to industry may unduly infuence professional judgments in ol ing the primary interests and goals of medicine. Such conficts of interest threaten the integrity of scientifc in estigations, the objecti ity of professional education, the quality of patient care, and the public’s trust in medicine. This Institute of Medicine report examines conficts of interest in medical research, education, and practice and in the de elopment of clinical practice guidelines. It re iews the a ailable e idence on the extent of industry relationships with physicians and researchers and their consequences, and it describes current policies intended to identify, limit, or manage conficts of interest. Although this report builds on the analyses and recommendations of other groups, it differs from other reports in its focus on conficts of interest across the spectrum of medicine and its identifcation of o erarching principles for assessing both conficts of interest and confict of interest policies. Physicians and researchers must exercise judgment in complex situations that are fraught with uncertainty. Colleagues, patients, students, and the public need to trust that these judgments are not compromised by physicians’ or researchers’ fnancial ties to pharmaceutical, medical device, and biotechnology companies. Some have produced important benefts, particularly through research collaborations that improve individual and public health. At the same time, widespread relationships with industry have created signifcant risks that individual and institutional fnancial interests may unduly infuence professionals’ judgments about the primary interests or goals of medicine. Such conficts of interest threaten the integrity of scientifc investigations, the objectivity of medical education, and the quality of patient care. Surveys show the breadth and diversity of relationships between industry and physicians, researchers, and educators in academic and community settings. Department of Justice by medical device and pharmaceutical companies to avoid prosecution for alleged illegal payments or gifts to physicians;. Although the causes of these situations are various and their extent is unclear, they highlight the tension that may exist between fnancial relationships with industry and the primary missions of medical research, education, and practice. In addition to these examples, research on industry gifts and other fnancial relationships has generated troublesome fndings. For example, systematic reviews of the evidence sponsored by a pharmaceutical company are more likely than other reviews to present conclusions favorable to the company, even when the actual fndings of the analysis are not favorable. In addition, articles based on company-sponsored clinical trials are more likely to draw conclusions favorable to the company’s product than articles trials not sponsored by industry. Although these fndings do not necessarily show that the research is biased and other explanations can be offered. To cite another example, the availability of drug samples may be associated with the prescription of new brand name drugs when they are not recommended by evidence-based practice guidelines or when appropriate but less expensive drugs or generic equivalents are available for the same indication. Also, although small gifts to physicians may seem to be inconsequential, some research suggests that small gifts can contribute to unconscious bias in decision making and advice giving. It also seems unlikely that companies would give such gifts to physicians if they did not believe that they would beneft the company in some way. In addition to information that raises concern about the scope and consequences of industry fnancial ties in medicine, surveys and other studies have reported inconsistencies in the adoption and implementation of confict of interest policies by medical institutions. Relationships and practices that are forbidden by one institution may be allowed and even encouraged by others. Reports also have described shortcomings in the oversight of conficts of interest in research by federal agencies and medical institutions. Unfortunately, the empirical evidence relevant to fnancial relationships and conficts of interest is limited. On many topics related to conficts of interest, no systematic studies are available. The studies that have been conducted have primarily been observational rather than interventional, in large part because the issues cannot be investigated using randomized controlled trials of the effects of different kinds of relationships or different approaches to identifying and managing conficts of interest. A number of academic medical centers, professional associations, and other institutions have taken steps to strengthen their confict of interest policies, but few data that can be used to assess the consequences—positive or negative—of these changes are available. Some prominent physicians and researchers have argued that concerns about conficts of interest are far out of proportion to the evidence that they exist or are harmful, and some contend that measures designed to address conficts of interest have interfered with benefcial collaborations with industry. Critics of confict of interest policies have also charged that the great majority of individuals who have not acted in an unethical manner may be subjected to onerous regulations and tacit conclusions that they are culpable of misconduct until proven otherwise. Responding to the situations and concerns outlined above, the Institute of Medicine appointed a committee to investigate and develop a consensus report on conficts of interest in medical research, education, and practice and in the development of clinical practice guidelines. During its work, the committee kept in mind the core goals of medical research, education, and practice and practice guideline development, which include serving the best interests of patients and society through the generation of valid scientifc knowledge, the independent evaluation of evidence and the application of critical thinking, and the creation and use of evidence-based recommendations for patient care. Refecting concerns that were raised during the planning of the project and the central issues in debates and policies on conficts of interest in medicine, the committee focused on fnancial relationships involving pharmaceutical, medical device, and biotechnology companies. Although it did not investigate in depth the conficts of interest associated with different physician payment arrangements or with physician referral of patients to facilities in which they have an ownership interest, the committee recognized the seriousness of those types of conficts and the diffculties that policy makers have encountered in trying to eliminate or manage them. It also recognized other sources of conficts of interest, for example, desires for professional advancement and recognition. After examining a wide array of evidence, analyses, and perspectives on conficts of interest, the committee reached several overarching conclusions. The goals of confict of interest policies in medicine are primarily to protect the integrity of professional judgment and to preserve public trust rather than to try to remediate bias or mistrust after they occur. Conficts of interest are defned as circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly infuenced by a secondary interest. Primary interests include promoting and protecting the integrity of research, the quality of medical education, and the welfare of patients. Secondary interests include not only fnancial interests—the focus of this report—but also other interests, such as the pursuit of professional advancement and recognition and the desire to do favors for friends, family, students, or colleagues. Confict of interest policies typically focus on fnancial gain because it is relatively more objective, fungible, and quantifable. Financial gain can therefore be more effectively and fairly regulated than other secondary interests. The severity of a confict of interest depends on (1) the likelihood that professional decisions made under the relevant circumstances would be unduly infuenced by a secondary interest and (2) the seriousness of the harm or wrong that could result from such an infuence. The likelihood of undue infuence is affected by the value of the secondary interest, its duration and depth, and the extent of discretion that the individual has in making important decisions. Confict of interest policies generally emphasize prevention and management rather than punishment.

Review of guidelines for good practice in decision-analytic modelling in health technology assessment blood pressure medication causes nightmares order torsemide amex. Pulling cost-effectiveness analysis up by its bootstraps: a non-parametric approach to confidence interval estimation heart attack aspirin discount 20 mg torsemide otc. Thinking outside the box: recent advances in the analysis and presentation of uncertainty in cost-effectiveness studies pulse pressure and stroke volume torsemide 20 mg lowest price. How sensitive are cost-effectiveness analyses to choice of parametric distributions? Increasing decision-makers’ access to economic evaluations: alternative methods of communicating the information arrhythmia vertigo quality 10 mg torsemide. The cost utility of bupropion in smoking cessation health programs: simulation model results for Sweden. Cost-effectiveness of pharmacotherapies for nicotine dependence in primary care settings: a multinational comparison. Cost-benefit analysis of sustained-release bupropion, nicotine patch, or both for smoking cessation. There is growing recognition of the contribution that qualitative research can make to reviews of effectiveness, particularly in relation to understanding the what, how and why. This includes shaping questions of importance to end users,1 understanding the mechanisms behind effectiveness or ineffectiveness, understanding heterogeneous results, identifying factors that impact on the implementation of an intervention, describing the experience of people receiving the interventions, and providing participants’ subjective evaluations of outcomes. For example, what is it about the workings of a stroke unit that result in better survival rates? What elements of a community-based programme to prevent falls enable older people to retain their independence? How was the process of care perceived and what counts as a successful outcome for those receiving the intervention? An approach that uses qualitative research to address questions such as these helps to ensure that reviews are of maximum value in the decision-making process. Despite recognition of the importance of qualitative research to effectiveness reviews, so far the number of available examples is relatively small. Poor availability may reflect a relative lack of interest in applying review methods to qualitative research and/or lack of consensus about whether it is appropriate to do so. In recent years new approaches and techniques for reviewing qualitative studies have emerged, although debates about appropriateness continue. Because review methods are not well-developed or tested we outline various options for consideration, and provide references which should be consulted where more detailed information is required. We also include worked examples; where possible these have been selected because they are directly linked or related to reviews of effectiveness. But because these are few in number, other types of example are included, such as stand-alone reviews of qualitative research. The process for reviewing qualitative studies has been argued to be an iterative one which might not proceed in a linear way. Qualitative research is concerned with the subjective world and offers insight into social, emotional, and experiential phenomena. The aim is to draw out understandings4 and perceptions, to explore the features of settings and culture and to understand the linkages between process and outcomes. Most qualitative studies are small scale, focusing on a single or small number of cases, and they provide depth and contextualised detail. Qualitative research is not a single method but includes a range of designs such as interviews, direct observation, analysis of texts/documents or of audio/video recorded speech or behaviour. As a result qualitative and quantitative methods are increasingly being used together in primary evaluative research (mixed-method). For example qualitative methods have been used to understand participants’ experiences in a trial evaluating a computerised decision support tool for patients with atrial fibrillation being considered for anti-coagulation treatment. The main reason for the adoption of mixed-methods in primary research is6 to enhance relevance in the decision-making process. Important to note is that some primarily quantitative studies provide information of a qualitative form such as observations or quotes, which are unlikely to be the result of a formal research process. Sometimes no detail is reported of how these ‘data’ have been collected or analysed and researchers need to be cautious if using such information. This issue has been discussed with respect to the implementation of community-based interventions to reduce unintentional injuries in children and young people. Outlined below are three options for including qualitative evidence in/alongside quantitative effectiveness reviews; the first offers a more informal approach; the second involves a formal synthesis of the qualitative findings. Both options treat qualitative and quantitative evidence as complementary with the qualitative evidence offering an explanation for, and interpretation of, the quantitative findings; the third combines the findings from the quantitative and qualitative syntheses. Used in this way the qualitative evidence does not contribute directly to the effectiveness data. If researchers are interested in including both quantitative and qualitative research to address questions of effectiveness they might consider using techniques or approaches capable of combining different types of research evidence such as Bayesian meta-analysis, critical8 interpretive synthesis or realist synthesis. Use the findings from one or more qualitative studies in the discussion and interpretation of the results of the quantitative studies to help make sense of, or place the review findings in context. Usually (although not always) the qualitative evidence will be linked to the quantitative studies included in the effectiveness review. Qualitative and quantitative evidence might be included in the same publication or in separate but associated publications. Undertake a review of qualitative studies alongside the review of quantitative studies and use the formal qualitative synthesis to interpret the findings of the quantitative synthesis (sometimes referred to as parallel synthesis). Researchers might choose to include qualitative research embedded within the quantitative studies or stand-alone qualitative studies that address the question of interest. Where reviews of both quantitative and qualitative evidence are undertaken there is also the option to combine the results of the two syntheses. This approach is sometimes referred to as multi-level, sequenced, cross-design or meta-synthesis. A search for quantitative studies will often identify associated or linked studies using qualitative methods. However relying solely on this approach is questionable, as the studies are identified by chance rather than in a structured systematic way. Both quantitative and qualitative studies would be identified, but this method is likely to result in large numbers of records being retrieved. Qualitative research may be given a descriptive or creative title that makes retrieval using standard search techniques difficult. Database abstracts, where included, are often not structured and can have variable content, which further complicates their identification. For example, the headings ‘qualitative studies’ and ’grounded theory’ were both introduced in 1988. Search filters for identifying qualitative research are available for use in a number of electronic databases. For researchers wishing to use existing search filters, two resources are particularly helpful. A range of filters is available for each database, together with information about the research papers underlying the development of the filter hiru. Where the aim is to comprehensively identify all papers on a topic, a filter with high sensitivity should be selected. If it is of less importance to identify all papers, a filter with high precision will usually be appropriate. Reading the accompanying research paper that describes the development of each filter can help researchers to choose the filter that is most appropriate. This resource includes a wider range of filters than the Hedges Project, but in some cases the filter is not displayed in full on the website, although details of where it is published are given. Options include purposive and/or theoretical sampling where papers are selected for inclusion on the basis of particular criteria such as rich description or conceptual clarity. Examples of purposive sampling are provided in reviews of caring24 and access to health care. It is important to outline the steps taken and discuss the potential impact of 224 Incorporating qualitative evidence in or alongside systematic reviews of effect any limitations. Proposed standards for reporting literature searches are available, and provide a useful resource. For example, it has been noted that the distinguishing mark of all ‘good’ research is the awareness and acknowledgement of error and, that what flows from this is the necessity of establishing procedures which will minimize the effect such errors may have on what counts as knowledge. Qualitative researchers from different disciplines and from different theoretical backgrounds may have different criteria for assessing the quality of a study. Despite lack of consensus about quality assessment a number of different tools and techniques are now available.

A focal asymmetry is a small area of fibroglandular tissue that is visible on one projection and in one breast blood pressure good average buy torsemide online. Eleven studies and three narrative literature reviews included in this literature review commented on asymmetry blood pressure up and down discount 20 mg torsemide fast delivery. Systematic reviews and narrative literature reviews Systematic reviews: none Narrative literature reviews: Eghtedari et al heart attack calculator buy torsemide without a prescription. The authors reported that cancers were still difficult to detect due to a mammographic presentation based on focal asymmetry or negative mammographic findings arrhythmia burlington ma order line torsemide. It is not clear whether these study result included a mix of prevalent and incident screening examinations but given that data is drawn from a screening population, it is likely to be more representative of real-world clinical practice than some other studies reported in this literature review and it is indicative of the potential of reduced future work-up due to increased reader confidence. Other smaller studies also demonstrated decreases in recall to assessment due to asymmetry, but the findings were considerably smaller (for example, McDonald et al. Complicating matters is the fact that presentation of other microor macrocalcification patterns (such as oval) can be indicative of benign or normal breast structures. All the studies reported in this section were completed using Hologic’s Selenia Dimensions units (except for Kopans et al. Retrospective studies of symptomatic women only In studies of symptomatic women only, Mariscotti et al. One of the earliest studies retrieved for this literature review was Spangler et al (2011). Since the publication of the studies previously discussed, a range of other studies reporting equivalent or superior diagnostic performance for microcalcifications have been completed. Different dimensions of diagnostic performance that have been explored include the following: Both readers were experienced but there were considerable differences in the depth of experience (having fiveor 35-years’ experience). Overall, readers considered that microcalcifications were seen more clearly on 41. Retrospective non-blinded reader (n=3) 23 lesions presented as microcalcifications (20. Fifteen studies and four narrative literature reviews commented on masses as a mammographic presentation. Most studies describing masses did not differentiate between different types of mass (eg, branching, presenting with spiculation or oval, well-circumscribed masses). Systematic reviews and narrative literature reviews Systematic reviews: none Four narrative literature reviews: Michell & Batohi (2018); Destounis et al. Reasons for this were improved lesion margin visibility resulting in reclassification of asymmetry to masses. It is not clear whether these study result include a mix of prevalent and incident screening but given that data is drawn from a screening population, it is likely to be more representative of real-world clinical practice than some other studies reported in this literature review. Other studies also demonstrated increases in recall to assessment due to mass, but the findings were considerably smaller (for example, McDonald et al. The authors concluded that improved conspicuity and 3D planes make it easier to differentiate between malignant and benign masses, a common refrain in the studies reporting on this mammographic finding. All sub-group analyses also reported equivalent or superior visibility but only results for breast density achieved statistical significance (p. Physical characteristics like tumour size, grade and lymph node status also play an important role ensuring accurate diagnosis of cancer type and determining treatment options and how an individual may respond to treatment/overall prognosis. The discussion includes a description of the number of studies identified, statements about the overall quality of the studies, and a summary of the results from all studies. Study tables provide additional detail about study population, methodology, intervention, comparator and key results. Pooled analysis drawn from studies of women participating in screening as well women recalled to assessment reported this result consistently. Studies in other populations (including symptomatic women) reported the same result. Increases in detection of invasive cancers is likely to be indicative of detection of more clinically relevant cancers which have poorer prognosis if not detected early. While studies focused on diagnostic populations or cancer-enriched cohorts were excluded from the literature review on screening, some included studies reported on tumour characteristics. Much of the evidence discussing cancer type/histology is included in literature from diagnostic populations. Further information about differences in primary mammographic finding (including microcalcifications) is provided in section 3. While many studies described cancer type/histology in patient characteristics tables, few papers provided comparative analysis between different imaging modalities. Primary studies already incorporated into systematic or literature reviews were reviewed but not separately assessed unless additional material not described in the systematic review or narrative literature review was included in the primary study. Studies were excluded if participants were not drawn from a general screening population, had study cohorts of fewer than 1000 women, were interpreted without blinding to reference standard results, or used data from other studies. No further analysis of other histological types of cancer due to a limited range of studies reporting on these. Participants were drawn from the Verona population-based breast cancer 15 Yun et al. The authors found no significant differences between the two groups for patient age (p=. Breast cancers were considered screening-detected if diagnosed within 365 days of a positive screening exam. Interval cancers were those diagnosed within 365 days of a negative screening assessment. From a screening cohort of 12,444 women, 65 breast cancers were detected in 63 patients. When the area of concern was known for readers, an additional 29% of cancers were able to be detected. Prospective studies from mixed or symptomatic populations the literature review returned two prospective studies comparing detection of invasive cancers. No further information about the number of women in each category was provided in the article. No significant differences were seen between the two modalities for alveolar and pleomorphic subtypes. All lesions in their study that met this definition were found to be invasive cancers. More information about the size of tumour at detection and the detection of this cancers from this study is included in section 5. Results presented in these studies are broadly consistent with the findings from screening populations (reported in Yun et al. Reporting on matched comparison data (all images read three ways) for 1112 cancers, Gilbert et al. While in a mixed study population of asymptomatic women and those with symptoms, this result is consistent with the findings presented in section 5. Of these, 93 were non-calcified lesions (not further described) and 14 were calcified. The assessment of newly diagnosed breast cancer is essential to obtain an estimate of staging, which is integral in prognosis development. It involves determining the extent of disease in the affected breast and in the contralateral breast, evaluating regional lymph nodes and identifying other sites of disease if the cancer has metastasised. Staging is also used to assist in treatment planning and informs follow-up surveillance. Each section is assigned to a subcategory depending on the lesion’s characteristics (such as size, margin outline, and extent of growth). Imaging and histological and pathology testing are used to place breast cancers into the correct stage and subcategory. Breast cancer grading is conducted histologically after a successful biopsy is completed and depends on how the tumour cells differ from healthy cells. Grade 1 breast cancer cells look small and uniform like healthy cells and are usually slow growing. Grade 3 breast cancer cells appear abnormal, usually due to a much faster rate of growth. Early detection of breast cancer is one of the key ways in which mortality is reduced. In this literature review, one systematic review, three literature reviews and 11 studies reported comparative results on the stage and grade of cancers. Table 15: Study summaries from three narrative literature reviews Study Design Results Amer et al.

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