Association of Screening and Treatment With Breast Cancer Mortality by Molecular Subtype in US Women, 2000-2012

Molecular Mechanism of lncRNAs in Regulation of Breast Cancer Metastasis; a Comprehensive Review

Although the number of breast cancer deaths has decreased, and there have been developments in targeted therapies and combination treatments for the management of metastatic illness, metastatic breast cancer is still the second most common cause of cancer-related deaths in U.S. women. Numerous phases and a vast number of proteins and signaling molecules are involved in the invasion-metastasis cascade. The tumor cells penetrate and enter the blood or lymphatic vessels, and travel to distant organs via the lymphatic or blood vessels. Tumor cells enter cell cycle arrest, adhere to capillary beds in the target organ, and then disseminate throughout the organ's parenchyma, proliferating and enhancing angiogenesis. Each of these processes is regulated by changes in the expression of different genes, in which lncRNAs play a role in this regulation. Transcripts that are longer than 200 nucleotides and do not translate into proteins are called RNAs. LncRNA molecules, whose function depends on their unique molecular structure, play significant roles in controlling the expression of genes at various epigenetic levels, transcription, and so on. LncRNAs have essential functions in regulating the expression of genes linked to cell development in healthy and pathological processes, specialization, programmed cell death, cell division, invasion, DNA damage, and spread to other parts of the body. A number of cancer types have been shown to exhibit aberrant expression of lncRNAs. In this review, we describe the general characteristics, potential molecular mechanisms and targeted therapy of lncRNAs and discuss the emerging functions of lncRNAs in breast cancer.

Mathematical Modeling to Address Questions in Breast Cancer Screening: An Overview of the Breast Cancer Models of the Cancer Intervention and Surveillance Modeling Network

The National Cancer Institute-funded Cancer Intervention and Surveillance Modeling Network (CISNET) breast cancer mathematical models have been increasingly utilized by policymakers to address breast cancer screening policy decisions and influence clinical practice. These well-established and validated models have a successful track record of use in collaborations spanning over 2 decades. While mathematical modeling is a valuable approach to translate short-term screening performance data into long-term breast cancer outcomes, it is inherently complex and requires numerous inputs to approximate the impacts of breast cancer screening. This review article describes the 6 independently developed CISNET breast cancer models, with a particular focus on how they represent breast cancer screening and estimate the contribution of screening to breast cancer mortality reduction and improvements in life expectancy. We also describe differences in structures and assumptions across the models and how variation in model results can highlight areas of uncertainty. Finally, we offer insight into how the results generated by the models can be used to aid decision-making regarding breast cancer screening policy.

Therapeutic Targeting of the Galectin-1/miR-22-3p Axis Regulates Cell Cycle and EMT Depending on the Molecular Subtype of Breast Cancer

Breast cancer is a highly heterogeneous disease; hence, it is crucial to understand its biology and identify new targets for the development of effective treatments. Galectin-1 is known to play an oncogenic role in breast cancer progression. It is known that oncogenic factors can influence cancer progression through interactions with miRNAs. The purpose of this study is to identify the clinical significance and biological role of galectin-1 and miR-22-3p in cancer progression according to the molecular subtype of breast cancer. We analyzed the expression of galectin-1 and miR-22-3p using cancer tissues and the correlation with clinical pathological characteristics. In addition, we investigated the regulation of the cell cycle and EMT processes of cancer progression through the galectin-1/miR-22-3p axis using cell lines of different breast cancer subtypes. miR-22-3p negatively regulates galectin-1 expression and the two molecules have opposite patterns of oncogenic and tumor-suppressive functions, respectively; furthermore, these two molecules are associated with metastasis-free survival. Cell experiments showed that miR-22-3p overexpression and galectin-1 knockdown inhibited the proliferation and invasion of breast cancer cells. Galectin-1 regulates different cancer progression pathways depending on the molecular subtype. In hormone receptor-positive breast cancer cells, galectin-1 knockdown mainly inhibited cell cycle-related substances and induced G0/G1 arrest, whereas in triple-negative breast cancer cells, it suppressed molecules related to the epithelial-mesenchymal transition pathway. In conclusion, the miR-22-3p/galectin-1 axis regulates different cancer metastasis mechanisms depending on the specific molecular subtype of breast cancer, and miR-22-3p/galectin-1 axis modulation may be a novel target for molecular subtype-specific personalized treatment.

Auricular acupressure for insomnia in women with breast cancer: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Breast cancer as the malignant tumor with the highest incidence and mortality rate among the global female population. Insomnia is a common complaint in breast cancer patients, more than one-third (38-47%) of breast cancer patients suffer it. Auricular acupressure (AA), a non-pharmacological therapy, has been used in the studies to intervene in insomnia in breast cancer patients. The objective of this systematic review and meta-analysis is to investigate the efficacy and safety of AA therapy in intervening with insomnia in breast cancer.

METHODS

A systematic literature search was performed for 10 databases up to January of 2024 to identify randomized control trials (RCTs). The methodological quality of RCTs was assessed independently using the Cochrane Handbook for Systematic Reviews of Interventions. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach. Data were screened and extracted independently using predesigned forms. The meta-analysis was conducted using RevMan 5.3 software, P-value < .05 means statistically significant.

RESULTS

This review included 15 studies from 3 different countries with a total of 1125 adult participants. The pooled results showed that AA significantly in improving sleep quality (mean difference [MD] = -3.36, 95% confidence interval [CI]: [-4.65, -2.07], P < .001) and life quality (MD = -7.82, 95% CI: [-14.76, -0.88], P = .03). Based on data from sleep monitoring devices, AA was valuable for improving sleep efficiency (MD = -3.63, 95% CI: [-4.19,-3.07], P = .03) in breast cancer patients. Adverse events were reported in 5 RCTs. Common adverse reactions include auricular skin allergic reaction (10/259, 3.9%), bruising (7/259, 2.7%), pain (3/259, 1.2%), and local pressure ulcers on the auricular points (2/259, 0.8%). The evidence grade was moderate because of the substantial heterogeneity among studies. Heart, Shenmen, and Subcortex were the 3 most numerous auricular points, with a total share of up to 71.70%.

CONCLUSION

This systematic review and meta-analysis demonstrates the efficacy and safety of AA in intervening insomnia in breast cancer patients, providing a basis for the selection of clinical auricular points. However, the high-quality RCTs in existence are not enough, and more rigorous trials are needed to identify the efficacy of AA and insomnia.

Risk factors for interval breast cancer: insights from a decade of a mammography screening program

PURPOSE

Breast cancer remains a major global health issue, with mammography screening programs (MSPs) being critical for early detection to improve survival. Interval breast cancers (IBC) are an important quality criterion and have been linked with increased mortality. We aimed to identify risk factors for IBC diagnoses, based on MSP data.

METHODS

In this retrospective cohort study, we merged data from the Swiss MSP "donna" with data from cancer registries from 2010 to 2019 to categorize cases as IBC or screen-detected breast cancer (SBC). We compared the incidence, tumor characteristics, and survival proportions of women with IBC versus SBC. We used a multivariable Poisson regression with robust errors to identify risk factors for IBC diagnoses.

RESULTS

We identified 1134 breast cancer cases, specifically 251 IBC and 883 SBC. The 7-year survival proportions significantly deviated with 92.9% for women with IBC and 96.4% for women with SBC (p < 0.05). Women with IBC are diagnosed with significantly higher tumor stages (p < 0.05) and have a worse tumor biology in multiple dimensions e.g. larger tumor size or more often triple negative (p < 0.05). Higher breast density (BI-RADS d risk ratio (RR): 3.293), certain age groups (55-59 years RR: 1.345), and a family breast cancer history (RR: 1.299) were identified as significant (p < 0.05) risk factors for IBC diagnoses.

CONCLUSIONS

Women with IBC had lower overall survival proportions than women with SBC, possibly due to higher stages at diagnosis. Increased breast density and a positive family history of breast cancer could encourage MSPs to personalize their screening process (e.g. additional diagnostics).

Design Paper: A Prospective, Multicenter, Single-arm, Phase II Trial of Tailored Axillary Surgery in Patients with Clinically Node-positive Breast Cancer in the Upfront Surgery Setting

Introduction

This prospective, multicenter, single-arm Phase II trial investigates the feasibility and the safety of tailored axillary surgery (TAS) in patients with clinically node-positive breast cancer who are undergoing upfront surgery. The trial aims to establish the criteria for safely omitting axillary lymph node dissection (ALND) in these cases, potentially shifting breast cancer management by minimizing surgical complications and preserving the patients' quality of life (QOL).

Methods

The study includes patients who were diagnosed with invasive breast cancer, particularly those with limited metastatic lymph nodes. The primary objective of this work is to determine the specific combination of clinical and pathological factors that would result in a non-TAS lymph node metastasis proportion of less than 10%. The secondary objectives include assessing the identification rate of the metastatic lymph nodes, the incidence of upper limb lymphedema, and the QOL measures.

Results

The results will identify the patient eligibility criteria for the Phase III TAS trial, potentially allowing the omission of ALND in selected patients. This may lead to reduced surgical complications and better preservation of the QOL of patients with breast cancer.

Conclusions

The trial's outcome will contribute to the development of the criteria for safely omitting ALND in certain patients with clinically node-positive breast cancer. This approach aims to enhance breast cancer management by reducing surgical burden and improving the patient outcomes.jRCTs: 061220113.

AI image analysis as the basis for risk-stratified screening

Artificial intelligence (AI) has emerged as a transformative tool in breast cancer screening, with two distinct applications: computer-aided cancer detection (CAD) and risk prediction. While AI CAD systems are slowly finding its way into clinical practice to assist radiologists or make independent reads, this review focuses on AI risk models, which aim to predict a patient's likelihood of being diagnosed with breast cancer within a few years after negative screening. Unlike AI CAD systems, AI risk models are mainly explored in research settings without widespread clinical adoption. This review synthesizes advances in AI-driven risk prediction models, from traditional imaging biomarkers to cutting-edge deep learning methodologies and multimodal approaches. Contributions by leading researchers are explored with critical appraisal of their methods and findings. Ethical, practical, and clinical challenges in implementing AI models are also discussed, with an emphasis on real-world applications. This review concludes by proposing future directions to optimize the adoption of AI tools in breast cancer screening and improve equity and outcomes for diverse populations.

Screening for breast cancer: a systematic review update to inform the Canadian Task Force on Preventive Health Care guideline

OBJECTIVE

This systematic review update synthesized recent evidence on the benefits and harms of breast cancer screening in women aged ≥ 40 years and aims to inform the Canadian Task Force on Preventive Health Care's (CTFPHC) guideline update.

METHODS

We searched Ovid MEDLINE® ALL, Embase Classic + Embase and Cochrane Central Register of Controlled Trials to update our searches to July 8, 2023. Search results for observational studies were limited to publication dates from 2014 to capture more relevant studies. Screening was performed independently and in duplicate by the review team. To expedite the screening process, machine learning was used to prioritize relevant references. Critical health outcomes, as outlined by the CTFPHC, included breast cancer and all-cause mortality, treatment-related morbidity and overdiagnosis. Randomized controlled trials (RCTs), non/quasi RCTs and observational studies were included. Data extraction and quality assessment were performed by one reviewer and verified by another. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool for RCTs and the Joanna Brigg's Institute (JBI) checklists for non-randomized and observational studies. When deemed appropriate, studies were pooled via random-effects models. The overall certainty of the evidence was assessed following GRADE guidance.

RESULTS

Three new papers reporting on existing RCT trial data and 26 observational studies were included. No new RCTs were identified in this update. No study reported results by ethnicity, race, proportion of study population with dense breasts, or socioeconomic status. For breast cancer mortality, RCT data from the prior review reported a significant relative reduction in the risk of breast cancer mortality with screening mammography for a general population of 15% (RR 0.85 95% CI 0.78 to 0.93). In this review update, the breast cancer mortality relative risk reduction based on RCT data remained the same, and absolute effects by age decade over 10 years were 0.27 fewer deaths per 1000 in those aged 40 to 49; 0.50 fewer deaths per 1000 in those aged 50 to 59; 0.65 fewer deaths per 1000 in those aged 60 to 69; and 0.92 fewer deaths per 1000 in those aged 70 to 74. For observational data, the relative mortality risk reduction ranged from 29 to 62%. Absolute effects from breast cancer mortality over 10 years ranged from 0.79 to 0.94 fewer deaths per 1000 in those aged 40 to 49; 1.45 to 1.72 fewer deaths per 1000 in those aged 50 to 59; 1.89 to 2.24 fewer deaths per 1000 in those aged 60 to 69; and 2.68 to 3.17 fewer deaths per 1000 in those aged 70 to 74. For all-cause mortality, RCT data from the prior review reported a non-significant relative reduction in the risk of all-cause mortality of screening mammography for a general population of 1% (RR 0.99, 95% CI 0.98 to 1.00). In this review update, the absolute effects for all-cause mortality over 10 years by age decade were 0.13 fewer deaths per 1000 in those aged 40 to 49; 0.31 fewer deaths per 1000 in those aged 50 to 59; 0.71 fewer deaths per 1000 in those aged 60 to 69; and 1.41 fewer deaths per 1000 in those aged 70 to 74. No observational data were found for all-cause mortality. For overdiagnosis, this review update found the absolute effects for RCT data (range of follow-up between 9 and 15 years) to be 1.95 more invasive and in situ cancers per 1000, or 1 more invasive cancer per 1000, for those aged 40 to 49 and 1.93 more invasive and in situ cancers per 1000, or 1.18 more invasive cancers per 1000, for those aged 50 to 59. A sensitivity analysis removing high risk of bias studies found 1.57 more invasive and in situ cancers, or 0.49 more invasive cancers, per 1000 for those aged 40 to 49 and 3.95 more invasive and in situ cancers per 1000, or 2.81 more invasive cancers per 1000, in those aged 50 to 59. For observational data, one report (follow-up for 13 years) found 0.34 more invasive and in situ cancers per 1000 in those aged 50 to 69. Overall, the GRADE certainty of evidence was assessed as low or very low, suggesting that the evidence is very uncertain about the effect of screening for breast cancer on the outcomes evaluated in this review.

CONCLUSIONS

This systematic review update did not identify any new trials comparing breast cancer screening to no screening. Although 26 new observational studies were identified, the overall quality of evidence remains generally low or very low. Future research initiatives should prioritize studying screening in higher risk populations such as those from different ages, racial or ethnic groups, with dense breasts or family history.

SYSTEMATIC REVIEW REGISTRATION

Protocol available on the Open Science Framework: https://osf.io/xngsu/.

Survival feature and trend of female breast cancer: A comprehensive review of survival analysis from cancer registration data

To better understand global patterns, chronological changes, and international comparisons of female breast cancer survival, we reviewed published data from population-based cancer registries worldwide. Using PubMed, Embase, Web of Science, SEER, and SinoMed, a comprehensive literature search was conducted for female breast cancer survival from the population-based cancer registries through 31 December 2023. Observed, relative, and net survival rates and their corresponding age-standardized survival rates since the 1990s were collected and further stratified by prognostic factors. The prognosis of female breast cancer patients was favorable, with 5-year relative survival rates above 80 % in most regions. The trend in breast cancer survival showed annual increases in most countries but was accompanied by geographical disparities. The highest age-standardized 5-year relative survival rate was identified in the USA (2010-2014) at 90.2 %, while the lowest was in India (2010-2014) at 66.1 %. Overall, North America and Oceania had the best survival, and, for Europe, survival was worst in Eastern Europe. The survival in some Asian countries was disturbing. Younger age groups had a better prognosis than those aged 75 years and over. The lowest survival rates were observed in patients with distant metastatic and triple-negative breast cancer. Worldwide, there has been a steady improvement in female breast cancer survival. However, the survival gap between developed and developing countries has remained wide over the past 30 years. Differences in age, stage at diagnosis, and molecular subtype may explain some of the disparities, providing evidence for targeted management strategies.

Disparities and Gaps in Breast Cancer Screening for Women Aged 40 to 49 Years

This cross-sectional study analyzes factors associated with overdue or lack of mammogram screening among women aged 40 to 49 years.

Targeted lung cancer screening in the age of immunotherapies and targeted therapies - an economic evaluation for Australia

Background

The cost-effectiveness of different lung cancer screening strategies has been evaluated from an Australian public health system perspective using static models. In addition, the impact of novel therapies, including immunotherapies and targeted therapies, on the cost-effectiveness of lung cancer screening has not yet been evaluated comprehensively. We evaluated the benefits, harms and cost-effectiveness of a targeted national lung screening program in Australia, accounting for the increasing uptake of novel therapies, which informed the lung cancer screening recommendations of the Australian Medical Services Advisory Committee (MSAC).

Methods

Australia-specific data on lung cancer epidemiology, smoking behaviour and care costs were used to adapt the MIcrosimulation SCreening ANalysis (MISCAN)-Lung model. Benefits, harms and cost-effectiveness of different targeted lung cancer screening scenarios were evaluated for individuals born between 1945 and 1969. The scenarios considered various screening age ranges, intervals and eligibility criteria (minimum accumulated smoking history and PLCOm2012 risk thresholds).

Findings

The MSAC-recommended scenario was cost-effective at AUD62,754 per quality-adjusted life-year compared to no screening. This scenario biennially screens current and former smokers (quit ≤10 years ago) who smoked ≥30 pack-years between ages 50 and 70, preventing 62 lung cancer deaths per 100,000 and yielding 8.4 quality-adjusted life-years per prevented lung cancer death. Using novel therapies reduced the incremental costs of screening compared to no-screening by 14.8% but yielded 11.3% fewer incremental quality-adjusted life-years compared to traditional anti-cancer therapies, due to the improved survival yielded by novel therapies. Overall, the cost-effectiveness of screening was better when costs and effects of novel therapies were applied (AUD62,754 vs AUD65,340 per quality-adjusted life-year gained; 4% difference).

Interpretation

Targeted lung cancer screening is more cost-effective when costs and effects of novel therapies are applied, although impacts on cost-effectiveness are likely to be marginal.

Funding

Cancer Australia.

Non-Palpable Breast Cancer: A Targeting Challenge-Comparison of Radio-Guided vs. Wire-Guided Localization Techniques

Background: The incidence of non-palpable breast cancer is increasing due to widespread screening and neo-adjuvant therapies. Among the available tumor localization techniques, radio-guided occult lesion localization (ROLL) has largely replaced wire-guided localization (WGL). The aim of this study was to compare the ROLL and WGL techniques in terms of the effectiveness of isotopic marking of axillary sentinel lymph nodes and to assess patient perspectives along with surgeon and radiologist preferences. Methods: A single-center, prospective, randomized study enrolled 110 patients with non-palpable breast lesions (56 ROLL, 54 WGL). Breast type, tumor volume, location, histological and radiological features, and localization/surgical duration were evaluated in the context of sentinel lymph node marking using isotope (technetium-99m-labeled human serum albumin) and blue dye. Statistical analysis was performed with significance set at p < 0.05 and strong significance at p < 0.01. Results: A single-center, prospective, randomized study enrolled 110 patients with non-palpable breast lesions (56 ROLL, 54 WGL). Breast type, tumor volume, location, histological and radiological features, and localization/surgical duration were evaluated in the context of sentinel lymph node marking using isotope (technetium-99m-labeled human serum albumin) and blue dye. Statistical analysis was performed with significance set at p < 0.05 and strong significance at p < 0.01. Conclusions: While ROLL provided advantages in terms of patient comfort and logistical simplicity, WGL was superior for axillary sentinel lymph node marking, particularly in inner quadrant tumors, suggesting that WGL may be preferred in these cases.

Comprehensive diagnosis of advanced-stage breast cancer: exploring detection methods, molecular subtypes, and demographic influences - A cross-sectional study

BACKGROUND

Brazil faces notable Breast Cancer (BC) mortality despite lower incidence rates versus developed countries. Despite guidelines from medical societies, Brazilian public policy recommends biennial mammographic screening for women aged 50 to 69. This study investigates sociodemographic and clinical factors related to BC detection methods and clinical stage at diagnosis.

METHODS

The authors conducted a cross-sectional study at a São Paulo tertiary hospital. Patients were divided into 'symptomatic' and 'mammographic' detection groups. Bivariate analyses by detection method and clinical stage compared groups' profiles in terms of sociodemographic and clinical characteristics. Poisson regression analyses assessed sociodemographic and molecular subtypes´ influence on "mammographic detection" prevalence and "advanced-stage BC", reporting prevalence ratios and 95 % Confidence Intervals.

RESULTS

The authors studied 1,536 BC patients admitted from January 2016 to December 2017. The "mammographic detection" group had a higher proportion of patients aged 50‒69 years (62.9 % vs. 44.1 %), white race (63.3 % vs. 51.6 %), Catholic religion (58.2 % vs. 51.1 %), and Luminal A subtype (25.2 % vs. 13.2 %) compared to the "symptomatic detection" group. Patients with early-stage disease were more likely to have higher education levels (8.1 % vs. 5.5 %) and be married (39.8 % vs. 46.6 %) compared to those with advanced-stage. Molecular subtypes were significantly associated with the detection method and stage. The prevalence of advanced-stage disease in "mammographic" (n=313) and "symptomatic" (n=1191) groups was 18.5 % and 55 %, respectively . Mammographic detection significantly reduced advanced-stage BC prevalence (PR = 0.40, 95 % CI 0.31‒0.51).

CONCLUSION

Mammographic detection reduces advanced-stage breast cancer prevalence in Brazil, emphasizing the importance of regular screenings, especially among at-risk sociodemographic groups. Enhancing mammographic screening accessibility, lowering the starting age to 40, and extending coverage to include annual mammograms can significantly lower breast cancer mortality in Brazil, benefiting public health and patient outcomes.

Targeted therapy approaches for epithelial-mesenchymal transition in triple negative breast cancer

Triple-negative breast cancer (TNBC) is distinguished by negative expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2), making it an aggressive subtype of breast cancer and contributes to 15-20% of the total incidence. TNBC is a diverse disease with various genetic variations and molecular subtypes. The tumor microenvironment involves multiple cells, including immune cells, fibroblast cells, extracellular matrix (ECM), and blood vessels that constantly interact with tumor cells and influence each other. The ECM undergoes significant structural changes, leading to induced cell proliferation, migration, adhesion, invasion, and epithelial-to-mesenchymal transition (EMT). The involvement of EMT in the occurrence and development of tumors through invasion and metastasis in TNBC has been a matter of concern. Therefore, EMT markers could be prognostic predictors and potential therapeutic targets in TNBC. Chemotherapy has been one of the primary options for treating patients with TNBC, but its efficacy against TNBC is still limited. Targeted therapy is a critical emerging option with enhanced efficacy and less adverse effects on patients. Various targeted therapy approaches have been developed based on the specific molecules and the signaling pathways involved in TNBC. These include inhibitors of signaling pathways such as TGF-β, Wnt/β-catenin, Notch, TNF-α/NF-κB and EGFR, as well as immune checkpoint inhibitors, such as pembrolizumab, 2laparib, and talazoparib have been widely explored. This article reviews recent developments in EMT in TNBC invasion and metastasis and potential targeted therapy strategies.

Breast Cancer Screening Using Mammography, Digital Breast Tomosynthesis, and Magnetic Resonance Imaging by Breast Density

Importance

Information on long-term benefits and harms of screening with digital breast tomosynthesis (DBT) with or without supplemental breast magnetic resonance imaging (MRI) is needed for clinical and policy discussions, particularly for patients with dense breasts.

Objective

To project long-term population-based outcomes for breast cancer mammography screening strategies (DBT or digital mammography) with or without supplemental MRI by breast density.

Design, Setting, and Participants

Collaborative modeling using 3 Cancer Intervention and Surveillance Modeling Network (CISNET) breast cancer simulation models informed by US Breast Cancer Surveillance Consortium data. Simulated women born in 1980 with average breast cancer risk were included. Modeling analyses were conducted from January 2020 to December 2023.

Intervention

Annual or biennial mammography screening with or without supplemental MRI by breast density starting at ages 40, 45, or 50 years through age 74 years.

Main outcomes and Measures

Lifetime breast cancer deaths averted, false-positive recall and false-positive biopsy recommendations per 1000 simulated women followed-up from age 40 years to death summarized as means and ranges across models.

Results

Biennial DBT screening for all simulated women started at age 50 vs 40 years averted 7.4 vs 8.5 breast cancer deaths, respectively, and led to 884 vs 1392 false-positive recalls and 151 vs 221 false-positive biopsy recommendations, respectively. Biennial digital mammography had similar deaths averted and slightly more false-positive test results than DBT screening. Adding MRI for women with extremely dense breasts to biennial DBT screening for women aged 50 to 74 years increased deaths averted (7.6 vs 7.4), false-positive recalls (919 vs 884), and false-positive biopsy recommendations (180 vs 151). Extending supplemental MRI to women with heterogeneously or extremely dense breasts further increased deaths averted (8.0 vs 7.4), false-positive recalls (1088 vs 884), and false-positive biopsy recommendations (343 vs 151). The same strategy for women aged 40 to 74 years averted 9.5 deaths but led to 1850 false-positive recalls and 628 false-positive biopsy recommendations. Annual screening modestly increased estimated deaths averted but markedly increased estimated false-positive results.

Conclusions and relevance

In this model-based comparative effectiveness analysis, supplemental MRI for women with dense breasts added to DBT screening led to greater benefits and increased harms. The balance of this trade-off for supplemental MRI use was more favorable when MRI was targeted to women with extremely dense breasts who comprise approximately 10% of the population.

Breast cancer incidence and stage at diagnosis in the six US-Affiliated Pacific Islands

BACKGROUND

Breast cancer is the most common cancer diagnosed among women globally and in the United States (US); however, its incidence in the six US-Affiliated Pacific Islands (USAPI) remains less characterized.

METHODS

We analyzed data from a population-based cancer registry using different population estimates to calculate incidence rates for breast cancer among women aged >20 years in the USAPI. Rate ratios and 95 % confidence intervals (CI) were calculated to compare incidence rates between the USAPI and the US (50 states and the District of Columbia).

RESULTS

From 2007-2020, 1118 new cases of breast cancer were diagnosed in the USAPI, with 66.3 % (n = 741) of cases reported in Guam. Age-standardized incidence rates ranged from 66.4 to 68.7 per 100,000 women in USAPI and 101.1-110.5 per 100,000 women in Guam. Compared to the US, incidence rates were lower in USAPI, with rate ratios ranging from 0.38 (95 % CI: 0.36, 0.40) to 0.39 (95 % CI: 0.37, 0.42). The proportion of late-stage cancer was significantly higher in the USAPI (48.7 %) than in the US (34.0 %), particularly in the Federated States of Micronesia (78.7 %) and Palau (73.1 %).

CONCLUSIONS

Breast cancer incidence rates were lower in the USAPI than in the US; however, late-stage diagnoses were disproportionately higher. Low incidence and late-stage cancers may signal challenges in screening, cancer surveillance, and health care access and resources. Expanding access to timely breast cancer screening, diagnosis, and treatment could reduce the proportion of late-stage cancers and improve survival in the USAPI.

Improving lesion volume measurements on digital mammograms

Lesion volume is an important predictor for prognosis in breast cancer. However, it is currently impossible to compute lesion volumes accurately from digital mammography data, which is the most popular and readily available imaging modality for breast cancer. We make a step towards a more accurate lesion volume measurement on digital mammograms by developing a model that allows to estimate lesion volumes on processed mammogram. Processed mammograms are the images routinely used by radiologists in clinical practice as well as in breast cancer screening and are available in medical centers. Processed mammograms are obtained from raw mammograms, which are the X-ray data coming directly from the scanner, by applying certain vendor-specific non-linear transformations. At the core of our volume estimation method is a physics-based algorithm for measuring lesion volumes on raw mammograms. We subsequently extend this algorithm to processed mammograms via a deep learning image-to-image translation model that produces synthetic raw mammograms from processed mammograms in a multi-vendor setting. We assess the reliability and validity of our method using a dataset of 1778 mammograms with an annotated mass. Firstly, we investigate the correlations between lesion volumes computed from mediolateral oblique and craniocaudal views, with a resulting Pearson correlation of 0.93 [95% confidence interval (CI) 0.92 - 0.93]. Secondly, we compare the resulting lesion volumes from true and synthetic raw data, with a resulting Pearson correlation of 0.998 [95%CI 0.998 - 0.998] . Finally, for a subset of 100 mammograms with a malignant mass and concurrent MRI examination available, we analyze the agreement between lesion volume on mammography and MRI, resulting in an intraclass correlation coefficient of 0.81 [95%CI 0.73 - 0.87] for consistency and 0.78 [95%CI 0.66 - 0.86] for absolute agreement. In conclusion, we developed an algorithm to measure mammographic lesion volume that reached excellent reliability and good validity, when using MRI as ground truth. The algorithm may play a role in lesion characterization and breast cancer prognostication on mammograms.

The prognostic potential of mammographic growth rate of invasive breast cancer in the Nijmegen breast cancer screening cohort

OBJECTIVES

Insight into the aggressiveness of potential breast cancers found in screening may optimize recall decisions. Specific growth rate (SGR), measured on mammograms, may provide valuable prognostic information. This study addresses the association of SGR with prognostic factors and overall survival in patients with invasive carcinoma of no special type (NST) from a screened population.

METHODS

In this historic cohort study, 293 women with NST were identified from all participants in the Nijmegen screening program (2003-2007). Information on clinicopathological factors was retrieved from patient files and follow-up on vital status through municipalities. On consecutive mammograms, tumor volumes were estimated. After comparing five growth functions, SGR was calculated using the best-fitting function. Regression and multivariable survival analyses described associations between SGR and prognostic factors as well as overall survival.

RESULTS

Each one standard deviation increase in SGR was associated with an increase in the Nottingham prognostic index by 0.34 [95% confidence interval (CI): 0.21-0.46]. Each one standard deviation increase in SGR increased the odds of a tumor with an unfavorable subtype (based on histologic grade and hormone receptors; odds ratio 2.14 [95% CI: 1.45-3.15]) and increased the odds of diagnosis as an interval cancer (versus screen-detected; odds ratio 1.57 [95% CI: 1.20-2.06]). After a median of 12.4 years of follow-up, 78 deaths occurred. SGR was not associated with overall survival (hazard ratio 1.12 [95% CI: 0.87-1.43]).

CONCLUSIONS

SGR may indicate prognostically relevant differences in tumor aggressiveness if serial mammograms are available. A potential association with cause-specific survival could not be determined and is of interest for future research.

Enhancing Post-Mastectomy Care: Telehealth's Impact on Breast Reconstruction Accessibility for Breast Cancer Patients

OBJECTIVE

To examine how the recent sharp rise in telemedicine has impacted trends in accessibility of breast reconstruction (BR).

PATIENTS AND METHODS

A retrospective study reviewed patients who underwent a total mastectomy at our institution from 1 August 2016 to 31 January 2022. By comparing cohorts before and during the widespread implementation of telemedicine, we assessed telehealth's impact on healthcare accessibility, measured by distance from patients' residences to our institution.

RESULTS

A total of 359 patients were included in this study. Of those, 176 received total mastectomy prior to the availability of telemedicine, and 183 in the subsequent period. There were similar baseline characteristics among patients undergoing mastectomy, including distance from place of residence to hospital (p = 0.67). The same proportion elected to receive BR between groups (p = 0.22). Those declining BR traveled similar distances as those electing the procedure, both before the era of widespread telemedicine adoption (40.3 and 35.6 miles, p = 0.56) and during the height of telemedicine use (22.3 and 61.3 miles, p = 0.26). When tracking follow-up care, significantly more patients during the pandemic pursued at least one follow-up visit with their original surgical team, indicative of the increased utilization of telehealth services.

CONCLUSIONS

While the rate of BR remained unchanged during the pandemic, our findings reveal significant shifts in healthcare utilization, highly attributed to the surge in telehealth adoption. This suggests a transformative impact on breast cancer care, emphasizing the need for continued exploration of telemedicine's role in enhancing accessibility and patient follow-up in the post-pandemic era.

Receptor subtype and outcome of breast cancer - Single-center experience from North India

AIMS/OBJECTIVES

In resource-limited settings, data regarding the impact of molecular/receptor subtypes on breast cancer (BC) are sparse. In this single-center retrospective study from north India, we analyze the outcomes of various molecular subtypes of BC.

MATERIALS AND METHODS

Females with biopsy-proven BC who were treated at our State Cancer Institute from 2014-2018 were included. Data regarding clinicopathological parameters and follow-up details were evaluated. For data analysis, cancers were categorized into 4 subtypes: HR+HER2-, HR+HER2+, HR-HER2+, and HR-HER2-.

RESULTS

Among 944 patients included, HR+HER2- (49.1%) and HR+HER2+ (13.1%) were the most and least common subtypes, respectively. The receptor subtype significantly impacted overall survival (OS). HR+HER2- cancers had the best outcomes while HR-HER2- cancers fared worst (3-yr OS of 94.3% and 69.1%, respectively). On subgroup analysis, the molecular subtype continued to significantly impact OS in patients with tumor grades II and III, disease stages II and III, and age groups of <40 and 40-60 years, respectively (HR-HER2- cancers had the lowest cumulative survival in each subgroup). In patients with metastatic BC, all molecular subtypes except HR+HER2- had a dismal prognosis.

CONCLUSIONS

Overall and across various subgroups, patients with triple-negative BC had the poorest outcomes. Ensuring optimal treatment utilization including affordable access to personalized tailored therapy is the need of the hour to improve long-term outcomes in these patients.

Breast Cancer Method of Detection: 5-Year Outcomes Across a Multisite Health Care Enterprise

PURPOSE

To investigate the feasibility and accuracy of radiologists categorizing the method of detection (MOD) when performing image-guided breast biopsies.

METHODS

This retrospective, observational study was conducted across a health care enterprise that provides breast imaging services at 18 imaging sites across four US states. Radiologists used standardized templates to categorize the MOD, defined as the first test, sign, or symptom that triggered the subsequent workup and recommendation for biopsy. All image-guided breast biopsies since the implementation of the MOD-inclusive standardized template-from October 31, 2017 to July 6, 2023-were extracted. A random sample of biopsy reports was manually reviewed to evaluate the accuracy of MOD categorization.

RESULTS

A total of 29,999 biopsies were analyzed. MOD was reported in 29,423 biopsies (98.1%) at a sustained rate that improved over time. The 10 MOD categories in this study included the following: 15,184 mammograms (51.6%); 4,561 MRIs (15.5%); 3,473 ultrasounds (11.8%); 2,382 self-examinations (8.1%); 2,073 tomosynthesis studies (7.0%); 432 clinical examinations (1.5%); 421 molecular breast imaging studies (1.4%); 357 other studies (1.2%); 338 contrast-enhanced digital mammograms (1.1%); and 202 PET studies (0.7%). Original assignments of the MOD agreed with author assignments in 87% of manually reviewed biopsies (n = 100, 95% confidence interval: [80.4%, 93.6%]).

CONCLUSIONS

This study demonstrates that US radiologists can consistently and accurately categorize the MOD over an extended time across a health care enterprise.

Collaborative Modeling to Compare Different Breast Cancer Screening Strategies: A Decision Analysis for the US Preventive Services Task Force

Importance

The effects of breast cancer incidence changes and advances in screening and treatment on outcomes of different screening strategies are not well known.

Objective

To estimate outcomes of various mammography screening strategies.

Design, Setting, and Population

Comparison of outcomes using 6 Cancer Intervention and Surveillance Modeling Network (CISNET) models and national data on breast cancer incidence, mammography performance, treatment effects, and other-cause mortality in US women without previous cancer diagnoses.

Exposures

Thirty-six screening strategies with varying start ages (40, 45, 50 years) and stop ages (74, 79 years) with digital mammography or digital breast tomosynthesis (DBT) annually, biennially, or a combination of intervals. Strategies were evaluated for all women and for Black women, assuming 100% screening adherence and "real-world" treatment.

Main Outcomes and Measures

Estimated lifetime benefits (breast cancer deaths averted, percent reduction in breast cancer mortality, life-years gained), harms (false-positive recalls, benign biopsies, overdiagnosis), and number of mammograms per 1000 women.

Results

Biennial screening with DBT starting at age 40, 45, or 50 years until age 74 years averted a median of 8.2, 7.5, or 6.7 breast cancer deaths per 1000 women screened, respectively, vs no screening. Biennial DBT screening at age 40 to 74 years (vs no screening) was associated with a 30.0% breast cancer mortality reduction, 1376 false-positive recalls, and 14 overdiagnosed cases per 1000 women screened. Digital mammography screening benefits were similar to those for DBT but had more false-positive recalls. Annual screening increased benefits but resulted in more false-positive recalls and overdiagnosed cases. Benefit-to-harm ratios of continuing screening until age 79 years were similar or superior to stopping at age 74. In all strategies, women with higher-than-average breast cancer risk, higher breast density, and lower comorbidity level experienced greater screening benefits than other groups. Annual screening of Black women from age 40 to 49 years with biennial screening thereafter reduced breast cancer mortality disparities while maintaining similar benefit-to-harm trade-offs as for all women.

Conclusions

This modeling analysis suggests that biennial mammography screening starting at age 40 years reduces breast cancer mortality and increases life-years gained per mammogram. More intensive screening for women with greater risk of breast cancer diagnosis or death can maintain similar benefit-to-harm trade-offs and reduce mortality disparities.

Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement

Importance

Among all US women, breast cancer is the second most common cancer and the second most common cause of cancer death. In 2023, an estimated 43 170 women died of breast cancer. Non-Hispanic White women have the highest incidence of breast cancer and non-Hispanic Black women have the highest mortality rate.

Objective

The USPSTF commissioned a systematic review to evaluate the comparative effectiveness of different mammography-based breast cancer screening strategies by age to start and stop screening, screening interval, modality, use of supplemental imaging, or personalization of screening for breast cancer on the incidence of and progression to advanced breast cancer, breast cancer morbidity, and breast cancer-specific or all-cause mortality, and collaborative modeling studies to complement the evidence from the review.

Population

Cisgender women and all other persons assigned female at birth aged 40 years or older at average risk of breast cancer.

Evidence Assessment

The USPSTF concludes with moderate certainty that biennial screening mammography in women aged 40 to 74 years has a moderate net benefit. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of screening mammography in women 75 years or older and the balance of benefits and harms of supplemental screening for breast cancer with breast ultrasound or magnetic resonance imaging (MRI), regardless of breast density.

Recommendation

The USPSTF recommends biennial screening mammography for women aged 40 to 74 years. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women 75 years or older. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasonography or MRI in women identified to have dense breasts on an otherwise negative screening mammogram. (I statement).

Contrast-Enhanced Mammography Radiomics Analysis for Preoperative Prediction of Breast Cancer Molecular Subtypes

BACKGROUND

Predicting breast cancer molecular subtypes can help guide individualised clinical treatment of patients who need the rational preoperative treatment. This study aimed to investigate the efficacy of preoperative prediction of breast cancer molecular subtypes by contrast-enhanced mammography (CEM) radiomic features.

METHODS

This retrospective two-centre study included women with breast cancer who underwent CEM preoperatively between August 2016 and May 2022. We included 356 patients with 386 lesions, which were grouped into training (n = 162), internal test (n = 160) and external test sets (n = 64). Radiomics features were extracted from low-energy (LE) images and recombined (RC) images and selected. Three dichotomous tasks were established according to postoperative immunohistochemical results: Luminal vs. non-Luminal, human epidermal growth factor receptor (HER2)-enriched vs. non-HER2-enriched, and triple-negative breast cancer (TNBC) vs. non-TNBC. For each dichotomous task, the LE, RC, and LE+RC radiomics models were built by the support vector machine classifier. The prediction performance of the models was assessed by the area under the receiver operating characteristic curve (AUC). Then, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the models. DeLong's test was utilised to compare the AUCs.

RESULTS

Radiomics models based on CEM are valuable for predicting breast cancer molecular subtypes. The LE+RC model achieved the best performance in the test set. The LE+RC model predicted Luminal, HER2-enriched, and TNBC subtypes with AUCs of 0.93, 0.89, and 0.87 in the internal test set and 0.82, 0.83, and 0.69 in the external test set, respectively. In addition, the LE model performed more satisfactorily than the RC model.

CONCLUSION

CEM radiomics features can effectively predict breast cancer molecular subtypes preoperatively, and the LE+RC model has the best predictive performance.

Circulating tumor DNA (ctDNA): can it be used as a pan-cancer early detection test?

Circulating tumor DNA (ctDNA, DNA shed by cancer cells) is emerging as one of the most transformative cancer biomarkers discovered to-date. Although potentially useful at all the phases of cancer detection and patient management, one of its most exciting possibilities is as a relatively noninvasive pan-cancer screening test. Preliminary findings with ctDNA tests such as Galleri or CancerSEEK suggest that they have high specificity (> 99.0%) for malignancy. Their sensitivity varies depending on the type of cancer and stage of disease but it is generally low in patients with stage I disease. A major advantage of ctDNA over existing screening strategies is the potential ability to detect multiple cancer types in a single test. A limitation of most studies published to-date is that they are predominantly case-control investigations that were carried out in patients with a previous diagnosis of malignancy and that used apparently healthy subjects as controls. Consequently, the reported sensitivities, specificities and positive predictive values might be lower if the tests are used for screening in asymptomatic populations, that is, in the population where these tests are likely be employed. To demonstrate clinical utility in an asymptomatic population, these tests must be shown to reduce cancer mortality without causing excessive overdiagnosis in a large randomized prospective randomized trial. Such trials are currently ongoing for Galleri and CancerSEEK.

Breast cancer patients enrolled in the Swiss mammography screening program "donna" demonstrate prolonged survival

STUDY GOAL

We compared the survival rates of women with breast cancer (BC) detected within versus outside the mammography screening program (MSP) "donna".

METHODS

We merged data from the MSP with the data from corresponding cancer registries to categorize BC cases as within MSP (screen-detected and interval carcinomas) and outside the MSP. We analyzed the tumor stage distribution, tumor characteristics and the survival of the women. We further estimated hazard ratios using Cox-regressions to account for different characteristics between groups and corrected the survival rates for lead-time bias.

RESULTS

We identified 1057 invasive (ICD-10: C50) and in-situ (D05) BC cases within the MSP and 1501 outside the MSP between 2010 and 2019 in the Swiss cantons of St. Gallen and Grisons. BC within the MSP had a higher share of stage I carcinoma (46.5% vs. 33.0%; p < 0.01), a smaller (mean) tumor size (19.1 mm vs. 24.9 mm, p < 0.01), and fewer recurrences and metastases in the follow-up period (6.7% vs. 15.6%, p < 0.01). The 10-year survival rates were 91.4% for women within and 72.1% for women outside the MSP (p < 0.05). Survival difference persisted but decreased when women within the same tumor stage were compared. Lead-time corrected hazard ratios for the MSP accounted for age, tumor size and Ki-67 proliferation index were 0.550 (95% CI 0.389, 0.778; p < 0.01) for overall survival and 0.469 (95% CI 0.294, 0.749; p < 0.01) for BC related survival.

CONCLUSION

Women participating in the "donna" MSP had a significantly higher overall and BC related survival rate than women outside the program. Detection of BC at an earlier tumor stage only partially explains the observed differences.

Artificial intelligence in screening and diagnosis of surgical diseases: A narrative review

Artificial intelligence (AI) is playing an increasing role in several fields of medicine. It is also gaining popularity among surgeons as a valuable screening and diagnostic tool for many conditions such as benign and malignant colorectal, gastric, thyroid, parathyroid, and breast disorders. In the literature, there is no review that groups together the various application domains of AI when it comes to the screening and diagnosis of main surgical diseases. The aim of this review is to describe the use of AI in these settings. We performed a literature review by searching PubMed, Web of Science, Scopus, and Embase for all studies investigating the role of AI in the surgical setting, published between January 01, 2000, and June 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly enhance the screening efficiency, clinical ability, and diagnostic accuracy for several surgical conditions. Some of the future advantages of this technology include implementing, speeding up, and improving the automaticity with which AI recognizes, differentiates, and classifies the various conditions.

A Novel Inhibitor of Poly(-ibose) Polymerase-1 Inhibits Proliferation of a BRCA-Deficient Breast Cancer Cell Line the DNA amage-ctivated cGAS-STING Pathway

Loss-of-function mutations in the Breast Cancer Susceptibility Gene (BRCA1 and BRCA2) are often detected in patients with breast cancer. Poly(ADP-ribose) polymerase-1 (PARP1) plays a key role in the repair of DNA strand breaks, and PARP inhibitors have been shown to induce highly selective killing of BRCA1/2-deficient tumor cells, a mechanism termed synthetic lethality. In our previous study, a novel PARP1 inhibitor─(E)-2-(2,3-dibromo-4,5-dimethoxybenzylidene)-N-(4-fluorophenyl) hydrazine-1-carbothioamide (4F-DDC)─was synthesized, which significantly inhibited PARP1 activity with an IC50 value of 82 ± 9 nM. The current study aimed to explore the mechanism(s) underlying the antitumor activity of 4F-DDC under in vivo and in vitro conditions. 4F-DDC was found to selectively inhibit the proliferation of BRCA mutant cells, with highly potent effects on HCC-1937 (BRCA1-/-) cells. Furthermore, 4F-DDC was found to induce apoptosis and G2/M cell cycle arrest in HCC-1937 cells. Interestingly, immunofluorescence and Western blot results showed that 4F-DDC induced DNA double strand breaks and further activated the cGAS-STING pathway in HCC-1937 cells. In vivo analysis results revealed that 4F-DDC inhibited the growth of HCC-1937-derived tumor xenografts, possibly via the induction of DNA damage and activation of the cGAS-STING pathway. In summary, the current study provides a new perspective on the antitumor mechanism of PARP inhibitors and showcases the therapeutic potential of 4F-DDC in the treatment of breast cancer.

Exploring long-term breast cancer survivors' care trajectories using dynamic time warping-based unsupervised clustering

OBJECTIVES

Long-term breast cancer survivors (BCS) constitute a complex group of patients, whose number is estimated to continue rising, such that, a dedicated long-term clinical follow-up is necessary.

MATERIALS AND METHODS

A dynamic time warping-based unsupervised clustering methodology is presented in this article for the identification of temporal patterns in the care trajectories of 6214 female BCS of a large longitudinal retrospective cohort of Spain. The extracted care-transition patterns are graphically represented using directed network diagrams with aggregated patient and time information. A control group consisting of 12 412 females without breast cancer is also used for comparison.

RESULTS

The use of radiology and hospital admission are explored as patterns of special interest. In the generated networks, a more intense and complex use of certain healthcare services (eg, radiology, outpatient care, hospital admission) is shown and quantified for the BCS. Higher mortality rates and numbers of comorbidities are observed in various transitions and compared with non-breast cancer. It is also demonstrated how a wealth of patient and time information can be revealed from individual service transitions.

DISCUSSION

The presented methodology permits the identification and descriptive visualization of temporal patterns of the usage of healthcare services by the BCS, that otherwise would remain hidden in the trajectories.

CONCLUSION

The results could provide the basis for better understanding the BCS' circulation through the health system, with a view to more efficiently predicting their forthcoming needs and thus designing more effective personalized survivorship care plans.

Identification of a Group of Therapeutic Targets and Prognostic Biomarker for Triple Negative Breast Cancer

INTRODUCTION

Triple-negative breast cancer (TNBC) is a highly heterogeneous disease. Mining differentially expressed genes of TNBC is helpful to explore new therapeutic targets. This study aimed to investigate diagnostic biomarker genes in TNBC compared to normal tissue. Additionally, we explored the functions and prognostic value of these key genes as well as potential targeted drugs that could affect these genes.

METHODS

Differential gene expression analysis was conducted using the R software with data from the Gene Expression Omnibus (GEO) database. Then, the identified differentially expressed genes (DEGs) were used to construct a protein-protein interaction (PPI) network using the Search Tool for the Retrieval of Interacting Genes (STRING) database and Cytoscape software. The mRNA expression levels of key genes were analyzed using the UALCAN database with data from The Cancer Genome Atlas (TCGA). Enrichment and survival analyses were performed using R software. In addition, potential compounds showing sensitivity to key genes were identified by gene set cancer analysis (GSCA).

RESULTS

Compared with normal tissues, a total of 203 DEGs were upregulated in TNBC. These DEGs participated in various biological processes including nuclear division, microtubule binding, cell cycle, and the p53 signaling pathway. Through the PPI network analysis, ten key genes were identified, among which four genes showed significant correlation with poor progression-free interval (PFI) in patients with TNBC. Moreover, the four survival-related genes were found to act as sensitive therapeutic targets.

CONCLUSION

The identified four key genes were considered new biomarkers for diagnosis and prognosis and also potential therapeutic targets for TNBC.

Method of primary breast cancer detection and the disease-free interval, adjusting for lead time

BACKGROUND

Little is known about the impact of screen-detected breast cancer compared with clinically detected breast cancer on the disease-free interval (ie, free from locoregional recurrences, distant metastasis, contralateral breast cancer). Moreover, it is thought that most studies overestimate the beneficial effect of screening, as they do not adjust for lead time. We investigated the association between method of breast cancer detection and disease-free interval, taking lead time into account.

METHODS

Women aged 50-76 years, diagnosed with breast cancer between 2005 and 2008 were selected from the Netherlands Cancer Registry. Women diagnosed in 2005 were divided into screen-detected and clinically detected cancer and had a follow-up of 10 years (2005 cohort). Women diagnosed in 2006-2008 were divided into screen-detected, interval, and nonscreen-related cancer and had a follow-up of 5 years (2006-2008 cohort). A previously published method was used to adjust for lead time. Analyses were repeated correcting for confounding variables instead of lead time.

RESULTS

The 2005 cohort included 6215 women. Women with screen-detected cancer had an improved disease-free interval compared with women with clinically detected cancer (hazard ratio [HR] = 0.77, 95% confidence interval [CI] = 0.68 to 0.87). The 2006-2008 cohort included 15 176 women. Women with screen-detected or interval cancer had an improved disease-free interval compared with women with nonscreen-related cancer (HR = 0.76, 95% CI = 0.66 to 0.88; HR = 0.88, 95% CI = 0.78 to 0.99, respectively). Correcting for confounders instead of lead time did not change associations.

CONCLUSION

Women with screen-detected cancer had an improved disease-free interval compared with women with a nonscreen-related or clinically detected cancer, after correction for lead time.

Differences in up-to-date colorectal and cervical cancer screening rates by ethnicity and preferred language: An analysis across patient-, clinic-, and area-level data sources

Research objective

There is interest in using clinic- and area-level data to inform cancer control, but it is unclear what value these sources may add in combination with patient-level data sources. This study aimed to investigate associations of up-to-date colorectal and cervical cancer screenings at community health centers (CHCs) with ethnicity and language variables at patient-, clinic-, and area-levels, while exploring whether patient-level associations differed based on clinic-level patient language and ethnicity distributions.

Study design

This was a cross-sectional study using data from multiple sources, including electronic health records, clinic patient panel data, and area-level demographic data. The study sample included English-preferring Hispanic, Spanish-preferring Hispanic, English-preferring non-Hispanic, and non-English-preferring non-Hispanic patients eligible for either colorectal cancer (N = 98,985) or cervical cancer (N = 129,611) screenings in 2019 from 130 CHCs in the OCHIN network in CA, OR, and WA.

Population studied

The study population consisted of adults aged 45+ eligible for colorectal cancer screening and adults with a cervix aged 25-65 eligible for cervical cancer screening.

Principal findings

Spanish-preferring Hispanic patients were significantly more likely to be up-to-date with colorectal and cervical cancer screenings than other groups. Patients seen at clinics with higher concentrations of Spanish-preferring Hispanics were significantly more likely to be up-to-date, as were individuals residing in areas with higher percentages of Spanish-speaking residents. Differential associations between patient ethnicity and language and up-to-date colorectal cancer screenings were greater among patients seen at clinics with higher concentrations of Spanish-preferring Hispanics.

Conclusions

The findings highlight that Spanish-speaking Hispanics seen in CHCs have higher rates of up-to-date cervical and colorectal cancer screenings than other groups and that this relationship is stronger at clinics with higher percentages of Spanish-preferring Hispanic patients. Our findings suggest area-level variables are not good substitutions for patient-level data, but variables at the clinic patient panel-level are more informative.

Investigation of Genetic Alterations Associated With Interval Breast Cancer

Importance

Breast cancers (BCs) diagnosed between 2 screening examinations are called interval cancers (ICs), and they have worse clinicopathological characteristics and poorer prognosis than screen-detected cancers (SDCs). However, the association of rare germline genetic variants with IC have not been studied.

Objective

To evaluate whether rare germline deleterious protein-truncating variants (PTVs) can be applied to discriminate between IC and SDC while considering mammographic density.

Design, Setting, and Participants

This population-based genetic association study was based on women aged 40 to 76 years who were attending mammographic screening in Sweden. All women with a diagnosis of BC between January 2001 and January 2016 were included, together with age-matched controls. Patients with BC were followed up for survival until 2021. Statistical analysis was performed from September 2021 to December 2022.

Exposure

Germline PTVs in 34 BC susceptibility genes as analyzed by targeted sequencing.

Main Outcomes and Measures

Odds ratios (ORs) were used to compare IC with SDC using logistic regression. Hazard ratios were used to investigate BC-specific survival using Cox regression.

Results

All 4121 patients with BC (IC, n = 1229; SDC, n = 2892) were female, with a mean (SD) age of 55.5 (7.1) years. There were 5631 age-matched controls. The PTVs of the ATM, BRCA1, BRCA2, CHEK2, and PALB2 genes were more common in patients with IC compared with SDC (OR, 1.48; 95% CI, 1.06-2.05). This association was primarily influenced by BRCA1/2 and PALB2 variants. A family history of BC together with PTVs of any of these genes synergistically increased the probability of receiving a diagnosis of IC rather than SDC (OR, 3.95; 95% CI, 1.97-7.92). Furthermore, 10-year BC-specific survival revealed that if a patient received a diagnosis of an IC, carriers of PTVs in any of these 5 genes had significantly worse survival compared with patients not carrying any of them (hazard ratio, 2.04; 95% CI, 1.06-3.92). All of these associations were further pronounced in a subset of patients with IC who had a low mammographic density at prior screening examination.

Conclusions and Relevance

The results of this study may be helpful in future optimizations of screening programs that aim to lower mortality as well as the clinical treatment of patients with BC.

A promising target for breast cancer: B7-H3

Breast cancer (BC) is the second-leading factor of mortality for women globally and is brought on by a variety of genetic and environmental causes. The conventional treatments for this disease have limitations, making it difficult to improve the lifespan of breast cancer patients. As a result, extensive research has been conducted over the past decade to find innovative solutions to these challenges. Targeting of the antitumor immune response through the immunomodulatory checkpoint protein B7 family has revolutionized cancer treatment and led to intermittent patient responses. B7-H3 has recently received attention because of its significant demodulation and its immunomodulatory effects in many cancers. Uncontrolled B7-H3 expression and a bad outlook are strongly associated, according to a substantial body of cancer research. Numerous studies have shown that BC has significant B7-H3 expression, and B7-H3 induces an immune evasion phenotype, consequently enhancing the survival, proliferation, metastasis, and drug resistance of BC cells. Thus, an innovative target for immunotherapy against BC may be the B7-H3 checkpoint.In this review, we discuss the structure and regulation of B7-H3 and its double costimulatory/coinhibitory function within the framework of cancer and normal physiology. Then we expound the malignant behavior of B7-H3 in BC and its role in the tumor microenvironment (TME) and finally focus on targeted drugs against B7-H3 that have opened new therapeutic opportunities in BC.

Benefits and Harms of Mammography Screening in 75 + Women to Inform Shared Decision-making: a Simulation Modeling Study

BACKGROUND

Guidelines recommend shared decision-making (SDM) around mammography screening for women ≥ 75 years old.

OBJECTIVE

To use microsimulation modeling to estimate the lifetime benefits and harms of screening women aged 75, 80, and 85 years based on their individual risk factors (family history, breast density, prior biopsy) and comorbidity level to support SDM in clinical practice.

DESIGN, SETTING, AND PARTICIPANTS

We adapted two established Cancer Intervention and Surveillance Modeling Network (CISNET) models to evaluate the remaining lifetime benefits and harms of screening U.S. women born in 1940, at decision ages 75, 80, and 85 years considering their individual risk factors and comorbidity levels. Results were summarized for average- and higher-risk women (defined as having breast cancer family history, heterogeneously dense breasts, and no prior biopsy, 5% of the population).

MAIN OUTCOMES AND MEASURES

Remaining lifetime breast cancers detected, deaths (breast cancer/other causes), false positives, and overdiagnoses for average- and higher-risk women by age and comorbidity level for screening (one or five screens) vs. no screening per 1000 women.

RESULTS

Compared to stopping, one additional screen at 75 years old resulted in six and eight more breast cancers detected (10% overdiagnoses), one and two fewer breast cancer deaths, and 52 and 59 false positives per 1000 average- and higher-risk women without comorbidities, respectively. Five additional screens over 10 years led to 23 and 31 additional breast cancer cases (29-31% overdiagnoses), four and 15 breast cancer deaths avoided, and 238 and 268 false positives per 1000 average- and higher-risk screened women without comorbidities, respectively. Screening women at older ages (80 and 85 years old) and high comorbidity levels led to fewer breast cancer deaths and a higher percentage of overdiagnoses.

CONCLUSIONS

Simulation models show that continuing screening in women ≥ 75 years old results in fewer breast cancer deaths but more false positive tests and overdiagnoses. Together, clinicians and 75 + women may use model output to weigh the benefits and harms of continued screening.

Analysis of Breast Cancer Mortality in the US-1975 to 2019

Importance

Breast cancer mortality in the US declined between 1975 and 2019. The association of changes in metastatic breast cancer treatment with improved breast cancer mortality is unclear.

Objective

To simulate the relative associations of breast cancer screening, treatment of stage I to III breast cancer, and treatment of metastatic breast cancer with improved breast cancer mortality.

Design, Setting, and Participants

Using aggregated observational and clinical trial data on the dissemination and effects of screening and treatment, 4 Cancer Intervention and Surveillance Modeling Network (CISNET) models simulated US breast cancer mortality rates. Death due to breast cancer, overall and by estrogen receptor and ERBB2 (formerly HER2) status, among women aged 30 to 79 years in the US from 1975 to 2019 was simulated.

Exposures

Screening mammography, treatment of stage I to III breast cancer, and treatment of metastatic breast cancer.

Main Outcomes and Measures

Model-estimated age-adjusted breast cancer mortality rate associated with screening, stage I to III treatment, and metastatic treatment relative to the absence of these exposures was assessed, as was model-estimated median survival after breast cancer metastatic recurrence.

Results

The breast cancer mortality rate in the US (age adjusted) was 48/100 000 women in 1975 and 27/100 000 women in 2019. In 2019, the combination of screening, stage I to III treatment, and metastatic treatment was associated with a 58% reduction (model range, 55%-61%) in breast cancer mortality. Of this reduction, 29% (model range, 19%-33%) was associated with treatment of metastatic breast cancer, 47% (model range, 35%-60%) with treatment of stage I to III breast cancer, and 25% (model range, 21%-33%) with mammography screening. Based on simulations, the greatest change in survival after metastatic recurrence occurred between 2000 and 2019, from 1.9 years (model range, 1.0-2.7 years) to 3.2 years (model range, 2.0-4.9 years). Median survival for estrogen receptor (ER)-positive/ERBB2-positive breast cancer improved by 2.5 years (model range, 2.0-3.4 years), whereas median survival for ER-/ERBB2- breast cancer improved by 0.5 years (model range, 0.3-0.8 years).

Conclusions and Relevance

According to 4 simulation models, breast cancer screening and treatment in 2019 were associated with a 58% reduction in US breast cancer mortality compared with interventions in 1975. Simulations suggested that treatment for stage I to III breast cancer was associated with approximately 47% of the mortality reduction, whereas treatment for metastatic breast cancer was associated with 29% of the reduction and screening with 25% of the reduction.

Stage I Breast Cancer in the Modern Era: A Retrospective Cohort Study of 328 Patients Diagnosed from 2002 to 2006 with a 14-Year Median Follow-Up

INTRODUCTION

This study aimed to evaluate the long-term outcomes of stage I breast cancer (BC) patients diagnosed during the current era of screening mammography, immunohistochemistry receptor testing, and systemic adjuvant therapy.

METHODS

A retrospective cohort study was conducted on 328 stage I BC patients treated consecutively in a single referral center with a follow-up period of at least 12 years. The primary endpoints were invasive disease-free survival (IDFS) and overall survival (OS). The influence of tumor size, grade, and subtype on the outcomes was analyzed.

RESULTS

Most patients were treated by lumpectomy, sentinel node biopsy, and adjuvant endocrine therapy, and most (82%) were of subtype luminal A. Adjuvant chemotherapy was administered to 25.6% of our cohort. Only 24 patients underwent gene expression testing, which was introduced toward the end of the study period. Mean IDFS was 14.64 years, with a 15-year IDFS of 75.6%. Mean OS was 15.28 years with a 15-year OS of 74.9%. In a Cox multivariate analysis, no clinical or pathologic variable impacted on OS and only tumor size (<1 cm vs. 1-2 cm) impacted significantly on IDFS. During follow-up, 20.1% of the cohort developed second primary cancers, including BC. The median time to diagnosis of a second BC was 6.49 years.

CONCLUSION

The study results emphasize the importance of long-term follow-up and screening for subsequent malignancies of patients with stage I BC and support the need for using prognostic and predictive indicators beyond the routine clinicopathological characteristics in luminal A patients.

Rethinking screening mammography in Japan: next-generation breast cancer screening through breast awareness and supplemental ultrasonography

Breast cancer mortality has not been reduced in Japan despite more than 20 years of population-based screening mammography. Screening mammography might not be suitable for Japanese women who often have dense breasts, thus decreasing mammography sensitivity because of masking. The J-START study showed that breast ultrasonography increases the sensitivity and the detection rate for early invasive cancers and lowers the rate of interval cancers for Japanese women in their 40 s. Breast awareness and breast cancer survival are directly correlated; however, breast awareness is not widely known in Japan. Next-generation breast cancer screening in Japan should consist of breast awareness campaigns for improving breast cancer literacy and supplemental breast ultrasonography to address the problem of false-negative mammograms attributable to dense breasts.

Data gaps and opportunities for modeling cancer health equity

Population models of cancer reflect the overall US population by drawing on numerous existing data resources for parameter inputs and calibration targets. Models require data inputs that are appropriately representative, collected in a harmonized manner, have minimal missing or inaccurate values, and reflect adequate sample sizes. Data resource priorities for population modeling to support cancer health equity include increasing the availability of data that 1) arise from uninsured and underinsured individuals and those traditionally not included in health-care delivery studies, 2) reflect relevant exposures for groups historically and intentionally excluded across the full cancer control continuum, 3) disaggregate categories (race, ethnicity, socioeconomic status, gender, sexual orientation, etc.) and their intersections that conceal important variation in health outcomes, 4) identify specific populations of interest in clinical databases whose health outcomes have been understudied, 5) enhance health records through expanded data elements and linkage with other data types (eg, patient surveys, provider and/or facility level information, neighborhood data), 6) decrease missing and misclassified data from historically underrecognized populations, and 7) capture potential measures or effects of systemic racism and corresponding intervenable targets for change.

Population simulation modeling of disparities in US breast cancer mortality

BACKGROUND

Populations of African American or Black women have persistently higher breast cancer mortality than the overall US population, despite having slightly lower age-adjusted incidence.

METHODS

Three Cancer Intervention and Surveillance Modeling Network simulation teams modeled cancer mortality disparities between Black female populations and the overall US population. Model inputs used racial group-specific data from clinical trials, national registries, nationally representative surveys, and observational studies. Analyses began with cancer mortality in the overall population and sequentially replaced parameters for Black populations to quantify the percentage of modeled breast cancer morality disparities attributable to differences in demographics, incidence, access to screening and treatment, and variation in tumor biology and response to therapy.

RESULTS

Results were similar across the 3 models. In 2019, racial differences in incidence and competing mortality accounted for a net ‒1% of mortality disparities, while tumor subtype and stage distributions accounted for a mean of 20% (range across models = 13%-24%), and screening accounted for a mean of 3% (range = 3%-4%) of the modeled mortality disparities. Treatment parameters accounted for the majority of modeled mortality disparities: mean = 17% (range = 16%-19%) for treatment initiation and mean = 61% (range = 57%-63%) for real-world effectiveness.

CONCLUSION

Our model results suggest that changes in policies that target improvements in treatment access could increase breast cancer equity. The findings also highlight that efforts must extend beyond policies targeting equity in treatment initiation to include high-quality treatment completion. This research will facilitate future modeling to test the effects of different specific policy changes on mortality disparities.

Growth Dynamics of Ductal Carcinoma in Situ Recapitulate Normal Breast Development

Ductal carcinoma in situ (DCIS) and invasive breast cancer share many morphologic, proteomic, and genomic alterations. Yet in contrast to invasive cancer, many DCIS tumors do not progress and may remain indolent over decades. To better understand the heterogenous nature of this disease, we reconstructed the growth dynamics of 18 DCIS tumors based on the geo-spatial distribution of their somatic mutations. The somatic mutation topographies revealed that DCIS is multiclonal and consists of spatially discontinuous subclonal lesions. Here we show that this pattern of spread is consistent with a new 'Comet' model of DCIS tumorigenesis, whereby multiple subclones arise early and nucleate the buds of the growing tumor. The discontinuous, multiclonal growth of the Comet model is analogous to the branching morphogenesis of normal breast development that governs the rapid expansion of the mammary epithelium during puberty. The branching morphogenesis-like dynamics of the proposed Comet model diverges from the canonical model of clonal evolution, and better explains observed genomic spatial data. Importantly, the Comet model allows for the clinically relevant scenario of extensive DCIS spread, without being subjected to the selective pressures of subclone competition that promote the emergence of increasingly invasive phenotypes. As such, the normal cell movement inferred during DCIS growth provides a new explanation for the limited risk of progression in DCIS and adds biologic rationale for ongoing clinical efforts to reduce DCIS overtreatment.

Discovery of lipid profiles in plasma-derived extracellular vesicles as biomarkers for breast cancer diagnosis

Lipids are a major component of extracellular vesicles; however, their significance in tumorigenesis and progression has not been well elucidated. As we previously found that lipid profiles drastically changed in breast tumors upon progression, we hypothesized that lipid profiles of plasma-derived extracellular vesicles could be utilized as breast cancer biomarkers. Here, we adopted modified sucrose cushion ultracentrifugation to isolate plasma-derived extracellular vesicles from breast cancer (n = 105), benign (n = 11), and healthy individuals (n = 43) in two independent cohorts (n = 126 and n = 33) and conducted targeted lipidomic analysis. We established a breast cancer diagnostic model comprising three lipids that showed favorable performance with the area under the receiver operating characteristic curve of 0.759, 0.743, and 0.804 in the training, internal validation, and external test sets, respectively. Moreover, we identified several lipids that could effectively discriminate breast cancer progression and subtypes: phosphatidylethanolamines and phosphatidylserines were relatively higher in Stage III, whereas phosphatidylcholines and sphingomyelins were higher in Stage IV; phosphatidylcholines and ceramides were correspondingly concentrated in HER2-positive patients, while lysophosphatidylcholines and polyunsaturated triglycerides were concentrated in the triple-negative breast cancer subtype. Lipid profiling of plasma-derived extracellular vesicles is a non-invasive and promising approach for diagnosing, staging, and subtyping breast cancer.

Imaging Challenges in Diagnosing Triple-Negative Breast Cancer

Triple-negative breast cancer (TNBC) refers to a heterogeneous group of carcinomas that have more aggressive biologic features, faster growth, and a propensity for early distant metastasis and recurrence compared with other breast cancer subtypes. Due to the aggressiveness and rapid growth of TNBCs, there are specific imaging challenges associated with their timely and accurate diagnosis. TNBCs commonly manifest initially as circumscribed masses and therefore lack the typical features of a primary breast malignancy, such as irregular shape, spiculated margins, and desmoplastic reaction. Given the potential for misinterpretation, review of the multimodality imaging appearances of TNBCs is important for guiding the radiologist in distinguishing TNBCs from benign conditions. Rather than manifesting as a screening-detected cancer, TNBC typically appears clinically as a palpable area of concern that most commonly corresponds to a discrete mass at mammography, US, and MRI. The combination of circumscribed margins and hypoechoic to anechoic echogenicity may lead to TNBC being misinterpreted as a benign fibroadenoma or cyst. Therefore, careful mammographic and sonographic evaluation with US image optimization can help avoid misinterpretation. Radiologists should recognize the characteristics of TNBCs that can mimic benign entities, as well as the subtle features of TNBCs that should raise concern for malignancy and aid in timely and accurate diagnosis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Overcoming the limitations of screening mammography in Japan and Korea: a paradigm shift to personalized breast cancer screening based on ultrasonography

Screening mammography programs have been implemented in numerous Western countries with the aim of reducing breast cancer mortality. However, despite over 20 years of population-based screening mammography, the mortality rates in Japan and Korea continue to rise. This may be due to the fact that screening mammography is not as effective for Japanese and Korean women, who often have dense breasts. This density decreases the sensitivity of mammography due to a masking effect. Therefore, the early detection of small invasive cancers requires more than just mammography, particularly for women in their 40s. This review discusses the limitations and challenges of screening mammography, as well as the keys to successful population-based breast cancer screening in Japan and Korea. This includes a focus on breast ultrasonography techniques, which are based on histopathologic anatomical knowledge, and personalized screening strategies that are based on risk assessments measured by glandular tissue components.

Functional inhibition of the RNA-binding protein HuR sensitizes triple-negative breast cancer to chemotherapy

Chemotherapy remains the standard treatment for triple-negative breast cancer (TNBC); however, chemoresistance compromises its efficacy. The RNA-binding protein Hu antigen R (HuR) could be a potential therapeutic target to enhance the chemotherapy efficacy. HuR is known to mainly stabilize its target mRNAs, and/or promote the translation of encoded proteins, which are implicated in multiple cancer hallmarks, including chemoresistance. In this study, a docetaxel-resistant cell subline (231-TR) was established from the human TNBC cell line MDA-MB-231. Both the parental and resistant cell lines exhibited similar sensitivity to the small molecule functional inhibitor of HuR, KH-3. Docetaxel and KH-3 combination therapy synergistically inhibited cell proliferation in TNBC cells and tumor growth in three animal models. KH-3 downregulated the expression levels of HuR targets (e.g., β-Catenin and BCL2) in a time- and dose-dependent manner. Moreover, KH-3 restored docetaxel's effects on activating Caspase-3 and cleaving PARP in 231-TR cells, induced apoptotic cell death, and caused S-phase cell cycle arrest. Together, our findings suggest that HuR is a critical mediator of docetaxel resistance and provide a rationale for combining HuR inhibitors and chemotherapeutic agents to enhance chemotherapy efficacy.

Can the Clinical Utility of iBreastExam, a Novel Device, Aid in Optimizing Breast Cancer Diagnosis? A Systematic Review

PURPOSE

A portable, cost-effective, easy-to-use, hand-held Intelligent Breast Exam (iBE), which is a wireless, radiation-free device, may be a valuable screening tool in resource-limited settings. While multiple studies evaluating the use of iBE have been conducted worldwide, there are no cumulative studies evaluating the iBE's performance. Therefore this review aims to determine the clinical utility and applicability of iBE compared with clinical breast examinations, ultrasound, and mammography and discuss its strengths and weaknesses when performing breast-cancer screening.

METHODS

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four electronic databases were searched: PubMed, Cochrane Library, Web of Science, and Google Scholar.

RESULTS

The review included 11 studies with a total sample size of 16,052 breasts. The mean age ranged from 42 to 58 years. The sensitivity and specificity of the iBE ranged from 34.3% to 86% and 59% to 94%, respectively. For malignant lesions, iBE demonstrated a moderate to higher diagnostic capacity ranging from 57% to 93% and could identify tumor sizes spanning from 0.5 cm to 9 cm.

CONCLUSION

Our findings underscore the potential clinical utility and applicability of iBE as a prescreening and triaging tool, which may aid in reducing the burden of patients undergoing diagnostic imaging in lower- and middle-income countries. Furthermore, iBE has shown to diagnose cancers as small as 0.5 cm, which can be a boon in early detection and reduce mortality rates. However, the encouraging results of this systematic review should be interpreted with caution because of the device's low sensitivity and high false-positive rates.

Quality assurance in Mammography: An overview

Since 1989, hundreds of thousands of lives have been saved worldwide by the widespread use of screening mammography alongside new developments in breast cancer treatment [1]. The ability of screening mammography to detect cancer early, when treatment is most effective, is optimized when it is performed in the highest quality manner and accessed by all eligible candidates. Currently, worldwide, there are over 14 guidance documents for mammographic quality [2]. Some countries, such as the United Kingdom (UK), monitor quality through a national screening program. In the United States (US), where 39 million mammograms are performed annually [3], there is not a national screening program, but the federal government mandates minimum quality standards for the performance of mammography. Among a consortium of European countries, the European Reference Organisation for Quality Assured Breast Screening and Diagnostic Services (EUREF) promotes voluntary adherence to European mammography quality standards. Setting quality standards at national or international levels ensures the uniformity of practice and identifies substandard practices in need of improvement, ultimately maximizing the benefit of screening mammography.

Racial disparity in tumor microenvironment and distant recurrence in residual breast cancer after neoadjuvant chemotherapy

Black, compared to white, women with residual estrogen receptor-positive (ER+) breast cancer after neoadjuvant chemotherapy (NAC) have worse distant recurrence-free survival (DRFS). Such racial disparity may be due to difference in density of portals for systemic cancer cell dissemination, called TMEM doorways, and pro-metastatic tumor microenvironment (TME). Here, we evaluate residual cancer specimens after NAC from 96 Black and 87 white women. TMEM doorways are visualized by triple immunohistochemistry, and cancer stem cells by immunofluorescence for SOX9. The correlation between TMEM doorway score and pro-metastatic TME parameters with DRFS is examined using log-rank and multivariate Cox regression. Black, compared to white, patients are more likely to develop distant recurrence (49% vs 34.5%, p = 0.07), receive mastectomy (69.8% vs 54%, p = 0.04), and have higher grade tumors (p = 0.002). Tumors from Black patients have higher TMEM doorway and macrophages density overall (p = 0.002; p = 0.002, respectively) and in the ER+/HER2- (p = 0.02; p = 0.02, respectively), but not in the triple negative disease. Furthermore, high TMEM doorway score is associated with worse DRFS. TMEM doorway score is an independent prognostic factor in the entire study population (HR, 2.02; 95%CI, 1.18-3.46; p = 0.01), with a strong trend in ER+/HER2- disease (HR, 2.38; 95%CI, 0.96-5.95; p = 0.06). SOX9 expression is not associated with racial disparity in TME or outcome. In conclusion, higher TMEM doorway density in residual breast cancer after NAC is associated with higher distant recurrence risk, and Black patients are associated with higher TMEM doorway density, suggesting that TMEM doorway density may contribute to racial disparities in breast cancer.