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Daly GR, Naidoo S, Alabdulrahman M, McGrath J, Dowling GP, AlRawashdeh MM, Hill ADK, Varešlija D, Young L. Screening and Testing for Homologous Recombination Repair Deficiency (HRD) in Breast Cancer: an Overview of the Current Global Landscape. Curr Oncol Rep 2024; 26:890-903. [PMID: 38822929 PMCID: PMC11300621 DOI: 10.1007/s11912-024-01560-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE OF REVIEW Homologous recombination repair deficiency (HRD) increases breast cancer susceptibility and influences both prophylactic and active management of breast cancer. This review evaluates HRD testing and the therapeutic implications of HRD in a global context. RECENT FINDINGS Ongoing research efforts have highlighted the importance of HRD beyond BRCA1/2 as a potential therapeutic target in breast cancer. However, despite the improved affordability of next-generation sequencing (NGS) and the discovery of PARP inhibitors, economic and geographical barriers in access to HRD testing and breast cancer screening do not allow all patients to benefit from the personalized treatment approach they provide. Advancements in HRD testing modalities and targeted therapeutics enable tailored breast cancer management. However, inequalities in access to testing and optimized treatments are contributing to widening health disparities globally.
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Affiliation(s)
- Gordon R Daly
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
- The Department of Surgery, Beaumont Hospital, Dublin, Ireland.
| | - Sindhuja Naidoo
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Mohammad Alabdulrahman
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Jason McGrath
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Gavin P Dowling
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- The Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Maen M AlRawashdeh
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Arnold D K Hill
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- The Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Damir Varešlija
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Beaumont RCSI Cancer Centre, Beaumont Hospital, Dublin, Ireland
| | - Leonie Young
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Beaumont RCSI Cancer Centre, Beaumont Hospital, Dublin, Ireland
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Gootzen TA, Steenbeek MP, van Bommel M, IntHout J, Kets CM, Hermens R, de Hullu JA. Risk-reducing salpingectomy with delayed oophorectomy to prevent ovarian cancer in women with an increased inherited risk: insights into an alternative strategy. Fam Cancer 2024:10.1007/s10689-024-00412-0. [PMID: 38907139 DOI: 10.1007/s10689-024-00412-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/13/2024] [Indexed: 06/23/2024]
Abstract
Epithelial ovarian cancer (EOC) is the most lethal type of gynaecological cancer, due to lack of effective screening possibilities and because the disease tends to metastasize before onset of symptoms. Women with an increased inherited risk for EOC are advised to undergo a risk-reducing salpingo-oophorectomy (RRSO), which decreases their EOC risk by 96% when performed within guideline ages. However, it also induces premature menopause, which has harmful consequences. There is compelling evidence that the majority of EOCs originate in the fallopian tube. Therefore, a risk-reducing salpingectomy with delayed oophorectomy (RRS with DO) has gained interest as an alternative strategy. Previous studies have shown that this alternative strategy has a positive effect on menopause-related quality of life and sexual health when compared to the standard RRSO. It is hypothesized that the alternative strategy is non-inferior to the standard RRSO with respect to oncological safety (EOC incidence). Three prospective studies are currently including patients to compare the safety and/or quality of life of the two distinct strategies. In this article we discuss the background, opportunities, and challenges of the current and alternative strategy.
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Affiliation(s)
- T A Gootzen
- Department of Gynaecology and Obstetrics, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA, 6525, The Netherlands.
| | - M P Steenbeek
- Department of Gynaecology and Obstetrics, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA, 6525, The Netherlands
| | - Mhd van Bommel
- Department of Gynaecology and Obstetrics, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA, 6525, The Netherlands
| | - J IntHout
- Department of IQ Health, Radboudumc, Kapittelweg 54, Nijmegen, EP, 6525, The Netherlands
| | - C M Kets
- Department of Genetics, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA, 6525, The Netherlands
| | - Rpmg Hermens
- Department of IQ Health, Radboudumc, Kapittelweg 54, Nijmegen, EP, 6525, The Netherlands
| | - J A de Hullu
- Department of Gynaecology and Obstetrics, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA, 6525, The Netherlands
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Mahiou K, Jankowski C, Vincent L, Costaz H, Padeano MM, Mamguem A, Dabakuyo S, Coutant C. Impact of breast surgical procedure on survival in BRCA mutated patients with invasive breast cancer: Mastectomy versus conservative treatment. J Gynecol Obstet Hum Reprod 2024; 53:102760. [PMID: 38428460 DOI: 10.1016/j.jogoh.2024.102760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 02/28/2024] [Indexed: 03/03/2024]
Abstract
INTRODUCTION Patients with BRCA1/2 mutations have a higher risk of developing breast cancer compared to the wild-type population. For patients with a BRCA mutation, there are no specific recommendations for surgical management. The aim of this study was therefore to retrospectively investigate overall survival (OS) and recurrence-free survival (RFS) of BRCA mutated patients with localized invasive breast cancer, by comparing conservative surgery versus mastectomy. METHODS This study was based on data from the Côte d'Or breast and gynecological cancer registry. Data from patients with a constitutional BRCA1/2 mutation who presented with invasive breast cancer were collected retrospectively from 1998 to 2018. The Kaplan-Meier method was used to describe RFS and OS. RESULTS A total of 104 patients were included in the analysis, of whom 69 had conservative surgery and 35 underwent mastectomy. Regarding survival, there was no significant difference in OS (HR =1.49; 95 % confidence interval (CI) [0.76-2.93], p = 0.25). Similarly, there was no significant difference in RFS (HR =1.40; 95 % CI [0.81-2.40], p = 0.22), survival without homolateral recurrence (HR =0.88; 95 % CI [0.30-2.61], p = 0.89), without contralateral recurrence (HR =1.50; 95 % CI [0.55-4.09], p = 0.42), or without distant metastatic recurrence (HR =1.42, 95 % CI [0.69-2.90], p = 0.33). CONCLUSION In invasive breast cancer in a patient with a germline BRCA1/2 mutation, conservative surgery, when possible, appears to be a feasible option over total mastectomy, with no difference in overall survival. However, the patient should be informed of the aggressive nature of recurrence in this population requiring chemotherapy in most cases.
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Affiliation(s)
- Katia Mahiou
- Department of Surgical Oncology, Georges François Leclerc Cancer Center -UNICANCER, Dijon, France.
| | - Clémentine Jankowski
- Department of Surgical Oncology, Georges François Leclerc Cancer Center -UNICANCER, Dijon, France
| | - Laura Vincent
- Department of Surgical Oncology, Georges François Leclerc Cancer Center -UNICANCER, Dijon, France
| | - Hélène Costaz
- Department of Surgical Oncology, Georges François Leclerc Cancer Center -UNICANCER, Dijon, France
| | - Marie-Martine Padeano
- Department of Surgical Oncology, Georges François Leclerc Cancer Center -UNICANCER, Dijon, France
| | - Ariane Mamguem
- National Quality of Life and Cancer Clinical Research Platform, Georges François Leclerc Cancer Center -UNICANCER, Dijon, France
| | - Sandrine Dabakuyo
- National Quality of Life and Cancer Clinical Research Platform, Georges François Leclerc Cancer Center -UNICANCER, Dijon, France
| | - Charles Coutant
- Department of Surgical Oncology, Georges François Leclerc Cancer Center -UNICANCER, Dijon, France; University of Burgundy-Franche Comté, Dijon, France
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Gauna F, Carof S, Mouret-Fourme E, Coupier I, Mari V, Moretta-Serra J, Mancini J, Noguès C, Bouhnik AD. Links between gender norms and the intergenerational transmission of health information in parents carrying BRCA1/2 pathogenic variants. J Genet Couns 2024; 33:370-381. [PMID: 37282361 DOI: 10.1002/jgc4.1734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/08/2023]
Abstract
Understanding how gender norms affect parents' communication of genetic and cancer risk information to their children can enable healthcare professionals to better facilitate cascade genetic testing. We conducted a qualitative study with semi-structured interviews to determine social factors associated with parents carrying the BRCA1/2 pathogenic variants who communicated cancer prevention practices to their children. Thirty adult carriers (23 women, 7 men) participated in the interviews. All had at least one child aged over 8 years old. Interview topics included their discovery of the variants, their relationship to their body and to the risk of cancer, as well as disclosure to and subsequent communication with their children after testing positive for BRCA1/2. The interviews were analyzed qualitatively, and the major themes identified were identified and compared. We described the roles played by the BRCA1/2 carriers and their partners in communicating cancer prevention practices to their children, from how they managed their own risk of cancer after testing positive, to how they disclosed the risks linked to these pathogenic variants to their children. We also described their involvement in the process of their children going for professional genetic consultation. Gender norms lead women to be more attentive than men to their own health and that of their loved ones. In the context of the transmission of genetic information to children, gender differences in behavior are reinforced by perceptions of the risks of BRCA1/2 variants and women's related health management practices. Cancer prevention is shaped by complex links between gender norms and health management practices.
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Affiliation(s)
- F Gauna
- Aix-Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - S Carof
- Sorbonne Université, GEMASS (CNRS, Sorbonne Université), Paris, France
| | | | - I Coupier
- Gastroenterology and Genetic Department, Montpellier Hospital, Montpellier, France
| | - V Mari
- Unité d'Oncogénétique, Centre Antoine Lacassagne, Nice, France
| | - J Moretta-Serra
- Institut Paoli Calmette, Departement d'Anticipation et de Suivi du Cancer, Pôle Clinique Consultations d'Oncologie Genétique, Marseille, France
| | - J Mancini
- Aix-Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
- AP-HM, BIOSTIC, Hop Timone, Marseille, France
| | - C Noguès
- Aix-Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
- Institut Paoli Calmette, Departement d'Anticipation et de Suivi du Cancer, Pôle Clinique Consultations d'Oncologie Genétique, Marseille, France
| | - A D Bouhnik
- Aix-Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
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Meshkani Z, Moradi N, Aboutorabi A, Farabi H, Moini N. A cost-benefit analysis of genetic screening test for breast cancer in Iran. BMC Cancer 2024; 24:279. [PMID: 38429685 PMCID: PMC10905849 DOI: 10.1186/s12885-024-12003-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/14/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the implementation of the population- and family history (FH) -based screening for BReast CAncer (BRCA) in Iran, a country where less than 10% of breast cancer cases are attributable to a gene mutation. METHODS This was an economic evaluation study. The Benefit-Cost Ratio (BCR) for genetic screening test strategies in Iranian women older than 30 was calculated. To this end, the monetary value of the test was estimated using the willingness-to-pay (WTP) approach using the contingent valuation method (CVM) by payment card. From a healthcare perspective, direct medical and non-medical costs were considered and a decision model for the strategies was developed to simulate the costs. A one-way sensitivity analysis assessed the robustness of the analysis. The data were analyzed using Excel 2010. RESULTS 660 women were included for estimating WTP and 2,176,919 women were considered in the costing model. The cost per genetic screening test for population- and FH-based strategies was $167 and $8, respectively. The monetary value of a genetic screening test was $20 and it was $27 for women with a family history or gene mutation in breast cancer. The BCR for population-based and FH-based screening strategies was 0.12 and 3.37, respectively. Sensitivity analyses confirmed the robustness of the results. CONCLUSIONS This study recommends the implementation of a FH-based strategy instead of a population-based genetic screening strategy in Iran, although a cascade genetic screening test strategy should be evaluated in future studies.
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Affiliation(s)
- Zahra Meshkani
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
- Health Management and Economics Research Center, Iran University of Medical Sciences, 13833-19967, Tehran, Iran.
| | - Najmeh Moradi
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ali Aboutorabi
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hiro Farabi
- Barts and The London Pragmatic Clinical Trial Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Nazi Moini
- Breast Cancer Research Centre, Motamed Cancer Institute, ACECR, Tehran, Iran
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Padamsee TJ, Bijou C, Swinehart-Hord P, Hils M, Muraveva A, Meadows RJ, Shane-Carson K, Yee LD, Wills CE, Paskett ED. Risk-management decision-making data from a community-based sample of racially diverse women at high risk of breast cancer: rationale, methods, and sample characteristics of the Daughter Sister Mother Project survey. Breast Cancer Res 2024; 26:8. [PMID: 38212792 PMCID: PMC10785448 DOI: 10.1186/s13058-023-01753-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/13/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND To understand the dynamics that limit use of risk-management options by women at high risk of breast cancer, there is a critical need for research that focuses on patient perspectives. Prior research has left important gaps: exclusion of high-risk women not in risk-related clinical care, exclusion of non-white populations, and lack of attention to the decision-making processes that underlie risk-management choices. Our objective was to create a more inclusive dataset to facilitate research to address disparities related to decision making for breast cancer risk management. METHODS The Daughter Sister Mother Project survey collects comprehensive information about the experiences of women at high risk of breast cancer. We collected novel measures of feelings about and reactions to cancer screenings; knowledge, barriers, and facilitators of risk-management options; beliefs related to cancer risk and risk management; and involvement with loved ones who had cancer. Eligible individuals were non-Hispanic white and non-Hispanic Black adult women who self-identified as having high risk of breast cancer and had no personal history of cancer. Between October 2018 and August 2019, 1053 respondents completed the online survey. Of these, 717 were confirmed through risk prediction modeling to have a lifetime breast cancer risk of ≥ 20%. Sociodemographic characteristics of this sample were compared to those of nationally representative samples of the US population: the 2019 Health Information National Trends Survey and the Pew Research Center report: Jewish Americans in 2020. RESULTS The sample of 717 women at objectively high risk of breast cancer was largely (95%) recruited from non-clinical sources. Of these respondents, only 31% had seen a genetic counselor, 34% had had genetic testing specific to breast cancer risk, and 35% had seen at least one breast or cancer care specialist. The sample includes 35% Black respondents and 8% with Ashkenazi Jewish ancestry. Although encompassing a substantial range of ages, incomes, and education levels, respondents are overall somewhat younger, higher-income, and more educated than the US population as a whole. CONCLUSIONS The DSM dataset offers comprehensive data from a community-based, diverse sample of women at high risk of breast cancer. The dataset includes substantial proportions of Black and Ashkenazi Jewish women and women who are not already in clinical care related to their breast cancer risk. This sample will facilitate future studies of risk-management behaviors among women who are and are not receiving high-risk care, and of variations in risk-management experiences across race and ethnicity.
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Affiliation(s)
- Tasleem J Padamsee
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43220, USA.
| | - Christina Bijou
- Department of Sociology, The Ohio State University, Columbus, OH, USA
| | - Paige Swinehart-Hord
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43220, USA
| | - Megan Hils
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43220, USA
| | - Anna Muraveva
- Government Resources Center, The Ohio State University, Columbus, OH, USA
| | - Rachel J Meadows
- Center for Epidemiology and Healthcare Delivery Research, JPS Health Network, Fort Worth, TX, USA
| | | | - Lisa D Yee
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Celia E Wills
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Electra D Paskett
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
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Wong SM, Apostolova C, Eisenberg E, Foulkes WD. Counselling Framework for Germline BRCA1/2 and PALB2 Carriers Considering Risk-Reducing Mastectomy. Curr Oncol 2024; 31:350-365. [PMID: 38248108 PMCID: PMC10814079 DOI: 10.3390/curroncol31010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Female BRCA1/2 and PALB2 germline pathogenic variant carriers have an increased lifetime risk of breast cancer and may wish to consider risk-reducing mastectomy (RRM) for surgical prevention. Quantifying the residual lifetime risk and absolute benefit from RRM requires careful consideration of a patient's age, pathogenic variant, and their personal history of breast or ovarian cancer. Historically, patients have been counselled that RRM does not necessarily prolong survival relative to high-risk surveillance, although recent studies suggest a possible survival benefit of RRM in BRCA1 carriers. The uptake of RRM has increased dramatically over the last several decades yet varies according to sociodemographic factors and geographic region. The increased adoption of nipple-sparing mastectomy techniques, ability to avoid axillary staging, and availability of reconstructive options for most germline pathogenic variant carriers has helped to minimize the morbidity of RRM. Preoperative discussions should include evidence regarding postmastectomy sensation, the potential for supplemental surgery, pregnancy-related chest wall changes, and the need for continued clinical surveillance. Approaches that include sensation preservation and robotic nipple-sparing mastectomy are an area of evolving research that may be more widely adopted in the future.
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Affiliation(s)
- Stephanie M. Wong
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3T2, Canada
| | - Carla Apostolova
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Elisheva Eisenberg
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - William D. Foulkes
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3T2, Canada
- Department of Human Genetics, McGill University, Montreal, QC H3A 0C7, Canada
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Zaluzec EK, Sempere LF. Systemic and Local Strategies for Primary Prevention of Breast Cancer. Cancers (Basel) 2024; 16:248. [PMID: 38254741 PMCID: PMC10814018 DOI: 10.3390/cancers16020248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/29/2023] [Accepted: 12/31/2023] [Indexed: 01/24/2024] Open
Abstract
One in eight women will develop breast cancer in the US. For women with moderate (15-20%) to average (12.5%) risk of breast cancer, there are few options available for risk reduction. For high-risk (>20%) women, such as BRCA mutation carriers, primary prevention strategies are limited to evidence-based surgical removal of breasts and/or ovaries and anti-estrogen treatment. Despite their effectiveness in risk reduction, not many high-risk individuals opt for surgical or hormonal interventions due to severe side effects and potentially life-changing outcomes as key deterrents. Thus, better communication about the benefits of existing strategies and the development of new strategies with minimal side effects are needed to offer women adequate risk-reducing interventions. We extensively review and discuss innovative investigational strategies for primary prevention. Most of these investigational strategies are at the pre-clinical stage, but some are already being evaluated in clinical trials and others are expected to lead to first-in-human clinical trials within 5 years. Likely, these strategies would be initially tested in high-risk individuals but may be applicable to lower-risk women, if shown to decrease risk at a similar rate to existing strategies, but with minimal side effects.
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Affiliation(s)
- Erin K. Zaluzec
- Precision Health Program, Michigan State University, East Lansing, MI 48824, USA;
- Department of Pharmacology & Toxicology, College of Veterinary Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Lorenzo F. Sempere
- Precision Health Program, Michigan State University, East Lansing, MI 48824, USA;
- Department of Radiology, College of Human Medicine, Michigan State University, East Lansing, MI 48824, USA
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Nahshon C, Segev Y, Schmidt M, Lavie O. Attitude of BRCA1/2 mutation carriers towards surgical risk reduction for breast, ovarian and uterine cancer: still much to be done. Int J Gynecol Cancer 2023:ijgc-2023-004801. [PMID: 37918957 DOI: 10.1136/ijgc-2023-004801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVE To study and quantify the attitude of BRCA1/2 mutation carriers towards surgical risk reduction procedures. METHODS This cross-sectional national study was conducted by distribution of an anonymous questionnaire on social media platforms and to BRCA1/2 carriers' medical clinic. RESULTS 530 BRCA1/2 mutation carriers answered the survey. Risk reduction bilateral salpingo-oophorectomy was discussed with 447/489 (91%) of patients and performed in 260/489 (53%). Hormonal replacement therapy was discussed in 280/474 (59%) of patients. Addition of hysterectomy to risk reduction bilateral salpingo-oophorectomy was discussed in 129/481 (27%) of patients and performed in 44/443(10%). Age over 35 years at time of mutation detection was found to be significant in raising risk reduction bilateral salpingo-oophorectomy and hysterectomy performance rates. Risk reduction mastectomy was discussed in 390/471 (83%) of patients and performed in 156/471 (33%). In a multivariate analysis, BRCA1 mutation carriers (OR=1.66 (95% CI 1.07 to 2.57), p=0.024) and a personal cancer history leading to the mutation detection (OR=4.75 (95% CI 1.82 to 12.4), p=0.001) were found to be significant in increasing the likelihood of opting for risk reduction mastectomy. Additionally, highest risk reduction mastectomy performance rates were observed in the group of patients with a first-degree family history of breast cancer under the age of 50 years (OR=1.58 (95% CI 1.07 to 2.32), p=0.01). CONCLUSIONS This study highlights the high performance rates of risk reduction bilateral salpingo-oophorectomy, while hysterectomy was added in 10%, and that despite high awareness and acceptance rates for risk reduction mastectomy, only 33% had the procedure. The data presented provides insights for the clinician counseling BRCA1/2 mutation carriers, with regards to adherence to recommendations, understanding their concerns towards treatment and management alternatives; and finally, to construct a personalized management medical plan.
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Affiliation(s)
- Chen Nahshon
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yakir Segev
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Meirav Schmidt
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ofer Lavie
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Manna EDF, Serrano D, Aurilio G, Bonanni B, Lazzeroni M. Chemoprevention and Lifestyle Modifications for Risk Reduction in Sporadic and Hereditary Breast Cancer. Healthcare (Basel) 2023; 11:2360. [PMID: 37628558 PMCID: PMC10454363 DOI: 10.3390/healthcare11162360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
Female breast cancer is the most commonly diagnosed malignancy worldwide. Risk assessment helps to identify women at increased risk of breast cancer and allows the adoption of a comprehensive approach to reducing breast cancer incidence through personalized interventions, including lifestyle modification, chemoprevention, intensified surveillance with breast imaging, genetic counseling, and testing. Primary prevention means acting on modifiable risk factors to reduce breast cancer occurrence. Chemoprevention with tamoxifen, raloxifene, anastrozole, and exemestane has already shown benefits in decreasing breast cancer incidence in women at an increased risk for breast cancer. For healthy women carrying BRCA 1 or BRCA 2 pathogenic/likely pathogenic (P/LP) germline variants, the efficacy of chemoprevention is still controversial. Adopting chemoprevention strategies and the choice among agents should depend on the safety profile and risk-benefit ratio. Unfortunately, the uptake of these agents has been low. Lifestyle modifications can reduce breast cancer incidence, and the recommendations for BRCA 1 or BRCA 2 P/LP germline variant carriers are comparable to the general population. This review summarizes the most recent evidence regarding the efficacy of chemoprevention and lifestyle interventions in women with sporadic and hereditary breast cancer.
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Affiliation(s)
- Eliza Del Fiol Manna
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (D.S.); (G.A.); (B.B.); (M.L.)
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Evron E, Ben-David MA, Kaidar-Person O, Corn BW. Nonsurgical Options for Risk Reduction of Contralateral Breast Cancer in BRCA Mutation Carriers With Early-Stage Breast Cancer. J Clin Oncol 2023; 41:964-969. [PMID: 36306484 DOI: 10.1200/jco.22.01609] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ella Evron
- Kaplan Hospital, Hadassah Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Merav A Ben-David
- Assuta Medical Center, Tel-Aviv, Faculty of Health Science, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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12
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Guan Z, Huang T, McCarthy AM, Hughes K, Semine A, Uno H, Trippa L, Parmigiani G, Braun D. Combining Breast Cancer Risk Prediction Models. Cancers (Basel) 2023; 15:1090. [PMID: 36831433 PMCID: PMC9953824 DOI: 10.3390/cancers15041090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023] Open
Abstract
Accurate risk stratification is key to reducing cancer morbidity through targeted screening and preventative interventions. Multiple breast cancer risk prediction models are used in clinical practice, and often provide a range of different predictions for the same patient. Integrating information from different models may improve the accuracy of predictions, which would be valuable for both clinicians and patients. BRCAPRO is a widely used model that predicts breast cancer risk based on detailed family history information. A major limitation of this model is that it does not consider non-genetic risk factors. To address this limitation, we expand BRCAPRO by combining it with another popular existing model, BCRAT (i.e., Gail), which uses a largely complementary set of risk factors, most of them non-genetic. We consider two approaches for combining BRCAPRO and BCRAT: (1) modifying the penetrance (age-specific probability of developing cancer given genotype) functions in BRCAPRO using relative hazard estimates from BCRAT, and (2) training an ensemble model that takes BRCAPRO and BCRAT predictions as input. Using both simulated data and data from Newton-Wellesley Hospital and the Cancer Genetics Network, we show that the combination models are able to achieve performance gains over both BRCAPRO and BCRAT. In the Cancer Genetics Network cohort, we show that the proposed BRCAPRO + BCRAT penetrance modification model performs comparably to IBIS, an existing model that combines detailed family history with non-genetic risk factors.
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Affiliation(s)
- Zoe Guan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
| | | | - Anne Marie McCarthy
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kevin Hughes
- Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Alan Semine
- Advanced Image Enhancement, Fall River, MA 02720, USA
| | - Hajime Uno
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Lorenzo Trippa
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Giovanni Parmigiani
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Danielle Braun
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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13
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Comeaux JG, Culver JO, Lee JE, Dondanville D, McArthur HL, Quinn E, Gorman N, Ricker C, Li M, Lerman C. Risk‐reducing mastectomy decisions among women with mutations in high‐ and moderate‐ penetrance breast cancer susceptibility genes. Mol Genet Genomic Med 2022; 10:e2031. [PMID: 36054727 PMCID: PMC9544212 DOI: 10.1002/mgg3.2031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/08/2022] [Accepted: 07/25/2022] [Indexed: 12/02/2022] Open
Abstract
Background Women harboring mutations in breast cancer susceptibility genes are at increased lifetime risk of developing breast cancer and are faced with decisions about risk management, including whether to undergo high‐risk screening or risk‐reducing mastectomy (RRM). National guidelines recommend BRCA1 or BRCA2 mutation carriers consider RRM, but that carriers of moderate penetrance mutations (e.g., ATM or CHEK2) should be managed based on family history. We aimed to investigate determinants of decision for RRM, and hypothesized that mutation status, age, family history, partner status, and breast cancer would impact RRM decision making. Methods We performed a retrospective study assessing RRM decisions for 279 women. Results Women with BRCA and moderate penetrance gene mutations, a personal history of breast cancer, or a first degree relative with a history of breast cancer were more likely to undergo RRM. Breast cancer status and age showed an interaction effect such that women with breast cancer were less likely to undergo RRM with increasing age. Conclusion Although national guidelines do not recommend RRM for moderate penetrance carriers, the rates of RRM for this population approached those for BRCA mutation carriers. Further insights are needed to better support RRM decision‐making in this population.
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Affiliation(s)
- Jacob G. Comeaux
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Julie O. Culver
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - John E. Lee
- Samuel Oschin Cancer CenterCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | | | - Heather L. McArthur
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Emily Quinn
- Human Genetics and GenomicsKeck Graduate InstituteClaremontCaliforniaUSA
| | - Nicholas Gorman
- Human Genetics and GenomicsKeck Graduate InstituteClaremontCaliforniaUSA
| | - Charité Ricker
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Ming Li
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Caryn Lerman
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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14
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Warner NZ, Groarke A. A qualitative reflexive thematic analysis into the experiences of being identified with a BRCA1/2 gene alteration: "So many little, little traumas could have been avoided". BMC Health Serv Res 2022; 22:1007. [PMID: 35933387 PMCID: PMC9357316 DOI: 10.1186/s12913-022-08372-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/20/2022] [Indexed: 12/05/2022] Open
Abstract
Background BRCA1/2 alterations increase females’ lifetime breast cancer risk to 40 – 90%, ovarian cancer to 10 – 60%, and males’ lifetime prostate cancer risk to ~ 10 – 25%. Psychosocial issues such as heightened distress can, therefore, occur in this population. This study aimed to explore the subjective experiences and needs of the BRCA1/2 alteration population in navigating cancer risk reduction measures. Method This study aimed to explore the experiences and identify the needs of 18 BRCA1/2 alteration carriers, recruited through strategic sampling. A public and patient panel (N = 6) collaborated on study development. Data were analysed using reflexive thematic analysis. Results Two themes were identified: (i) Healthcare Services as a Burden to Navigate, and (ii) Burden Experienced Through Interactions with Healthcare Professionals. Results indicated uncertainty regarding care pathways, alongside a lack of relevant information. Participants felt unsupported by healthcare professionals, and as though healthcare professionals often perceive them as a burden. Conclusions These findings suggest that the quality of interactions in healthcare systems are of relevance to the BRCA1/2 alteration population, and that uncertainty surrounding access to services and information is prevalent. The establishment of specialist hereditary cancer clinics could reduce such burden. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08372-w.
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Affiliation(s)
| | - AnnMarie Groarke
- School of Psychology, National University of Ireland, Galway, Ireland
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15
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Bommer C, Lupatsch J, Bürki N, Schwenkglenks M. Cost-utility analysis of risk-reducing strategies to prevent breast and ovarian cancer in BRCA-mutation carriers in Switzerland. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:807-821. [PMID: 34767113 PMCID: PMC9170622 DOI: 10.1007/s10198-021-01396-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 10/21/2021] [Indexed: 05/02/2023]
Abstract
OBJECTIVE We aimed to identify the most cost-effective of all prophylactic measures available in Switzerland for women not yet affected by breast and ovarian cancer who tested positive for a BRCA1/2 mutation. METHODS Prophylactic bilateral mastectomy (PBM), salpingo-oophorectomy (PBSO), combined PBM&PBSO and chemoprevention (CP) initiated at age 40 years were compared with intensified surveillance (IS). A Markov model with a life-long time horizon was developed from the perspective of the Swiss healthcare system using mainly literature-derived data to evaluate costs, quality-adjusted life years (QALYs) and survival. Costs and QALYs were discounted by 3% per year. Robustness of the results was tested with deterministic and probabilistic sensitivity analyses. RESULTS All prophylactic measures were found to be cost-saving with an increase in QALYs and life years (LYs) compared to IS. PBM&PBSO were found to be most cost-effective and dominated all other strategies in women with a BRCA1 or BRCA2 mutation. Lifetime costs averaged to 141,293 EUR and 14.5 QALYs per woman with a BRCA1 mutation under IS, versus 76,639 EUR and 19.2 QALYs for PBM&PBSO. Corresponding results for IS per woman with a BRCA2 mutation were 102,245 EUR and 15.5 QALYs, versus 60,770 EUR and 19.9 QALYs for PBM&PBSO. The results were found to be robust in sensitivity analysis; no change in the dominant strategy for either BRCA-mutation was observed. CONCLUSION All more invasive strategies were found to increase life expectancy and quality of life of women with a BRCA1 or BRCA2 mutation and were cost-saving for the Swiss healthcare system compared to IS.
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Affiliation(s)
- Claudine Bommer
- University of Zurich, Zürich, Switzerland.
- Department of Gynaecological Oncology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Judith Lupatsch
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
| | - Nicole Bürki
- Gynaecological Tumor Center, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Matthias Schwenkglenks
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
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16
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Sun L, Cui B, Wei X, Sadique Z, Yang L, Manchanda R, Legood R. Cost-Effectiveness of Genetic Testing for All Women Diagnosed with Breast Cancer in China. Cancers (Basel) 2022; 14:cancers14071839. [PMID: 35406611 PMCID: PMC8997428 DOI: 10.3390/cancers14071839] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Unselected multigene testing at breast cancer (BC) diagnosis has been reported to be cost-effective compared with family history (FH)/clinical-criteria-based testing in high-income countries such as the US and UK. Chinese patients are younger than Caucasian women at diagnosis, tending to have a higher gene mutation prevalence, and the family size and number of female relatives are smaller due to the one-child policy (which has been changed) in China. Therefore, offering genetic testing for BC patients could potentially prevent more cancer cases and deaths in China. However, the health economic evidence for multigene testing at BC diagnosis in China is lacking. The aim of the current study was to evaluate the cost-effectiveness of three genetic testing strategies among BC patients using a microsimulation model at the individual level in China. We found that offering unselected multigene testing to all BC patients in China is highly cost-effective compared with FH/clinical-criteria-based testing or no testing from both the societal and payer perspectives. Abstract Unselected multigene testing for all women with breast cancer (BC) identifies more cancer susceptibility gene (CSG) carriers who can benefit from precision prevention compared with family history (FH)/clinical-criteria-based guidelines. Very little CSG testing is undertaken in middle-income countries such as China, and its cost-effectiveness remains unaddressed. We aimed to estimate cost-effectiveness and population impact of multigene testing for all Chinese BC patients. Data from 8085 unselected BC patients recruited to a Peking University Cancer Hospital study were used for microsimulation modeling, comparing three strategies in the Chinese setting: all BC women undergo BRCA1/BRCA2/PALB2 genetic testing, only BC women fulfilling FH/clinical criteria undergo BRCA testing, and no genetic testing. Prophylactic mastectomy and salpingo-oophorectomy would be adopted where appropriate. Societal and payer perspectives with a lifetime horizon along with sensitivity analyses were presented. Incremental cost-effectiveness ratio (ICER): incremental cost per quality-adjusted life-year (QALY) gained is compared to the USD 10,260/QALY (one-times GDP per capita) willingness-to-pay threshold. BC incidence, ovarian cancer (OC) incidence, and related deaths were also estimated. FH/clinical-criteria-based BRCA testing was ruled out on the principle of extensive dominance. Compared with no genetic testing, multigene testing for all BC patients had an ICER = USD 4506/QALY (societal perspective) and USD 7266/QALY (payer perspective), well below our threshold. Probabilistic sensitivity analysis showed unselected multigene testing remained cost-effective for 94.2%/86.6% of simulations from the societal and payer perspectives. One year’s unselected multigene testing could prevent 7868 BC/OC cases and 5164 BC/OC deaths in China. Therefore, unselected multigene testing is extremely cost-effective and should be offered to all Chinese women with BC.
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Affiliation(s)
- Li Sun
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
- Wolfson Institute for Population Health, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK
| | - Bin Cui
- School of Public Health, Peking University, Beijing 100191, China
| | - Xia Wei
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
- Wolfson Institute for Population Health, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK
- School of Public Health, Peking University, Beijing 100191, China
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
| | - Li Yang
- School of Public Health, Peking University, Beijing 100191, China
| | - Ranjit Manchanda
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
- Wolfson Institute for Population Health, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
- Department of Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
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17
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Ro V, McGuinness JE, Guo B, Trivedi MS, Jones T, Chung WK, Rao R, Levinson E, Koval C, Russo D, Chilton I, Kukafka R, Crew KD. Association Between Genetic Testing for Hereditary Breast Cancer and Contralateral Prophylactic Mastectomy Among Multiethnic Women Diagnosed With Early-Stage Breast Cancer. JCO Oncol Pract 2022; 18:e472-e483. [PMID: 34705516 PMCID: PMC9014479 DOI: 10.1200/op.21.00322] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Increasing usage of multigene panel testing has identified more patients with pathogenic or likely pathogenic (P or LP) variants in low-moderate penetrance genes or variants of uncertain significance (VUS). Our study evaluates the association between genetic test results and contralateral prophylactic mastectomy (CPM) among patients with breast cancer. METHODS We conducted a retrospective cohort study among women diagnosed with unilateral stage 0-III breast cancer between 2013 and 2020 who underwent genetic testing. We examined whether genetic test results were associated with CPM using multivariable logistic regression models. RESULTS Among 707 racially or ethnically diverse women, most had benign or likely benign (B or LB) variants, whereas 12.5% had P or LP and 17.9% had VUS. Racial or ethnic minorities were twice as likely to receive VUS. Patients with P or LP variants had higher CPM rates than VUS or B or LB (64.8% v 25.8% v 25.9%), and highest among women with P or LP variants in high-penetrance genes (74.6%). On multivariable analysis, P or LP compared with B or LB variants were significantly associated with CPM (odds ratio = 4.24; 95% CI, 2.48 to 7.26). CONCLUSION Women with P or LP variants on genetic testing were over four times more likely to undergo CPM than B or LB. Those with VUS had similar CPM rates as B or LB. Our findings suggest appropriate genetic counseling and communication of cancer risk to multiethnic breast cancer survivors.
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Affiliation(s)
- Vicky Ro
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY,Vicky Ro, MD, MPH, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032; e-mail:
| | - Julia E. McGuinness
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Boya Guo
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Meghna S. Trivedi
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Tarsha Jones
- Christine E Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL
| | - Wendy K. Chung
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY,Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Roshni Rao
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY,Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Elana Levinson
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY,Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Carrie Koval
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY,Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Donna Russo
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY,Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Ilana Chilton
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY,Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY,Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY,Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | - Katherine D. Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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18
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Simões Corrêa Galendi J, Kautz-Freimuth S, Stock S, Müller D. Uptake Rates of Risk-Reducing Surgeries for Women at Increased Risk of Hereditary Breast and Ovarian Cancer Applied to Cost-Effectiveness Analyses: A Scoping Systematic Review. Cancers (Basel) 2022; 14:cancers14071786. [PMID: 35406563 PMCID: PMC8997187 DOI: 10.3390/cancers14071786] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 01/09/2023] Open
Abstract
Simple Summary For women who have tested positive for BRCA mutations, the decision to make use of preventive surgical options, such as risk-reducing mastectomy (RRM) or risk-reducing bilateral salpingo-oophorectomy (RRSO), depends on the women’s personal preferences and the cultural/social context. Among others, the cost-effectiveness of RRM and RRSO can be affected by the uptake rate of these preventive surgical options. Uptake rates of surgery should be given more attention in the conceptualization of health economic modeling studies for RRM and RRSO. Prospective multicenter studies are recommended to reflect regional and national variations in women’s preferences for preventive surgery. Abstract The cost-effectiveness of genetic screen-and-treat strategies for women at increased risk for breast and ovarian cancer often depends on the women’s willingness to make use of risk-reducing mastectomy (RRM) or salpingo-oophorectomy (RRSO). To explore the uptake rates of RRM and RRSO applied in health economic modeling studies and the impact of uptake rates on the incremental cost-effectiveness ratios (ICER), we conducted a scoping literature review. In addition, using our own model, we conducted a value of information (VOI) analysis. Among the 19 models included in the review, the uptake rates of RRM ranged from 6% to 47% (RRSO: 10% to 88%). Fifty-seven percent of the models applied retrospective data obtained from registries, hospital records, or questionnaires. According to the models’ deterministic sensitivity analyses, there is a clear trend that a lower uptake rate increased the ICER and vice versa. Our VOI analysis showed high decision uncertainty associated with the uptake rates. In the future, uptake rates should be given more attention in the conceptualization of health economic modeling studies. Prospective studies are recommended to reflect regional and national variations in women’s preferences for preventive surgery.
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19
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Bellcross CA. Hereditary Breast and Ovarian Cancer. Obstet Gynecol Clin North Am 2022; 49:117-147. [DOI: 10.1016/j.ogc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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20
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Vasigh M, Eslami B, Elahi A, Kaviani A, Shirkoohi R, Majidzadeh K, Nazarian N, Omranipour R. Evaluation of the indication of BRCA1/2 genetic tests in Iranian women and acceptance rate of risk-reducing surgeries in BRCA mutation carriers. Mol Genet Genomic Med 2022; 10:e1867. [PMID: 35023322 PMCID: PMC8830810 DOI: 10.1002/mgg3.1867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/02/2021] [Accepted: 12/14/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND A higher risk for breast and ovarian cancer has been reported in BRCA carriers and prophylactic surgeries are proposed to reduce this risk. This retrospective cohort study has evaluated the indication of BRCA1/2 genetic tests in Iranian women and the rate of women's acceptance of prophylactic surgeries recommended by the surgeon. METHODS Medical records of 147 high-risk women according to NCCN clinical practice guidelines who referred for BRCA mutations testing were assessed. Individual information, indications for BRCA1/2 genetic testing and their results, physician recommendations, and type of accepted surgery were registered. To evaluate the current status of women an active visit follow-up every six months was conducted. RESULTS The mean age of women was 43.40 ± 10.94 and the median follow-up time was 1.92 years. Genetic test results showed 49(33.3%) women were positive for either BRCA1/2 mutations. Although the occurrence of breast cancer younger than 40 was the most common indication for genetic tests (26.5%), positive breast cancer history in first-degree relatives and two relatives younger than 50 was the most common indications with positive results. The rate of acceptance of prophylactic mastectomy and bilateral salpingo-oophorectomy was (14.3% and 34.7%) in BRCA mutation carriers. CONCLUSION If the onset of breast cancer at a young age (less than 40) will be the only indication for a BRCA analysis, the rate of a positive result (12.8%) is very low. Further studies are warranted to evaluate the age limit for genetic testing in our country. Prophylactic mastectomy acceptance is very low in BRCA1/2 carriers in our centers.
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Affiliation(s)
- Mahtab Vasigh
- Breast Disease Research Center, Cancer Institute,Tehran University of Medical Sciences, Tehran, Iran
| | - Bita Eslami
- Breast Disease Research Center, Cancer Institute,Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Elahi
- Department of Surgery, Alborz University of Medical Sciences, Karaj, Iran
| | - Ahmad Kaviani
- Breast Disease Research Center, Cancer Institute,Tehran University of Medical Sciences, Tehran, Iran.,Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Department of Surgical Oncology, University de Montreal, Montreal, Canada
| | - Reza Shirkoohi
- Department of Molecular Genetics, Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Keivan Majidzadeh
- Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Newsha Nazarian
- Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Ramesh Omranipour
- Breast Disease Research Center, Cancer Institute,Tehran University of Medical Sciences, Tehran, Iran.,Department of Surgical Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
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21
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Uptake and timing of risk-reducing salpingo-oophorectomy among patients with BRCA1 and BRCA2 mutations. Am J Obstet Gynecol 2021; 225:508.e1-508.e10. [PMID: 34171390 DOI: 10.1016/j.ajog.2021.06.070] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND In women with BRCA mutations, risk-reducing bilateral salpingo-oophorectomy has been shown to decrease gynecologic cancer-specific and overall mortality. The National Comprehensive Cancer Network recommends that patients with BRCA mutations undergo risk-reducing bilateral salpingo-oophorectomy between the ages of 35 and 40 years for BRCA1 mutation carriers and between the ages of 40 and 45 years for BRCA2 mutation carriers or after childbearing is complete. Currently, uptake and timing of risk-reducing bilateral salpingo-oophorectomy and reasons for delays in risk-reducing bilateral salpingo-oophorectomy are not well understood. OBJECTIVE We sought to evaluate uptake and timing of risk-reducing bilateral salpingo-oophorectomy among women with BRCA1 and BRCA2 mutations concerning the National Comprehensive Cancer Network guidelines and reasons for delays in risk-reducing bilateral salpingo-oophorectomy. STUDY DESIGN In this retrospective chart review, we identified women with BRCA1 and BRCA2 mutations who discussed risk-reducing bilateral salpingo-oophorectomy with a provider between 2012 and 2021. Uptake of risk-reducing bilateral salpingo-oophorectomy was documented, and patients were classified as having timely or delay in risk-reducing bilateral salpingo-oophorectomy based on the National Comprehensive Cancer Network guidelines. For those with delay in risk-reducing bilateral salpingo-oophorectomy, reasons cited for delay were collected. Comparative statistical analyses were performed to evaluate characteristics of those with timely vs delayed risk-reducing bilateral salpingo-oophorectomy. A multivariable logistic regression model was used to evaluate the associations among factors related to timing of risk-reducing bilateral salpingo-oophorectomy. RESULTS We identified 638 BRCA1 and BRCA2 mutation carriers seen between 2012 and 2021. Of these patients, 306 (48.0%) had undergone risk-reducing bilateral salpingo-oophorectomy and 332 (52.0%) had not. When evaluating the timing of risk-reducing bilateral salpingo-oophorectomy, 136 (21.3%) underwent timely risk-reducing bilateral salpingo-oophorectomy, 239 (37.5%) had delays in risk-reducing bilateral salpingo-oophorectomy, and 263 (41.2%) had not undergone risk-reducing bilateral salpingo-oophorectomy but were younger than the National Comprehensive Cancer Network age guidelines; therefore, they were neither timely nor delayed. Patients with delay in risk-reducing bilateral salpingo-oophorectomy were significantly older at the time of genetic testing than those with timely risk-reducing bilateral salpingo-oophorectomy (mean, 49.8 vs 36.3 years; P<.001). Of the 306 patients who underwent risk-reducing bilateral salpingo-oophorectomy, those with delayed risk-reducing bilateral salpingo-oophorectomy had a significantly shorter interval between BRCA identification and risk-reducing bilateral salpingo-oophorectomy than those with timely risk-reducing bilateral salpingo-oophorectomy (median, 8.7 vs 17.6 months; P<.001). Patients with delay in risk-reducing bilateral salpingo-oophorectomy were more likely to have a personal history of cancer than those with timely risk-reducing bilateral salpingo-oophorectomy (49.8% vs 37.5%; P=.028). Of the 239 women with delay in risk-reducing bilateral salpingo-oophorectomy, 188 (78.7%) had delayed BRCA mutation identification, 29 (12.1%) had menopausal concerns, 17 (7.1%) had ongoing cancer treatment, 12 (5.0%) had coordination with breast surgery, 20 (8.4%) had miscellaneous reasons, and 19 (7.9%) had no reason documented. In the multivariate model, older age at BRCA diagnosis (odds ratio, 0.73; 95% confidence interval, 0.68-0.78; P<.001) was significantly associated with delayed risk-reducing bilateral salpingo-oophorectomy timing; those with BRCA2 mutation type were 7.54 times as likely to have timely risk-reducing bilateral salpingo-oophorectomy than BRCA1 mutation carriers (odds ratio, 7.54; 95% confidence, 3.70-16.42; P<.001). CONCLUSION Nearly 38% of BRCA1 and BRCA2 mutation carriers undergo or have yet to undergo risk-reducing bilateral salpingo-oophorectomy over the recommended National Comprehensive Cancer Network age. The most common reason for the delay in risk-reducing bilateral salpingo-oophorectomy was delayed identification of BRCA mutation, noted in 79% of patients with delayed risk-reducing bilateral salpingo-oophorectomy. Timely genetic testing for eligible patients can increase appropriately timed risk-reducing bilateral salpingo-oophorectomy for the prevention of ovarian cancer and reduction of mortality in BRCA mutation carriers.
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Conduit C, Milne RL, Friedlander ML, Phillips KA. Bilateral Salpingo-oophorectomy and Breast Cancer Risk for BRCA1 and BRCA2 Mutation Carriers: Assessing the Evidence. Cancer Prev Res (Phila) 2021; 14:983-994. [PMID: 34348913 PMCID: PMC9662899 DOI: 10.1158/1940-6207.capr-21-0141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/24/2021] [Accepted: 07/20/2021] [Indexed: 01/07/2023]
Abstract
Without preventive interventions, women with germline pathogenic variants in BRCA1 or BRCA2 have high lifetime risks for breast cancer and tubo-ovarian cancer. The increased risk for breast cancer starts at a considerably younger age than that for tubo-ovarian cancer. Risk-reducing bilateral salpingo-oophorectomy (rrBSO) is effective in reducing tubo-ovarian cancer risk for BRCA1 and BRCA2 mutation carriers, but whether it reduces breast cancer risk is less clear. All studies of rrBSO and breast cancer risk are observational in nature and subject to various forms of bias and confounding, thus limiting conclusions that can be drawn about causation. Early studies supported a statistically significant protective association for rrBSO on breast cancer risk, which is reflected by several international guidelines that recommend consideration of premenopausal rrBSO for breast cancer risk reduction. However, these historical studies were hampered by the presence of several important biases, including immortal person-time bias, confounding by indication, informative censoring, and confounding by other risk factors, which may have led to overestimation of any protective benefit. Contemporary studies, specifically designed to reduce some of these biases, have yielded contradictory results. Taken together, there is no clear and consistent evidence for a role of premenopausal rrBSO in reducing breast cancer risk in BRCA1 or BRCA2 mutation carriers.
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Affiliation(s)
- Ciara Conduit
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Roger L. Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.,Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Michael L. Friedlander
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Barker St. Randwick, New South Wales, Australia
| | - Kelly-Anne Phillips
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia.,Corresponding Author: Kelly-Anne Phillips, Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St., Melbourne, Victoria, 3000, Australia. Phone: 613-8559-7902; Fax: 613-8559-7739; E-mail:
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Uptake and timing of bilateral and contralateral risk-reducing mastectomy in women with Li-Fraumeni syndrome. Breast Cancer Res Treat 2021; 191:159-167. [PMID: 34652547 DOI: 10.1007/s10549-021-06410-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Women with Li-Fraumeni Syndrome (LFS) often consider risk-reducing mastectomy (RRM) due to extremely high risk of breast cancer at early ages. Data on uptake of RRM in LFS are scarce, and are inferred from experience in women with pathogenic variants (PVs) in BRCA1/2, despite differences in cancer risks. This study evaluated RRM uptake in a cohort of women with LFS. METHODS Women (n = 205) with LFS enrolled in NCI's LFS study reported lifetime cancer diagnoses and mastectomies and completed questionnaires regarding reproductive history, cancer worry and risk perceptions. A subset of women participating in an annual cancer screening study received counseling regarding RRM. RESULTS 65% (n = 71) of women diagnosed with presumed unilateral breast cancer (n = 109) underwent contralateral RRM over their lifetime. Nearly half (49%, n = 25) of the women who did not complete contralateral RRM within one year of their breast cancer diagnosis (n = 51) developed contralateral breast cancer (median interval = 6 years). Only 18.5% (n = 15) of women without breast cancer history (n = 81) underwent bilateral RRM. Median age at bilateral RRM of 39 years was sub-optimal for breast cancer risk reduction. Contralateral RRM was associated with early genetic diagnosis, participation in the screening study, and fewer prior cancers. Bilateral RRM uptake was associated with having had children, having breastfed, and high cancer worry. CONCLUSION Uptake of contralateral RRM is high in women with LFS. The frequency of contralateral breast cancer necessitates active discussion of benefits of contralateral RRM and counseling regarding bilateral RRM should be tailored to the early age at risk of breast cancer onset in LFS. There is a need for research into the survival and long-term benefits of RRM in LFS.
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Hur YM, Mun J, Kim MK, Lee M, Kim YH, Kim SC. Disparities between Uptake of Germline BRCA1/ 2 Gene Tests and Implementation of Post-test Management Strategies in Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer Patients. J Korean Med Sci 2021; 36:e241. [PMID: 34609091 PMCID: PMC8490789 DOI: 10.3346/jkms.2021.36.e241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/08/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND To assess the rate of germline BRCA gene tests in epithelial ovarian cancer (EOC) patients and uptake of post-test risk management strategies in BRCA1/2-mutated patients. METHODS Institutional databases were searched to identify patients who were diagnosed with epithelial ovarian, fallopian tube, or primary peritoneal cancer (EOC) between 2009 and 2019 in two academic hospitals. Retrospective review on medical records was performed to collect clinico-pathologic variables, including performance of germline BRCA gene test and its results, as well as conduct of breast cancer screening tests and cascade testing. If annual mammography +/- breast ultrasonography was performed, it was considered that regular breast cancer surveillance was done. RESULTS A total of 840 women with EOC were identified during the study period. Of these, 454 patients (54.0%) received BRCA gene testing and 106 patients (106/454, 23.3%) were positive for BRCA1/2 mutations. The rate of BRCA tests has markedly increased from 25.8% in 2009-2012 to 62.7% in 2017-2019. Among the 93 patients with BRCA1/2 mutation without previous personal breast cancer history, 20 patients (21.5%) received annual mammography with or without breast ultrasonography for regular surveillance. Among the 106 BRCA1/2-mutated EOC patients, cascade testing on family members was performed only in 13 patients (12.3%). CONCLUSION Although BRCA1/2 gene tests have been substantially expanded, the uptake of post-test risk management strategies, including breast cancer screening for BRCA1/2-mutated patients and cascade testing for family members, has remained low. Strategies to increase its uptake and education about the importance of post-test risk managements are needed.
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Affiliation(s)
- Young Min Hur
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jaehee Mun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Mi-Kyung Kim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea.
| | - Maria Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Hwan Kim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Seung-Cheol Kim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
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Uptake of bilateral-risk-reducing-mastectomy: Prospective analysis of 7195 women at high-risk of breast cancer. Breast 2021; 60:45-52. [PMID: 34464846 PMCID: PMC8406355 DOI: 10.1016/j.breast.2021.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/21/2022] Open
Abstract
Background Bilateral-Risk-Reducing-Mastectomy-(BRRM) is well described in BRCA1/2 pathogenic variant carriers. However, little is known about the relative uptake, time trends or factors influencing uptake in those at increased breast cancer risk not known to be carriers. The aim of this study is to assess these factors in both groups. Methods BRRM uptake was assessed from entry to the Manchester Family History Clinic or from date of personal BRCA1/2 test. Follow up was censored at BRRM, breast cancer diagnosis, death or January 01, 2020. Cumulative incidence and cause specific and competing risk regression analyses were used to assess the significance of factors associated with BRRM. Results Of 7195 women at ≥25% lifetime breast cancer risk followed for up to 32 years, 451 (6.2%) underwent pre-symptomatic BRRM. Of those eligible in different risk groups the 20-year uptake of BRRM was 47.7%-(95%CI = 42.4–53.2%) in 479 BRCA1/2 carriers; 9.0% (95%CI = 7.26–11.24%) in 1261 women at ≥40% lifetime risk (non-BRCA), 4.8%-(95%CI = 3.98–5.73%) in 3561 women at 30–39% risk and 2.9%-(95%CI = 2.09–4.09%) in 1783 women at 25–29% lifetime risk. In cause-specific Cox regression analysis death of a sister with breast cancer<50 (OR = 2.4; 95%CI = 1.7–3.4), mother<60 (OR = 1.9; 95%CI = 1.5–2.3), having children (OR = 1.4; 95%CI = 1.1–1.8), breast biopsy (OR = 1.4; 95%CI = 1.0–1.8) were all independently associated with BRRM uptake, while being older at assessment was less likely to be associated with BRRM (>50; OR = 0.26,95%CI = 0.17–0.41). Uptake continued to rise to 20 years from initial risk assessment. Conclusion We have identified several additional factors that correlate with BRRM uptake and demonstrate continued increases over time. These factors will help to tailor counselling and support for women. BRRM continues even 20 years post original breast cancer risk assessment. Potential triggers include death of mother/sister, children and a breast biopsy. Uptake is clearly informed by lifetime risk of BC and higher in younger the women.
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Padamsee TJ, Meadows R, Hils M. Layers of information: interacting constraints on breast cancer risk-management by high-risk African American women. ETHNICITY & HEALTH 2021; 26:787-810. [PMID: 30589360 PMCID: PMC9529154 DOI: 10.1080/13557858.2018.1562053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/20/2018] [Indexed: 06/09/2023]
Abstract
Objectives: To understand how various decision-making dynamics interact to shape the risk-management choices of African American women at high-risk of breast cancer, and to explore whether African American and White women have differential access to the information and interactions that promote proactive, confident risk-management behavior.Design: This paper draws on 50 original in-depth, semi-structured interviews with African American and White women at elevated risk of breast cancer. We used inductive grounded-theory methodology to explore the processes by which women make risk-management decisions and to compare those processes between racial groups. Moving backward from women's decisions about whether or not to engage in specific risk-management behaviors, we explored the patterns that underlie behavioral decisions.Results: We find that decisions to engage in risk-management behavior rest on three accumulated layers of information. The layer most proximal to making risk-management decisions involves specific information about risk-management options; the middle layer involves general information about managing breast cancer risk; and the foundational layer involves personal perceptions of breast cancer risk and prevention. African American and White women experience distinct dynamics at each of these levels, and these differences may help explain racial differences in risk-management behavior. Compared to their White counterparts, African American women faced additional burdens at every step along the risk-management journey.Conclusion: These findings suggest that information gathering is more complex than has previously been addressed, that information access and provider access are closely related, and that African American women may be systematically disadvantaged with respect to information-generating experiences. Preventing cancer morbidity and mortality requires that all high-risk women have access to the layers of information necessary to engage in cancer screenings and preventive interventions. These results exemplify the ways that structural, social, and interpersonal inequalities combine to influence risk-management choices.
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Affiliation(s)
- Tasleem J. Padamsee
- Corresponding Author. 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, United States; ; Phone: 1-614-688-0986; Fax: 1-614-247-1846
| | - Rachel Meadows
- Suite 525 Gateway Building C, 1590 N High Street, Columbus, OH 43201, United States
| | - Megan Hils
- 282-2 Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, United States
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No Association of Early-Onset Breast or Ovarian Cancer with Early-Onset Cancer in Relatives in BRCA1 or BRCA2 Mutation Families. Genes (Basel) 2021; 12:genes12071100. [PMID: 34356116 PMCID: PMC8305427 DOI: 10.3390/genes12071100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/24/2021] [Accepted: 07/14/2021] [Indexed: 11/16/2022] Open
Abstract
According to clinical guidelines, the occurrence of very early-onset breast cancer (VEO-BC) (diagnosed ≤ age 30 years) or VEO ovarian cancer (VEO-OC) (diagnosed ≤ age 40 years) in families with BRCA1 or BRCA2 mutation (BRCAm) prompts advancing the age of risk-reducing strategies in relatives. This study aimed to assess the relation between the occurrence of VEO-BC or VEO-OC in families with BRCAm and age at BC or OC diagnosis in relatives. We conducted a retrospective multicenter study of 448 consecutive families with BRCAm from 2003 to 2018. Mean age and 5-year–span distribution of age at BC or OC in relatives were compared in families with or without VEO-BC or VEO-OC. Conditional probability calculation and Cochran–Mantel–Haenszel chi-square tests were used to investigate early-onset cancer occurrence in relatives of VEO-BC and VEO-OC cases. Overall, 15% (19/245) of families with BRCA1m and 9% (19/203) with BRCA2m featured at least one case of VEO-BC; 8% (37/245) and 2% (2/203) featured at least one case of VEO-OC, respectively. The cumulative prevalence of VEO-BC was 5.1% (95% CI 3.6–6.6) and 2.5% (95% CI 1.4–3.6) for families with BRCA1m and BRCA2m, respectively. The distribution of age and mean age at BC diagnosis in relatives did not differ by occurrence of VEO-BC for families with BRCA1m or BRCA2m. Conditional probability calculations did not show an increase of early-onset BC in VEO-BC families with BRCA1m or BRCA2m. Conversely, the probability of VEO-BC was not increased in families with early-onset BC. VEO-BC or VEO-OC occurrence may not be related to young age at BC or OC onset in relatives in families with BRCAm. This finding—together with a relatively high VEO-BC risk for women with BRCAm—advocates for MRI breast screening from age 25 regardless of family history.
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Makhnoon S, Tran G, Levin B, Mattie KD, Dreyer B, Volk RJ, Grana G, Arun BK, Peterson SK. Uptake of cancer risk management strategies among women who undergo cascade genetic testing for breast cancer susceptibility genes. Cancer 2021; 127:3605-3613. [PMID: 34157779 DOI: 10.1002/cncr.33668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Uptake of cancer risk management based on inherited predispositions, which encompasses bilateral mastectomy (BLM), bilateral salpingo-oophorectomy (BSO), and intensified screening, is the primary motivation for cascade testing for hereditary breast and ovarian cancer (HBOC). However, long-term outcome data for cascade testers are lacking. METHODS Medical records were abstracted for all unaffected women with pathogenic variants in HBOC genes from 2 cancer hospitals (2013-2019) with at least 1 year of follow-up to compare the uptake of surgery and screening between cascade and noncascade testers. RESULTS Cascade testers (79.8%) were younger than noncascade testers (mean age, 37.6 vs 43.5 years; P = .002). Among women aged ≥40 years, 43% underwent BLM, and 71.6% underwent BSO, with no significant difference in uptake between cascade and noncascade testers. The mean time to BSO among cascade testers was shorter among women aged ≥40 years versus those aged <40 years (11.8 vs 31.9 months; P = .04); no such difference was observed among noncascade testers. Mammography and breast magnetic resonance imaging rates were low in the recorded 6 years for both groups after genetic counseling. CONCLUSIONS Management uptake among cascade testers is high with rates comparable to those for unaffected BRCA-positive women. A large proportion of women act on cascade test results, and this represents a novel report of utilization of cancer management strategies.
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Affiliation(s)
- Sukh Makhnoon
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace Tran
- Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brooke Levin
- William G. Rohrer Cancer Genetics Program, Division of Hematology and Medical Oncology, MD Anderson Cancer Center at Cooper University Health Care, Camden, New Jersey
| | - Kristin D Mattie
- William G. Rohrer Cancer Genetics Program, Division of Hematology and Medical Oncology, MD Anderson Cancer Center at Cooper University Health Care, Camden, New Jersey
| | | | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Generosa Grana
- William G. Rohrer Cancer Genetics Program, Division of Hematology and Medical Oncology, MD Anderson Cancer Center at Cooper University Health Care, Camden, New Jersey
| | - Banu K Arun
- Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Corrado G, Marchetti C, Scambia G, Fagotti A. Response to: Should we or should we not? Risk reduction bilateral salpingectomy for BRCA mutation carriers. Int J Gynecol Cancer 2021; 31:1097. [PMID: 33990354 DOI: 10.1136/ijgc-2021-002738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Giacomo Corrado
- Department of Woman, Child Health and Public Health, Gynecologic Oncology Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Claudia Marchetti
- Department of Woman, Child Health and Public Health, Gynecologic Oncology Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Istituto di Ostetricia e Ginecologia, Fondazione Policlinico Universitario A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Fagotti
- Istituto di Ostetricia e Ginecologia, Fondazione Policlinico Universitario A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Trends and timing of risk-reducing mastectomy uptake in unaffected BRCA1 and BRCA2 carriers in Slovenia. Eur J Surg Oncol 2021; 47:1900-1906. [PMID: 33812767 DOI: 10.1016/j.ejso.2021.03.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/22/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively investigated the rate, timing and longitudinal trends of bilateral RRM uptake and the incidence and types of cancers among unaffected BRCA carriers who underwent genetic counseling at the Institute of Oncology Ljubljana in Slovenia. MATERIALS AND METHODS Female BRCA carriers without personal history of cancer were included in the study. Clinical data on PV/LPV type, date of RRM, type of reconstructive procedure, occult carcinoma and histopathology results was collected and analyzed. RESULTS Of the 346 unaffected BRCA carriers (median age 43 years, 70% BRCA1, 30% BRCA2, median follow-up 46 months) who underwent genetic testing between October 1999 and December 2019, 25.1% had a RRM (range 35-50 years, median age at surgery 38 years). A significant difference in time to prophylactic surgery between women undergoing RRM only vs. women undergoing RRM combined with risk-reducing salpingo-oophorectomy was observed (22.6 vs 8.7 months, p = 0.0009). We observed an upward trend in the annual uptake in line with the previously observed Angelina Jolie effect. In 5.7% of cases, occult breast cancer was detected. No women developed breast cancer after RRM. Women who did not opt for surgical prevention developed BRCA1/2-related cancers (9.3%). CONCLUSION The uptake of RRM among unaffected BRCA carriers is 25.1% and is similar to our neighboring countries. No women developed breast cancer after RRM while women who did not opt for surgical prevention developed BRCA1/2 related cancers in 9.3% of cases. The reported data may provide meaningful aid for carriers when deciding on an optimal prevention strategy.
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Chae S, Kim EK, Jang YR, Lee AS, Kim SK, Suh DH, Kim K, No JH, Kim YB, Kim SW, Kang E. Effect of risk-reducing salpingo-oophorectomy on the quality of life in Korean BRCA mutation carriers. Asian J Surg 2021; 44:1056-1062. [PMID: 33573923 DOI: 10.1016/j.asjsur.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This study aimed to compare the quality of life (QOL), psychosocial status, sexual function, and menopausal symptoms between the risk-reducing salpingo-oophorectomy (RRSO) and non-RRSO groups comprising BRCA mutation carriers and to evaluate the effect of timing of RRSO on those aspects. METHODS This cross-sectional study recruited BRCA mutation carriers aged ≥35 years between September 2015 and September 2016. Demographic data of carriers were collected. Outcomes were measured using the questionnaires addressing QOL, anxiety, depression, optimism, sexual function, and menopausal symptoms. RESULTS Of 52 participants, 30 (57.7%) underwent RRSO, whereas 22 (42.3%) did not. In the RRSO group, 16 (53.3%) and 14 (46.7%) women underwent RRSO before and after menopause, respectively. The mean age in the RRSO group was higher than that in the non-RRSO group (49.8 vs. 42.1 years, respectively, p = 0.002). The scores for QOL, anxiety, depression, optimism, sexual function, and menopausal symptoms were similar between both groups. In the multivariate analysis, RRSO uptake was associated with worse physical QOL (coefficient, -5.350; 95% confidence interval, -10.593 to -0.108). With respect to the timing of RRSO, only the mental QOL was significantly lower in the postmenopausal RRSO group than in the premenopausal RRSO group (39.2 vs. 43.7, respectively, p = 0.043). CONCLUSION We could not find any difference in mental QOL, psychosocial status, sexual function, and menopausal symptoms between the RRSO and non-RRSO groups. RRSO uptake only affected worse physical QOL. These results will help physicians counsel BRCA mutation carriers about the effect of RRSO on QOL.
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Affiliation(s)
- Sumin Chae
- Department of Surgery, Kyung Hee University College of Medicine, Kyung Hee University Medical Center, Seoul, South Korea
| | - Eun-Kyu Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ye Rang Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Angela Soeun Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae Hong No
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong-Beom Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sung-Won Kim
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, South Korea
| | - Eunyoung Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
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Basu NN, Hodson J, Chatterjee S, Gandhi A, Wisely J, Harvey J, Highton L, Murphy J, Barnes N, Johnson R, Barr L, Kirwan CC, Howell S, Baildam AD, Howell A, Evans DG. The Angelina Jolie effect: Contralateral risk-reducing mastectomy trends in patients at increased risk of breast cancer. Sci Rep 2021; 11:2847. [PMID: 33531640 PMCID: PMC7854742 DOI: 10.1038/s41598-021-82654-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/21/2021] [Indexed: 11/10/2022] Open
Abstract
Contralateral risk-reducing mastectomy (CRRM) rates have tripled over the last 2 decades. Reasons for this are multi-factorial, with those harbouring a pathogenic variant in the BRCA1/2 gene having the greatest survival benefit. On May 14th, 2013, Angelina Jolie shared the news of her bilateral risk-reducing mastectomy (BRRM), on the basis of her BRCA1 pathogenic variant status. We evaluated the impact of this news on rates of CRRM in women with increased risk for developing breast cancer after being diagnosed with unilateral breast cancer. The prospective cohort study included all women with at least a moderate lifetime risk of developing breast cancer who attended our family history clinic (1987–2019) and were subsequently diagnosed with unilateral breast cancer. Rates of CRRM were then compared between patients diagnosed with breast cancer before and after Angelina Jolie’s announcement (pre- vs. post-AJ). Of 386 breast cancer patients, with a mean age at diagnosis of 48 ± 8 years, 268 (69.4%) were diagnosed in the pre-AJ period, and 118 (30.6%) in the post-AJ period. Of these, 123 (31.9%) underwent CRRM, a median 42 (interquartile range: 11–54) days after the index cancer surgery. Rates of CRRM doubled following AJ’s news, from 23.9% pre-AJ to 50.0% post AJ (p < 0.001). Rates of CRRM were found to decrease with increasing age at breast cancer (p < 0.001) and tumour TNM stage (p = 0.040), and to increase with the estimated lifetime risk of breast cancer (p < 0.001) and tumour grade (p = 0.015) on univariable analysis. After adjusting for these factors, the step-change increase in CRRM rates post-AJ remained significant (odds ratio: 9.61, p < 0.001). The AJ effect appears to have been associated with higher rates of CRRM amongst breast cancer patients with increased cancer risk. CRRM rates were highest amongst younger women and those with the highest lifetime risk profile. Clinicians need to be aware of how media news can impact on the delivery of cancer related services. Communicating objective assessment of risk is important when counselling women on the merits of risk-reducing surgery.
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Affiliation(s)
- Narendra Nath Basu
- University of Birmingham, Birmingham, B15 2TT, UK. .,University Hospital Birmingham NHS Trust, Mindelsohn Way, Birmingham, B15 2TH, UK.
| | - James Hodson
- University Hospital Birmingham NHS Trust, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - Shaunak Chatterjee
- University Hospital Birmingham NHS Trust, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - Ashu Gandhi
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Julie Wisely
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - James Harvey
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Lyndsey Highton
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - John Murphy
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Nicola Barnes
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Richard Johnson
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Lester Barr
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Cliona C Kirwan
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Sacha Howell
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, M20, UK
| | - Andrew D Baildam
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Anthony Howell
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, M20, UK
| | - D Gareth Evans
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, M20, UK.,NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK.,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Clinical Genetics Service, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK
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Simoes Correa-Galendi J, Del Pilar Estevez Diz M, Stock S, Müller D. Economic Modelling of Screen-and-Treat Strategies for Brazilian Women at Risk of Hereditary Breast and Ovarian Cancer. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:97-109. [PMID: 32537695 PMCID: PMC7790767 DOI: 10.1007/s40258-020-00599-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Clinical evidence supports the use of genetic counselling and BRCA1/2 testing for women at risk for hereditary breast and ovarian cancer. Currently, screen-and-treat strategies are not reimbursed in the Brazilian Unified Healthcare System (SUS). The aim of this modelling study was to evaluate the cost effectiveness of a gene-based screen-and-treat strategy for BRCA1/2 in women with a high familial risk followed by preventive interventions compared with no screening. METHODS Adopting the SUS perspective, a Markov model with a lifelong time horizon was developed for a cohort of healthy women aged 30 years that fulfilled the criteria for BRCA1/2 testing according to the National Comprehensive Cancer Network (NCCN) guideline. For women who tested positive, preventive options included intensified surveillance, risk-reducing bilateral mastectomy and bilateral salpingo-oophorectomy. The Markov model comprised the health states 'well', 'breast cancer', 'death' and two post-cancer states. Outcomes were the incremental costs per quality-adjusted life-year (QALY) and the incremental costs per life-year gained (LYG). Data were mainly obtained by a literature review. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of the results. RESULTS In the base case, the screen-and-treat strategy resulted in additional costs of 3515 Brazilian reais (R$) (US$1698) and a gain of 0.145 QALYs, compared with no screening. The incremental cost-effectiveness ratio (ICER) was R$24,263 (US$21,724) per QALY and R$27,258 (US$24,405) per LYG. Applying deterministic sensitivity analyses, the ICER was most sensitive to the probability of a positive test result and the discount rate. In the probabilistic sensitivity analysis, a willingness to pay of R$25,000 per QALY gained for the screen-and-treat strategy resulted in a probability of cost effectiveness of 80%. CONCLUSION Although there is no rigorous cost-effectiveness threshold in Brazil, the result of this cost-effectiveness analysis may support the inclusion of BRCA1/2 testing for women at high-risk of cancer in the SUS. The ICER calculated for the provision of genetic testing for BRCA1/2 approximates the cost-effectiveness threshold proposed by the World Health Organization (WHO) for low- and middle-income countries.
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Affiliation(s)
- Julia Simoes Correa-Galendi
- Institute for Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Sao Paulo, SP, Brazil.
| | - Maria Del Pilar Estevez Diz
- Insituto Do Cancer Do Estado de Sao Paulo, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Sao Paulo, SP, Brazil
| | - Dirk Müller
- Institute for Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Sao Paulo, SP, Brazil
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Jiang H, Robinson DL, Lee PVS, Krejany EO, Yates CJ, Hickey M, Wark JD. Loss of bone density and bone strength following premenopausal risk-reducing bilateral salpingo-oophorectomy: a prospective controlled study (WHAM Study). Osteoporos Int 2021; 32:101-112. [PMID: 32856124 DOI: 10.1007/s00198-020-05608-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 08/19/2020] [Indexed: 02/07/2023]
Abstract
UNLABELLED Prophylactic oophorectomy is recommended for women at high risk for ovarian cancer, but the associated impact on bone health is of clinical concern. This prospective, controlled study demonstrated substantial loss of bone density and bone strength following surgical menopause. Postoperative hormone therapy alleviated, but not fully prevented, spinal bone loss. INTRODUCTION This prospective study investigated bone health in women following premenopausal oophorectomy. METHODS Dual-energy x-ray absorptiometry (DXA), peripheral quantitative computed tomography (pQCT), and pQCT-based finite element analysis (pQCT-FEA) were used to assess bone health between systemic hormone therapy (HT) users and non-users after premenopausal risk-reducing bilateral salpingo-oophorectomy (RRBSO) compared with premenopausal controls over 24-month follow-up. RESULTS Mean age was 42.4 ± 2.6 years (n = 30) for the surgery group and 40.2 ± 6.3 years for controls (n = 42), and baseline bone measures were similar between groups. Compromised bone variables were observed at 24 months after RRBSO, among which areal bone mineral density (aBMD) at the lumbar spine, tibial volumetric cortical density (Crt vBMD), and tibial bending stiffness (kbend) had decreased by 4.7%, 1.0%, and 12.1%, respectively (all p < 0.01). In non-HT users, significant losses in lumbar spine (5.8%), total hip (5.2%), femoral neck (6.0%) aBMD, tibial Crt vBMD (2.3%), and kbend (14.8%) were observed at 24 months (all p < 0.01). HT prevented losses in kbend, tibial Crt vBMD, and aBMD, except for modest 2.3% loss at the lumbar spine (p = 0.01). CONCLUSION This prospective, controlled study of bone health following RRBSO or premenopausal oophorectomy demonstrated substantial loss of bone density and bone strength following RRBSO. HT prevented loss of bone density and bone stiffness, although there was still a modest decrease in lumbar spine aBMD in HT users. These findings may inform decision-making about RRBSO and clinical management following premenopausal oophorectomy.
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Affiliation(s)
- H Jiang
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, 3050, Australia
| | - D L Robinson
- Department of Biomedical Engineering, University of Melbourne, Parkville, Australia
| | - P V S Lee
- Department of Biomedical Engineering, University of Melbourne, Parkville, Australia
| | - E O Krejany
- Department of Obstetrics and Gynaecology, University of Melbourne and Royal Women's Hospital, Parkville, Australia
| | - C J Yates
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, 3050, Australia
- Bone and Mineral Medicine, Royal Melbourne Hospital, Parkville, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Australia
| | - M Hickey
- Department of Obstetrics and Gynaecology, University of Melbourne and Royal Women's Hospital, Parkville, Australia
| | - J D Wark
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, 3050, Australia.
- Bone and Mineral Medicine, Royal Melbourne Hospital, Parkville, Australia.
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Australia.
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Michaan N, Leshno M, Safra T, Sonnenblick A, Laskov I, Grisaru D. Cost Effectiveness of Whole Population BRCA Genetic Screening for Cancer Prevention in Israel. Cancer Prev Res (Phila) 2020; 14:455-462. [PMID: 33355193 DOI: 10.1158/1940-6207.capr-20-0411] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/16/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022]
Abstract
With the growing technical ease and reduction in genetic screening costs, whole population BRCA screening may be a feasible option. Our objective was to investigate the cost effectiveness of whole population screening for BRCA mutations in Israel, for varying degrees of BRCA carrier state. Lifetime costs of whole female population screening for BRCA mutation carrier state versus nonscreening were compared using a Markovian process decision analysis model. Model parameters including ovarian and breast cancer risks were obtained from previously published data. Screening and other treatment-related costs were received from the Israeli Ministry of Health pricing list according to specified codes. Quality-adjusted life years were used for cost-effectiveness analysis. Sensitivity analysis was conducted to evaluate model uncertainties, specifically varying degrees of BRCA prevalence. Results show that whole population BRCA screening in Israel is cost effective across a wide range of BRCA prevalence rates with an incremental cost-effectiveness ratio of 81,493 new Israeli Shekels for a BRCA prevalence of 2.5%, increasing to 250,000 new Israeli Shekels for a 0.75% prevalence rate, per quality-adjusted life year gained. Discount rate and population BRCA prevalence and rate of risk reduction salpingo-oophorectomy are the most influential parameters in the model. Whole population screening for BRCA mutations should be offered as part of general health screening strategies by national medical insurance providers, even for non-Ashkenazi Jews. Our algorithm can be applied for other countries, adjusting local costs of screening and treatment. PREVENTION RELEVANCE: Whole population BRCA mutation screening in Israel is cost effective across a wide prevalence rate and should be offered as part of general health screening strategies by national medical insurance providers for cancer prevention.
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Affiliation(s)
- Nadav Michaan
- Gynecologic Oncology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Moshe Leshno
- Gastro-enterology, Tel Aviv Sourasky Medical Center, Coller School of Management and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Safra
- Oncology Department, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Sonnenblick
- Oncology Department, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Laskov
- Gynecologic Oncology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Grisaru
- Gynecologic Oncology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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36
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Fong A, Cass I, John C, Gillen J, Moore KM, Gangi A, Walsh C, Li AJ, Rimel BJ, Karlan BY, Amersi F. Breast Cancer Surveillance Following Ovarian Cancer in BRCA Mutation Carriers. Am Surg 2020; 86:1243-1247. [DOI: 10.1177/0003134820964208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BRCA1 or 2 mutations result in higher cancer risk for breast cancer (BC) and epithelial ovarian cancer (EOC) for carriers than exists in the general population. Optimal breast imaging surveillance in these patients has not been well defined. An Institutional Review Board-approved, multi-institutional retrospective chart review was performed. Patients diagnosed with BRCA-associated EOC between 1990-2015 were identified; demographic and clinical data were collected and analyzed. 192 BRCA mutation–positive patients with EOC were identified. 16/192 (8.3%) women were diagnosed with BC following EOC, at a median of 50 (range 5-327) months following EOC diagnosis and median age 59.5 (45-84) years. Breast cancer was most commonly detected on mammogram 7/16 (44%) or clinical exam 7/16 (44%). 2/16 (12.5%) had occult BC found during risk-reducing mastectomy. 14 (88%) had early-stage (0-2) disease. At mean follow-up of 8.1 years, 6 (37.5%) patients with BC following EOC had died due to EOC. The risk of BC diagnosis following EOC in BRCA mutation carriers is low; most of these BCs are early stage and diagnosed with mammography or physical exam. Overall, survival in BRCA mutation carriers is dominated by EOC-related mortality. Breast cancer surveillance in BRCA mutation carriers following EOC should prioritize nonsurgical strategies.
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Affiliation(s)
- Abigail Fong
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ilana Cass
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | | | | | | | - Andrew J. Li
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Farin Amersi
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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37
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Lynce F, Schlam I, Geng X, Peshkin BN, Friedman S, Dutil J, Nahleh Z, Campos C, Ricker C, Rodriguez P, Denduluri N, Ahn J, Isaacs C, Graves KD. BRCA1/2 mutations and risk-reducing bilateral salpingo-oophorectomy among Latinas: The UPTAKE study. J Genet Couns 2020; 30:383-393. [PMID: 33010199 PMCID: PMC10064975 DOI: 10.1002/jgc4.1322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/27/2020] [Accepted: 08/06/2020] [Indexed: 11/08/2022]
Abstract
Bilateral salpingo-oophorectomy (BSO) is a risk management approach with strong evidence of mortality reduction for women with germline mutations in the tumor suppressor genes BRCA1 and BRCA2 (BRCA1/2). Few studies to date have evaluated uptake of BSO in women from diverse racial and ethnic backgrounds who carry BRCA1/2 mutations. The objective of the UPTAKE study was to explore rates and predictors of risk-reducing BSO among Latinas affected and unaffected with breast cancer who had a deleterious BRCA1/2 mutation. We recruited 100 Latina women with deleterious BRCA1/2 mutations from community hospitals, academic health systems, community, and advocacy organizations. Women completed interviews in Spanish or English. We obtained copies of genetic test reports for participants who provided signed medical release. After performing threefold cross-validation LASSO for variable selection, we used multiple logistic regression to identify demographic and clinical predictors of BSO. Among 100 participants, 68 had undergone BSO at the time of interview. Of these 68, 35 were US-born (61% of all US-born participants) and 33 were not (77% of the non-US-born participants). Among Latinas with BRCA1/2 mutations, older age (p = 0.004), personal history of breast cancer (p = 0.003), higher income (p = 0.002), and not having a full-time job (p = 0.027) were identified as variables significantly associated with uptake of BSO. Results suggest a high rate of uptake of risk-reducing BSO among a sample of Latinas with BRCA1/2 mutations living in the US. We document factors associated with BSO uptake in a diverse sample of women. Relevant to genetic counseling, our findings identify possible targets for supporting Latinas' decision-making about BSO following receipt of a positive BRCA1/2 test.
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Affiliation(s)
- Filipa Lynce
- Lombardi Comprehensive Cancer Center and Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ilana Schlam
- Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Xue Geng
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC, USA
| | - Beth N Peshkin
- Lombardi Comprehensive Cancer Center and Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA
| | - Sue Friedman
- Force - Facing Our Risk of Cancer Empowered, Tampa, FL, USA
| | - Julie Dutil
- Cancer Biology Division, Ponce Research Institute, Ponce Health Sciences University, Ponce, PR, USA
| | | | | | - Charité Ricker
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Patricia Rodriguez
- Virginia Cancer Specialists, Arlington, VA, USA.,US Oncology Network, Virginia, VA, USA
| | - Neelima Denduluri
- Virginia Cancer Specialists, Arlington, VA, USA.,US Oncology Network, Virginia, VA, USA
| | - Jaeil Ahn
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC, USA
| | - Claudine Isaacs
- Lombardi Comprehensive Cancer Center and Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA
| | - Kristi D Graves
- Lombardi Comprehensive Cancer Center and Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA
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Galmor L, Bernstein-Molho R, Sklair-Levy M, Madoursky-Feldman D, Zippel D, Laitman Y, Friedman E. Time trends in uptake rates of risk-reducing mastectomy in Israeli asymptomatic BRCA1 and BRCA2 mutation carriers. Breast Cancer Res Treat 2020; 185:391-399. [PMID: 33000375 DOI: 10.1007/s10549-020-05949-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The rate of risk-reducing bilateral mastectomy (RRBM) among cancer-free Israeli female BRCA1/BRCA2 mutation carriers was reportedly 13% in 2010. Current RRBM rates in Israel and factors seemingly associated with opting for RRBM were reevaluated. METHODS Israeli female cancer-free BRCA1/BRCA2 mutation carriers, who were followed at the high-risk clinic at Sheba Medical Center between January 2011 and April 2020 were eligible. Univariate Cox regression and log-rank test were used to study the crude association between potential predictors and performance of RRBM. RESULTS Overall, 427 cancer-free BRCA1 (n = 218) or BRCA2 (n = 209) mutation carriers were included. Median age at genotyping was 33.6 years (interquartile range 26.8-41.8 years), median follow-up 4.4 years (range 0.1-7.6 years). Overall, 41/427 (9.6%) participants underwent RRBM, all of them within 5 years of genotyping. Being married (HR-2.57, p = 0.017) and having a first degree relative with breast cancer (BC) (HR-2.19, p = 0.017) were positively associated with RRBM, whereas any previous benign breast biopsy was negatively associated (HR-0.48, p = 0.029) with performing RRBM. CONCLUSIONS RRBM is still infrequently elected by Israeli BRCA1/BRCA2 mutation carriers, with married women with one relative with BC who have not undergone previous breast biopsy more likely to opt for RRBM.
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Affiliation(s)
- Lee Galmor
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rinat Bernstein-Molho
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Breast Cancer Unit, Oncology Institute, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Miri Sklair-Levy
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- The Meirav High-Risk Clinic-Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | | | - Dov Zippel
- The Meirav High-Risk Clinic-Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Yael Laitman
- Oncogenetics Unit, Institute of Genetics, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Eitan Friedman
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- The Meirav High-Risk Clinic-Chaim Sheba Medical Center, Tel-Hashomer, Israel.
- Oncogenetics Unit, Institute of Genetics, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel.
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39
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Manchanda R, Lieberman S, Gaba F, Lahad A, Levy-Lahad E. Population Screening for Inherited Predisposition to Breast and Ovarian Cancer. Annu Rev Genomics Hum Genet 2020; 21:373-412. [DOI: 10.1146/annurev-genom-083118-015253] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The discovery of genes underlying inherited predisposition to breast and ovarian cancer has revolutionized the ability to identify women at high risk for these diseases before they become affected. Women who are carriers of deleterious variants in these genes can undertake surveillance and prevention measures that have been shown to reduce morbidity and mortality. However, under current strategies, the vast majority of women carriers remain undetected until they become affected. In this review, we show that universal testing, particularly of the BRCA1 and BRCA2 genes, fulfills classical disease screening criteria. This is especially true for BRCA1 and BRCA2 in Ashkenazi Jews but is translatable to all populations and may include additional genes. Utilizing genetic information for large-scale precision prevention requires a paradigmatic shift in health-care delivery. To address this need, we propose a direct-to-patient model, which is increasingly pertinent for fulfilling the promise of utilizing personal genomic information for disease prevention.
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Affiliation(s)
- Ranjit Manchanda
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, United Kingdom;,
- Department of Gynaecological Oncology, Barts Health NHS Trust, London E1 1FR, United Kingdom
| | - Sari Lieberman
- Medical Genetics Institute, Shaare Zedek Medical Center, Jerusalem 9103102, Israel;,
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Faiza Gaba
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, United Kingdom;,
- Department of Gynaecological Oncology, Barts Health NHS Trust, London E1 1FR, United Kingdom
| | - Amnon Lahad
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
- Clalit Health Services, Jerusalem 9548323, Israel
| | - Ephrat Levy-Lahad
- Medical Genetics Institute, Shaare Zedek Medical Center, Jerusalem 9103102, Israel;,
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
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40
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Segerer R, Peschel C, Kämmerer U, Häussler S, Wöckel A, Segerer S. Factors Impacting on Decision-Making towards Prophylactic Surgeries in BRCA Mutation Carriers and Women with Familial Predisposition. Breast Care (Basel) 2020; 15:253-259. [PMID: 32774219 DOI: 10.1159/000503370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/29/2019] [Indexed: 12/19/2022] Open
Abstract
Background/Objectives BRCA mutation carriers and women at high risk of breast/ovarian cancer are faced with the intricate question to opt for prophylactic surgeries and/or a periodic screening. The aim of this study was therefore to identify objective and emotional factors that have an impact on the decision-making process. Methods Ninety-five women with BRCA mutations or women at increased breast/ovarian cancer lifetime risk were counseled at our outpatient department and either opted for prophylactic surgery or periodic screening. To identify the psychological factors that could have influenced the decision-making, a standardized questionnaire was applied. Additionally, clinical data were collected and were reviewed by a personal talk. Results Seventy-one of the patients opted for an increased surveillance only, 21 for prophylactic surgeries. Positive predictors for prophylactic surgeries were sociodemographic characteristics such as parity and objective variables such as verified mutation status. Hierarchical regression analysis revealed that the need for safety in health issues has been the only significant psychological predictor of surgery beyond the objective factors. Fear of surgical procedures, menopausal symptoms after surgery, loss of attractiveness, or fear of interferences with sexual life did not significantly affect decision-making. Conclusion Decision-making towards prophylactic surgeries is influenced by objective but also emotional factors. Knowing that fear and anxiety also have an important impact on decision-making, distinct counselling about the procedures, the subsequent risk reduction as well as the psychological effects of prophylactic surgeries are essential.
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Affiliation(s)
- Robin Segerer
- Institut für Psychologie, Universität Basel, Basel, Switzerland
| | - Clara Peschel
- Klinikum Stuttgart - Krankenhaus Bad Cannstatt, Stuttgart, Germany
| | | | | | - Achim Wöckel
- Universitätsfrauenklinik Würzburg, Würzburg, Germany
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Leser C, Deutschmann C, Dorffner G, Gschwantler-Kaulich D, Castillo DM, Abayev S, Stübler M, Reitsamer R, Singer C. Complication rates among women undergoing preventive mastectomy: An Austrian registry. Breast J 2020; 26:1639-1644. [PMID: 32452097 DOI: 10.1111/tbj.13877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 03/24/2020] [Accepted: 04/23/2020] [Indexed: 11/27/2022]
Abstract
Germline variations in the BRCA-1 and BRCA-2 genes are associated with an increased risk of breast cancer. These variants are found in 5% of all breast cancer cases. Prophylactic mastectomy is the most effective risk-reducing method and shows high rates of patient satisfaction and acceptance. We established a registry of Austrian BRCA-1 and BRCA-2 mutation carriers who had undergone mastectomy for oncologic or prophylactic reasons. Data were collected on the type of operation, complications, and type of reconstructive surgery for patients between 2014 and 2017. The complication rate in patients with nipple-sparing mastectomy was significantly lower (23.1%) than in those with other types of mastectomies (60.7%; P = .005). In patients with implant-based breast reconstruction, subpectoral placement was associated with a significantly higher rate of complications than prepectoral placement (P = .025). Median implant volume was 350 cc (range: 155-650 cc), and a 100-cc increase was associated with doubling of the odds of a complication (regression coefficient = 0.007); based on this finding, some surgeons may decide on using smaller implants. In summary, we identified significant associations between the risk of complications and surgical characteristics, and found host factors like diabetes, BMI, and smoking among Austrian patients with BRCA-1 and BRCA-2 variants.
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Affiliation(s)
- Carmen Leser
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria.,Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Christine Deutschmann
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria.,Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Georg Dorffner
- Institute for Artificial Intelligence and Decision Support, Medical University of Vienna, Vienna, Austria
| | - Daphne Gschwantler-Kaulich
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria.,Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Sara Abayev
- Department of Plastic and Reconstructive Surgery, Wilhelminen Hospital, Vienna, Austria
| | - Madeleine Stübler
- Department of Surgery, Kepler University Hospital Linz, Linz, Austria
| | - Roland Reitsamer
- Department of Obstetrics and Gynaecology, University Hospital Salzburg, Salzburg, Austria
| | - Christian Singer
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria.,Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Sroczynski G, Gogollari A, Kuehne F, Hallsson LR, Widschwendter M, Pashayan N, Siebert U. A Systematic Review on Cost-effectiveness Studies Evaluating Ovarian Cancer Early Detection and Prevention Strategies. Cancer Prev Res (Phila) 2020; 13:429-442. [PMID: 32071120 DOI: 10.1158/1940-6207.capr-19-0506] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/01/2020] [Accepted: 02/14/2020] [Indexed: 11/16/2022]
Abstract
Ovarian cancer imposes a substantial health and economic burden. We systematically reviewed current health-economic evidence for ovarian cancer early detection or prevention strategies. Accordingly, we searched relevant databases for cost-effectiveness studies evaluating ovarian cancer early detection or prevention strategies. Study characteristics and results including quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER) were summarized in standardized evidence tables. Economic results were transformed into 2017 Euros. The included studies (N = 33) evaluated ovarian cancer screening, risk-reducing interventions in women with heterogeneous cancer risks and genetic testing followed by risk-reducing interventions for mutation carriers. Multimodal screening with a risk-adjusted algorithm in postmenopausal women achieved ICERs of 9,800-81,400 Euros/QALY, depending on assumptions on mortality data extrapolation, costs, test performance, and screening frequency. Cost-effectiveness of risk-reducing surgery in mutation carriers ranged from cost-saving to 59,000 Euros/QALY. Genetic testing plus risk-reducing interventions for mutation carriers ranged from cost-saving to 54,000 Euros/QALY in women at increased mutation risk. Our findings suggest that preventive surgery and genetic testing plus preventive surgery in women at high risk for ovarian cancer can be considered effective and cost-effective. In postmenopausal women from the general population, multimodal screening using a risk-adjusted algorithm may be cost-effective.
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Affiliation(s)
- Gaby Sroczynski
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Artemisa Gogollari
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - Felicitas Kuehne
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Lára R Hallsson
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | | | - Nora Pashayan
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria.
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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44
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Kurian AW, Ward KC, Abrahamse P, Hamilton AS, Deapen D, Morrow M, Jagsi R, Katz SJ. Association of Germline Genetic Testing Results With Locoregional and Systemic Therapy in Patients With Breast Cancer. JAMA Oncol 2020; 6:e196400. [PMID: 32027353 PMCID: PMC7042883 DOI: 10.1001/jamaoncol.2019.6400] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/07/2019] [Indexed: 12/14/2022]
Abstract
Importance The increasing use of germline genetic testing may have unintended consequences on treatment. Little is known about how women with pathogenic variants in cancer susceptibility genes are treated for breast cancer. Objective To determine the association of germline genetic testing results with locoregional and systemic therapy use in women diagnosed with breast cancer. Design, Setting, and Participants For this population-based cohort study, data from women aged 20 years or older who were diagnosed with stages 0 to III breast cancer between 2014 and 2016 were accrued from the Surveillance, Epidemiology and End Results (SEER) registries of Georgia and California. The women underwent genetic testing within 3 months after diagnosis and were reported to the Georgia and California SEER registries by December 1, 2017. Exposures Pathogenic variant status based on linked results of clinical germline genetic testing by 4 laboratories that did most such testing in the studied regions. Main Outcomes and Measures Potential deviation of treatment from practice guidelines was assessed in the following clinical scenarios: (1) surgery: receipt of bilateral mastectomy by women eligible for less extensive unilateral surgery (unilateral breast tumor); (2) radiotherapy: omission in women indicated for postlumpectomy radiotherapy (all lumpectomy recipients except age ≥70 with stage I, estrogen and/or progesterone receptor [ER/PR] positive, ERBB2 [formerly HER2]-negative disease); and (3) chemotherapy: receipt by women eligible to consider chemotherapy omission (stages I-II, ER/PR-positive, ERBB2-negative, and 21-gene recurrence score of 0-30, which was the upper limit of the intermediate risk range during the study years). The adjusted percentage treated and adjusted odds ratio (OR) are reported based on multivariable modeling for each treatment-eligible group. Results A total of 20 568 women (17.3%) of 119 198 were eligible (mean [SD] age, 51.4 [12.2]). Compared with women whose test results were negative, those with BRCA1/2 pathogenic variants were more likely to receive bilateral mastectomy for a unilateral tumor (61.7% vs 24.3%; OR, 5.52, 95% CI, 4.73-6.44), less likely to receive postlumpectomy radiotherapy (50.2% vs 81.5%; OR, 0.22, 95% CI, 0.15-0.32), and more likely to receive chemotherapy for early-stage, ER/PR-positive disease (38.0% vs 30.3%; OR, 1.76, 95% CI, 1.31-2.34). Similar patterns were seen with pathogenic variants in other breast cancer-associated genes (ATM, CDH1, CHEK2, NBN, NF1, PALB2, PTEN, and TP53) but not with variants of uncertain significance. Conclusions and Relevance Women with pathogenic variants in BRCA1/2 and other breast cancer-associated genes were found to have distinct patterns of breast cancer treatment; these may be less concordant with practice guidelines, particularly for radiotherapy and chemotherapy.
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Affiliation(s)
- Allison W. Kurian
- Department of Medicine, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Paul Abrahamse
- Department of Medicine, University of Michigan School of Public Health, Ann Arbor
- Department of Health Management & Policy, University of Michigan School of Public Health, Ann Arbor
| | - Ann S. Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Dennis Deapen
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Steven J. Katz
- Department of Medicine, University of Michigan School of Public Health, Ann Arbor
- Department of Health Management & Policy, University of Michigan School of Public Health, Ann Arbor
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Evans DG, Howell SJ, Howell A. Should unaffected female BRCA2 pathogenic variant carriers be told there is little or no advantage from risk reducing mastectomy? Fam Cancer 2020; 18:377-379. [PMID: 31444676 PMCID: PMC6784814 DOI: 10.1007/s10689-019-00142-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D Gareth Evans
- NW Genomic Laboratory hub, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK. .,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK. .,Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester, University NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, UK. .,Manchester Breast Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK.
| | - Sacha J Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester, University NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, UK.,Manchester Breast Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK.,Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Anthony Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester, University NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, UK.,Manchester Breast Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK.,Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Evron E, Ben-David AM, Goldberg H, Fried G, Kaufman B, Catane R, Pfeffer MR, Geffen DB, Chernobelsky P, Karni T, Abdah-Bortnyak R, Rosengarten O, Matceyevsky D, Inbar M, Kuten A, Corn BW. Prophylactic irradiation to the contralateral breast for BRCA mutation carriers with early-stage breast cancer. Ann Oncol 2020; 30:412-417. [PMID: 30475942 DOI: 10.1093/annonc/mdy515] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Women who carry germ-line mutations in BRCA1/2 are at very high risk of developing breast and ovarian cancer. Breast conserving therapy is associated with a similar risk of ipsilateral cancer recurrence in BRCA carriers compared with non-carriers. However, the risk of subsequent contralateral breast cancer in carriers is markedly increased. Therefore, mastectomy of the diseased breast along with risk reducing mastectomy of the contralateral breast is often advocated for BRCA carriers who are treated for early breast cancer. Yet, many BRCA carriers forgo this option for fear of harmful effects and choose breast conserving treatment and observation instead. In Israel, BRCA-associated breast cancer is relatively common. Accordingly, a national protocol was devised for this enriched population. PATIENTS AND METHODS In this Institutional Review Board-approved phase II trial, the option of prophylactic irradiation to the contralateral breast, in addition to standard loco-regional treatment, was offered to BRCA carrier patients treated for early breast cancer who declined contralateral mastectomy. The primary end point was contralateral breast cancer. RESULTS Between May 2007 and October 2017, 162 patients were enrolled. Eighty-one patients opted for standard loco-regional treatment including surgery and radiation to the involved side (control arm) and 81 patients chose additional contralateral breast irradiation (intervention arm). At a median follow-up of 58 months, 10 patients developed contralateral breast cancer in the control arm at a median of 32 months, as compared with 2 patients in the intervention arm who developed contralateral breast cancer 80 and 105 months after bilateral breast irradiation (log-rank P = 0.011). CONCLUSIONS Among BRCA carrier patients treated for early breast cancer, the addition of contralateral breast irradiation was associated with a significant reduction of subsequent contralateral breast cancers and a delay in their onset. CLINICAL TRIAL Phase II, comparative two-arm trial (NCT00496288).
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Affiliation(s)
- E Evron
- Oncology, Kaplan Medical Institute, Rehovot; Hadassah Medical School, The Hebrew University, Jerusalem
| | - A M Ben-David
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv; Department of Oncology, Sheba Medical Center, Ramat-Gan
| | - H Goldberg
- Oncology Institute, Galilee Medical Center, Naharia
| | - G Fried
- Oncology Divisio, Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion, Haifa
| | - B Kaufman
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv; Department of Oncology, Sheba Medical Center, Ramat-Gan
| | - R Catane
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv; Department of Oncology, Sheba Medical Center, Ramat-Gan
| | | | - D B Geffen
- Department of Oncology, Soroka Medical Center, Beer-Sheva; Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva
| | - P Chernobelsky
- Department of Oncology, Soroka Medical Center, Beer-Sheva
| | - T Karni
- Assaf Harofe Medical Center, Zerifin
| | - R Abdah-Bortnyak
- Oncology Divisio, Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion, Haifa
| | | | | | - M Inbar
- Assuta Medical Center, Tel Aviv
| | - A Kuten
- Oncology Divisio, Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion, Haifa
| | - B W Corn
- Shaare Zedek Medical Center, Jerusalem.
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Golshan M, Loibl S, Wong SM, Houber JB, O'Shaughnessy J, Rugo HS, Wolmark N, McKee MD, Maag D, Sullivan DM, Metzger-Filho O, Von Minckwitz G, Geyer CE, Sikov WM, Untch M. Breast Conservation After Neoadjuvant Chemotherapy for Triple-Negative Breast Cancer: Surgical Results From the BrighTNess Randomized Clinical Trial. JAMA Surg 2020; 155:e195410. [PMID: 31913413 DOI: 10.1001/jamasurg.2019.5410] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Neoadjuvant systemic therapy (NST) is often administered to enable breast-conserving therapy (BCT) in stages II to III breast cancer. Objectives To prospectively evaluate the role of NST in conversion from BCT ineligibility to BCT eligibility and to assess the association of response to NST, germline BRCA (gBRCA) status, and region of treatment with surgical choice in women with triple-negative breast cancer (TNBC). Design, Setting, and Participants This prespecified secondary analysis of a multicentered, phase 3, double-blind, randomized clinical trial (BrighTNess) enrolled 634 eligible women across 145 centers in 15 countries in North America, Europe, and Asia. Women with operable, clinical stages II to III TNBC who underwent gBRCA mutation testing before initiating NST were eligible to participate. Data were collected from April 1, 2014, to December 8, 2016. This preplanned analysis was performed from January 5, 2018, to October 28, 2019. Interventions Study participants were randomized to receive 12 weeks of weekly paclitaxel alone or with the addition of carboplatin and/or veliparib, followed by 4 cycles of doxorubicin hydrochloride and cyclophosphamide. Main Outcomes and Measures Surgeons assessed BCT candidacy by clinical and radiographic criteria before and after NST. Surgical choices and whether BCT eligibility was associated with the likelihood of pathologic complete response were then analyzed. Results Among the 634 randomized patients (median age, 51 [range, 22-78] years), pre- and post-NST assessments were available for 604 patients. Of 141 patients deemed BCT ineligible at baseline, 75 (53.2%) converted to BCT eligible. Overall, 342 (68.1%) of 502 patients deemed BCT eligible after NST underwent BCT, including 42 (56.0%) of the 75 who converted to BCT eligible. Patients treated in Europe and Asia were more likely to undergo BCT (odds ratio, 2.66; 95% CI, 1.84-3.84) compared with those treated in North America. Among patients without gBRCA mutation undergoing mastectomy, those treated in North America were more likely to undergo contralateral prophylactic mastectomy (57 of 81 [70.4%] vs 6 of 30 [20.0%]; P < .001). Rates of pathologic complete response were similar between patients deemed BCT eligible at baseline and those who were BCT ineligible but converted to BCT eligibility after NST (55.3 [235 of 425] vs 49.3% [37 of 75]; P = .38). Conclusions and Relevance This prospective analysis of NST and BCT eligibility in TNBC demonstrates a conversion from BCT ineligibility to BCT eligibility of 53.2%. Lower BCT rates among eligible patients and higher bilateral mastectomy rates among patients without gBRCA mutation in North America merit investigation. Trial Registration ClinicalTrials.gov identifier: NCT02032277.
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Affiliation(s)
- Mehra Golshan
- Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sibylle Loibl
- Department of Medical Oncology, German Breast Group, Neu-Isenburg, Germany
| | - Stephanie M Wong
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Joyce O'Shaughnessy
- Department of Medical Oncology, Texas Oncology-Baylor Sammons Cancer Center, US Oncology, Dallas
| | - Hope S Rugo
- Department of Medical Oncology, University of California, San Francisco
| | - Norman Wolmark
- Department of Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | | | | | - Otto Metzger-Filho
- Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Charles E Geyer
- Department of Medical Oncology, Virginia Commonwealth University Massey Cancer Center, Richmond
| | - William M Sikov
- Department of Medical Oncology, Women and Infants Hospital of Rhode Island, Providence
| | - Michael Untch
- Department of Breast Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany
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Kamaraju S, Drope J, Sankaranarayanan R, Shastri S. Cancer Prevention in Low-Resource Countries: An Overview of the Opportunity. Am Soc Clin Oncol Educ Book 2020; 40:1-12. [PMID: 32239989 PMCID: PMC7935443 DOI: 10.1200/edbk_280625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Rising trends in the incidence of cancer in low- and middle-income countries (LMICs) add to the existing challenges with communicable and noncommunicable diseases. While breast and colorectal cancer incidence rates are increasing in LMICs, the incidence of cervical cancer shows a mixed trend, with rising incidence rates in China and sub-Saharan Africa and declining trends in the Indian subcontinent and South America. The increasing frequencies of unhealthy lifestyles, notably less physical activity, obesity, tobacco use, and alcohol consumption are causing a threat to health care in LMICs. Also, poorly developed health systems tend to have inadequate resources to implement early detection and adequate basic treatment. Inequalities in social determinants of health, lack of awareness of cancer and preventive care, lack of efficient referral pathways and patient navigation, and nonexistent or inadequate health care funding can lead to advanced disease presentation at diagnosis. This article provides an overview of opportunities to address cancer control in LMICs, with a focus on tobacco control, vaccination for cervical cancer, novel tools to assist with early detection, and screening for breast and other cancers.
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Kotsopoulos J, Narod SA. Prophylactic salpingectomy for the prevention of ovarian cancer: Who should we target? Int J Cancer 2020; 147:1245-1251. [PMID: 32037528 DOI: 10.1002/ijc.32916] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 12/12/2022]
Abstract
Ovarian cancer is the most fatal gynecologic malignancy (50% 5-year survival) due to a typically advanced stage at diagnosis and a high rate of recurrence. Chemoprevention options are limited, and few interventions have been shown to reduce cancer risk or mortality. Emerging data support the model that fallopian tubes are the site of origin for a proportion of high-grade serous cancers. This implies that a subset of cancers may be prevented by removing the fallopian tubes while leaving the ovaries intact. Accordingly, there has been shift in clinical practice for average risk women; some now recommend removal of both the fallopian tubes only instead of tubal ligation for sterilization or at the time of benign gynecologic surgery. This has been termed opportunistic salpingectomy and represents a means of decreasing the burden of ovarian cancer by preventing cancers that arise in the fallopian tubes. There have been no detailed, prospective reports that have estimated ovarian cancer risk reduction with opportunistic salpingectomy, neither among women at baseline population risk nor among women at a high risk of developing the disease. The situation is complicated for women with a BRCA mutation-bilateral salpingo-oophorectomy is a proven means of risk reduction and salpingectomy alone is not the standard of care. Based on the existing data, salpingectomy alone should only be reserved for women with a lifetime risk of ovarian cancer of less than 5%.
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Affiliation(s)
- Joanne Kotsopoulos
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Narod
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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50
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Health Disparities in Germline Genetic Testing for Cancer Susceptibility. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00354-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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