Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians

Health Economics Research in Cancer Screening: Research Opportunities, Challenges, and Future Directions

Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, "choosing wisely" screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.

Changes in Cancer Screening Rates Following a New Cancer Diagnosis in a Primary Care Patient Panel

IMPORTANCE

Although screenings for breast and colorectal cancer are widely recommended, patient screening rates vary greatly and remain below public health targets, and primary care physicians' (PCPs') counseling and referrals play critical roles in patients' use of cancer screenings. Recent adverse events may influence PCPs' decision-making, but it remains unknown whether cancer screening rates of PCPs' patients change after PCPs are exposed to new cancer diagnoses.

OBJECTIVE

To investigate whether PCPs' exposures to patients with new diagnoses of breast or colorectal cancer were associated with changes in screening rates for other patients subsequently visiting the affected PCPs.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used stacked difference-in-differences analyses of all-payer claims data for New Hampshire and Maine in 2009 to 2015. Participants were PCPs caring for patients. Data analysis was performed from June 2020 to May 2022.

EXPOSURES

New diagnosis of a PCP's patient with breast cancer or colorectal cancer.

MAIN OUTCOMES AND MEASURES

Patients' breast and colorectal cancer screening rates within 1 year of a PCP visit.

RESULTS

The sample included 3158 PCPs (1819 male PCPs [57.6%]) caring for 1 920 189 patients (1 073 408 female patients [55.9%]; mean [SD] age, 41.0 [21.9] years) aged 18 to 64 years. During the study period, 898 PCPs had a patient with a new diagnosis of breast cancer and 370 PCPs had a patient with a new diagnosis of colorectal cancer. In the preexposure period, 68 837 female patients (37.3% of those visiting a PCP) underwent breast cancer screening within 1 year of the visit, and 13 137 patients (10.1% of those visiting a PCP) underwent colorectal cancer screening within 1 year of the visit. For both cancer types, after exposure to a new cancer diagnosis, PCPs' cancer screening rates displayed a rapid, sustained increase. Breast cancer screening rates increased by 4.5 percentage points (95% CI, 3.0-6.1 percentage points; P < .001). Colorectal cancer screening rates increased by 1.3 percentage points (95% CI, 0.3-2.2 percentage points; P = .01). Observed breast cancer screening increases were higher for male PCPs than for female PCPs (3.1 percentage points; 95% CI, 0.4-5.8 percentage points; P = .03).

CONCLUSIONS AND RELEVANCE

This study found significant, sustained increases in cancer screening rates for patients visiting PCPs recently exposed to new breast and colorectal cancer diagnoses. These findings suggest that PCPs may update practice patterns on the basis of recent patient diagnoses. Future work should assess whether salient cues to PCPs about patient diagnoses when clinically appropriate can improve screening practices.

Are there employment and income gains of a national breast cancer screening program?

BACKGROUND

The Dutch national breast cancer screening program invites women aged 50-75 for screening. By detecting the disease in an early phase, the program aims to achieve lower breast cancer mortality and improve breast cancer survivors' health. Arguably, the latter also improves the employability of diagnosed women.

OBJECTIVE

This study investigates the effects of the Dutch national breast cancer screening program on diagnosed women's employment and income.

METHODS

The empirical analysis uses data of 229,357 women aged 40-59, of whom 10,515 were diagnosed with breast cancer at an age in the range 47-53. A regression-based difference-in-differences estimator is used to identify program effects by comparing outcomes for women diagnosed at ages 47-49 with the outcomes for those diagnosed at ages 50-53. The empirical models account for individual fixed effects, and for age and year fixed effects by using a control group of women who were not diagnosed with breast cancer.

RESULTS

Women's employment rates declined in the six-year period after a breast cancer diagnosis with, on average, about 3 percentage points and their incomes declined with, on average, about 5% over this period. The empirical evidence, based on a comparison of outcomes for women diagnosed at ages 47-49 with the outcomes for those diagnosed at ages 50-53 when covered by the breast cancer screening program, does not support that these declines in employment and income were affected by the program. The evidence also does not support short or medium-term survival gains of the program.

CONCLUSIONS

The findings of this study suggest that the Dutch national breast cancer screening program yields no discernible short or medium-term employment and income gains for women diagnosed with breast cancer.

How Did CNBSS Influence Guidelines for So Long and What Can That Teach Us?

The biased randomization and other quality concerns about the Canadian National Breast Screening Studies (CNBSS) were documented and criticized for decades, even by several individuals very close to the research. CNBSS were the outlier studies among several RCTs of the era and yet were given equal weighting and occasionally higher importance than the remainder of the canon of mammography RCTs. These studies have had an ongoing influence on subsequent evidence review, guideline formation, and, ultimately, patient access to screening. This article explores possible reasons for the ongoing inclusion of CNBSS in the body of mammography screening evidence, discusses the lack of expertise in critical healthcare guideline processes, and, ultimately, suggests several actions and reforms.

"It's something I'll do until I die": A qualitative examination into why older women in the U.S. continue screening mammography

BACKGROUND

Professional guidelines in the U.S. do not recommend routine screening mammography for women ≥75 years with limited life expectancy and/or poor health. Yet, routine mammography remains widely used in older women. We examined older women's experiences, beliefs, and opinions about screening mammography in relation to aging and health.

METHODS

We performed thematic analysis of transcribed semi-structured interviews with 19 women who had a recent screening visit at a mammography clinic in New York City (average age: 75 years, 63% Hispanic, 53% ≤high school education).

RESULTS

Three main themes emerged: (1) older women typically perceive mammograms as a positive, beneficial, and routine component of care; (2) participation in routine mammography is reinforced by factors at interpersonal, provider, and healthcare system levels; and (3) older women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency. Only a few older women reported having discussed mammography cessation or the potential harms of screening with their providers. A few women reported they would insist on receiving mammography even without a provider recommendation.

CONCLUSIONS

Older women's positive experiences and views, as well as multilevel and frequently automated cues toward mammography are important drivers of routine screening in older women. These findings suggest a need for synergistic patient, provider, and system level strategies to reduce mammography overuse in older women.

Inclusion of the US Preventive Services Task Force Recommendation for Mammography in State Comprehensive Cancer Control Plans in the US

IMPORTANCE

The recommendations for the age and frequency that women at average risk for breast cancer should undergo breast cancer mammography screening have been a matter of emotional, political, and scientific debate over the past decades. Multiple national organizations provide recommendations for breast cancer screening age and frequency. US Centers for Disease Control and Prevention (CDC) funding for state comprehensive cancer control (CCC) planning requires compliance with stated objectives for attaining goals. US Preventive Services Task Force (USPSTF) recommendations on cancer prevention and control are currently used to require coverage of prevention services.

OBJECTIVES

To evaluate the consistency of state CCC plan objectives compared with the most current (2016) USPSTF recommendations for the age and frequency that individuals should undergo mammography screening and to make recommendations for improvement of state CCC plans.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a descriptive, point-in-time evaluation and was conducted from November 1, 2019, to June 30, 2021. In November 2019, the most recent CCC plans from 50 US states and the District of Columbia were downloaded from the CDC website. The recommended ages at which to begin and end mammography examinations and the frequency of mammography examinations were extracted from plan objectives.

MAIN OUTCOMES AND MEASURES

The recommendations found in CCC plan objectives regarding the ages at which to begin and end mammography examinations and the frequency of mammography examinations for women with average risk for breast cancer were compared with USPSTF recommendations.

RESULTS

Of the 51 CCC plans, 16 (31%) were consistent with all USPSTF recommendations for age and frequency that women at average risk should undergo mammography. Twenty-six plans (51%) were partially consistent with recommendations, and 9 plans (18%) were not consistent with any of the 3 guideline components.

CONCLUSIONS AND RELEVANCE

Compared with the USPSTF recommendation, state CCC plans are not homogenous regarding the age and frequency that women at average risk for breast cancer should undergo mammography. This variation is partially due to differences in state-specific planning considerations and discretion, variations in recommendations among national organizations, and publication of plans prior to the most current USPSTF recommendation (2016). Specifying the concept that high-risk populations need different age and frequency of screening recommendations than the general population may reduce heterogeneity among plans.

Global Increase in Breast Cancer Incidence: Risk Factors and Preventive Measures

Breast cancer is a global cause for concern owing to its high incidence around the world. The alarming increase in breast cancer cases emphasizes the management of disease at multiple levels. The management should start from the beginning that includes stringent cancer screening or cancer registry to effective diagnostic and treatment strategies. Breast cancer is highly heterogeneous at morphology as well as molecular levels and needs different therapeutic regimens based on the molecular subtype. Breast cancer patients with respective subtype have different clinical outcome prognoses. Breast cancer heterogeneity emphasizes the advanced molecular testing that will help on-time diagnosis and improved survival. Emerging fields such as liquid biopsy and artificial intelligence would help to under the complexity of breast cancer disease and decide the therapeutic regimen that helps in breast cancer management. In this review, we have discussed various risk factors and advanced technology available for breast cancer diagnosis to combat the worst breast cancer status and areas that need to be focused for the better management of breast cancer.

Dual-specificity phosphatase 8 (DUSP8) induces drug resistance in breast cancer by regulating MAPK pathways

The aim of the study was to explore the role and molecular mechanism of dual-specificity phosphatase 8 (DUSP8) in the drug resistance of trastuzumab in breast cancer. Real-time PCR and western blot detected the difference in expression of DUSP8 between breast cancer tissue/cells and trastuzumab-resistant tissues/cells. Receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of DUSP8 in breast cancer. si-DUSP8 or dusp8 overexpression vector was transiently transfected, and the effects of si-DUSP8 on apoptosis, cell viability and cell migration of drug-resistant cell lines were investigated by flow cytometry, MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide) and Transwell assays, and its regulation mechanism finally explored. The results showed that the expression of DUSP8 in breast cancer tissues and cells was significantly higher than in matched non-tumor tissues and cells. DUSP8 was significantly upregulated in non-responsive patients compared with patients who responded to trastuzumab. ROC analysis showed that the area under the curve was 0.732, and the diagnostic sensitivity and specificity were 64.86% and 75.76%. DUSP8 knockdown promotes apoptosis and reduces trastuzumab resistance in BT474/TR and SKBR3/TR cells by inhibiting cell migration and cell viability. Knockdown of DUSP8 increased the expression of p-p38 and p-ERK, and the regulation of DUSP8 in chemotherapy resistance of breast cancer cells may be realized by mediating mitogen-activated protein kinase (MAPK)-related signaling pathways. In conclusion, knockdown of DUSP8 expression in trastuzumab-resistant cells can inhibit cell migration and proliferation, and leads to decreased drug resistance by activating MAPK signaling pathway in trastuzumab-resistant cells.

Breast cancer screening and early diagnosis in Chinese women

Breast cancer is the most common malignant tumor in Chinese women, and its incidence is increasing. Regular screening is an effective method for early tumor detection and improving patient prognosis. In this review, we analyze the epidemiological changes and risk factors associated with breast cancer in China and describe the establishment of a screening strategy suitable for Chinese women. Chinese patients with breast cancer tend to be younger than Western patients and to have denser breasts. Therefore, the age of initial screening in Chinese women should be earlier, and the importance of screening with a combination of ultrasound and mammography is stressed. Moreover, Chinese patients with breast cancers have several ancestry-specific genetic features, and aiding in the determination of genetic screening strategies for identifying high-risk populations. On the basis of current studies, we summarize the development of risk-stratified breast cancer screening guidelines for Chinese women and describe the significant improvement in the prognosis of patients with breast cancer in China.

Discontinuing Cancer Screening for Older Adults: a Comparison of Clinician Decision-Making for Breast, Colorectal, and Prostate Cancer Screenings

BACKGROUND

While guidelines recommend against routine screening for breast, prostate, and colorectal cancers in older adults (65+ years) with <10-year life expectancy, many of these patients continue to be screened. How clinicians consider screening cessation across multiple cancer screening types is unknown.

OBJECTIVE

To compare and contrast clinicians' perspectives on discontinuing breast, prostate, and colorectal cancer screenings in older adults.

DESIGN

Qualitative, semi-structured interviews.

PARTICIPANTS

Primary care clinicians in Maryland (N=30) APPROACH: We conducted semi-structured interviews with individual clinicians. Interviews were recorded, transcribed, and analyzed using standard techniques of qualitative content analysis to identify major themes.

KEY RESULTS

Participants were mostly physicians (24/30) and women (16/30). Four major themes highlighted differences in decision-making across cancer screenings: (1) Clinicians reported more often screening beyond guideline-recommended ages for breast and prostate cancers than colorectal cancer; (2) clinicians had different priorities when considering the benefits/harms of each screening; for example, some prioritized continuing colorectal cancer screening due to the test's high efficacy while others prioritized stopping colorectal cancer screening due to high procedural risk; some prioritized continuing prostate cancer screening due to poor outcomes from advanced prostate cancer while others prioritized stopping prostate cancer screening due to high false positive test rates and harms from downstream tests; (3) clinicians discussed harms of prostate and colorectal cancer screening more readily than for breast cancer screening; (4) clinicians perceived more involvement with gastroenterologists in colonoscopy decisions and less involvement from specialists for prostate and breast cancer screening.

CONCLUSIONS

Our results highlight the need for more explicit guidance on how to weigh competing considerations in cancer screening (such as test accuracy versus ease of cancer treatment after detection). Recognizing the complexity of the benefit/harms analysis as clinicians consider multiple cancer screenings, future decision support tools, and clinician education materials can specifically address the competing considerations.

Demographic Differences Among US Department of Veterans Affairs Patients Referred for Genetic Consultation to a Centralized VA Telehealth Program, VA Medical Centers, or the Community

Importance

Telehealth enables access to genetics clinicians, but impact on care coordination is unknown.

Objective

To assess care coordination and equity of genetic care delivered by centralized telehealth and traditional genetic care models.

Design, Setting, and Participants

This cross-sectional study included patients referred for genetic consultation from 2010 to 2017 with 2 years of follow-up in the US Department of Veterans Affairs (VA) health care system. Patients were excluded if they were referred for research, cytogenetic, or infectious disease testing, or if their care model could not be determined.

Exposures

Genetic care models, which included VA-telehealth (ie, a centralized team of genetic counselors serving VA facilities nationwide), VA-traditional (ie, a regional service by clinical geneticists and genetic counselors), and non-VA care (ie, community care purchased by the VA).

Main Outcomes and Measures

Multivariate regression models were used to assess associations between patient and consultation characteristics and the type of genetic care model referral; consultation completion; and having 0, 1, or 2 or more cancer surveillance (eg, colonoscopy) and risk-reducing procedures (eg, bilateral mastectomy) within 2 years following referral.

Results

In this study, 24 778 patients with genetics referrals were identified, including 12 671 women (51.1%), 13 193 patients aged 50 years or older (53.2%), 15 639 White patients (63.1%), and 15 438 patients with cancer-related referrals (62.3%). The VA-telehealth model received 14 580 of the 24 778 consultations (58.8%). Asian patients, American Indian or Alaskan Native patients, and Hawaiian or Pacific Islander patients were less likely to be referred to VA-telehealth than White patients (OR, 0.54; 95% CI, 0.35-0.84) compared with the VA-traditional model. Completing consultations was less likely with non-VA care than the VA-traditional model (OR, 0.45; 95% CI, 0.35-0.57); there were no differences in completing consultations between the VA models. Black patients were less likely to complete consultations than White patients (OR, 0.84; 95% CI, 0.76-0.93), but only if referred to the VA-telehealth model. Patients were more likely to have multiple cancer preventive procedures if they completed their consultations (OR, 1.55; 95% CI, 1.40-1.72) but only if their consultations were completed with the VA-traditional model.

Conclusions and Relevance

In this cross-sectional study, the VA-telehealth model was associated with improved access to genetics clinicians but also with exacerbated health care disparities and hindered care coordination. Addressing structural barriers and the needs and preferences of vulnerable subpopulations may complement the centralized telehealth approach, improve care coordination, and help mitigate health care disparities.

Breast Tumour Classification Using Ultrasound Elastography with Machine Learning: A Systematic Scoping Review

Simple Summary

Breast cancer is one of the most common cancers among women globally. Early and accurate screening of breast tumours can improve survival. Ultrasound elastography is a non-invasive and non-ionizing imaging approach to characterize lesions for breast cancer screening, while machine learning techniques could improve the accuracy and reliability of computer-aided diagnosis. This review focuses on the state-of-the-art development and application of the machine learning model in breast tumour classification.

Abstract

Ultrasound elastography can quantify stiffness distribution of tissue lesions and complements conventional B-mode ultrasound for breast cancer screening. Recently, the development of computer-aided diagnosis has improved the reliability of the system, whilst the inception of machine learning, such as deep learning, has further extended its power by facilitating automated segmentation and tumour classification. The objective of this review was to summarize application of the machine learning model to ultrasound elastography systems for breast tumour classification. Review databases included PubMed, Web of Science, CINAHL, and EMBASE. Thirteen (n = 13) articles were eligible for review. Shear-wave elastography was investigated in six articles, whereas seven studies focused on strain elastography (5 freehand and 2 Acoustic Radiation Force). Traditional computer vision workflow was common in strain elastography with separated image segmentation, feature extraction, and classifier functions using different algorithm-based methods, neural networks or support vector machines (SVM). Shear-wave elastography often adopts the deep learning model, convolutional neural network (CNN), that integrates functional tasks. All of the reviewed articles achieved sensitivity ≥80%, while only half of them attained acceptable specificity ≥95%. Deep learning models did not necessarily perform better than traditional computer vision workflow. Nevertheless, there were inconsistencies and insufficiencies in reporting and calculation, such as the testing dataset, cross-validation, and methods to avoid overfitting. Most of the studies did not report loss or hyperparameters. Future studies may consider using the deep network with an attention layer to locate the targeted object automatically and online training to facilitate efficient re-training for sequential data.

Cost-Effectiveness of Screening Mammography Beyond Age 75 Years : A Cost-Effectiveness Analysis

BACKGROUND

The cost-effectiveness of screening mammography beyond age 75 years remains unclear.

OBJECTIVE

To estimate benefits, harms, and cost-effectiveness of extending mammography to age 80, 85, or 90 years according to comorbidity burden.

DESIGN

Markov microsimulation model.

DATA SOURCES

SEER (Surveillance, Epidemiology, and End Results) program and Breast Cancer Surveillance Consortium.

TARGET POPULATION

U.S. women aged 65 to 90 years in groups defined by Charlson comorbidity score (CCS).

TIME HORIZON

Lifetime.

PERSPECTIVE

National health payer.

INTERVENTION

Screening mammography to age 75, 80, 85, or 90 years.

OUTCOME MEASURES

Breast cancer death, survival, and costs.

RESULTS OF BASE-CASE ANALYSIS

Extending biennial mammography from age 75 to 80 years averted 1.7, 1.4, and 1.0 breast cancer deaths and increased days of life gained by 5.8, 4.2, and 2.7 days per 1000 women for comorbidity scores of 0, 1, and 2, respectively. Annual mammography beyond age 75 years was not cost-effective, but extending biennial mammography to age 80 years was ($54 000, $65 000, and $85 000 per quality-adjusted life-year [QALY] gained for women with CCSs of 0, 1, and ≥2, respectively). Overdiagnosis cases were double the number of deaths averted from breast cancer.

RESULTS OF SENSITIVITY ANALYSIS

Costs per QALY gained were sensitive to changes in invasive cancer incidence and shift of breast cancer stage with screening mammography.

LIMITATION

No randomized controlled trials of screening mammography beyond age 75 years are available to provide model parameter inputs.

CONCLUSION

Although annual mammography is not cost-effective, biennial screening mammography to age 80 years is; however, the absolute number of deaths averted is small, especially for women with comorbidities. Women considering screening beyond age 75 years should weigh the potential harms of overdiagnosis versus the potential benefit of averting death from breast cancer.

PRIMARY FUNDING SOURCE

National Cancer Institute and National Institutes of Health.

Invasive Breast Cancer Treatment Patterns in Women Age 80 and Over: A Report from the National Cancer Database

BACKGROUND

There are no established treatment guidelines for women with breast cancer aged ≥80 despite increasing representation in the US population. Here we identify national treatment patterns and survival outcomes in women with stage I-III invasive breast cancer.

PATIENTS AND METHODS

Women age ≥80 diagnosed with stage I-III invasive breast cancer (IBC) were identified from 2005-2014 in the National Cancer Database. χ², Fisher's exact test, and logistic regression models were used to identify factors influencing receipt of breast surgery, and Cox proportional hazard models were used to evaluate overall survival (OS).

RESULTS

A total of 62,575 women with IBC met inclusion criteria, of which the majority received surgery (94%). Receipt of surgery was associated with White race, age <90, lower stage, and fewer comorbidities. OS was higher for those who received surgery compared to those who did not (HR 3.3 [3.18-3.46] P < .001). Molecular subtype analysis demonstrated improved survival with receipt of surgery or radiation for all subtypes, as well as improved survival with chemotherapy for those with triple negative breast cancer.

CONCLUSION

The vast majority of breast cancer patients aged ≥80 in the National Cancer Database with IBC received primary surgical management, which was associated with a significant OS benefit. Due to this finding, surgical resection should be considered for all patients ≥80 who are suitable operative candidates.

A review of screening mammography: The benefits and radiation risks put into perspective

INTRODUCTION/BACKGROUND

In medical imaging a benefit to risk analysis is required when justifying or implementing diagnostic procedures. Screening mammography is no exception and in particular concerns around the use of radiation to help diagnose cancer must be addressed.

METHODS

The Medline database and various established reports on breast screening and radiological protection were utilised to explore this review.

RESULTS/DISCUSSION

The benefit of screening is well argued; the ability to detect and treat breast cancer has led to a 91% 5-year survival rate and 497 deaths prevented from breast cancer amongst 100,000 screened women. Subsequently, screening guidelines by various countries recommend annual, biennial or triennial screening from ages somewhere between 40-74 years. Whilst the literature presents different perspectives on screening younger and older women, the current evidence of benefit for screening women <40 and ≥75 years is currently not strong. The radiation dose and associated risk delivered to each woman for a single examination is dependent upon age, breast density and breast thickness, however the average mean glandular dose is around 2.5-3 mGy, and this would result in 65 induced cancers and 8 deaths per 100,000 women over a screening lifetime from 40-74 years. This results in a ratio of lives saved to deaths from induced cancer of 62:1.

CONCLUSION

Therefore, compared to the potential mortality reduction achievable with screening mammography, the risk is small.

Clinical practice guidelines and consensus for the screening of breast cancer: A systematic appraisal of their quality and reporting

INTRODUCTION

Clinical practice guidelines (CPGs) and consensus statements (CSs) are being promoted to provide high-quality healthcare guidance. This systematic review has assessed the breast cancer (BC) screening CPGs and CSs quality and reporting.

METHODS

A search of bibliographic databases (MEDLINE, Embase, Web of Science, Scopus and CDSR), 12 guideline databases and 51 professional society websites was performed without language restrictions from January 2017 to June 2020, following prospective registration (Prospero no.: CRD42020203807). AGREE II (% of maximum score) and RIGHT (% of total 35 items) appraised quality and reporting individually, extracting data in duplicate; reviewer agreement was 98% and 93%, respectively.

RESULTS

Forty guidances with median overall quality and reporting 51% (interquartile range [IQR] 39-63) and 48% (IQR 35-65), respectively. Twenty-two (55%) and 20 (50%) did not reach the minimum standards (scores <50%). The guidances that deployed systematic reviews had better quality (74.2% vs. 46.9%; p = 0.001) and reporting (80.5% vs. 42.6%; p = 0.001). Guidances reporting a tool referral scored better (AGREE II: 72.8% vs. 43.1%, p = 0.002; RIGHT: 75.0% vs. 46.9%, p = 0.004).

CONCLUSION

BC screening CPGs and CSs suffered poor quality and reporting. More than half did not reach the minimum standards. They would improve if systematic reviews were used to underpin the recommendations made.

The Effect of Automated Mammogram Orders Paired With Electronic Invitations to Self-schedule on Mammogram Scheduling Outcomes: Observational Cohort Comparison

Background

Screening mammography is recommended for the early detection of breast cancer. The processes for ordering screening mammography often rely on a health care provider order and a scheduler to arrange the time and location of breast imaging. Self-scheduling after automated ordering of screening mammograms may offer a more efficient and convenient way to schedule screening mammograms.

Objective

The aim of this study was to determine the use, outcomes, and efficiency of an automated mammogram ordering and invitation process paired with self-scheduling.

Methods

We examined appointment data from 12 months of scheduled mammogram appointments, starting in September 2019 when a web and mobile app self-scheduling process for screening mammograms was made available for the Mayo Clinic primary care practice. Patients registered to the Mayo Clinic Patient Online Services could view the schedules and book their mammogram appointment via the web or a mobile app. Self-scheduling required no telephone calls or staff appointment schedulers. We examined uptake (count and percentage of patients utilizing self-scheduling), number of appointment actions taken by self-schedulers and by those using staff schedulers, no-show outcomes, scheduling efficiency, and weekend and after-hours use of self-scheduling.

Results

For patients who were registered to patient online services and had screening mammogram appointment activity, 15.3% (14,387/93,901) used the web or mobile app to do either some mammogram self-scheduling or self-cancelling appointment actions. Approximately 24.4% (3285/13,454) of self-scheduling occurred after normal business hours/on weekends. Approximately 9.3% (8736/93,901) of the patients used self-scheduling/cancelling exclusively. For self-scheduled mammograms, there were 5.7% (536/9433) no-shows compared to 4.6% (3590/77,531) no-shows in staff-scheduled mammograms (unadjusted odds ratio 1.24, 95% CI 1.13-1.36; P<.001). The odds ratio of no-shows for self-scheduled mammograms to staff-scheduled mammograms decreased to 1.12 (95% CI 1.02-1.23; P=.02) when adjusted for age, race, and ethnicity. On average, since there were only 0.197 staff-scheduler actions for each finalized self-scheduled appointment, staff schedulers were rarely used to redo or “clean up” self-scheduled appointments. Exclusively self-scheduled appointments were significantly more efficient than staff-scheduled appointments. Self-schedulers experienced a single appointment step process (one and done) for 93.5% (7553/8079) of their finalized appointments; only 74.5% (52,804/70,839) of staff-scheduled finalized appointments had a similar one-step appointment process (P<.001). For staff-scheduled appointments, 25.5% (18,035/70,839) of the finalized appointments took multiple appointment steps. For finalized appointments that were exclusively self-scheduled, only 6.5% (526/8079) took multiple appointment steps. The staff-scheduled to self-scheduled odds ratio of taking multiple steps for a finalized screening mammogram appointment was 4.9 (95% CI 4.48-5.37; P<.001).

Conclusions

Screening mammograms can be efficiently self-scheduled but may be associated with a slight increase in no-shows. Self-scheduling can decrease staff scheduler work and can be convenient for patients who want to manage their appointment scheduling activity after business hours or on weekends.

Contribution of clinical breast exam to cancer detection in women participating in a modern screening program

Purpose

Despite the controversy surrounding the role of clinical breast exam (CBE) in modern breast cancer screening, it is widely practiced. We examined the contribution of CBE in women undergoing routine screening mammography and in women under the screening age.

Methods

A retrospective cohort study including all women participating in a voluntary health screening program between 2007 and 2016. All participants undergo CBE; Screening mammography is done selectively based on age, breast imaging history and insurance coverage. Data collected included demographics, risk factors, previous imaging, and findings on CBE and mammography. Cancer detection rates within 3 months of the visit were calculated separately for women undergoing routine screening mammography, and women under the screening age.

Results

There were 14,857 CBE completed in 8378; women; 7% were abnormal. Within 3 months of the visit, 35 breast cancers (2.4 per 1000 visits) were diagnosed. In women within the screening age who completed a mammogram less than one year prior to the visit (N = 1898), 4 cancers (2.1 cancers per 1000 visits) were diagnosed. Only one was diagnosed in a woman with an abnormal CBE, suggesting that the cancer detection rate of CBE in women undergoing regular screening is very low (0.5 per 1000 visits). In women under the screening age (45), 3 cancers (0.4 per 1000 visits) were diagnosed; all were visualized on mammography, one had an abnormal CBE.

Conclusions

The contribution of CBE to cancer detection in women undergoing routine screening and in women under the screening age is rare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01507-x.

Cancer screening in the U.S. through the COVID-19 pandemic, recovery, and beyond

COVID-19 has proved enormously disruptive to the provision of cancer screening, which does not just represent an initial test but an entire process, including risk detection, diagnostic follow-up, and treatment. Successful delivery of services at all points in the process has been negatively affected by the pandemic. There is a void in empirical high-quality evidence to support a specific strategy for administering cancer screening during a pandemic and its resolution phase, but several pragmatic considerations can help guide prioritization efforts. Targeting guideline-eligible people who have never been screened, or those who are significantly out of date with screening, has the potential to maximize benefits now and into the future. Disruptions to care due to the pandemic could represent an unparalleled opportunity to reassess early detection programs towards an explicit, thoughtful, and just prioritization of populations historically experiencing cancer disparities. By focusing screening services on populations that have the most to gain, and by careful and deliberate planning for the period following the pandemic, we can positively affect cancer outcomes for all.

A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation

BACKGROUND

There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse.

METHODS

This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process.

RESULTS

Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening.

CONCLUSIONS

Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Preliminary Evaluation of a Breast Cancer Screening Shared Decision-Making Aid Utilized Within the Primary Care Clinical Encounter

Introduction:

The US Preventative Services Task Force recommends shared decision-making (SDM) between women aged 40 and 49 years and their physician regarding timing of mammography screening. This preliminary study evaluates women’s and physician’s satisfaction using Breast Cancer Risk Estimator & Decision Aid (BCARE-DA), a shared decision aid utilized during the clinical encounter, and examines SDM quality for these encounters.

Methods:

Fifty-three women and their physician utilized BCARE-DA and completed surveys measuring satisfaction with Likert-type and open-ended items and women completed the Decision Conflict Scale. Clinic visit transcripts were evaluated for SDM quality using Observer OPTION-5 and Breast Cancer Screening Decision Core Components Checklist.

Results:

Women and physicians positively evaluated BCARE-DA. Women had low decision conflict. Physicians demonstrated moderate effort toward SDM, greatest in offering options, and lowest for team talk. Physicians demonstrated 2/3 of core SDM elements in 80% to 100% of encounters.

Conclusion:

Preliminary findings suggest specific promise for such Decision Aids to facilitate SDM through understanding of personal risks for breast cancer formulated within each screening option, while some SDM elements likely require additional facilitating.

Mammography use and breast cancer incidence among older U.S. women

PURPOSE

The death rate for female breast cancer increases progressively with age, but organizations differ in their mammography screening recommendations for older women. To understand current patterns of screening mammography use and breast cancer diagnoses among older women, we examined recent national data on mammography screening use and breast cancer incidence and stage at diagnosis among women aged ≥ 65 years.

METHODS

We examined breast cancer incidence using the 2016 United States Cancer Statistics dataset and analyzed screening mammography use among women aged ≥ 65 years using the 2018 National Health Interview Survey.

RESULTS

Women aged 70-74 years had the highest breast cancer incidence rate (458.3 cases per 100,000 women), and women aged ≥ 85 years had the lowest rate (295.2 per 100,000 women). The proportion of cancer diagnosed at distant stage or with unknown stage increased with age. Over half of women aged 80-84 years and 26.0% of women aged ≥ 85 years reported a screening mammogram within the last 2 years. Excellent/very good/good self-reported health status (p = .010) and no dependency in activities of daily living/instrumental activities of daily living (p < .001) were associated with recent mammography screening.

CONCLUSION

Breast cancer incidence rates and stage at diagnosis vary by age. Many women aged ≥ 75 years receive screening mammograms. The results of this study point to areas for further investigation to promote optimal mammography screening among older women.

Early Detection and Dynamic Changes of Circulating Tumor Cells in Transgenic NeuN Transgenic (NTTg) Mice with Spontaneous Breast Tumor Development

Simple Summary

This study aimed to prove the early presence of circulating tumor cells (CTCs) with viability and tumorigenesis in a murine model that spontaneously develops breast cancer. Serial CTC examinations were performed on NeuN transgenic mice, starting from the age of 8 weeks and continuing after palpable tumor formation. Prior to the detection of palpable tumors, the CTC counts rose over time from 1 ± 1.6 to 16 ± 9.5 per 75 μL; this number continued to grow with tumor development. The viability and tumorigenesis of the collected CTCs were confirmed by re-implanting the cells into a non-cancer-bearing mouse. Ultrasonography with Doppler showed a significant correlation between CTCs and tumor vascular density (p-value < 0.01), rather than tumor volume (p-value 0.076).

Abstract

Background: This study used NeuN transgenic (NTTg) mice with spontaneous breast tumor development to evaluate the dynamic changes of circulating tumor cells (CTCs) prior to and during tumor development. Methods: In this longitudinal, clinically uninterrupted study, we collected 75 μL of peripheral blood at the age of 8, 12, 16, and 20 weeks in the first group of five mice, and at the age of 32 weeks, the time of tumor palpability, and one week after tumor palpability in the second group of four mice. Diluted blood samples were run through a modified mouse-CMx chip to isolate the CTCs. Results: The CTC counts of the first group of mice were low (1 ± 1.6) initially. The average CTC counts were 16 ± 9.5, 29.0 ± 18.2, and 70.0 ± 30.3 cells per 75 μL blood at the age of 32 weeks, the time of tumor palpability, and one week after tumor palpability, respectively. There was a significant positive correlation between an increase in CTC levels and tumor vascular density (p-value < 0.01). This correlation was stronger than that between CTC levels and tumor size (p-value = 0.076). The captured CTCs were implanted into a non-tumor-bearing NTTg mouse for xenografting, confirming their viability and tumorigenesis. Conclusion: Serial CTCs during an early stage of tumor progression were quantified and found to be positively correlated with the later tumor vascular density and size. Furthermore, the successful generation of CTC-derived xenografts indicates the tumorigenicity of this early onset CTC population.

Metastatic Breast Cancer Masked as Constipation

Even though screening mammography has been attributed to decreased mortality in recent decades, breast cancer is one of the leading causes of death among women in the United States. Disruption of screening protocols and variation in the presentation may alter the course of detection and management. We report a case of hormone receptor-positive breast cancer that presented as vague gastrointestinal symptoms in a patient with a delayed workup for a self-discovered breast lump during the coronavirus disease global pandemic.

A 48-year-old woman with a history of gastroesophageal reflux and hypertension presented to the emergency department with primary complaints of constipation and abdominal distention with associated flatus and nausea. Vitals were within normal limits, and physical examination was notable for abdominal distention and diffuse tenderness to palpation. Labs demonstrated hypercalcemia and an unremarkable complete blood count. A chest X-ray showed a right hilar mass, and a CT chest revealed multiple lytic bone lesions diffusely scattered throughout the entire skeleton; no hilar mass was noted on the CT chest. A CT scan of the abdomen and pelvis incidentally revealed a right breast mass. A bone marrow biopsy identified invasive ductal carcinoma. Mammography and biopsy of the breast mass identified estrogen receptor/progesterone receptor-positive invasive ductal carcinoma, consistent with the bone marrow biopsy, confirming the diagnosis of metastatic breast cancer.

Unpredicted disruptions in screening processes may result in delayed cancer diagnoses. This case illustrates the importance of routine self-breast examinations, screening mammography, and maintaining a broad differential diagnosis.

Breast Health Experiences in Women with Cerebral Palsy: A Qualitative Approach

Background: All women, regardless of disability status, should receive screening for breast cancer. In 2010, only 61.4% of women with disabilities (WWD) received a mammogram in the past 2 years compared to 75% of women without disabilities. The purpose of this study is to explore breast cancer screening experiences of women with cerebral palsy (CP) with the aim of identifying factors that could improve screening rates for WWD.

Methods: Thirty women with CP, 22–72 years of age, residing in New York, Chicago, or Los Angeles areas participated in individual or group interviews about breast health. Twenty-five of the participants identified themselves as white, and one self-identified as Hispanic or Latina. Facilitators used a semistructured guide across the three sites. Qualitative analysis utilized an iterative coding process to generate themes related to breast health.

Results: We identified six predominant themes in these interviews, which revolved around physical, environmental, and emotional barriers and facilitators. Within each theme, we identified subthemes. Physical barriers included the most highly identified subthemes of age, pain, holding breath, holding still, spasticity, standing, fatigue, and positioning. Self-advocacy and communication between the health care professional and the patient were the most common subthemes identified among the emotional facilitators.

Conclusion: Women with CP perceive a variety of issues impacting breast health. These findings are multifaceted and suggest that improving screening rates for women with CP should address these barriers and facilitators.

Cyclin-dependent kinase 15 upregulation is correlated with poor prognosis for patients with breast cancer

Objective

To investigate the clinical significance of cyclin-dependent kinase (CDK) 15 in breast cancer.

Methods

This prospective observational study enrolled 154 patients with breast cancer. Tumor tissues and paired paracancerous normal tissues were collected. Additionally, 85 samples of benign breast lesions were obtained from patients with mammary gland hyperplasia. Patient characteristics were recorded, and CDK15, human epidermal growth factor receptor (HER)2, estrogen receptor, progesterone receptor, and Ki67 immunohistochemical expression were determined.

Results

The rate of strong CDK15 expression was 63.6% (98/154) in breast cancer tissues, which was remarkably higher than that in benign breast lesions (34.1%, 29/85). Similarly, the ratio of strong CDK15 expression was markedly higher in tumor tissues (63.6%, 98/15) than in paracancerous normal tissues (27.3%, 42/154). Pearson’s analysis showed that the CDK15 expression score was positively correlated with HER2 and Ki67. Patients with high CDK15 expression showed markedly higher ratios of TNM stage III to IV, lymph node metastasis, and increased tumor diameters but a significantly lower rate of ductal carcinoma in situ. The median survival time of these patients was significantly shorter. Kaplan–Meier curve analysis showed that low CDK15 expression predicted longer survival times.

Conclusion

Upregulated CDK15 predicted poor clinical outcomes in breast cancer.

Performance of Digital Breast Tomosynthesis, Synthetic Mammography, and Digital Mammography in Breast Cancer Screening: A Systematic Review and Meta-Analysis

BACKGROUND

Our objective was to perform a systematic review and meta-analysis comparing the breast cancer detection rate (CDR), invasive CDR, recall rate, and positive predictive value 1 (PPV1) of digital mammography (DM) alone, combined digital breast tomosynthesis (DBT) and DM, combined DBT and synthetic 2-dimensional mammography (S2D), and DBT alone.

METHODS

MEDLINE and Embase were searched until April 2020 to identify comparative design studies reporting on patients undergoing routine breast cancer screening. Random effects model proportional meta-analyses estimated CDR, invasive CDR, recall rate, and PPV1. Meta-regression modeling was used to compare imaging modalities. All statistical tests were 2-sided.

RESULTS

Forty-two studies reporting on 2 606 296 patients (13 003 breast cancer cases) were included. CDR was highest in combined DBT and DM (6.36 per 1000 screened, 95% confidence interval [CI] = 5.62 to 7.14, P < .001), and combined DBT and S2D (7.40 per 1000 screened, 95% CI = 6.49 to 8.37, P < .001) compared with DM alone (4.68 per 1000 screened, 95% CI = 4.28 to 5.11). Invasive CDR was highest in combined DBT and DM (4.53 per 1000 screened, 95% CI = 3.97 to 5.12, P = .003) and combined DBT and S2D (5.68 per 1000 screened, 95% CI = 4.43 to 7.09, P < .001) compared with DM alone (3.42 per 1000 screened, 95% CI = 3.02 to 3.83). Recall rate was lowest in combined DBT and S2D (42.3 per 1000 screened, 95% CI = 37.4 to 60.4, P<.001). PPV1 was highest in combined DBT and DM (10.0%, 95% CI = 8.0% to 12.0%, P = .004), and combined DBT and S2D (16.0%, 95% CI = 10.0% to 23.0%, P < .001), whereas no difference was detected for DBT alone (7.0%, 95% CI = 6.0% to 8.0%, P = .75) compared with DM alone (7.0%, 95.0% CI = 5.0% to 8.0%).

CONCLUSIONS

Our findings provide evidence on key performance metrics for DM, DBT alone, combined DBT and DM, and combined DBT and S2D, which may inform optimal application of these modalities for breast cancer screening.

Physicians' perceptions of breast density notification laws and appropriate patient follow-up

Breast density notification laws have been adopted in the absence of consistent guidelines for post-notification follow-up. This can lead to inconsistent and potentially deficient management of women's health due to inconsistent physician practices. We examined physicians' knowledge and practices regarding follow-up for patients who receive density notifications. Physicians who referred patients to a Michigan hospital network for screening mammograms were recruited to participate in survey study; 105 (29.8%) responded. The survey assessed physicians' demographics, knowledge, and awareness of breast density and breast cancer risk and of density notification laws, and perceptions of appropriate follow-up behaviors for their patients who received density notifications. Most physicians (75%) knew about the notification law, and they were generally comfortable responding to breast density questions and deciding on follow-up. Most indicated that additional breast imaging (68.0%), followed by assessing breast cancer risk (24.7%) were appropriate follow-up responses. Physicians who performed breast cancer risk assessments, and who were more comfortable with breast density questions and follow-up decision making, were more likely to propose additional imaging. Male physicians were less likely to propose assessing breast cancer risk, and less likely to propose clinical and/or breast self-examinations. Divergence between practice and guidelines when it comes to supplemental breast cancer screening, coupled with density notification language that promotes additional screening in the absence of consistent evidence, remains concerning. Improved understanding of how density notification recipients and their physicians make decisions about supplemental screening is warranted to ensure that breast cancer risk is properly considered.

Annual Screening Mammography Associated With Lower Stage Breast Cancer Compared With Biennial Screening

OBJECTIVE. The purpose of this study was to compare breast cancer characteristics and treatment regimens among women undergoing annual versus nonannual screening mammography. MATERIALS AND METHODS. In this retrospective, institutional review board-approved, HIPAA-compliant cohort study, a breast cancer database was queried for patients who received a mammographic or clinical diagnosis of breast cancer during 2016-2017. Annual versus biennial and annual versus nonannual (biennial and triennial) mammography screening cohorts were compared using t tests or Wilcoxon rank sum tests for continuous variables and chi-square or Fisher exact tests for categoric variables. RESULTS. A total of 490 patients were diagnosed with breast cancer during 2016-2017. Among these women, 245 had an assignable screening frequency and were 40-84 years old (mean, 61.8 ± 9.9 [SD] years; median, 62 years). Screening frequency was annual for 200 of these 245 patients (81.6%), biennial for 32 (13.1%), and triennial for 13 (5.3%). Annual screening resulted in fewer late-stage presentations (AJCC stage II, III, or IV in 48 of 200 patients undergoing annual [24.0%] vs 14 of 32 undergoing biennial [43.8%; p = .02] and vs 20 of 45 undergoing nonannual screening [44.4%; p = .006]), fewer interval cancers (21 of 200 for annual [10.5%] vs 12 of 32 for biennial [37.5%; p < .001] and vs 15 of 45 for nonannual [33.3%; p < .001]), and smaller mean tumor diameter (1.4 ± 1.2 cm for annual vs 1.8 ± 1.6 cm for biennial [p = .04] and vs 1.8 ± 1.5 cm nonannual [p = .03]). Lower AJCC stage, fewer interval cancers, and smaller tumor diameter also persisted among postmenopausal women undergoing annual screening. Patients undergoing biennial and nonannual screening showed nonsignificant greater use of axillary lymph node dissection (annual, 24 of 200 [12.0%]; biennial, 6 of 32 [18.8%]; nonannual, 7 of 45 [15.6%]) and chemotherapy (annual, 55 of 200 [27.5%]; biennial, 12 of 32 [37.5%]; nonannual, 16 of 45 [35.6%]). CONCLUSION. Annual mammographic screening was associated with lower breast cancer stage and fewer interval cancers than biennial or nonannual screening.

Understanding Regional Variation in the Cost of Breast Cancer Screening Among Privately Insured Women in the United States

BACKGROUND

Breast cancer screening for women aged 40-49 years is prevalent and costly, with costs varying substantially across US regions. Newer approaches to mammography may improve cancer detection but also increase screening costs. We assessed factors associated with regional variation in screening costs.

METHODS

We used Blue Cross Blue Shield Axis, a large US commercial claims database accessed through secure portal, to assess regional variation in screening utilization and costs. We included screening mammography±digital breast tomosynthesis (DBT), screening ultrasound, diagnostic mammography±DBT, diagnostic ultrasound, magnetic resonance imaging and biopsy, and evaluated their utilization and costs. We assessed regional variation in annual per-screened-beneficiary costs and examined potential savings from reducing regional variation.

RESULTS

Of the 2,257,393 privately insured women, 41.2% received screening mammography in 2017 (range: 26.6%-54.2% across regions). Wide regional variation was found in the DBT proportion (0.7%-91.1%) and mean costs of DBT ($299; range: $113-714) and 2-dimensional (D) mammograms ($213; range: $107-471). In one-fourth of the regions, the mean DBT cost was lower than the mean 2D mammography cost in the full sample. Regional variation in the per-screened-beneficiary cost (mean: $353; range: $151-751) was mainly attributable to variation in the cost of DBT (accounting for 23.4% of regional variation) and 2D mammography (23.0%). Reducing regional variation by decreasing the highest values to the national mean was projected to save $79-335 million annually.

CONCLUSIONS

The mean mammogram cost for privately insured women ages 40-49 varies 7-fold across regions, driving substantial variation in breast cancer screening costs. Reducing this regional variation would substantially decrease the screening costs.

Bevacizumab Plays a double-edged role in Neoadjuvant Therapy for Non-metastatic Breast Cancer: A Systemic Review and Meta-Analysis

The anti-angiogenic drug Bevacizumab (Bev) is engaged in neoadjuvant therapy for non-metastatic breast cancer (NMBC). However, whether neoadjuvant Bev providing a greater benefit to patients is debatable. Our study aimed to review Bev's role in Neoadjuvant therapy (NAT) in NMBC and identify predictive markers associated with its efficacy by systemic review and meta-analysis. Eligible trials were retrieved from the Pubmed, Embase, and Cochrane Library, and random or fixed effects models were applied to synthesize data. Power of pCR to predict DFS or OS was evaluated by nonlinear mixed effect model. In NMBC, Bev significantly improved the rate of patients achieving pCR, but this benefit discontinued in DFS or OS. Biomarkers such as PAM50 intrinsic subtype, VEGF overexpression, regulation of VEGF signaling pathway, hypoxia-related genes, BRCA1/2 mutation, P53 mutation and immune phenotype can be used to predict Bev-inducing pCR and/or DFS/OS. Unfortunately, although patients with pCR survived longer than those without pCR when ignoring the use of Bev, but patients achieving pCR with Bev might survive shorter than those achieving pCR without Bev. Subgroup analyses found Bev prolonged patients' OS when given pre- and post-surgery. Lastly, adding Bev increased adverse effects. Overall, Bev offered limited effect for patients with NMBC in an unscreened population. However, in biomarkers - identified subgroup, Bev could be promising to ameliorate the prognosis of specific patients with NMBC.

Evaluation of serum Nestin and HOTAIR rs12826786 C>T polymorphism as screening tools for breast cancer in Egyptian women

BACKGROUND

Nestin is a neural stem cell protein that plays an important role in cancer stem cells (CSC) development and proliferation. It has been identified as a marker for newly formed endothelial cells and was shown to be preferentially expressed in basal and myoepithelial cells of the mammary gland. HOTAIR is long intergenic non-coding (linRNA) associated with tumorigenesis through promotion of epithelial-mesenchymal transition (EMT) and stemness as well. HOTAIR gene contains a functioning single nucleotide polymorphic site rs12826786 C>T that has been associated with several cancer types.

METHODS

We evaluated serum Nestin and the HOTAIR rs12826786 C>T polymorphism in healthy Egyptian women and those with breast cancer as a possible screening tool to identify patients with breast cancer. Also, we tested the possible association of the two markers with each other and the aggressiveness of the disease.

RESULTS

Patients with breast cancer had a median (Min-Max) of serum Nestin 31.3 (6.7-167.3 pg/mL), while control subjects had a median (Min-Max) of serum Nestin 42.3 (25.7-315.95) pg/mL. The best cut-off value for serum Nestin to differentiate normal subjects and patients with breast cancer was 39.9 pg/mL. This cut-off value had a diagnostic sensitivity of 84.8% and specificity of 65.1%. There was a significant difference in the distribution of different alleles in patients with breast cancer than normal subjects (P=0.039 Exact Fisher test). The breast cancer patients group had 23.9% CC, 52.1% CT, and 23.9% TT genotypes, respectively, while the control group had 46.9% CC, 42.8% CT, and 10.2% TT, respectively.

CONCLUSIONS

A significantly low serum Nestin below 39.9 pg/mL and a higher percentage of the T/T homozygous variant allele of HOTAIR rs12826786 C>T were found in Egyptian patients with breast cancer. We suggest that the reported cut-off value of serum Nestin and the presence of C/T polymorphism can be used to assess the risk of females for developing breast cancer and might be of potential benefit in screening the disease. Larger studies in different ethnic groups are needed to confirm our findings.

Trends in the kidney cancer mortality-to-incidence ratios according to health care expenditures of 56 countries

The incidence and mortality rates in kidney cancer (KC) are increasing. However, the trends for mortality have varied among regions over the past decade, which may be due to the disparities in medical settings, such as the availability of frequent imaging examinations and effective systemic therapies. The availability of these two medical options has been proven to be positively correlated with a favorable prognosis in KC and may be more common in countries with better health care systems and greater expenditures. The delicate association between the trends in clinical outcomes in KC and health care disparities warrant detailed observation. We applied a delta-mortality-to-incidence ratio (δMIR) for KC to compare two years as an index for the improvement in clinical outcomes and the mortality-to-incidence ratio (MIR) of a single year to evaluate their association with the Human Development Index (HDI), current health expenditure (CHE) per capita, and CHE as a percentage of gross domestic product (CHE/GDP) by using linear regression analyses. A total of 56 countries were included based on data quality reports and missing data. We discovered that the HDI, CHE per capita, and CHE/GDP were negatively correlated with the MIRs for KC (p < 0.001, p < 0.001, and p < 0.001, respectively). No significant association was observed between the δMIRs and the HDI, CHE per capita, and CHE/GDP among the included countries, and only the CHE/GDP shows a trend toward significance. Interestingly, the δMIRs related with an increase in relative health care investment include δCHE per capita and δCHE/GDP.

Predictors of Healthcare Access and Utilization by Syrian Americans in the United States

There are currently no studies examining healthcare access and utilization by Syrian Americans. A better understanding of the determinants of healthcare utilization among this group could help aid in the design of culturally competent programs. A self-administered survey was distributed at events across Southern California and Jacksonville, Florida from January 2018 to May 2019. Statistical analysis utilized multivariate regressions. Insurance coverage was associated with a preference for speaking Arabic (OR 0.433, p = 0.02) and increased length of residency (OR 1.04, p = 0.02). Routine checkup was associated with female sex (OR 1.97, p = 0.001), age (OR 1.05, p < 0.001), and insurance coverage (OR 6.96, p < 0.001). Colonoscopy compliance rate was 43.3% and positively associated with higher education (OR 2.70, p = 0.002), routine checkup (OR 7.61, p = 0.009) and increased length of residency (OR 1.06, p < 0.001). Syrian Americans may benefit from further health promotion campaigns with regard to insurance coverage, preventative care and cancer screenings.

Harms and Benefits of Cancer Screening

In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.

Overdiagnosis and Risks of Breast Cancer Screening

Since its widespread introduction 30 years ago, screening mammography has contributed to substantial reduction in breast cancer-associated mortality, ranging from 15% to 50% in observational trials. It is currently the best examination available for the early diagnosis of breast cancer, when survival and treatment options are most favorable. However, like all medical tests and procedures, screening mammography has associated risks, including overdiagnosis and overtreatment, false-positive examinations, false-positive biopsies, and radiation exposure. Women should be aware of the benefits and risks of screening mammography in order to make the most appropriate care decisions for themselves.

Simplified Breast Risk Tool Integrating Questionnaire Risk Factors, Mammographic Density, and Polygenic Risk Score: Development and Validation

BACKGROUND

Clinical use of breast cancer risk prediction requires simplified models. We evaluate a simplified version of the validated Rosner-Colditz model and add percent mammographic density (MD) and polygenic risk score (PRS), to assess performance from ages 45-74. We validate using the Mayo Mammography Health Study (MMHS).

METHODS

We derived the model in the Nurses' Health Study (NHS) based on: MD, 77 SNP PRS and a questionnaire score (QS; lifestyle and reproductive factors). A total of 2,799 invasive breast cancer cases were diagnosed from 1990-2000. MD (using Cumulus software) and PRS were assessed in a nested case-control study. We assess model performance using this case-control dataset and evaluate 10-year absolute breast cancer risk. The prospective MMHS validation dataset includes 21.8% of women age <50, and 434 incident cases identified over 10 years of follow-up.

RESULTS

In the NHS, MD has the highest odds ratio (OR) for 10-year risk prediction: OR_{per SD} = 1.48 [95% confidence interval (CI): 1.31-1.68], followed by PRS, OR_{per SD} = 1.37 (95% CI: 1.21-1.55) and QS, OR_{per SD} = 1.25 (95% CI: 1.11-1.41). In MMHS, the AUC adjusted for age + MD + QS 0.650; for age + MD + QS + PRS 0.687, and the NRI was 6% in cases and 16% in controls.

CONCLUSION

A simplified assessment of QS, MD, and PRS performs consistently to discriminate those at high 10-year breast cancer risk.

IMPACT

This simplified model provides accurate estimation of 10-year risk of invasive breast cancer that can be used in a clinical setting to identify women who may benefit from chemopreventive intervention.See related commentary by Tehranifar et al., p. 587.

Screening Mammography Utilization Among Female Medicare Beneficiaries and Breast Cancer Survivors in 2002-2016

Background: The use of screening mammography varies by patient characteristics. This study examined the annual mammography utilization trends among female Medicare beneficiaries and breast cancer survivors, overall and by beneficiary characteristics. Materials and Methods: This retrospective, serial cross-sectional study used the 2002-2016 Medicare Current Beneficiary Survey (MCBS), including fee-for-service female Medicare beneficiaries who resided in community settings and who completed the survey (n = 53,788, weighted n = 206,259,890). Self-reported mammography utilization and breast cancer history were identified through the survey. Annual trends in the proportion of using mammography were examined using simple linear regression models, overall and by beneficiary's age, race, geographic region, and count of comorbidities. Multivariable models with generalized estimating equations were used to examine factors associated with mammography utilization. Results: Overall, the mammography utilization trends significantly decreased during the 2002-2016 period for both cohorts (p = 0.004 for female beneficiaries from 50.85% in 2002 to 40.55% in 2016 and p = 0.041 for breast cancer survivors from 68.36% in 2002 to 55.21% in 2016). Among female beneficiaries, trends also significantly decreased in different age groups, Whites, residential regions (Midwest, South, West, Metro, and Nonmetro), and count of comorbid conditions (all p < 0.05). Trends also declined among the breast cancer survivors who were ≥70 years old, ≥40 years old, and in South region (all p < 0.05). Beneficiary's demographic and socioeconomic factors, comorbidity, smoking, and health status were associated with the likelihood of screening mammography utilization among female beneficiaries; however, such associations were limited among breast cancer survivors. Conclusions: In 2002-2016, the overall trends in mammography use among female Medicare beneficiaries and breast cancer survivors declined significantly. Variations in mammography use among different subgroups were observed.

The Development of Cancer Screening Guidelines

Clinicians and the public have always depended on expert advice to guide clinical practice. However, since the 1970s, a growing emphasis on evidence-based medicine has led to clinical practice guidelines being less expert based and increasingly evidence based and judgments about the balance between the two. Because the existence of standards for guidelines development is no guarantee that a guideline will be trustworthy, tools and instruments have been developed to measure the degree to which a guideline has been developed with rigorous adherence to methodology, and has not been influenced by conflicts of interest.

Is It the Era for Personalized Screening?

Breast cancer screening is a recognized tool for early detection of the disease in asymptomatic women, improving treatment efficacy and reducing the mortality rate. There is raised awareness that a "one-size-fits-all" approach cannot be applied for breast cancer screening. Currently, despite specific guidelines for a minority of women who are at very high risk of breast cancer, all other women are still treated alike. This article reviews the current recommendations for breast cancer risk assessment and breast cancer screening in average-risk and higher-than-average-risk women. Also discussed are new developments and future perspectives for personalized breast cancer screening.

Web-based decision aids to support breast cancer screening decisions: systematic review and meta-analysis

Aim: Breast cancer is a leading cause of cancer among women. Because guidelines on screening for breast cancer for certain ages are controversial, many experts advocate the use of shared decision making (SDM) using validated decision aids (DAs). Recent studies have concluded that DAs are beneficial; however, the results have great heterogeneity. Therefore, further studies are needed to improve understanding of these tools. Objective: This systematic review and meta-analysis aimed to investigate the impact of using web-based DAs in women aged 50 years and below facing the decision to be screened for breast cancer in comparison with usual care. Methods: PubMed, Web of Science, Embase and the Cochrane CENTRAL databases were searched up to February 2020 for studies assessing web-based DAs for women making a breast cancer screening decision and reported quality of decision-making outcomes. Using a random-effects model or a fixed-effects model, meta-analyses were conducted pooling results using mean differences (MD), standardized mean differences (SMD) and relative risks (RR). Results: Of 1097 unique citations, three randomized controlled trials and two before-after studies met the study eligibility criteria. Compared with usual care, web-based DAs increased knowledge (SMD = 0.69; 95% CI: 0.57-0.80; p < 0.00001), reduced decision conflict and increased the proportion of women who made an informed choice (RR = 1.86; 95% CI: 1.38 to 2.50; p < 0.0001), but did not change the intention of women deciding to be screened or affect decision regret. Conclusion: This analysis showed the positive effect of web-based DAs on patient-centered outcomes in breast cancer screening. In the future, more internet devices and free or larger discount WI-FI should be established to ensure more women can benefit from this effective tool.

Older Women’s Perspectives Driving Mammography Screening Use and Overuse: a Narrative Review of Mixed-Methods Studies

Purpose of Review

Examining what older women know and perceive about mammography screening is critical for understanding patterns of under- and overuse, and concordance with screening mammography guidelines in the USA. This narrative review synthesizes qualitative and quantitative evidence around older women’s perspectives toward mammography screening.

Recent Findings

The majority of 43 identified studies focused on promoting mammography screening in women of different ages, with only four studies focusing on the overuse of mammography in women ≥ 70 years old. Older women hold positive attitudes around screening, perceive breast cancer as serious, believe the benefits outweigh the barriers, and are worried about undergoing treatment if diagnosed. Older women have limited knowledge of screening guidelines and potential harms of screening.

Summary

Efforts to address inequities in mammography access and underuse need to be supplemented by epidemiologic and interventional studies using mixed-methods approaches to improve awareness of benefits and harms of mammography screening in older racially and ethnically diverse women. As uncertainty around how best to approach mammography screening in older women remains, understanding women’s perspectives along with healthcare provider and system-level factors is critical for ensuring appropriate and equitable mammography screening use in older women.

Breast Cancer Screening Recommendations: African American Women Are at a Disadvantage

Since 1990, breast cancer mortality has decreased by 40% in white women but only 26% in African American women. The age at diagnosis of breast cancer is younger in black women. Breast cancer diagnosed before age 50 represents 23% of all breast cancers in African American women but only 16% of all breast cancers in white women. White women have a higher incidence of breast cancer over the age of 60. Tumor subtypes also vary among racial and ethnic groups. The triple-negative (TN) subtype, which has a poorer outcome and occurs at a younger age, represents 21% of invasive breast cancers in black women but only 10% of invasive breast cancers in white women. The hormone receptor-positive subtype, which is more common in older women and has the best outcome, has a higher incidence in white women (70%) than in black women (61%). The BRCA2 mutation is also more common in black women than in white women (other than those who are of Ashkenazi Jewish ancestry). There are also many barriers to screening. Major ones include the lack of contact with a primary health care provider as well as a decreased perceived risk of having breast cancer in the African American population. Given the younger age of onset and the higher incidence of the TN molecular subtype, following breast cancer screening guidelines that do not support screening before the age of 50 may disadvantage black women.

Long term absence of invasive breast cancer diagnosis in 2,402,672 pre and postmenopausal women: A systematic review and meta-analysis

BACKGROUND

Invasive Breast Cancer (IBC) risk estimates continue to be based on data collated from cancer registries, i.e., retrospective research that excludes disease-free women. For women without a prior diagnosis, these estimates inflate both risk and screening frequency recommendations and inadvertently increase recently recognized harms from overdiagnosis and overtreatment.

OBJECTIVE

To estimate the likelihood that pre or postmenopausal women with no prior diagnosis will remain free of IBC in order to enable evidence-based screening recommendations.

METHODS

Prospective data from 21 studies of 2,402,672 women were analyzed, updating our previously published systematic search of 19 studies. This second systematic search included PubMed and The Cochrane Library from 2012 through April 2019. Inclusion criteria: only studies reporting the number of women enrolled, length of follow-up, and number of women diagnosed with IBC. Linear regression was used to estimate the percentage of women expected to remain free from an IBC diagnosis based on follow-up duration. To minimize non-response bias and selective outcome bias, only studies reporting outcomes for all enrolled women followed for similar, specific lengths of time were included. Sensitivity analyses confirm that the overall findings were unchanged by age at enrollment, menopausal status, screened women, variation in sample size, duration of follow-up, and heteroskedasticity.

RESULTS

The calculated percentage of women remaining IBC-free after follow-ups of 5, 10, 15, 20 and 25 years decreases uniformly by about one-fourth of one percent per year, i.e., 0.255% (95% CI: -0.29, -0.22; p < .0001). At 25 years, the expected percentage of women with no invasive breast cancer is 93.41% (95% CI: 92.75, 94.07).

CONCLUSIONS

Over 99.7% of pre/postmenopausal women with no prior diagnosis continued with no IBC each year, with 93.41% still free after 25 years. Our study supports the medical justification for reducing the frequency of mammograms for menopausal women with no prior IBC diagnosis.

A Pre-Test-Post-Test Trial of a Breast Cancer Risk Report for Women in Their 40s

INTRODUCTION

Guidelines recommend individualized breast cancer screening and prevention interventions for women in their 40s. Yet, few primary care clinicians assess breast cancer risk.

STUDY DESIGN

Pretest-Posttest trial.

SETTING/PARTICIPANTS

Women aged 40-49 years were recruited from one large Boston-based academic primary care practice between July 2017 and April 2019.

INTERVENTION

Participants completed a pretest, received a personalized breast cancer risk report, saw their primary care clinician, and completed a posttest.

MAIN OUTCOME MEASURES

Using mixed effects models, changes in screening intentions (0-100 scale [0=will not screen to 100=will screen]), mammography knowledge, decisional conflict, and receipt of screening were examined. Analyses were conducted from June 2019 to February 2020.

RESULTS

Patient (n=337) mean age was 44.1 (SD=2.9) years, 61.4% were non-Hispanic white, and 76.6% were college graduates; 306 (90.5%) completed follow-up (203 with 5-year breast cancer risk <1.1%). Screening intentions declined from pre- to post-visit (79.3 to 68.0, p<0.0001), especially for women with 5-year risk <1.1% (77.2 to 63.3, p<0.0001), but still favored screening. In the 2 years prior, 37.6% had screening mammography compared with 41.8% over a mean 16 months follow-up (p=0.17). Mammography knowledge increased and decisional conflict declined. Eleven (3.3%) women met criteria for breast cancer prevention medications (ten discussed medications with their clinicians), 22 (6.5%) for MRI (19 discussed MRI with their clinician), and 67 (19.8%) for genetic counseling (47 discussed with the clinician).

CONCLUSIONS

Receipt of a personalized breast cancer report was associated with women in their 40s making more-informed and less-conflicted mammography screening decisions and with high-risk women discussing breast cancer prevention interventions with clinicians.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.govNCT03180086.

Implementation and Utilization of a "Pink Card" Walk-In Screening Mammography Program Integrated With Physician Visits

PURPOSE

The aim of this study was to evaluate the implementation and utilization of the Pink Card program, which links a physician-delivered reminder that a woman is due for screening mammography (SM) during an office visit with the opportunity to undergo walk-in screening.

METHODS

In 2016, the authors' community-based breast imaging center provided physicians from three primary care and obstetrics and gynecology practices located in the same outpatient facility business card-sized Pink Cards to offer women due for SM during office visits. The card includes a reminder that screening is due and can be used to obtain SM on a walk-in basis. The primary outcome measure was the proportion of women who used Pink Cards among all screened women over 2 years. Independent predictors of Pink Card utilization were evaluated using multivariate logistic regression analyses.

RESULTS

Among 3,688 women who underwent SM, Pink Cards were used by 19.9% (733 of 3,688). Compared with women with prescheduled screening visits, Pink Card users were more likely to be Asian (odds ratio [OR], 1.37; P =.032), Black (OR, 2.05; P = .002), and Medicaid insured (OR, 1.71; P = .013) and less likely to use English as their primary language (OR, 2.75; P = .003). Additionally, Pink Card users were less likely to be up to date for biennial SM compared with women with prescheduled visits (31.9% [234 of 733] versus 66.6% [1,968 of 2,955], P < .001).

CONCLUSIONS

The Pink Card walk-in SM program can improve screening access, particularly for racial/ethnic minorities and Medicaid-insured patients. Expansion of this program may help reduce disparities and increase engagement in breast cancer screening.

A Strategy to Prepare Primary Care Clinicians for Discussing Stopping Cancer Screening With Adults Older Than 75 Years

Background and Objectives

Adults older than 75 years are overscreened for cancer, especially those with less than 10-year life expectancy. This study aimed to learn the effects of providing primary care providers (PCPs) with scripts for discussing stopping mammography and colorectal cancer (CRC) screening and with information on patient’s 10-year life expectancy on their patients’ intentions to be screened for these cancers.

Research Design and Methods

Patient participants, identified via PCP appointment logs, completed a questionnaire pre- and postvisit. Primary care providers were given scripts for discussing stopping screening and information on patient’s 10-year life expectancy before these visits. Primary care providers completed a questionnaire at the end of the study. Patients and PCPs were asked about discussing stopping cancer screening and patient life expectancy. Patient screening intentions (1–15 Likert scale; lower scores suggest lower intentions) were compared pre- and postvisit using the Wilcoxon signed-rank test.

Results

Ninety patients older than 75 years (47% of eligible patients reached by phone) from 45 PCPs participated. Patient mean age was 80.0 years (SD = 2.9), 43 (48%) were female, and mean life expectancy was 9.7 years (SD = 2.4). Thirty-seven PCPs (12 community-based) completed a questionnaire. Primary care providers found the scripts helpful (32 [89%]) and thought they would use them frequently (29 [81%]). Primary care providers also found patient life expectancy information helpful (35 [97%]). However, only 8 PCPs (22%) reported feeling comfortable discussing patient life expectancy. Patients’ intentions to undergo CRC screening (9.0 [SD = 5.3] to 6.5 [SD = 6.0], p < .0001) and mammography screening (12.9 [SD = 3.0] to 11.7 [SD = 4.9], p = .08) decreased from pre- to postvisit (significantly for CRC). Sixty-three percent of patients (54/86) were interested in discussing life expectancy with their PCP previsit and 56% (47/84) postvisit.

Discussion and Implications

PCPs found scripts for discussing stopping cancer screening and information on patient life expectancy helpful. Possibly, as a result, their patients older than 75 years had lower intentions of being screened for CRC.

Clinical Trials Registration Number

NCT03480282

Scripts and Strategies for Discussing Stopping Cancer Screening with Adults > 75 Years: a Qualitative Study

BACKGROUND

Despite guidelines recommending not to continue cancer screening for adults > 75 years old, especially those with short life expectancy, primary care providers (PCPs) feel ill-prepared to discuss stopping screening with older adults.

OBJECTIVE

To develop scripts and strategies for PCPs to use to discuss stopping cancer screening with adults > 75.

DESIGN

Qualitative study using semi-structured interview guides to conduct individual interviews with adults > 75 years old and focus groups and/or individual interviews with PCPs.

PARTICIPANTS

Forty-five PCPs and 30 patients > 75 years old participated from six community or academic Boston-area primary care practices.

APPROACH

Participants were asked their thoughts on discussions around stopping cancer screening and to provide feedback on scripts that were iteratively revised for PCPs to use when discussing stopping mammography and colorectal cancer (CRC) screening.

RESULTS

Twenty-one (47%) of the 45 PCPs were community based. Nineteen (63%) of the 30 patients were female, and 13 (43%) were non-Hispanic white. PCPs reported using different approaches to discuss stopping cancer screening depending on the clinical scenario. PCPs noted it was easier to discuss stopping screening when the harms of screening clearly outweighed the benefits for a patient. In these cases, PCPs felt more comfortable being more directive. When the balance between the benefits and harms of screening was less clear, PCPs endorsed shared decision-making but found this approach more challenging because it was difficult to explain why to stop screening. While patients were generally enthusiastic about screening, they also reported not wanting to undergo tests of little value and said they would stop screening if their PCP recommended it. By the end of participant interviews, no further edits were recommended to the scripts.

CONCLUSIONS

To increase PCP comfort and capability to discuss stopping cancer screening with older adults, we developed scripts and strategies that PCPs may use for discussing stopping cancer screening.

Primary Care Providers Underutilize Breast Screening MRI for High-Risk Women

OBJECTIVE

Supplemental MRI screening for women at high risk for breast cancer is underutilized. Our study assessed how primary care providers in our healthcare network identify high-risk women and recommend high-risk screening breast MRI.

METHODS

An electronic survey was distributed to providers in OB/GYN, family, and internal medicine departments between 1/14/19 and 3/22/19. The survey inquired about methods used to assess breast cancer risk, familiarity with the American Cancer Society's definition of high-risk, and whether screening breast MRI is recommended for high-risk women.

RESULTS

Response rate was 17% (89/524). After excluding providers who ordered ≤10 mammograms per year, the study included 75 respondents, who mostly ordered 10-1000 mammograms per year and supported annual/biennial screening mammogram starting at age 40-50 years. More providers reported estimating breast cancer risk qualitatively (with family, clinical history, and/or breast density) than quantitatively with risk calculators (73/75, 97% vs 22/75, 29%). A minority of providers (23/75, 31%) correctly defined high lifetime risk. Only 9/75 (12%) providers recommended screening MRI for high-risk women. Use of quantitative risk calculators or ability to correctly define high-risk were not associated with likelihood of recommending MRI screening. More providers had recommended MRI for screening in the setting of dense breasts than for high-risk screening (23/75, 31% vs 9/75, 12%).

CONCLUSION

Primary care providers at our institution did not routinely recommend screening MRI for high-risk women. Risk assessment and reporting at the time of mammography may improve MRI utilization and is an opportunity for radiologists to add value and directly participate in patient-centered care.