Breast-Cancer Tumor Size, Overdiagnosis, and Mammography Screening Effectiveness

Breast cancer in women under age 40: A decade of trend analysis at a single institution

BACKGROUND

Women should be evaluated for breast cancer risk by age 30 to assess for screening need. Recent trends in breast cancer in this population may further inform recommendations.

OBJECTIVE

The aim of this study was to analyze trends over time in the rate of breast cancer, tumor characteristics and treatment in women under age 40.

METHODS

Retrospective cohort study of women under age 40 at our institution diagnosed with breast cancer from January 2007 to April 2018 was conducted. Patient demographics, tumor characteristics and treatment outcomes were collected. Descriptive statistics and the Mann-Kendell Trend test were calculated. Two-proportion z-tests were used to compare proportions of stage, pathology and treatment between 2007-2013 and 2014-2018.

RESULTS

197 women under age 40 were treated for a new diagnosis of breast cancer at our institution. A higher proportion of women were diagnosed with invasive carcinoma in 2013-2018 (91%) compared to 2007-2012 (78%), p = 0.008. A higher proportion of women were diagnosed with advanced stage disease (stage III-IV) in 2013-2018 (24%) compared to 2007-2012 (2%), p = 0.001. No statistically significant evidence for an increasing trend of overall rate of breast cancer over the last 11 years (p = 0.419) was observed.

CONCLUSIONS

While no statistically significant increase in overall rate of breast cancer was noted, an increase in invasive and later staged breast cancers was observed.

CLINICAL IMPACT

Rise in more aggressive cancers in a population that is largely not screened may have implications both on the individual young woman's morbidity as well as on a public health level.

Implementing Multilabeling, ADASYN, and ReliefF Techniques for Classification of Breast Cancer Diagnostic through Machine Learning: Efficient Computer-Aided Diagnostic System

Multilabel recognition of morphological images and detection of cancerous areas are difficult to locate in the scenario of the image redundancy and less resolution. Cancerous tissues are incredibly tiny in various scenarios. Therefore, for automatic classification, the characteristics of cancer patches in the X-ray image are of critical importance. Due to the slight variation between the textures, using just one feature or using a few features contributes to inaccurate classification outcomes. The present study focuses on five different algorithms for extracting features that can extract further different features. The algorithms are GLCM, LBGLCM, LBP, GLRLM, and SFTA from 8 image groups, and then, the extracted feature spaces are combined. The dataset used for classification is most probably imbalanced. Additionally, another focal point is to eradicate the unbalanced data problem by creating more samples using the ADASYN algorithm so that the error rate is minimized and the accuracy is increased. By using the ReliefF algorithm, it skips less contributing features that relieve the burden on the process. Finally, the feedforward neural network is used for the classification of data. The proposed method showed 99.5% micro, 99.5% macro, 0.5% misclassification, 99.5% recall rats, specificity 99.4%, precision 99.5%, and accuracy 99.5%, showing its robustness in these results. To assess the feasibility of the new system, the INbreast database was used.

The impact of mammographic screening on the subsequent breast cancer risk associated with biopsy-proven benign breast disease

Data on the risk of breast cancer following a benign breast disease (BBD) diagnosis were derived predominantly from populations of women biopsied before the widespread use of mammographic screening and in whom these lesions were mostly incidental findings. Whether or not similar risk associations are seen when these lesions are detected in mammographically screened populations is unknown. To address this, we examined the variation in BBD and breast cancer risk associations by the calendar time of BBD diagnosis (pre- vs. post-mammography era [before vs. 1985 and after]) in a nested case–control study within the Nurses’ Health Study (NHS) and NHSII BBD subcohort (488 cases; 1908 controls). We performed logistic regression analysis, adjusting for matching factors and potential confounders, to estimate odds ratio (ORs) and 95% confidence interval (CI) for the association between BBD subtype (non-proliferative, proliferative without atypia, proliferative with atypical hyperplasia (AH)) and subsequent breast cancer risk. When compared with non-proliferative lesions, both proliferative lesions without atypia (PWA) and AHs were associated with similar levels of risk in the pre-mammographic (pre) and post-mammographic (post) time periods (PWA: OR [95% CI] = 1.73 [1.27, 2.36] pre vs. 1.12 [0.73, 1.74] post; AH: 4.41 [2.90, 6.70] pre vs. 3.69 [2.21, 6.15] post). The interaction by mammography era was not statistically significant (p-interaction = 0.47). These results suggest that the risk associations reported for BBD subtypes in the pre-mammography era remain valid for BBD detected after the widespread implementation of mammographic screening.

Breast cancer detection by dedicated breast positron emission tomography according to the World Health Organization classification of breast tumors

OBJECTIVE

Considering the difficulty in detecting primary breast cancers using whole-body positron emission tomography (WBPET) owing to its limited spatial resolution, we aimed to evaluate the detectability of breast cancer by ring-type dedicated breast PET (DbPET) on the World Health Organization (WHO) histological classification in comparison with WBPET.

METHODS

A total of 938 patients with breast cancer underwent WBPET and ring-type DbPET, and 1021 lesions were histologically assessed based on the WHO classification of tumors of the breast. The findings of WBPET and DbPET were retrospectively evaluated and compared.

RESULTS

The size-related sensitivity of DbPET was superior to that of WBPET for subcentimetric tumors (81.9% vs. 52.4%, P < 0.001). The histological distribution was as follows: 11 lobular carcinoma in situ, 158 ductal carcinoma in situ, 738 infiltrating duct carcinoma not otherwise specified (NOS), 12 lobular carcinoma NOS, 40 mucinous adenocarcinoma, 13 tubular carcinoma, 36 invasive breast carcinoma others, and 13 papillary neoplasms. WBPET had low sensitivity for lobular carcinoma in situ, ductal carcinoma in situ, lobular carcinoma NOS, mucinous adenocarcinoma, and tubular carcinoma. DbPET showed improved sensitivity for all the above except lobular and tubular carcinoma. The maximum standardized uptake values (SUVmax) of DbPET were significantly higher than those of WBPET for histological types, excluding lobular carcinoma in situ. The SUVmax of papillary neoplasms was high regardless of low-grade histology and Ki-67 labeling index.

CONCLUSIONS

DBPET was found to have high sensitivity and SUVmax values for all histologic types that showed low sensitivity of detection on WBPET, except lobular carcinoma in situ.

Immunotherapeutic strategies in breast cancer: A clinical update

Immunotherapy has been incorporated into the standard of care for a wide range of malignancies. The study of tumor-infiltrating lymphocytes has emphasized the importance of the host antitumor immune response in the natural history of breast cancer. Recent clinical trials have used immunotherapeutic approaches to augment this response and improve outcomes for patients with breast cancer. Here, we review several current clinical trial data that indicate checkpoint blockade may mediate clinically significant responses.

Predictors of Women's Awareness of the Benefits and Harms of Mammography Screening and Associations with Confusion, Ambivalence, and Information Seeking

In recent years, there has been a shift toward promoting informed decision making for mammography screening for average-risk women in their 40s. Professional organizations such as the American Cancer Society and U.S. Preventive Services Task Force recommend that women weigh the potential benefits and harms of mammography prior to initiating screening. This decision-making process assumes that women are aware of both the benefits and harms of screening, yet little is known about the prevalence and antecedents of such awareness. Moreover, it is conceivable that women who are aware of both the benefits and harms may interpret this information as conflicting - which could be concerning, as researchers have documented adverse effects of exposure to conflicting health information in prior research. Using data from a population-based survey of U.S. women aged 30-59 (N = 557), the current study found that awareness of mammography's harms is relatively low compared to awareness of benefits. Health news exposure and interpersonal communication about health were associated with greater awareness of harms. In addition, women's awareness of both the benefits and harms was positively associated with confusion about breast cancer screening recommendations, ambivalence about getting a mammogram, and mammogram-related information seeking from online sources. Implications for cancer screening communication are discussed.

Comparing Health Outcomes of Privileged US Citizens With Those of Average Residents of Other Developed Countries

IMPORTANCE

The average health outcomes in the US are not as good as the average health outcomes in other developed countries. However, whether high-income US citizens have better health outcomes than average individuals in other developed countries is unknown.

OBJECTIVE

To assess whether the health outcomes of White US citizens living in the 1% and 5% richest counties (hereafter referred to as privileged White US citizens) are better than the health outcomes of average residents in other developed countries.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness study, conducted from January 1, 2013, to December 31, 2015, identified White US citizens living in the 1% (n = 32) and 5% (n = 157) highest-income counties in the US and measured the following 6 health outcomes associated with health care interventions: infant and maternal mortality, colon and breast cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction. The study used Organisation for Economic Co-operation and Development data, CONCORD-3 cancer data, and Medicare data to compare their outcomes with all residents in 12 other developed countries: Australia, Austria, Canada, Denmark, Finland, France, Germany, Japan, the Netherlands, Norway, Sweden, and Switzerland. Statistical analysis took place from July 25, 2017, to August 29, 2020.

MAIN OUTCOMES AND MEASURES

Infant mortality; maternal mortality; 5-year survival of patients with colon cancer, breast cancer, or childhood acute lymphocytic leukemia; and 30-day age-standardized case fatality after acute myocardial infarction.

RESULTS

The infant mortality rate among White US citizens in the 5% highest-income counties was 4.01 per 1000, and the maternal mortality rate among White US citizens in the 5% highest-income counties was 10.85 per 100 000, both higher than the mean rates for any of the 12 comparison countries. (The infant mortality rate for the top 1% counties was 3.54 per 1000, and the maternal mortality rate was 10.05 per 100 000.) The 5-year survival rate for White US citizens in the 5% highest-income counties was 67.2% (95% CI, 66.7%-67.7%) for colon cancer, higher than that of average US citizens (64.9% [95% CI, 64.7%-65.1%]) and average citizens in 6 countries, comparable with that of average citizens in 4 countries, and lower than that of average citizens for 2 countries. The 5-year survival rate for breast cancer among White US women in the 5% highest-income US counties was 92.0% (95% CI, 91.6%-92.4%), higher than in all 12 comparison countries. The 5-year survival rate for White children with acute lymphocytic leukemia in the 5% highest-income US counties was 92.6% (95% CI, 90.7%-94.2%), exceeding the mean survival rate for only 1 country and comparable with the mean survival rates in 11 countries. The adjusted 30-day acute myocardial infarction case-fatality rate for White US citizens in the 5% highest-income US counties was 8% below the rate for all US citizens and was 5% below the rate for all US citizens in the 1% highest-income US counties; these estimates were similar to the median outcome of other high-income countries.

CONCLUSIONS AND RELEVANCE

This study suggests that privileged White US citizens have better health outcomes than average US citizens for 6 health outcomes but often fare worse than the mean measure of health outcomes of 12 other developed countries. These findings imply that even if all US citizens experienced the same health outcomes enjoyed by privileged White US citizens, US health indicators would still lag behind those in many other countries.

The changing face of central chondrosarcoma of bone. One UK-based orthopaedic oncology unit's experience of 33 years referrals

AIM

To ascertain the changing incidence over time of the three commonest primary sarcomas of bone. Data obtained with particular reference to central chondrosarcoma from the annual referral rate to a large UK-based specialist orthopaedic oncology unit. To discuss how the "barnyard pen" analogy of cancers previously applied to certain commoner cancers can also be applicable to central chondrosarcoma (CS) of bone.

MATERIALS AND METHODS

A retrospective review was conducted of a computerised database identifying all central cartilage tumours (CCT) of bone, including enchondroma and CS subtypes, between 1985 and 2018. These were compared with the referrals of the other two commonest primary sarcomas of bone, osteosarcoma and Ewing sarcoma.

RESULTS

There was a total of 1507 CS showing a 68% overall increase in annual referral rate/incidence over the study period. 68% cases were the borderline malignant lesions now known as atypical cartilaginous tumour (ACT). The annual referral rate/incidence of this entity increased by 194% over the 30 years. Whereas, the annual referral rate/incidence for osteosarcoma and Ewing sarcoma was static for the past 20 years.

CONCLUSION

The annual incidence of central CS of bone showed a marked increase over the 33-year period as compared with both osteosarcoma and Ewing sarcoma. This is especially in the ACT category and is thought to be due to the increased provision of MRI scanning flagging up a rise in incidental findings. The spectrum of CCTs from benign to highly malignant elegantly fits the "barn yard" pen analogy and could prove useful as an explanatory tool for patients and clinicians unfamiliar with these diseases.

Clinical impact of LncRNA XIST and LncRNA NEAT1 for diagnosis of high-risk group breast cancer patients

Long noncoding RNAs (lncRNAs) are evolving as contributing biomarkers for many diseases. Among these lncRNAs, X inactive-specific transcript (XIST), and nuclear paraspeckle assembly transcript 1 (NEAT1) were studied as undesirable upregulated nucleic acid markers for unfavorable prognosis of cancer. The authors aimed to investigate their role as diagnostic markers for breast cancer (BC) patients with high-risk factors. Serum samples were obtained from BC patients (n = 121), patients with benign breast lesions (n = 35), and healthy volunteers (n = 22). Assessment of lncRNA XIST, and lncRNA NEAT1 expression was performed using real time PCR. Expression levels of the investigated lncRNAs were significantly higher in BC patients as compared to the other groups. Both lncRNAs were significantly correlated with BC laterality, lymph node involvement, and clinical stages. LncRNA NEAT1 reported a significant aberrant expression with pathological types, histological grading and, hormonal status. The sensitivity of lncRNA NEAT1 was superior for detection of BC with high risk-factors as compared to lncRNA XIST. In conclusion, the detection of lncRNAs in body fluids has demonstrated a significant importance for detecting BC patients with high-risk factors, and was related to hormonal receptors, thus may be used for determining the direction of treatment strategy.

PUM1 and RNase P genes as potential cell-free DNA markers in breast cancer

BACKGROUND

Cell-free DNA (cfDNA) is used in clinical research to identify biomarkers for diagnosis of and follow-up on cancer. Here, we propose a fast and innovative approach using traditional housekeeping genes as cfDNA targets in a copy number analysis. We focus on the application of highly sensitive technology such as digital PCR (dPCR) to differentiate breast cancer (BC) patients and controls by quantifying regions of PUM1 and RPPH1 (RNase P) in plasma samples.

METHODS

We conducted a case-control study with 82 BC patients and 82 healthy women. cfDNA was isolated from plasma using magnetic beads and quantified by spectrophotometry to estimate total cfDNA. Then, both PUM1 and RPPH1 genes were specifically quantified by dPCR. Data analysis was calibrated using a reference genomic DNA in different concentrations.

RESULTS

We found RNase P and PUM1 values were correlated in the patient group (intraclass correlation coefficient [ICC] = 0.842), but they did not have any correlation in healthy women (ICC = 0.519). In dPCR quantification, PUM1 showed the capacity to distinguish early-stage patients and controls with good specificity (98.67%) and sensitivity (100%). Conversely, RNase P had lower cfDNA levels in triple-negative BC patients than luminal subtypes (p < 0.025 for both), confirming their utility for patient classification.

CONCLUSION

We propose the PUM1 gene as a cfDNA marker for early diagnosis of BC and RNase P as a cfDNA marker related to hormonal status and subtype classification in BC. Further studies with larger sample sizes are warranted.

Regenerative tissue filler for breast conserving surgery and other soft tissue restoration and reconstruction needs

Complete removal of cancerous tissue and preservation of breast cosmesis with a single breast conserving surgery (BCS) is essential for surgeons. New and better options would allow them to more consistently achieve this goal and expand the number of women that receive this preferred therapy, while minimizing the need for re-excision and revision procedures or more aggressive surgical approaches (i.e., mastectomy). We have developed and evaluated a regenerative tissue filler that is applied as a liquid to defects during BCS prior to transitioning to a fibrillar collagen scaffold with soft tissue consistency. Using a porcine simulated BCS model, the collagen filler was shown to induce a regenerative healing response, characterized by rapid cellularization, vascularization, and progressive breast tissue neogenesis, including adipose tissue and mammary glands and ducts. Unlike conventional biomaterials, no foreign body response or inflammatory-mediated "active" biodegradation was observed. The collagen filler also did not compromise simulated surgical re-excision, radiography, or ultrasonography procedures, features that are important for clinical translation. When post-BCS radiation was applied, the collagen filler and its associated tissue response were largely similar to non-irradiated conditions; however, as expected, healing was modestly slower. This in situ scaffold-forming collagen is easy to apply, conforms to patient-specific defects, and regenerates complex soft tissues in the absence of inflammation. It has significant translational potential as the first regenerative tissue filler for BCS as well as other soft tissue restoration and reconstruction needs.

Performance of dedicated breast positron emission tomography in the detection of small and low-grade breast cancer

PURPOSE

This study compares the sensitivity of dedicated breast positron emission tomography (DbPET) and whole body positron emission tomography (WBPET) in detecting invasive breast cancer based on tumor size and biology. Further, we explored the relationship between maximum standardized uptake value (SUVmax) of DbPET and biological features of the tumor.

METHODS

A total of 639 invasive breast cancer lesions subjected to both DbPET and WBPET before surgery, between January 2016 and May 2019, were included in the study. The sensitivity of DbPET and WBPET in detection and the biology of the tumor according to the clinicopathological features were retrospectively evaluated.

RESULTS

The overall sensitivity of DbPET was higher than that of WBPET (91.4% vs. 80.3%, p < 0.001). Subcentimetric tumors were significant (80.9% vs. 54.3%, p < 0.001). Regardless of the nuclear grade, DbPET could detect more lesions than WBPET. The SUVmax was positively correlated with tumor size (R = 0.395, p < 0.001) and the nuclear grade (p < 0.001). Luminal A-like breast cancer had significantly lower SUVmax values than the other subtypes (p < 0.001).

CONCLUSIONS

DbPET is superior to WBPET in the detection of subcentimetric, low-grade breast cancers. Further, by using SUVmax, DbPET can distinguish luminal A-like breast cancer from the other subtypes.

Magnetic Resonance Imaging in Screening of Breast Cancer

Magnetic Resonance (MR) imaging is the most sensitive modality for breast cancer detection but is currently limited to screening women at high risk due to limited specificity and test accessibility. However, specificity of MR imaging improves with successive rounds of screening, and abbreviated approaches have the potential to increase access and decrease cost. There is growing evidence to support supplemental MR imaging in moderate-risk women, and current guidelines continue to evolve. Functional imaging has the potential to maximize survival benefit of screening. Leveraging MR imaging as a possible primary screening tool is therefore also being investigated in average-risk women.

Diffusion-Weighted Magnetic Resonance Imaging for Breast Cancer Screening in High-Risk Women: Design and Imaging Protocol of a Prospective Multicenter Study in Korea

Purpose

Interest in unenhanced magnetic resonance imaging (MRI) screening for breast cancer is growing due to concerns about gadolinium deposition in the brain and the high cost of contrast-enhanced MRI. The purpose of this report is to describe the protocol of the Diffusion-Weighted Magnetic Resonance Imaging Screening Trial (DWIST), which is a prospective, multicenter, intraindividual comparative cohort study designed to compare the performance of mammography, ultrasonography, dynamic contrast-enhanced (DCE) MRI, and diffusion-weighted (DW) MRI screening in women at high risk of developing breast cancer.

Methods

A total of 890 women with BRCA mutation or family history of breast cancer and lifetime risk ≥ 20% are enrolled. The participants undergo 2 annual breast screenings with digital mammography, ultrasonography, DCE MRI, and DW MRI at 3.0 T. Images are independently interpreted by trained radiologists. The reference standard is a combination of pathology and 12-month follow-up. Each image modality and their combination will be compared in terms of sensitivity, specificity, accuracy, positive predictive value, rate of invasive cancer detection, abnormal interpretation rate, and characteristics of detected cancers. The first participant was enrolled in April 2019. At the time of manuscript submission, 5 academic medical centers in South Korea are actively enrolling eligible women and a total of 235 women have undergone the first round of screening. Completion of enrollment is expected in 2022 and the results of the study are expected to be published in 2026.

Discussion

DWIST is the first prospective multicenter study to compare the performance of DW MRI and conventional imaging modalities for breast cancer screening in high-risk women. DWIST is currently in the patient enrollment phase.

Trial Registration

ClinicalTrials.gov Identifier: NCT03835897

Survival Outcome and Impact of Chemotherapy in T1 Node-Negative Triple-Negative Breast Cancer: A SEER Database Analysis

Objective

Although triple-negative breast cancer (TNBC) has been considered to be an aggressive disease, the outcome of small-tumor (T1abcN0M0) TNBC and the effect of adjuvant chemotherapy on TNBC survival remain controversial.

Methods

We identified 4565 T1abcN0M0 TNBC patients in the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2010, to December 31, 2015. After propensity score matching (PSM), 3214 patients were finally analyzed. Survival rates were compared among T1a, T1b, and T1c patients and between patients with and without adjuvant chemotherapy.

Results

We classified 424, 1040, and 3101 cases as T1a, T1b, and T1c TNBC, respectively. A total of 2760 (60.5%) patients received adjuvant chemotherapy, accounting for 25.5%, 56.0%, and 66.8% of T1a, T1b, and T1c patients, respectively. Rates of 5-year breast cancer-specific survival (BCSS) for T1a, T1b, and T1c patients receiving chemotherapy were 97.8%, 94.1%, and 94.5%, respectively, compared with 97.2%, 94.0%, and 89.9% in patients without chemotherapy. Patients receiving adjuvant chemotherapy had higher 5-year BCSS (94.5% vs. 89.9%, P = 0.004) in the T1c subgroup, but no significant difference was detected in T1a or T1b patients due to adjuvant chemotherapy.

Conclusion

Small-tumor TNBC showed very good prognosis. Adjuvant chemotherapy improved prognosis in T1c TNBC cases to a greater extent than in T1a and T1b patients. More large-scale clinical trials are needed, and further study should be conducted to determine appropriate adjuvant chemotherapy for T1c TNBC patients.

Screening and Selection: The Case of Mammograms

We analyze selection into screening in the context of recommendations that breast cancer screening start at age 40. Combining medical claims with a clinical oncology model, we document that compliers with the recommendation are less likely to have cancer than younger women who select into screening or women who never screen. We show this selection is quantitatively important: shifting the recommendation from age 40 to 45 results in three times as many deaths if compliers were randomly selected than under the estimated patterns of selection. The results highlight the importance of considering characteristics of compliers when making and designing recommendations.

Non-surgical treatment for ductal carcinoma in situ of the breasts - a prospective study on patient's perspective

INTRODUCTION

Several ongoing trials are currently investigating the feasibility and non-inferiority of active surveillance for managing low-risk DCIS. However, little is known on the proposed non-surgical treatment for DCIS from patient's perspective.

METHODS

A prospective cohort study was performed on 1000 consecutive patients aged 18 to 90 years old with various breast disorders between 1st July 2019 and 31st December 2019. Patients were asked about their opinions on non-surgical treatments for DCIS after thorough explanation of the clinical scenario.

RESULTS

Median age was 55 years old (Range 18 - 87). 692 patients had past history of breast cancer, 279 patients had benign breast conditions, 29 patients had borderline breast lesions. 891 (89.1%) patients opted for standard surgical excision for low-risk DCIS, most of them (N = 757, 85.0%) decided for operative management for DCIS to avoid life-time anxiety of disease progression. Patients of older age and with history of malignant breast conditions are more likely to choose surgical treatment for DCIS (p<0.0001). Of note, 112 (11.2%) patients in the cohort had history of DCIS with excision done, 111 (99.1%) patients would still decide for surgical excision as the treatment of DCIS, only 1 patient expressed the wish for conservative treatment for DCIS.

CONCLUSION

Majority of patients decided for surgical treatment for DCIS despite being offered the condition that conservative treatment could be oncologically safe. Patient anxiety and cost of extensive breast surveillance are two important factors.

Breast cancer distant recurrence lead time interval by detection method in an institutional cohort

BACKGROUND

Lead time, the interval between screen detection and when a disease would have become clinically evident, has been cited to explain longer survival times in mammography detected breast cancer cases (BC).

METHODS

An institutional retrospective cohort study of BC outcomes related to detection method (mammography (MamD) vs. patient (PtD)). Cases were first primary invasive stage I-III BC, age 40-74 years (n = 6603), 1999-2016. Survival time was divided into 1) distant disease-free interval (DDFI) and 2) distant disease-specific survival (DDSS) as two separate time interval outcomes. We measured statistical association between detection method and diagnostic, treatment and outcome variables using bivariate comparisons, Cox proportional hazards analyses and mean comparisons. Outcomes were distant recurrence (n = 422), DDFI and DDSS.

RESULTS

39% of cases were PtD (n = 2566) and 61% were MamD (n = 4037). MamD cases had a higher percentage of Stage I tumors [MamD 69% stage I vs. PtD 31%, p < .001]. Rate of distant recurrence was 11% among PtD BC cases (n = 289) vs. 3% of MamD (n = 133) (p < .001). Order of factor entry into the distant recurrence time interval (DDFI) model was 1) TNM stage (p < .001), 2) HR/HER2 status (p < .001), 3) histologic grade (p = .005) and 4) detection method (p < .001). Unadjusted PtD DDFI mean time was 4.34 years and MamD 5.52 years (p < .001), however when stratified by stage, the most significant factor relative to distant recurrence, there was no significant difference between PtD and MamD BC. Distant disease specific survival time did not differ by detection method.

CONCLUSION

We observed breast cancer distant disease-free interval to be primarily associated with stage at diagnosis and tumor characteristics with less contribution of detection method to the full model. Patient and mammography detected breast cancer mean lead time to distant recurrence differed significantly by detection method for all stages but not significantly within stage with no difference in time from distant recurrence to death. Lead time difference related to detection method appears to be present but may be less influential than other factors in distant disease-free and disease specific survival.

Breast cancer, screening and diagnostic tools: All you need to know

Breast cancer is one of the most frequent malignancies among women worldwide. Methods for screening and diagnosis allow health care professionals to provide personalized treatments that improve the outcome and survival. Scientists and physicians are working side-by-side to develop evidence-based guidelines and equipment to detect cancer earlier. However, the lack of comprehensive interdisciplinary information and understanding between biomedical, medical, and technology professionals makes innovation of new screening and diagnosis tools difficult. This critical review gathers, for the first time, information concerning normal breast and cancer biology, established and emerging methods for screening and diagnosis, staging and grading, molecular and genetic biomarkers. Our purpose is to address key interdisciplinary information about these methods for physicians and scientists. Only the multidisciplinary interaction and communication between scientists, health care professionals, technical experts and patients will lead to the development of better detection tools and methods for an improved screening and early diagnosis.

Evaluation of Adjuvant Treatments for T1 N0 M0 Triple-Negative Breast Cancer

IMPORTANCE

Adjuvant chemotherapy remains the only recommended treatment for patients with triple-negative breast cancer (TNBC). However, the existing evidence is not enough to recommend adjuvant therapies to patients with T1 N0 M0 TNBC.

OBJECTIVE

To evaluate the association of different adjuvant therapies with survival outcome in patients with T1 N0 M0 TNBC stratified by cancer stage and age.

DESIGN, SETTING, AND PARTICIPANTS

Postoperative patients diagnosed as having T1 N0 M0 TNBC between 2010 and 2015 who were enrolled in the Surveillance, Epidemiology, and End Results cancer registry program were included in this population-based cohort study. Data analysis was performed from March 27, 2019, to August 10, 2020.

EXPOSURES

Chemotherapy and radiotherapy.

MAIN OUTCOMES AND MEASURES

Kaplan-Meier curve and univariate and multivariable Cox proportional hazards regression analyses were performed to compare overall survival (OS) and breast cancer-specific survival (BCSS) between the different treatments.

RESULTS

A cohort of 7739 eligible patients (mean [SD] age, 59.5 [12.4] years; all female) were included in the present study. The 5-year OS of the total patients was 91.7% (95% CI, 90.9%-92.5%), and median follow-up was 45 months (95% CI, 44-46 months). Patients aged 70 years and older or with T1a TNBC were more likely to receive adjuvant radiotherapy than chemotherapy. Although any adjuvant therapy could improve OS in T1 N0 M0 TNBC, only chemotherapy was associated with significantly better breast cancer-specific survival (BCSS adjusted hazard ratio: 0.657; 95% CI, 0.460-0.939; P = .02). Adjuvant radiotherapy after breast-conserving surgery was associated with better OS and BCSS in patients aged 70 years and older but not in those younger than 70 years. For patients with T1c BC, chemotherapy after breast-conserving surgery or other surgery was associated with improved OS, whereas only chemotherapy after other surgery was associated with better BCSS.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that adjuvant therapies could improve OS in patients with T1 N0 M0 TNBC, whereas only chemotherapy was associated with better BCSS. Older patients with early-stage TNBC may benefit from adjuvant radiotherapy. Administration of adjuvant therapies to patients with different ages and cancer stages should be discussed carefully, which necessitates guidance from updated guidelines.

Personalized early detection and prevention of breast cancer: ENVISION consensus statement

The European Collaborative on Personalized Early Detection and Prevention of Breast Cancer (ENVISION) brings together several international research consortia working on different aspects of the personalized early detection and prevention of breast cancer. In a consensus conference held in 2019, the members of this network identified research areas requiring development to enable evidence-based personalized interventions that might improve the benefits and reduce the harms of existing breast cancer screening and prevention programmes. The priority areas identified were: 1) breast cancer subtype-specific risk assessment tools applicable to women of all ancestries; 2) intermediate surrogate markers of response to preventive measures; 3) novel non-surgical preventive measures to reduce the incidence of breast cancer of poor prognosis; and 4) hybrid effectiveness-implementation research combined with modelling studies to evaluate the long-term population outcomes of risk-based early detection strategies. The implementation of such programmes would require health-care systems to be open to learning and adapting, the engagement of a diverse range of stakeholders and tailoring to societal norms and values, while also addressing the ethical and legal issues. In this Consensus Statement, we discuss the current state of breast cancer risk prediction, risk-stratified prevention and early detection strategies, and their implementation. Throughout, we highlight priorities for advancing each of these areas.

The Evolution of Our Understanding of the Biology of Cancer Is the Key to Avoiding Overdiagnosis and Overtreatment

There has been a tremendous evolution in our thinking about cancer since the 1880s. Breast cancer is a particularly good example to evaluate the progress that has been made and the new challenges that have arisen due to screening that inadvertently identifies indolent lesions. The degree to which overdiagnosis is a problem depends on the reservoir of indolent disease, the disease heterogeneity, and the fraction of the tumors that have aggressive biology. Cancers span the spectrum of biological behavior, and population-wide screening increases the detection of tumors that may not cause harm within the patient's lifetime or may never metastasize or result in death. Our approach to early detection will be vastly improved if we understand, address, and adjust to tumor heterogeneity. In this article, we use breast cancer as a case study to demonstrate how the approach to biological characterization, diagnostics, and therapeutics can inform our approach to screening, early detection, and prevention. Overdiagnosis can be mitigated by developing diagnostics to identify indolent disease, incorporating biology and risk assessment in screening strategies, changing the pathology rules for tumor classification, and refining the way we classify precancerous lesions. The more the patterns of cancers can be seen across other cancers, the more it is clear that our approach should transcend organ of origin. This will be particularly helpful in advancing the field by changing both our terminology for what is cancer and also by helping us to learn how best to mitigate the risk of the most aggressive cancers.See all articles in this CEBP Focus section, "NCI Early Detection Research Network: Making Cancer Detection Possible."

Artificial Intelligence in plastic surgery: What is it? Where are we now? What is on the horizon?

INTRODUCTION

An increasing quantity of data is required to guide precision medicine and advance future healthcare practices, but current analytical methods often become overwhelmed. Artificial intelligence (AI) provides a promising solution. Plastic surgery is an innovative surgical specialty expected to implement AI into current and future practices. It is important for all plastic surgeons to understand how AI may affect current and future practice, and to recognise its potential limitations.

METHODS

Peer-reviewed published literature and online content were comprehensively reviewed. We report current applications of AI in plastic surgery and possible future applications based on published literature and continuing scientific studies, and detail its potential limitations and ethical considerations.

FINDINGS

Current machine learning models using convolutional neural networks can evaluate breast mammography and differentiate benign and malignant tumours as accurately as specialist doctors, and motion sensor surgical instruments can collate real-time data to advise intraoperative technical adjustments. Centralised big data portals are expected to collate large datasets to accelerate understanding of disease pathogeneses and best practices. Information obtained using computer vision could guide intraoperative surgical decisions in unprecedented detail and semi-autonomous surgical systems guided by AI algorithms may enable improved surgical outcomes in low- and middle-income countries. Surgeons must collaborate with computer scientists to ensure that AI algorithms inform clinically relevant health objectives and are interpretable. Ethical concerns such as systematic biases causing non-representative conclusions for under-represented patient groups, patient confidentiality and the limitations of AI based on the quality of data input suggests that AI will accompany the plastic surgeon, rather than replace them.

[First results of a breast cancer risk assessment and management consultation]

INTRODUCTION

In France, participation in the organized breast cancer screening program remains insufficient. A personalized approach adapted to the risk factors for breast cancer (RBC) should make screening more efficient. A RBC evaluation consultation would therefore make it possible to personalize this screening. Here we report our initial experience.

MATERIAL AND METHOD

This is a prospective study on women who were seen at the RBC evaluation consultation and analyzing: their profile, their risk assessed according to Tyrer Cuzick model (TC)±Mammorisk© (MMR), the existence of an indication of oncogenetic consultation (Eisinger and Manchester score), their satisfaction and the recommended monitoring.

RESULTS

Among the women who had had a TCS and/or MMR evaluation of SCR (n=153), 76 (50%) had a high risk (n=67) or a very high risk (n=9). Almost half (47%) had a possible (15%) or certain (32%) indication to an oncogenetic consultation. Regarding this consultation, 98% of women were satisfied or very satisfied. In total, 60% of women had a change in screening methods.

CONCLUSION

This RBC evaluation consultation satisfies women and for a majority of them, modifies their methods of breast cancer screening.

The role of adjuvant chemotherapy in stage I-III male breast cancer: a SEER-based analysis

Background and aims:

Male breast cancer is an uncommon disease. The benefit of adjuvant chemotherapy in the treatment of male breast cancer patients has not been determined. The aim of this study was to explore the value of adjuvant chemotherapy in men with stage I–III breast cancer, and we hypothesized that some male patients may safely skip adjuvant chemotherapy.

Methods:

Male breast cancer patients between 2010 and 2015 from the Surveillance Epidemiology and End Results database were included. Univariate and multivariate Cox analyses were used to analyse the factors associated with survival. The propensity score matching method was adopted to balance baseline characteristics. Kaplan–Meier curves were used to evaluate the impacts of adjuvant chemotherapy on survival. The primary endpoint was survival.

Results:

We enrolled 514 patients for this study, including 257 patients treated with chemotherapy and 257 patients without. There was a significant difference in overall survival (OS) but not in breast cancer-specific survival (BCSS) between the two groups (p < 0.001 for OS and p = 0.128 for BCSS, respectively). Compared with the non-chemotherapy group, the chemotherapy group had a higher 4-year OS rate (97.5% versus 95.2%, p < 0.001), while 4-year BCSS was similar (98% versus 98.8%, p = 0.128). The chemotherapy group had longer OS than the non-chemotherapy group among HR+, HER2–, tumour size >2 cm, lymph node-positive male breast cancer patients (p < 0.05). Regardless of tumour size, there were no differences in OS or BCSS between the chemotherapy and non-chemotherapy cohorts for lymph node-negative patients (OS: p > 0.05, BCSS: p > 0.05). Adjuvant chemotherapy showed no significant effects on both OS and BCSS in patients with stage I (OS: p = 0.100, BCSS: p = 0.858) and stage IIA breast cancer (OS: p > 0.05, BCSS: p > 0.05).

Conclusion:

For stage I and stage IIA patients, adjuvant chemotherapy could not improve OS and BCSS. Therefore, adjuvant chemotherapy might be skipped for stage I and stage IIA male breast cancer patients.

Prospective Multicenter Study Validate a Prediction Model for Surgery Uptake Among Women with Atypical Breast Lesions

BACKGROUND

Diagnosis of atypical breast lesions (ABLs) leads to unnecessary surgery in 75-90% of women. We have previously developed a model including age, complete radiological target excision after biopsy, and focus size that predicts the probability of cancer at surgery. The present study aimed to validate this model in a prospective multicenter setting.

- METHODS

Women with a recently diagnosed ABL on image-guided biopsy were recruited in 18 centers, before wire-guided localized excisional lumpectomy. Primary outcome was the negative predictive value (NPV) of the model.

RESULTS

The NOMAT model could be used in 287 of the 300 patients included (195 with ADH). At surgery, 12 invasive (all grade 1), and 43 in situ carcinomas were identified (all ABL: 55/287, 19%; ADH only: 49/195, 25%). The area under the receiving operating characteristics curve of the model was 0.64 (95% CI 0.58-0.69) for all ABL, and 0.63 for ADH only (95% CI 0.56-0.70). For the pre-specified threshold of 20% predicted probability of cancer, NPV was 82% (77-87%) for all ABL, and 77% (95% CI 71-83%) for patients with ADH. At a 10% threshold, NPV was 89% (84-94%) for all ABL, and 85% (95% CI 78--92%) for the ADH. At this threshold, 58% of the whole ABL population (and 54% of ADH patients) could have avoided surgery with only 2 missed invasive cancers.

CONCLUSION

The NOMAT model could be useful to avoid unnecessary surgery among women with ABL, including for patients with ADH.

CLINICAL TRIAL REGISTRATION

NCT02523612.

Impalpable breast lesion localisation, a logistical challenge: results of the UK iBRA-NET national practice questionnaire

INTRODUCTION

Breast conserving surgery of impalpable breast lesions requires safe and effective localisation techniques. Wire localisation has traditionally been used, but has limitations. Newer techniques are now being introduced to mitigate this. The iBRA-NET group aims to robustly evaluate these new techniques in well-designed prospective studies. We report the first phase of this evaluation, a survey to establish current practice and service provision of breast localisation techniques in the UK.

METHODS

A national practice questionnaire was designed using 'SurveyMonkey^®' and was circulated to UK breast surgeons via the Association of Breast Surgery and the Mammary Fold. The questionnaire was live from 6th October 2018 to 6th April 2019. Only one response per unit was requested to reflect the unit's practice.

RESULTS

Complete responses were received from 98 breast units across the UK. Wires were the mostly commonly used localisation technique (n = 82) with fewer units using Magseed^® (n = 9), Radioguided Occult Lesion Localisation (n = 5) and Radioiodine Seed Localisation (n = 2). There was significant variation in practice and logistics involved. Frequent delays and theatre overruns were reported in 39 and 16 units, respectively. The median satisfaction score of the current technique was 7 out of 10. The main perceived limitation of existing localisation methods was logistics affecting theatre scheduling and the main barrier to introducing a new technique was cost.

CONCLUSION

Wires are currently the most commonly used localisation technique but are associated with significant logistical issues. Newer techniques may offer a better solution but will need robust evaluation before they are adopted to ensure safety and efficacy.

Identification of Women at High Risk of Breast Cancer Who Need Supplemental Screening

Background Mammography screening reduces breast cancer mortality, but a proportion of breast cancers are missed and are detected at later stages or develop during between-screening intervals. Purpose To develop a risk model based on negative mammograms that identifies women likely to be diagnosed with breast cancer before or at the next screening examination. Materials and Methods This study was based on the prospective screening cohort Karolinska Mammography Project for Risk Prediction of Breast Cancer (KARMA), 2011-2017. An image-based risk model was developed by using the Stratus method and computer-aided detection mammographic features (density, masses, microcalcifications), differences in the left and right breasts, and age. The lifestyle extended model included menopausal status, family history of breast cancer, body mass index, hormone replacement therapy, and use of tobacco and alcohol. The genetic extended model included a polygenic risk score with 313 single nucleotide polymorphisms. Age-adjusted relative risks and tumor subtype specific risks were estimated by using logistic regression, and absolute risks were calculated. Results Of 70 877 participants in the KARMA cohort, 974 incident cancers were sampled from 9376 healthy women (mean age, 54 years ± 10 [standard deviation]). The area under the receiver operating characteristic curve (AUC) for the image-based model was 0.73 (95% confidence interval [CI]: 0.71, 0.74). The AUCs for the lifestyle and genetic extended models were 0.74 (95% CI: 0.72, 0.75) and 0.77 (95% CI: 0.75, 0.79), respectively. There was a relative eightfold difference in risk between women at high risk and those at general risk. High-risk women were more likely to be diagnosed with stage II cancers and with tumors 20 mm or larger and were less likely to have stage I and estrogen receptor-positive tumors. The image-based model was validated in three external cohorts. Conclusion By combining three mammographic features, differences in the left and right breasts, and optionally lifestyle factors and family history and a polygenic risk score, the model identified women at high likelihood of being diagnosed with breast cancer within 2 years of a negative screening examination and in possible need of supplemental screening. © RSNA, 2020 Online supplemental material is available for this article.

Breast Cancer and the Obstetrician-Gynecologist: A Focus on Screening, Risk Assessment and Treatment of Survivors With Genitourinary Syndrome of Menopause

Because of conflicting guidelines, providing appropriate breast cancer screening recommendations to our patients has become challenging. Given the high prevalence of genitourinary syndrome of menopause (GSM) overall, and among breast cancer survivors, and the understandable reluctance of physicians to prescribe effective hormonal treatments to survivors with this condition, addressing the needs of breast cancer survivors with bothersome GSM is both a common and controversial issue. In this review, we detail current breast cancer screening recommendations, breast cancer risk assessment, and management of GSM in breast cancer survivors.

Clinical performance of contrast-enhanced spectral mammography in pre-surgical evaluation of breast malignant lesions in dense breasts: a single center study

PURPOSE

To compare the efficacy of contrast-enhanced spectral mammography, with ultrasound, full field digital mammography and magnetic resonance imaging in detection and size estimation of histologically proven breast tumors.

METHODS

This open-label, single center, prospective study, included 160 dense breast women with at least one suspicious mammary lesion evaluated by ultrasound, full field digital mammography and magnetic resonance imaging in whom a mammary tumor was histologically proven after surgery performed at the European Institute of Oncology between January 2013 and December 2015. Following the complete diagnostic procedure, the patients were further investigated by contrast-enhanced spectral mammography prior to surgery.

RESULTS

Overall, the detection rate of malignant breast lesions (in situ and invasive) was 93.8% (165/176) for contrast-enhanced spectral mammography, 94.4% (168/178) for ultrasound, 85.5 (147/172) for full field digital mammography and 97.7% (173/177) for magnetic resonance imaging. Radiological measurements were concordant with the post-surgical pathological measurements of the invasive tumor (i.e., within 5 mm) in: 64.6% for contrast-enhanced spectral mammography, 62.0% for ultrasound, 45.2% for full field digital mammography (p < 0.0001) and 69.9% for magnetic resonance imaging (p = 0.28); underestimated in: 17.4% for contrast-enhanced spectral mammography, 19.6% for ultrasound, 24.2% for full field digital mammography (p = 0.03) and 6.7% for magnetic resonance imaging (p = 0.0005); and overestimated in: 16.2% for contrast-enhanced spectral mammography, 16.6% for ultrasound, 16.6% for full field digital mammography and 22.7% for magnetic resonance imaging (p = 0.02).

CONCLUSIONS

Our data suggest that contrast-enhanced spectral mammography improves on full field digital mammography and is comparable to ultrasound and magnetic resonance imaging in terms of detection sensitivity and size estimation of malignant lesions in dense breasts.

57% decline in Rhode Island invasive breast cancer mortality between 1987 and 2017: mammography predominates in preventing mortality

BACKGROUND

Controversy exists regarding proportional contributions of mammographic screening versus systemic therapy to declining disease-specific mortality of female invasive breast cancer (IBC) in the United States. Understanding relative contributions may help address allocation of medical resources.

METHODS

A 31-year (1987-2017) review of Rhode Island (RI) Cancer Registry data of female IBC was carried out in a state with high rates of mammographic screening.

RESULTS

Over 31 years in RI, statistically significant improvements occurred at initial diagnosis of IBC: mean and median maximum cancer diameters decreased by 21% and 30% respectively. Despite 1997 introduction of more accurate sentinel lymph node biopsy, the proportion of patients with axillary lymph node metastases (LNM) decreased by 27%. Extent of LNM also decreased as patients with over three node metastases decreased 67%. By 2017, 53% of all patients with LNM had only one. Poorly differentiated cancers decreased 50%. Disease-specific mortality decreased 57%.

DISCUSSION

Improvements in initial presentation of IBC are consistent with most having progressive growth, from cellular origin to palpable mass, the currently accepted biological model. Breast cancers identified earlier at initial diagnosis through screening mammography are characterized by smaller size, fewer axillary LNMs, better grade differentiation, and decreased mortality. Statistical analysis from these improved diagnostic parameters indicate that the majority of mortality decline from invasive breast cancer in RI can be attributed to earlier detection. Thus, mammography predominates in preventing mortality.

Association of Endocrine Therapy With Overall Survival in Women With Small, Hormone Receptor-Positive, ERBB2-Negative Breast Cancer

This cohort study examines the association of overall survival with endocrine therapy to treat hormone receptor–positive, ERBB2-negative breast cancer.

Overdiagnosis and overtreatment; how to deal with too much medicine

The past few decades have seen medical science making rapid strides in the field of diagnostic technologies, thus making it possible to detect some conditions at a very early stage. An unwanted effect of these developments is overdiagnosis which occurs when a true abnormality is discovered, but detection of that abnormality and its treatment does not benefit the patient. Overdiagnosis is encountered as a result cancer screening, in genetic diseases and in some chronic conditions when disease definition is broadened. There is urgent need of development of evidence based decision-making tools for clinicians which will help patients understand the benefits and harms of different screening and treatment methods. And the treating physician has to play a important role to convince the patient that watchful waiting, for some of the lesions may be the best option available in some circumstances.

Impact of Phone-Call and Access-Enhancing Intervention on Mammography Uptake among Primary Care Patients at an Urban Safety-Net Hospital: A Randomized Controlled Study

BACKGROUND

Our urban safety-net hospital (SNH) has very low screening mammogram rates within its primary care clinics. Despite Commission on Cancer (CoC) accreditation, we see ~ 3 × more late-stage breast cancer diagnoses than other CoC sites across the country, and recently showed this to be strongly associated with lack of screening (Ahmadiyeh et al. in J Health Care Poor Underserved, in press, 2020). Here we study whether a two-step intervention (phone calls and assistance scheduling mammograms) increases uptake over usual care.

PATIENTS AND METHODS

Randomized controlled study of 890 women aged 50-65 years who were due for biennial screening mammograms and who were established within one of five primary care clinics at an urban SNH. Each patient in the intervention group was called with overdue status (up to three times, voicemail left if needed) and offered assistance scheduling mammogram appointment. Mammography uptake at 3 and 6 months was analyzed.

RESULTS

Intervention significantly increased uptake compared with usual care at both timepoints (18% versus 6% at 3 months; χ² = 27.597, p < 0.0001; 23% versus 12% at 6 months; χ² = 18.0, p < 0.0001), with scheduling component driving effectiveness. Of those who were successfully contacted, uptake was significantly greater among those who scheduled appointments versus those who did not (47% versus 9%, χ² = 95, p < 0.0001), and uptake was no different between contacted but not scheduled patients and usual care controls.

CONCLUSIONS

Phone call with access-enhancing intervention (facilitating mammogram appointments) increased screening mammogram uptake among primary care patients in an urban safety-net setting and may be applicable to other urban SNHs around the country.

Evaluation of a beneficial effect of adjuvant chemotherapy in patients with stage I triple-negative breast cancer: a population-based study using the SEER 18 database

PURPOSE

To evaluate the effect of adjuvant chemotherapy on improving the prognosis of patients with stage I triple-negative breast cancer (TNBC).

METHODS

TNBC patients diagnosed in the SEER 18 database from 2010 to 2015 were included. Kaplan-Meier plots and log-rank tests were used to compare the differences in breast cancer-specific survival (BCSS) and overall survival (OS) between subgroups of variables. A Cox proportional hazard model was used to determine the prognostic factors affecting BCSS and OS.

RESULTS

A total of 9256 patients were enrolled in this study. Among these patients, 380 died from breast cancer, and 703 died from all causes. Patients who received chemotherapy had significantly better BCSS and OS than those who did not receive chemotherapy for stage T1cN0M0 (BCSS, hazard ratio (HR) = 0.68, 95% confidence interval (CI) 0.51-0.90; OS, HR = 0.54, 95% CI 0.44-0.67) and stage IB (BCSS, HR = 0.39, 95% CI 0.16-0.95; OS, HR = 0.41, 95% CI 0.19-0.87) disease. Patients who received chemotherapy did not have significantly better BCSS or OS than those who did not receive chemotherapy for stage T1aN0M0 or T1bN0M0 disease. The patients who received chemotherapy in the poorly differentiated and undifferentiated groups had better BCSS (HR = 0.68, 95% CI 0.52-0.88) and OS (HR = 0.54, 95% CI 0.44-0.66) than the patients who did not receive chemotherapy.

CONCLUSION

According to current clinical guidelines, patients with stage T1bN0M0 TNBC are probably overtreated. The prognosis of these patients with stage T1aN0M0 or T1bN0M0 disease is good enough that adjuvant chemotherapy cannot improve it further.

Effect of Different Types of Mammography Equipment on Screening Outcomes: A Report by the Alliance for Breast Cancer Screening in Korea

Objective

To investigate the effects of different types of mammography equipment on screening outcomes by comparing the performance of film-screen mammography (FSM), computed radiography mammography (CRM), and digital mammography (DM).

Materials and Methods

We retrospectively enrolled 128756 sets of mammograms from 10 hospitals participating in the Alliance for Breast Cancer Screening in Korea between 2005 and 2010. We compared the diagnostic accuracy of the types of mammography equipment by analyzing the area under the receiver operating characteristic curve (AUC) with a 95% confidence interval (CI); performance indicators, including recall rate, cancer detection rate (CDR), positive predictive value₁ (PPV₁), sensitivity, specificity, and interval cancer rate (ICR); and the types of breast cancer pathology.

Results

The AUCs were 0.898 (95% CI, 0.878–0.919) in DM, 0.860 (0.815–0.905) in FSM, and 0.866 (0.828–0.903) in CRM (p = 0.150). DM showed better performance than FSM and CRM in terms of the recall rate (14.8 vs. 24.8 and 19.8%), CDR (3.4 vs. 2.2 and 2.1 per 1000 examinations), PPV₁ (2.3 vs. 0.9 and 1.1%), and specificity (85.5 vs. 75.3 and 80.3%) (p < 0.001) but not in terms of sensitivity (86.3 vs. 87.4 and 86.3%) and ICR (0.6 vs. 0.4 and 0.4). The proportions of carcinoma in situ (CIS) were 27.5%, 13.6%, and 11.8% for DM, CRM, and FSM, respectively (p = 0.003).

Conclusion

In comparison to FSM and CRM, DM showed better performance in terms of the recall rate, CDR, PPV₁, and specificity, although the AUCs were similar, and more CISs were detected using DM. The application of DM may help to improve the quality of mammography screenings. However, the overdiagnosis issue of CIS using DM should be evaluated.

Is mammography screening beneficial: An individual-based stochastic model for breast cancer incidence and mortality

The benefits of mammography screening have been controversial, with conflicting findings from various studies. We hypothesize that unmeasured heterogeneity in tumor aggressiveness underlies these conflicting results. Based on published data from the Canadian National Breast Screening Study (CNBSS), we develop and parameterize an individual-based mechanistic model for breast cancer incidence and mortality that tracks five stages of breast cancer progression and incorporates the effects of age on breast cancer incidence and all-cause mortality. The model accurately reproduces the reported outcomes of the CNBSS. By varying parameters, we predict that the benefits of mammography depend on the effectiveness of cancer treatment and tumor aggressiveness. In particular, patients with the most rapidly growing or potentially largest tumors have the highest benefit and least harm from the screening, with only a relatively small effect of age. However, the model predicts that confining mammography to populations with a high risk of acquiring breast cancer increases the screening benefit only slightly compared with the full population.

Supplemental breast cancer-screening ultrasonography in women with dense breasts: a systematic review and meta-analysis

Background

Mammography is not effective in detecting breast cancer in dense breasts.

Methods

A search in Medline, Cochrane, EMBASE and Google Scholar databases was conducted from January 1, 1980 to April 10, 2019 to identify women with dense breasts screened by mammography (M) and/or ultrasound (US). Meta-analysis was performed using the random-effect model.

Results

A total of 21 studies were included. The pooled sensitivity values of M alone and M + US in patients were 74% and 96%, while specificity of the two methods were 93% and 87%, respectively. Screening sensitivity was significantly higher in M + US than M alone (risk ratio: M alone vs. M + US = 0.699, P < 0.001), but the slight difference in specificity was statistically significant (risk ratio = 1.060, P = 0.001). Pooled diagnostic performance of follow-up US after initial negative mammography demonstrated a high pooled sensitivity (96%) and specificity (88%). The findings were supported by subgroup analysis stratified by study country, US method and timing of US.

Conclusions

Breast cancer screening by supplemental US among women with dense breasts shows added detection sensitivity compared with M alone. However, US slightly decreased the diagnostic specificity for breast cancer. The cost-effectiveness of supplemental US in detecting malignancy in dense breasts should be considered additionally.

Breast-specific gamma imaging or ultrasonography as adjunct imaging diagnostics in women with mammographically dense breasts

BACKGROUND

Mammography (MMG) shows decreased diagnostic accuracy in dense breast tissue, and thus, ultrasonography (US) and breast-specific gamma imaging (BSGI) have gradually been adopted for women with mammographically dense breasts. However, these two adjunct modalities have not been directly compared in previous studies. Hence, we investigated the adjunctive efficacy of US and BSGI in mammographically dense breasts.

METHODS

This retrospective, comparative study recruited women with mammographically dense breasts. All enrolled women underwent US and BSGI as adjunctive imaging, and the comparative sensitivity, specificity, and diagnostic accuracy of combined MMG plus BSGI versus MMG plus US were evaluated. McNemar's test was used for paired binary data in this comparative analysis.

RESULTS

From April 2013 to April 2016, 364 women with mammographically dense breasts and a final surgical or biopsy pathological diagnosis were recruited, comprising 218 cases of malignant disease (59.9%) and 146 cases of benign disease (40.1%). There was no difference between BSGI and US in enhancing the sensitivity of MMG diagnosis (Se-Difference 3.2%, p = 0.23), but the diagnostic specificity of MMG plus BSGI was superior to that of MMG plus US (Sp-Difference 10.3%, p = 0.003). The area under the ROC curve showed that MMG plus BSGI had better diagnostic accuracy than MMG plus US (0.90 vs. 0.83, p = 0.0019).

CONCLUSIONS

For women with mammographically dense breasts, MMG plus BSGI or US can improve the diagnostic accuracy. In addition, BSGI has high specificity and could reduce invasive biopsies and thus may represent a viable diagnostic imaging alternative for mammographically dense breasts.

KEY POINTS

• Both BSGI and US can be applied as adjunct imaging diagnostics in women with mammographically dense breasts. • The diagnostic accuracy of MMG plus BSGI was higher than that of MMG plus US. • BSGI has the potential to be used as an adjunct diagnostic modality in women with mammographically dense breasts.

LGR5 in breast cancer and ductal carcinoma in situ: a diagnostic and prognostic biomarker and a therapeutic target

BACKGROUND

Novel biomarkers are required to discern between breast tumors that should be targeted for treatment from those that would never become clinically apparent and/or life threatening for patients. Moreover, therapeutics that specifically target breast cancer (BC) cells with tumor-initiating capacity to prevent recurrence are an unmet need. We investigated the clinical importance of LGR5 in BC and ductal carcinoma in situ (DCIS) to explore LGR5 as a biomarker and a therapeutic target.

METHODS

We stained BC (n = 401) and DCIS (n = 119) tissue microarrays with an antibody against LGR5. We examined an LGR5 knockdown ER^- cell line that was orthotopically transplanted and used for in vitro colony assays. We also determined the tumor-initiating role of Lgr5 in lineage-tracing experiments. Lastly, we transplanted ER^- patient-derived xenografts into mice that were subsequently treated with a LGR5 antibody drug conjugate (anti-LGR5-ADC).

RESULTS

LGR5 expression correlated with small tumor size, lower grade, lymph node negativity, and ER-positivity. ER⁺ patients with LGR5^high tumors rarely had recurrence, while high-grade ER^- patients with LGR5^high expression recurred and died due to BC more often. Intriguingly, all the DCIS patients who later died of BC had LGR5-positive tumors. Colony assays and xenograft experiments substantiated a role for LGR5 in ER^- tumor initiation and subsequent growth, which was further validated by lineage-tracing experiments in ER^- /triple-negative BC mouse models. Importantly, by utilizing LGR5^high patient-derived xenografts, we showed that anti-LGR5-ADC should be considered as a therapeutic for high-grade ER^- BC.

CONCLUSION

LGR5 has distinct roles in ER^- vs. ER⁺ BC with potential clinical applicability as a biomarker to identify patients in need of therapy and could serve as a therapeutic target for high-grade ER^- BC.

Current controversies in breast cancer screening

Multiple large-scale, randomized controlled trials throughout the world have demonstrated screening mammography significantly reduces a woman's risk of dying from breast cancer. Despite the known mortality reduction, the perceived harms of mammography are weighed against the known value. Multiple national guidelines have moved away from recommending all women have annual screening mammograms beginning at age 40. Instead, many now encourage women at average risk for developing breast cancer to engage in shared decision-making with their providers, carefully weighing the perceived harms against the known benefits of mammography. These factors should be incorporated into the decision about when to begin and how often to screen. This paradigm shift has been particularly controversial as it relates to women in the 40-49-year age group, considering their incidence of breast cancer and therefore derived benefit of screening is lower, yet the breast cancers that do occur tend to be more aggressive and often require intensive therapy. Thus, debates ensue over the appropriate age at which to begin screening for breast cancer, how often screening should occur, and when to stop.

Epithelial-Mesenchymal Transition Programs and Cancer Stem Cell Phenotypes: Mediators of Breast Cancer Therapy Resistance

Epithelial-mesenchymal transition (EMT) programs play essential functions in normal morphogenesis and organogenesis, including that occurring during mammary gland development and glandular regeneration. Historically, EMT programs were believed to reflect a loss of epithelial gene expression signatures and morphologies that give way to those associated with mesenchymal cells and their enhanced migratory and invasive behaviors. However, accumulating evidence now paints EMT programs as representing a spectrum of phenotypic behaviors that also serve to enhance cell survival, immune tolerance, and perhaps even metastatic dormancy. Equally important, the activation of EMT programs in transformed mammary epithelial cells not only enhances their acquisition of invasive and metastatic behaviors, but also expands their generation of chemoresistant breast cancer stem cells (BCSC). Importantly, the net effect of these events results in the appearance of recurrent metastatic lesions that remain refractory to the armamentarium of chemotherapies and targeted therapeutic agents deployed against advanced stage breast cancers. Here we review the molecular and cellular mechanisms that contribute to the pathophysiology of EMT programs in human breast cancers and how these events impact their "stemness" and acquisition of chemoresistant phenotypes.

Do 21-Gene Recurrence Score Influence Chemotherapy Decisions in T1bN0 Breast Cancer Patients?

Purpose: Hormone receptor (HR)-positive breast cancer patients with tumor size ≤1.0 cm and negative node have favorable outcomes. The 21-gene Recurrence Score (RS) could predict response to chemotherapy for HR+ breast cancer, but its role in T1bN0 disease is challenging.

Methods: T1bN0 breast cancer patients diagnosed between January 2014 and June 2019 with RS results were included and categorized as Low- (RS < 18), Intermediate- (RS 18–30), or High-risk (RS > 30) groups. Univariate and multivariate analysis were used to assess factors associated with RS distribution and chemotherapy recommendation. Chemotherapy decisions change and patient adherence after 21-gene RS testing were also evaluated.

Results: Among 237 patients with T1bN0 tumors, proportions of Low-, Intermediate-, and High-risk RS were 19.8, 63.3, and 16.9%, respectively. Multivariate analysis found that ER expression (P = 0.011), PR expression (P < 0.001), and Ki-67 index (P = 0.001) were independently associated with RS distribution. Adjuvant chemotherapy was recommended for 31.6% of patients, which was more frequently given to patients with higher tumor grade [Odds ratio (OR) = 2.99 for grade II, OR = 59.19 for grade III, P = 0.006], lymph vascular invasion (OR = 8.22, P = 0.032), Luminal-B subtype (OR = 5.68, P < 0.001), and Intermediate-to High-risk RS (OR = 10.01 for Intermediate-risk, OR = 192.42 for High-risk, P < 0.001). Chemotherapy decision change was found in 18.6% of patients, mainly in those with Intermediate- to High-risk RS tumor with the majority from no-chemotherapy to chemotherapy. The treatment compliance rate after the 21-gene RS testing with MDT was 95.4%.

Conclusion: RS category was related to ER, PR, and Ki-67 expression, which was recognized as an independent factor of chemotherapy recommendation in T1bN0 breast cancer. The 21-gene RS testing would lead to a chemotherapy decision change rate of 18.6% as well as a high treatment adherence, which can be applied in T1bN0 patients.

Noninvasive biomarkers for lung cancer diagnosis, where do we stand?

The 2010's saw demonstration of the power of lung cancer screening to reduce mortality. However, with implementation of lung cancer screening comes the challenge of diagnosing millions of lung nodules every year. When compared to other cancers with widespread screening strategies (breast, colorectal, cervical, prostate, and skin), obtaining a lung nodule tissue biopsy to confirm a positive screening test remains associated with higher morbidity and cost. Therefore, non-invasive diagnostic biomarkers may have a unique opportunity in lung cancer to greatly improve the management of patients at risk. This review covers recent advances in the field of liquid biomarkers and computed tomographic imaging features, with special attention to new methods for combination of biomarkers as well as the use of artificial intelligence for the discrimination of benign from malignant nodules.

Breast cancer: are long-term and intermittent endocrine therapies equally effective?

Purpose

In breast cancer (BC), the duration of endocrine adjuvant therapies (AT) has been extended continuously up to 10 years. We present an alternative explanation for the effect, which could enable shorter treatments.

Method

The relevant literature on chemoprevention and (neo-)adjuvant therapy was reviewed. Data for initiation and growth of primary and contralateral BCs and their metastases (MET) were considered. Also, population-based data from the Munich Cancer Registry for MET-free survival, time trends of MET patterns, and survival achieved by improved ATs are used to estimate all events in the long-term follow-up.

Results

Extended ATs (EAT) that continue after 1, 2, or 5 years reduce mortality only slightly. The effect is delayed, occurring more than 5 years after extension. EATs does not affect the prognosis of 1stBCs, they preventively eradicate contralateral 2ndBCs and thus their future life-threatening METs. Because chemoprevention can eradicate BCs from the smallest clusters to almost detectable BCs, ATs can be temporarily suspended without imposing harm. Results equal to EATs can be achieved by short-term ATs of the 1stBC and by repeated neo-ATs targeted at the indefinitely developing 2ndBCs. Considering this potential in de-escalation, a 70–80% reduction of overtreatment seems possible.

Conclusion

Knowledge of initiation and growth of tumors with known effects of neo-ATs suggest that intermittent endocrine ATs may achieve the same results as EATs but with improved quality of life and survival because of fewer side effects and better compliance. The challenge for developments of repeated ATs becomes: how short is short enough.

Electric Fields at Breast Cancer and Cancer Cell Collective Galvanotaxis

Cancer growth interferes with local ionic environments, membrane potentials, and transepithelial potentials, resulting in small electrical changes in the tumor microenvironment. Electrical fields (EFs) have significant effects on cancer cell migration (galvanotaxis/electrotaxis), however, their role as a regulator of cancer progression and metastasis is poorly understood. Here, we employed unique probe systems to characterize the electrical properties of cancer cells and their migratory ability under an EF. Subcutaneous tumors were established from a triple-negative murine breast cancer cell line (4T1), electric currents and potentials of tumors were measured using vibrating probe and glass microelectrodes, respectively. Steady outward and inward currents could be detected at different positions on the tumor surface and magnitudes of the electric currents on the tumor surface strongly correlated with tumor weights. Potential measurements also showed the non-homogeneous intratumor electric potentials. Cancer cell migration was then surveyed in the presence of EFs in vitro. Parental 4T1 cells and metastatic sublines in isolation showed random migration in EFs of physiological strength, whereas cells in monolayer migrated collectively to the anode. Our data contribute to an improved understanding of breast cancer metastasis, providing new evidence in support of an electrical mechanism that promotes this phenomenon.