Patterns of Early Life Weight Gain and Female Onset of Puberty

Context

Prepubertal obesity is a well-established predictor of earlier pubertal onset, which is itself a risk factor for poor health and well-being. Identifying specific patterns of weight gain in early life may help explain differential risk for earlier pubertal onset.

Objective

The objective of the study was to examine patterns of weight gain across infancy and early childhood in relation to pubertal onset outcomes.

Design, Setting, and Participants

Participants were 426 girls in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, a longitudinal birth cohort of children and their families followed between birth and adolescence.

Main Outcome Measures

Three pubertal onset outcomes were examined, including age at menarche and ages at Tanner stage II for dimensions of breast and pubic hair development.

Results

In infancy (birth to 15 months), greater percent weight gain and higher birthweight predicted earlier pubertal onset for all outcomes (Ps < 0.05). In early childhood (24 months to grade 1), body mass index (BMI) trajectories reflecting BMI values that were persistently high or changed from low to high over time (vs BMI values that were stable at median or low levels), predicted younger ages at menarche and the onset of breast (Ps < 0.05), but not pubic hair (Ps > 0.05), development. All associations were independent of breastfeeding, maternal menarcheal age, and race/ethnicity.

Conclusions

Distinct patterns of early life weight gain predict differential risk for earlier onset puberty. Focusing on these patterns for earlier and more targeted intervention may help lessen life course linkages between prepubertal obesity, accelerated pubertal development, and negative postpubertal outcomes.

Elevated risk thresholds predict endocrine risk-reducing medication use in the Athena screening registry

Risk-reducing endocrine therapy use, though the benefit is validated, is extremely low. The FDA has approved tamoxifen and raloxifene for a 5-year Breast Cancer Risk Assessment Tool (BCRAT) risk ≥ 1.67%. We examined the threshold at which high-risk women are likely to be using endocrine risk-reducing therapies among Athena Breast Health Network participants from 2011-2018. We identified high-risk women by a 5-year BCRAT risk ≥ 1.67% and those in the top 10% and 2.5% risk thresholds by age. We estimated the odds ratio (OR) of current medication use based on these thresholds using logistic regression. One thousand two hundred and one (1.2%) of 104,223 total participants used medication. Of the 33,082 participants with 5-year BCRAT risk ≥ 1.67%, 772 (2.3%) used medication. Of 2445 in the top 2.5% threshold, 209 (8.6%) used medication. Participants whose 5-year risk exceeded 1.67% were more likely to use medication than those whose risk was below this threshold, OR 3.94 (95% CI = 3.50-4.43). The top 2.5% was most strongly associated with medication usage, OR 9.50 (8.13-11.09) compared to the bottom 97.5%. Women exceeding a 5-year BCRAT ≥ 1.67% had modest medication use. We demonstrate that women in the top 2.5% have higher odds of medication use than those in the bottom 97.5% and compared to a risk of 1.67%. The top 2.5% threshold would more effectively target medication use and is being tested prospectively in a randomized control clinical trial.

Childhood Socioeconomic Status and Menarche: A Prospective Study

PURPOSE

The relationship between socioeconomic status (SES) and menarche has implications for understanding social level influences on early life development and adult disease, including breast cancer, but remains ill defined. We report here results from the Breast Cancer and the Environment Research Program, which permitted a longitudinal study of age at menarche in relationship to childhood SES in a diverse cohort of 1,069 girls across three urban areas of the United States.

METHODS

We assessed the association of SES index quintiles with age at pubertal onset with breast budding and subsequent tempo to the age at menarche between 2004 and 2015 using multiple-event Cox regression models to estimate hazard ratios and 95% confidence intervals.

RESULTS

In an unadjusted model, lower SES was predictive of both earlier pubertal onset and tempo and thus earlier age at menarche in trends across quintiles. After adjusting for the potentially mediating effects of body mass index, SES trends remained significant for both outcomes. After adjusting for both body mass index and race/ethnicity, the association with SES remained substantial for pubertal onset but was much diminished and nonsignificant for tempo and thus age at menarche.

CONCLUSIONS

These results suggest that a lower SES environment and social adversity affect the age at menarche primarily by hastening pubertal onset rather than by shortening tempo.

Early Life Adversity and Pubertal Timing: Implications for Cardiometabolic Health

OBJECTIVE

To identify early life adversity (ELA) risk factors for earlier pubertal timing, itself a risk factor for poor cardiometabolic health, and to determine whether such ELA-related risk may be mediated by pre-pubertal body mass index (BMI).

METHODS

Subjects included 426 female participants in a prospective birth cohort study, the NICHD Study of Early Child Care and Youth Development. Survival analysis models were fit to examine ELA exposures, representing childhood socioeconomic status (SES), maternal sensitivity, mother-child attachment, and negative life events, along with child health indicators and covariates, in relation to pubertal timing outcomes, including age at menarche and ages at Tanner stage II for breast and pubic hair development.

RESULTS

Higher childhood SES emerged as an independent predictor of older age at menarche, showing each one standard deviation increase in childhood SES corresponded to a 1.3% increase in age at menarche (factor change = 1.013; 1.003-1.022; p < .01), but did not predict breast or pubic hair development (ps > .05). In mediation analyses, indirect (mediated) effects of mother-child attachment on the pubertal timing outcomes, via pre-pubertal BMI, were all statistically significant (ps < .05).

CONCLUSIONS

Higher childhood SES predicted directly, and secure (vs. insecure) mother-child attachment predicted indirectly (via pre-pubertal BMI), later pubertal timing, suggesting these factors may protect girls from earlier pubertal development. By extension, clinical implications are that intervention strategies designed to lessen ELA- and pre-pubertal obesity-related risk may be effective in remediating life course pathways linking ELA, accelerated pubertal development, and cardiometabolic risk.

Cancer and climate change

The acute impact of climate change on human health is receiving increased attention, but little is known or appreciated about the effect of climate change on chronic diseases, particularly cancer. This Review provides a synopsis of what is known about climate change and the exposures it generates relevant to cancer. In the context of the world's cancer burden and the probable direction we could expect to follow in the absence of climate change, this scoping review of the literature summarises the effects that climate change is having on major cancers, from environmental exposures to ultraviolet radiation, air pollution, disruptions in the food and water supply, environmental toxicants, and infectious agents. Finally, we explore the effect of climate change on the possible disruption of health systems that have been essential to cancer control practice. We conclude with potential responses and opportunities for intervention.

A Complex Systems Model of Breast Cancer Etiology: The Paradigm II Conceptual Model

BACKGROUND

The etiology of breast cancer is a complex system of interacting factors from multiple domains. New knowledge about breast cancer etiology continues to be produced by the research community, and the communication of this knowledge to other researchers, practitioners, decision makers, and the public is a challenge.

METHODS

We updated the previously published Paradigm model (PMID: 25017248) to create a framework that describes breast cancer etiology in four overlapping domains of biologic, behavioral, environmental, and social determinants. This new Paradigm II conceptual model was part of a larger modeling effort that included input from multiple experts in fields from genetics to sociology, taking a team and transdisciplinary approach to the common problem of describing breast cancer etiology for the population of California women in 2010. Recent literature was reviewed with an emphasis on systematic reviews when available and larger epidemiologic studies when they were not. Environmental chemicals with strong animal data on etiology were also included.

RESULTS

The resulting model illustrates factors with their strength of association and the quality of the available data. The published evidence supporting each relationship is made available herein, and also in an online dynamic model that allows for manipulation of individual factors leading to breast cancer (https://cbcrp.org/causes/).

CONCLUSIONS

The Paradigm II model illustrates known etiologic factors in breast cancer, as well as gaps in knowledge and areas where better quality data are needed.

IMPACT

The Paradigm II model can be a stimulus for further research and for better understanding of breast cancer etiology.

Abstract IA02: Science to policy for a ban on the sale of menthol and flavored tobacco products: The San Francisco Cancer Initiative (SF CAN)

The San Francisco Cancer Initiative (SF CAN) seeks to implement evidence-based interventions for the top five most prevalent cancers for which prevention and early detection procedures are available. In San Francisco, breast, prostate, colorectal, liver, and lung and other tobacco-caused cancers account for 48% of cancer mortality, and cancer is now the leading cause of death. SF CAN uses a “collective impact” structure whereby multiple health systems, the Department of Public Health, safety net clinics, nongovernmental agencies, and community groups all work together on the same goal of accelerating the reduction in cancer mortality at the population level, with the University of California San Francisco (UCSF) serving as the backbone entity. SF CAN has been active for 3 years and is supported by philanthropy, grants, and in-kind contributions from collaborative partners. Implementation work is carried out by five task forces, each made up of members from UCSF and collaborating institutions and agencies. The Tobacco Task Force, led by Dr. Stanton Glantz and his colleagues, has sought to have an impact on the use of menthol and flavored cigarettes on African Americans and other targeted ethnic groups, youth, and young adult tobacco use and tobacco cessation among homeless and substance-abusing populations within the city. Some of the interventions they are implementing, based on scientific evidence of impact, have had or will have direct policy implications. Foremost among these has been the use of evidence on the impact of menthol cigarettes, commonly used by African American, Latino, and LGBT communities. The Task Force investigators assembled data on both the biologic mechanisms by which menthol additives increase the likelihood of addiction and the historical data from examination of documents obtained through legal channels from the tobacco industry. These data were first supplied to the FDA to assist in their decision-making and then made available to San Francisco Supervisors for their consideration for actions by local government ordinance. After consideration of the evidence and motivated by the health issues of their constituents, they wrote an ordinance completely banning the sale of all flavored tobacco products (including menthol). The ordinance passed unanimously in June 2017 and was signed into law by then-Mayor Lee. A petition drive to revoke the ordinance by referendum, heavily financed by RJ Reynolds Tobacco (maker of the leading menthol cigarette, Newport) with support from other tobacco companies, failed with 68% of voters in favor of keeping the ban. The ordinance went into effect in July 2018 with systematic outreach and education to retailers of tobacco by the SF DPH, and initial inspections were begun in Dec 2018 and have continued as routine since April of 2019 and found strong by tobacco outlets. This and other efforts at policy change in tobacco that have been conducted in the area of health economics of tobacco use and in the institution of smoke-free areas in homeless shelters around the city will be described.

Citation Format: Robert A. Hiatt. Science to policy for a ban on the sale of menthol and flavored tobacco products: The San Francisco Cancer Initiative (SF CAN) [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr IA02.

The Use of Technology for Communicating With Clinicians or Seeking Health Information in a Multilingual Urban Cohort: Cross-Sectional Survey

Background

Technology is being increasingly used to communicate health information, but there is limited knowledge on whether these strategies are effective for vulnerable populations, including non–English speaking or low-income individuals.

Objective

This study assessed how language preferences (eg, English, Spanish, or Chinese), smartphone ownership, and the type of clinic for usual source of care (eg, no usual source of care, nonintegrated safety net, integrated safety net, private or community clinic, academic tertiary medical center, or integrated payer-provider) affect technology use for health-related communication.

Methods

From May to September 2017, we administered a nonrandom, targeted survey to 1027 English-, Spanish-, and Chinese-speaking San Francisco residents and used weighted multivariable logistic regression analyses to assess predictors of five technology use outcomes. The three primary predictors of interest—language preference, smartphone ownership, and type of clinic for usual care—were adjusted for age, gender, race or ethnicity, limited English proficiency, educational attainment, health literacy, and health status. Three outcomes focused on use of email, SMS text message, or phone apps to communicate with clinicians. The two other outcomes were use of Web-based health videos or online health support groups.

Results

Nearly one-third of participants watched Web-based health videos (367/1027, 35.74%) or used emails to communicate with their clinician (318/1027, 30.96%). In adjusted analyses, individuals without smartphones had significantly lower odds of texting their clinician (adjusted odds ratio [aOR] 0.27, 95% CI 0.13-0.56), using online health support groups (aOR 0.14, 95% CI 0.04-0.55), or watching Web-based health videos (aOR 0.31, 95% CI 0.15-0.64). Relative to English-speaking survey respondents, individuals who preferred Chinese had lower odds of texting their clinician (aOR 0.25, 95% CI 0.08-0.79), whereas Spanish-speaking survey respondents had lower odds of using apps to communicate with clinicians (aOR 0.34, 95% CI 0.16-0.75) or joining an online support group (aOR 0.30, 95% CI 0.10-0.92). Respondents who received care from a clinic affiliated with the integrated safety net, academic tertiary medical center, or integrated payer-provider systems had higher odds than individuals without a usual source of care at using emails, SMS text messages, or apps to communicate with clinicians.

Conclusions

In vulnerable populations, smartphone ownership increases the use of many forms of technology for health purposes, but device ownership itself is not sufficient to increase the use of all technologies for communicating with clinicians. Language preference impacts the use of technology for health purposes even after considering English proficiency. Health system factors impact patients’ use of technology-enabled approaches for communicating with clinicians. No single factor was associated with higher odds of using technology for all health purposes; therefore, existing disparities in the use of digital health tools among diverse and vulnerable populations can only be addressed using a multipronged approach.

Factors associated with biomedical research participation within community-based samples across 3 National Cancer Institute-designated cancer centers

BACKGROUND

Engaging diverse populations in biomedical research, including biospecimen donation, remains a national challenge. This study examined factors associated with an invitation to participate in biomedical research, intent to participate in biomedical research in the future, and participation in biomedical research and biospecimen donation among a diverse, multilingual, community-based sample across 3 distinct geographic areas.

METHODS

Three National Cancer Institute-designated cancer centers engaged in community partnerships to develop and implement population health assessments, reaching a convenience sample of 4343 participants spanning their respective catchment areas. Data harmonization, multiple imputation, and multivariable logistic modeling were used.

RESULTS

African Americans, Hispanic/Latinos, and other racial minority groups were more likely to be offered opportunities to participate in biomedical research compared to whites. Access to care, history of cancer, educational level, survey language, nativity, and rural residence also influenced opportunity, intent, and actual participation in biomedical research.

CONCLUSIONS

Traditionally underserved racial and ethnic groups reported heightened opportunity and interest in participating in biomedical research. Well-established community partnerships and long-standing community engagement around biomedical research led to a diverse sample being reached at each site and may in part explain the current study findings. However, this study illustrates an ongoing need to establish trust and diversify biomedical research participation through innovative and tailored approaches. National Cancer Institute-designated cancer centers have the potential to increase opportunities for diverse participation in biomedical research through community partnerships and engagement. Additional work remains to identify and address system-level and individual-level barriers to participation in both clinical trials and biospecimen donation for research.

Breast Cancer in San Francisco: Disentangling Disparities at the Neighborhood Level

BACKGROUND

This study uses a novel geographic approach to summarize the distribution of breast cancer in San Francisco and aims to identify the neighborhoods and racial/ethnic groups that are disproportionately affected by this disease.

METHODS

Nine geographic groupings were newly defined on the basis of racial/ethnic composition and neighborhood socioeconomic status. Distribution of breast cancer cases from the Greater Bay Area Cancer Registry in these zones were examined. Multivariable logistic regression models were used to determine neighborhood associations with stage IIB⁺ breast cancer at diagnosis. Cox proportional hazards regression was used to estimate the hazard ratios for all-cause and breast cancer-specific mortality.

RESULTS

A total of 5,595 invasive primary breast cancers were diagnosed between January 1, 2006 and December 31, 2015. We found neighborhood and racial/ethnic differences in stage of diagnosis, molecular subtype, survival, and mortality. Patients in the Southeast (Bayview/Hunter's Point) and Northeast (Downtown, Civic Center, Chinatown, Nob Hill, Western Addition) areas were more likely to have stage IIB⁺ breast cancer at diagnosis, and those in the East (North Beach, Financial District, South of Market, Mission Bay, Potrero Hill) and Southeast were more likely to be diagnosed with triple-negative breast cancers (TNBC). Compared with other racial/ethnic groups, Blacks/African Americans (B/AA) experienced the greatest disparities in breast cancer-related outcomes across geographic areas.

CONCLUSIONS

San Francisco neighborhoods with lower socioeconomic status and larger minority populations experience worse breast cancer outcomes.

IMPACT

Our findings, which reveal breast cancer disparities at sub-county geographic levels, have implications for population-level health interventions.

Environmental Tobacco Smoke Exposure in Relation to Family Characteristics, Stressors and Chemical Co-Exposures in California Girls

Childhood environmental tobacco smoke (ETS) exposure is a risk factor for adverse health outcomes and may disproportionately burden lower socioeconomic status groups, exacerbating health disparities. We explored associations of demographic factors, stressful life events, and chemical co-exposures, with cotinine levels, among girls in the CYGNET Study. Data were collected from families of girls aged 6–8 years old in Northern California, through clinic exams, questionnaires and biospecimens (n = 421). Linear regression and factor analysis were conducted to explore predictors of urinary cotinine and co-exposure body burdens, respectively. In unadjusted models, geometric mean cotinine concentrations were higher among Black (0.59 ug/g creatinine) than non-Hispanic white (0.27), Asian (0.32), or Hispanic (0.34) participants. Following adjustment, living in a rented home, lower primary caregiver education, and lack of two biologic parents in the home were associated with higher cotinine concentrations. Girls who experienced parental separation or unemployment in the family had higher unadjusted cotinine concentrations. Higher cotinine was also associated with higher polybrominated diphenyl ether and metals concentrations. Our findings have environmental justice implications as Black and socio-economically disadvantaged young girls experienced higher ETS exposure, also associated with higher exposure to other chemicals. Efforts to reduce ETS and co-exposures should account for other disparity-related factors.

How current reporting practices may mask differences: A call for examining cancer-specific demographic enrollment patterns in cancer treatment clinical trials

Background

A lack of diversity among clinical trial (CT) participants remains a critical problem. Few studies have examined recruitment variability in cancer treatment CTs by cancer type. Given the increasing organ-specific specialization of oncologic care, an understanding of this variability may affect institutional recruitment practices.

Methods

This study examines three data sources from 2010 through 2014. The analyzed sample includes 3,580 CT participants identified in the institutional Clinical Trials Management System (CTMS) database and 20,305 incident cases of invasive cancer within a Comprehensive Cancer Center (CCC) institutional catchment area. A total of 341,114 incident cases of primary invasive cancer were identified through the California Cancer Registry (CCR). The primary study measurements were sociodemographic characteristics of the three populations (age, sex, race/ethnicity, and health insurance).

Results

Racial/ethnic disparities were observed, with more incident cases of Whites seen in cancer center (68%) and enrolled in CTs (72%) compared to incident cases in catchment area (67%) (p < 0.001) overall. More older adults (65) were enrolled in prostate cancer CTs (58%) than seen in cancer center (45%) (p < 0.001). Alternatively, fewer older adults were enrolled in breast and colorectal CTs than seen in cancer center (p < 0.001). Among colon (p < 0.001), breast (p < 0.001), and prostate (p<0.001) cancer types, insurance type significantly varied between incident cases in catchment area, cancer center, and among CT participants. For colorectal cancer, no difference in sex distribution was observed overall. A significant difference in insurance type within each cancer type was observed (p < 0.001).

Conclusions

These findings suggest that reporting overall recruitment frequencies may mask differences by cancer type.

Longitudinal study of age of menarche in association with childhood concentrations of persistent organic pollutants

BACKGROUND

Age at female puberty is associated with adult morbidities, including breast cancer and diabetes. Hormonally active chemicals are suspected of altering pubertal timing. We examined whether persistent organic pollutants (POPs) are associated with age at menarche in a longitudinal study.

METHODS

We analyzed data for females enrolled at age 6-8 years in the Breast Cancer and Environment Research Program from California and Ohio. Participants were followed annually 2004-2013 and provided serum (mean age 7.8 years) for measurement of polychlorinated biphenyl (PCB), organochlorine pesticide (OCP), and polybrominated diphenyl ether (PBDE) concentrations. Age of menarche was assigned based on parental and participant reported dates and ages of menarche. Adjusted hazard ratios (aHRs) for menarchal onset were calculated with Cox proportional regression. Body mass index (BMI), potentially on the causal pathway, was added to parallel analyses.

RESULTS

Age of menarche was later with higher summed PCB levels (median 11.9 years in quartile 1 [Q1] versus 12.7 in quartile 4 [Q4]) and OCP levels (12.1 years versus 12.4, respectively). When adjusting for all covariates except BMI, higher POP concentrations were associated with later age at menarche (Q4 versus Q1 aHRs: PBDEs 0.75 [95% CI 0.58, 0.97], PCBs 0.67 [95% CI 0.5, 0.89], and OCPs 0.66 [95% CI 0.50, 0.89]). Additional adjustment for BMI attenuated aHRs; PCB aHR approached the null.

CONCLUSION

Findings revealed later onset of menarche with higher concentrations of certain POPs, possibly through an association with BMI. Altered pubertal timing may have long lasting effects on reproductive health and disease risk, so continued attention is important for understanding the biological processes affected by hormonally active chemicals.

Perfluorooctanoate and changes in anthropometric parameters with age in young girls in the Greater Cincinnati and San Francisco Bay Area

METHODS

We conducted a study of per- and polyfluoroalkyl substance biomarkers, including PFOA, in girls from Greater Cincinnati (CIN, N = 353) and the San Francisco Bay Area (SFBA, N = 351). PFOA was measured in the baseline serum sample collected in 2004-2007 of 704 girls at age 6-8 years. Mixed effects models were used to derive the effect of PFOA on BMI, waist-to-height and waist-to-hip ratios over increasing age in this longitudinal cohort.

RESULTS

Median PFOA serum concentrations were 7.3 (CIN) and 5.8 (SFBA) ng/mL, above the U.S. population median for children 12-19 years in 2005-2006 (3.8 ng/mL). Log-transformed serum PFOA had a strong inverse association with BMIz in the CIN girls (p = 0.0002) and the combined two-site data (p = 0.0008); the joint inverse effect of PFOA and Age*PFOA weakened at age at 10-11 years. However, in the SFBA group alone, the relationship was not significant (p = 0.1641) with no evidence of changing effect with age. The effect of PFOA on waist:height ratio was similar to BMIz at both sites, but we did not find a significant effect of PFOA on waist:hip ratio in either the CIN or SFBA girls.

CONCLUSIONS

PFOA is associated with decreased BMI and waist:height ratio in young girls, but the strength of the relationship decreases with age. Site heterogeneity may be due to greater early life exposure in Cincinnati.

DISCLAIMER

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Use of trade names is for identification only and does not imply endorsement by the CDC, the Public Health Service, or the US Department of Health and Human Services.

Longitudinal Changes in Volumetric Breast Density in Healthy Women across the Menopausal Transition

BACKGROUND

Mammographic breast density declines during menopause. We assessed changes in volumetric breast density across the menopausal transition and factors that influence these changes.

METHODS

Women without a history of breast cancer, who had full field digital mammograms during both pre- and postmenopausal periods, at least 2 years apart, were sampled from four facilities within the San Francisco Mammography Registry from 2007 to 2013. Dense breast volume (DV) was assessed using Volpara on mammograms across the time period. Annualized change in DV from pre- to postmenopause was estimated using linear mixed models adjusted for covariates and per-woman random effects. Multiplicative interactions were evaluated between premenopausal risk factors and time to determine whether these covariates modified the annualized changes.

RESULTS

Among the 2,586 eligible women, 1,802 had one premenopausal and one postmenopausal mammogram, 628 had an additional perimenopausal mammogram, and 156 had two perimenopausal mammograms. Women experienced an annualized decrease in DV [-2.2 cm³ (95% confidence interval, -2.7 to -1.7)] over the menopausal transition. Declines were greater among women with a premenopausal DV above the median (54 cm³) versus below (DV, -3.5 cm³ vs. -1.0 cm³; P < 0.0001). Other breast cancer risk factors, including race, body mass index, family history, alcohol, and postmenopausal hormone therapy, had no effect on change in DV over the menopausal transition.

CONCLUSIONS

High premenopausal DV was a strong predictor of greater reductions in DV across the menopausal transition.

IMPACT

We found that few factors other than premenopausal density influence changes in DV across the menopausal transition, limiting targeted prevention efforts.

Combined effect of volumetric breast density and body mass index on breast cancer risk

BACKGROUND

Breast density and body mass index (BMI) are used for breast cancer risk stratification. We evaluate whether the positive association between volumetric breast density and breast cancer risk is strengthened with increasing BMI.

METHODS

The San Francisco Mammography Registry and Mayo Clinic Rochester identified 781 premenopausal and 1850 postmenopausal women with breast cancer diagnosed between 2007 and 2015 that had a screening digital mammogram at least 6 months prior to diagnosis. Up to three controls (N = 3535) were matched per case on age, race, date, mammography machine, and state. Volumetric percent density (VPD) and dense volume (DV) were measured with Volpara™. Breast cancer risk was assessed with logistic regression stratified by menopause status. Multiplicative interaction tests assessed whether the association of density measures was differential by BMI categories.

RESULTS

The increased risk of breast cancer associated with VPD was strengthened with higher BMI for both premenopausal (p_interaction = 0.01) and postmenopausal (p_interaction = 0.0003) women. For BMI < 25, 25-30, and ≥ 30 kg/m², ORs for breast cancer for a 1 SD increase in VPD were 1.24, 1.65, and 1.97 for premenopausal, and 1.20, 1.55, and 2.25 for postmenopausal women, respectively. ORs for breast cancer for a 1 SD increase in DV were 1.39, 1.33, and 1.51 for premenopausal (p_interaction = 0.58), and 1.31, 1.34, and 1.65 (p_interaction = 0.03) for postmenopausal women for BMI < 25, 25-30 and ≥ 30 kg/m², respectively.

CONCLUSIONS

The effect of volumetric percent density on breast cancer risk is strongest in overweight and obese women. These associations have clinical relevance for informing prevention strategies.

Screening mammography use in older women according to health status: a systematic review and meta-analysis

Background

The extent to which screening mammography (SM) recommendations in older women incorporate life expectancy factors is not well established.

Objective

The objective of this review was to evaluate evidence on SM utilization in older women by life expectancy factors.

Data sources

We searched Medline, Embase and Web of Science from January 1991 to March 2016.

Study selection

We included studies examining SM utilization in women ages ≥65 years that measured life expectancy using comorbidity, functional limitations or health or prognostic status.

Data extraction and synthesis

ORs and 95% CIs were extracted and grouped by life expectancy category. Findings were aggregated into pooled ORs and 95% CIs and meta-analyzed by life expectancy category.

Main outcomes and measures

The primary outcome was SM utilization within the last 5 years. Life expectancy factors included number of comorbidities, Charlson Comorbidity Index (CCI), activities of daily living, instrumental activities of daily living, self-reported health status and 5-year prognostic indices.

Results

Of 2,606 potential titles, we identified 25 meeting the inclusion criteria (comorbidity: eight studies, functional status: 11 studies and health/prognostic status: 13 studies). Women with higher CCI scores had decreased SM utilization (pooled OR: 0.75, 95% CI: 0.67–0.85), but increased absolute number of comorbidities were weakly associated with increased SM utilization (pooled OR: 1.17, 95% CI: 1.00–1.36). Women with more functional limitations had lower SM use odds than women with no limitations (pooled OR: 0.72, 95% CI: 0.62–0.83). Screening utilization odds were lower among women with poor vs excellent health (pooled OR: 0.85, 95% CI: 0.74–0.96).

Conclusion

Greater CCI score, functional limitations and lower perceived health were associated with decreased SM use, whereas higher absolute number of comorbidities was associated with increased SM use. SM guidelines should consider these factors to improve assessments of potential benefits and harms in older women.

Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans

Background

Pulmonary nodule guidelines do not indicate how to individualize follow-up according to comorbidity or life expectancy.

Objectives

To characterize comorbidity and life expectancy in older veterans with incidental, symptom-detected, or screen-detected nodules in 2008–09 compared to 2013–14. To determine the impact of these patient factors on four-year nodule follow-up among the 2008–09 subgroup.

Design

Retrospective cohort study.

Setting

Urban Veterans Affairs Medical Center.

Participants

243 veterans age ≥65 with newly diagnosed pulmonary nodules in 2008–09 (followed for four years through 2012 or 2013) and 446 older veterans diagnosed in 2013–14.

Measurements

The primary outcome was receipt of any follow-up nodule imaging and/or biopsy within four years after nodule diagnosis. Primary predictor variables included age, Charlson-Deyo Comorbidity Index (CCI), and life expectancy. Favorable life expectancy was defined as age 65–74 with CCI 0 while limited life expectancy was defined as age ≥85 with CCI ≥1 or age ≥65 with CCI ≥4. Interaction by nodule size was also examined.

Results

From 2008–09 to 2013–14, the number of older veterans diagnosed with new pulmonary nodules almost doubled, including among those with severe comorbidity and limited life expectancy. Overall among the 2008–09 subgroup, receipt of nodule follow-up decreased with increasing comorbidity (CCI ≥4 versus 0: adjusted RR 0.61, 95% CI 0.39–0.95) with a trend towards decreased follow-up among those with limited life expectancy (adjusted RR 0.69, 95% CI 0.48–1.01). However, we detected an interaction effect with nodule size such that comorbidity and life expectancy were associated with decreased follow-up only among those with nodules ≤6 mm.

Conclusions

We found some individualization of pulmonary nodule follow-up according to comorbidity and life expectancy in older veterans with smaller nodules only. As increased imaging detects nodules in sicker patients, guidelines need to be more explicit about how to best incorporate comorbidity and life expectancy to maximize benefits and minimize harms for patients with nodules of all sizes.

No one to turn to: low social support and the incidence of undesired pregnancy in the United States

OBJECTIVE

Young women may experience social barriers to achieving their reproductive goals. This analysis explored whether low social support may contribute to the high incidence of undesired pregnancy in young women in the United States.

STUDY DESIGN

Using 6 months of data from a prospective cohort of 970 women ages 18-22 years in the United States, we described contraceptive use and applied multivariable logistic regression and standardization to estimate adjusted odds and absolute risk of undesired pregnancy among women reporting low social support versus higher social support. We investigated several measures of contraceptive use as possible explanations for this pathway.

RESULTS

Sixty-five pregnancies were reported in the 6 months of the study, of which 30 (46%) were classified as undesired prior to conception. Among young women who reported low social support, 8% reported an undesired pregnancy during the study period as compared to 3% of the young women who reported higher levels of social support. Among non-black women, those who reported low social support had nearly seven times the odds of an undesired pregnancy as compared to women who reported higher social support (aOR: 6.8, 95%CI: 1.7, 27.1). We found no association between social support and undesired pregnancy among young black women. Contraceptive method use differed by social support at baseline, and throughout follow-up.

CONCLUSIONS

Low social support - defined as the feeling of not having anyone to turn to - may be a risk factor for persistently high levels of undesired pregnancy among young women in the U.S. This association may be driven by differences in contraceptive use by level of social support.

IMPLICATIONS

Interventions to increase young women's perceptions of social support may reduce the risk of undesired pregnancy for some individuals.

New Directions in Cancer Control and Population Sciences

Cancer control science has been evolving since it first became a focus for cancer research and program activities a century ago. The evolution of the field has responded to historical megatrends along the way that keep it relevant to the cancer-related needs of society. This commentary describes some of the key trends and developments now influencing cancer control and population sciences that reflect societal change and new tools and concepts in modern biomedical science. New directions include the impact of climate change, health care delivery research, the growth of population health science, data science, precision medicine, data sharing, implementation science, and new technologies, including social media and new geospatial methodologies. Cancer Epidemiol Biomarkers Prev; 26(8); 1165-9. ©2017 AACR.