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Kregting LM, Vrancken Peeters NJMC, Clarijs ME, Koppert LB, Korfage IJ, van Ravesteyn NT. Health utility values of breast cancer treatments and the impact of varying quality of life assumptions on cost-effectiveness. Int J Cancer 2024; 155:117-127. [PMID: 38478916 DOI: 10.1002/ijc.34899] [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: 07/31/2023] [Revised: 12/01/2023] [Accepted: 02/06/2024] [Indexed: 05/04/2024]
Abstract
In breast cancer research, utility assumptions are outdated and inconsistent which may affect the results of quality adjusted life year (QALY) calculations and thereby cost-effectiveness analyses (CEAs). Four hundred sixty four female patients with breast cancer treated at Erasmus MC, the Netherlands, completed EQ-5D-5L questionnaires from diagnosis throughout their treatment. Average utilities were calculated stratified by age and treatment. These utilities were applied in CEAs analysing 920 breast cancer screening policies differing in eligible ages and screening interval simulated by the MISCAN-Breast microsimulation model, using a willingness-to-pay threshold of €20,000. The CEAs included varying sets on normative, breast cancer treatment and screening and follow-up utilities. Efficiency frontiers were compared to assess the impact of the utility sets. The calculated average patient utilities were reduced at breast cancer diagnosis and 6 months after surgery and increased toward normative utilities 12 months after surgery. When using normative utility values of 1 in CEAs, QALYs were overestimated compared to using average gender and age-specific values. Only small differences in QALYs gained were seen when varying treatment utilities in CEAs. The CEAs varying screening and follow-up utilities showed only small changes in QALYs gained and the efficiency frontier. Throughout all variations in utility sets, the optimal strategy remained robust; biennial for ages 40-76 years and occasionally biennial 40-74 years. In sum, we recommend to use gender and age stratified normative utilities in CEAs, and patient-based breast cancer utilities stratified by age and treatment or disease stage. Furthermore, despite varying utilities, the optimal screening scenario seems very robust.
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Affiliation(s)
- Lindy M Kregting
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Noëlle J M C Vrancken Peeters
- Academic Breast Cancer Center, Department of Oncologic and Gastro-intestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marloes E Clarijs
- Academic Breast Cancer Center, Department of Oncologic and Gastro-intestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Linetta B Koppert
- Academic Breast Cancer Center, Department of Oncologic and Gastro-intestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Lapointe J, Côté JM, Mbuya-Bienge C, Dorval M, Pashayan N, Chiquette J, Eloy L, Turgeon A, Lambert-Côté L, Brooks JD, Walker MJ, Blackmore KM, Joly Y, Knoppers BM, Chiarelli AM, Simard J, Nabi H. Canadian Healthcare Professionals' Views and Attitudes toward Risk-Stratified Breast Cancer Screening. J Pers Med 2023; 13:1027. [PMID: 37511640 PMCID: PMC10381377 DOI: 10.3390/jpm13071027] [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: 04/14/2023] [Revised: 06/02/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023] Open
Abstract
Given the controversy over the effectiveness of age-based breast cancer (BC) screening, offering risk-stratified screening to women may be a way to improve patient outcomes with detection of earlier-stage disease. While this approach seems promising, its integration requires the buy-in of many stakeholders. In this cross-sectional study, we surveyed Canadian healthcare professionals about their views and attitudes toward a risk-stratified BC screening approach. An anonymous online questionnaire was disseminated through Canadian healthcare professional associations between November 2020 and May 2021. Information collected included attitudes toward BC screening recommendations based on individual risk, comfort and perceived readiness related to the possible implementation of this approach. Close to 90% of the 593 respondents agreed with increased frequency and earlier initiation of BC screening for women at high risk. However, only 9% agreed with the idea of not offering BC screening to women at very low risk. Respondents indicated that primary care physicians and nurse practitioners should play a leading role in the risk-stratified BC screening approach. This survey identifies health services and policy enhancements that would be needed to support future implementation of a risk-stratified BC screening approach in healthcare systems in Canada and other countries.
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Affiliation(s)
- Julie Lapointe
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Jean-Martin Côté
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Cynthia Mbuya-Bienge
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050, Av de la Médecine, Québec City, QC G1V 0A6, Canada
| | - Michel Dorval
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- Faculty of Pharmacy, Université Laval, 1050, Av de la Médecine, Québec City, QC G1V 0A6, Canada
- CISSS de Chaudière-Appalaches Research Center, 143 Rue Wolfe, Lévis, QC G6V 3Z1, Canada
| | - Nora Pashayan
- Department of Applied Health Research, Institute of Epidemiology and Healthcare, University College London, Gower Street, London WC1E 6BT, UK
| | - Jocelyne Chiquette
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- CHU de Québec-Université Laval, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Laurence Eloy
- Programme Québécois de Cancérologie, Ministère de la Santé et des Services Sociaux, 1075, Chemin Sainte-Foy, Québec City, QC G1S 2M1, Canada
| | - Annie Turgeon
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Laurence Lambert-Côté
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Jennifer D Brooks
- Dalla Lana School of Public Health, University of Toronto, 155, College Street, Toronto, ON M5T 3M7, Canada
| | - Meghan J Walker
- Dalla Lana School of Public Health, University of Toronto, 155, College Street, Toronto, ON M5T 3M7, Canada
- Cancer Care Ontario, Ontario Health, 525, University Avenue, Toronto, ON M5G 2L3, Canada
| | | | - Yann Joly
- Centre of Genomics and Policy, McGill University, 740, Ave Penfield, Montreal, QC H3A 0G1, Canada
- Human Genetics Department and Bioethics Unit, Faculty of Medicine, McGill University, 3647, Peel Street, Montreal, QC G1V 0A6, Canada
| | - Bartha Maria Knoppers
- Centre of Genomics and Policy, McGill University, 740, Ave Penfield, Montreal, QC H3A 0G1, Canada
| | - Anna Maria Chiarelli
- Dalla Lana School of Public Health, University of Toronto, 155, College Street, Toronto, ON M5T 3M7, Canada
- Cancer Care Ontario, Ontario Health, 525, University Avenue, Toronto, ON M5G 2L3, Canada
| | - Jacques Simard
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, 1050, Avenue de la Médecine, Québec City, QC G1V 0A6, Canada
| | - Hermann Nabi
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050, Av de la Médecine, Québec City, QC G1V 0A6, Canada
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Breast Cancer Risk Assessment Tools for Stratifying Women into Risk Groups: A Systematic Review. Cancers (Basel) 2023; 15:cancers15041124. [PMID: 36831466 PMCID: PMC9953796 DOI: 10.3390/cancers15041124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND The benefits and harms of breast screening may be better balanced through a risk-stratified approach. We conducted a systematic review assessing the accuracy of questionnaire-based risk assessment tools for this purpose. METHODS Population: asymptomatic women aged ≥40 years; Intervention: questionnaire-based risk assessment tool (incorporating breast density and polygenic risk where available); Comparison: different tool applied to the same population; Primary outcome: breast cancer incidence; Scope: external validation studies identified from databases including Medline and Embase (period 1 January 2008-20 July 2021). We assessed calibration (goodness-of-fit) between expected and observed cancers and compared observed cancer rates by risk group. Risk of bias was assessed with PROBAST. RESULTS Of 5124 records, 13 were included examining 11 tools across 15 cohorts. The Gail tool was most represented (n = 11), followed by Tyrer-Cuzick (n = 5), BRCAPRO and iCARE-Lit (n = 3). No tool was consistently well-calibrated across multiple studies and breast density or polygenic risk scores did not improve calibration. Most tools identified a risk group with higher rates of observed cancers, but few tools identified lower-risk groups across different settings. All tools demonstrated a high risk of bias. CONCLUSION Some risk tools can identify groups of women at higher or lower breast cancer risk, but this is highly dependent on the setting and population.
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Usher-Smith JA, Hindmarch S, French DP, Tischkowitz M, Moorthie S, Walter FM, Dennison RA, Stutzin Donoso F, Archer S, Taylor L, Emery J, Morris S, Easton DF, Antoniou AC. Proactive breast cancer risk assessment in primary care: a review based on the principles of screening. Br J Cancer 2023; 128:1636-1646. [PMID: 36737659 PMCID: PMC9897164 DOI: 10.1038/s41416-023-02145-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that women at moderate or high risk of breast cancer be offered risk-reducing medication and enhanced breast screening/surveillance. In June 2022, NICE withdrew a statement recommending assessment of risk in primary care only when women present with concerns. This shift to the proactive assessment of risk substantially changes the role of primary care, in effect paving the way for a primary care-based screening programme to identify those at moderate or high risk of breast cancer. In this article, we review the literature surrounding proactive breast cancer risk assessment within primary care against the consolidated framework for screening. We find that risk assessment for women under 50 years currently satisfies many of the standard principles for screening. Most notably, there are large numbers of women at moderate or high risk currently unidentified, risk models exist that can identify those women with reasonable accuracy, and management options offer the opportunity to reduce breast cancer incidence and mortality in that group. However, there remain a number of uncertainties and research gaps, particularly around the programme/system requirements, that need to be addressed before these benefits can be realised.
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Affiliation(s)
- Juliet A. Usher-Smith
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hindmarch
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Marc Tischkowitz
- grid.5335.00000000121885934Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Sowmiya Moorthie
- grid.5335.00000000121885934PHG Foundation, University of Cambridge, Cambridge, UK
| | - Fiona M. Walter
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca A. Dennison
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francisca Stutzin Donoso
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Psychology, University of Cambridge, Cambridge, UK
| | - Lily Taylor
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- grid.1008.90000 0001 2179 088XCentre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC Australia
| | - Stephen Morris
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Antonis C. Antoniou
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Clift AK, Hippisley-Cox J, Dodwell D, Lord S, Brady M, Petrou S, Collins GS. Development and validation of clinical prediction models for breast cancer incidence and mortality: a protocol for a dual cohort study. BMJ Open 2022; 12:e050828. [PMID: 35351695 PMCID: PMC8961149 DOI: 10.1136/bmjopen-2021-050828] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 01/07/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Breast cancer is the most common cancer and the leading cause of cancer-related death in women worldwide. Risk prediction models may be useful to guide risk-reducing interventions (such as pharmacological agents) in women at increased risk or inform screening strategies for early detection methods such as screening. METHODS AND ANALYSIS The study will use data for women aged 20-90 years between 2000 and 2020 from QResearch linked at the individual level to hospital episodes, cancer registry and death registry data. It will evaluate a set of modelling approaches to predict the risk of developing breast cancer within the next 10 years, the 'combined' risk of developing a breast cancer and then dying from it within 10 years, and the risk of breast cancer mortality within 10 years of diagnosis. Cox proportional hazards, competing risks, random survival forest, deep learning and XGBoost models will be explored. Models will be developed on the entire dataset, with 'apparent' performance reported, and internal-external cross-validation used to assess performance and geographical and temporal transportability (two 10-year time periods). Random effects meta-analysis will pool discrimination and calibration metric estimates from individual geographical units obtained from internal-external cross-validation. We will then externally validate the models in an independent dataset. Evaluation of performance heterogeneity will be conducted throughout, such as exploring performance across ethnic groups. ETHICS AND DISSEMINATION Ethics approval was granted by the QResearch scientific committee (reference number REC 18/EM/0400: OX129). The results will be written up for submission to peer-reviewed journals.
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Affiliation(s)
- Ashley Kieran Clift
- Cancer Research UK Oxford Centre, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Simon Lord
- Department of Oncology, University of Oxford, Oxford, UK
| | - Mike Brady
- Department of Oncology, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
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Kregting LM, Sankatsing VD, Heijnsdijk EA, de Koning HJ, van Ravesteyn NT. Finding the optimal mammography screening strategy: a cost‐effectiveness analysis of 920 modelled strategies. Int J Cancer 2022; 151:287-296. [PMID: 35285018 PMCID: PMC9310858 DOI: 10.1002/ijc.34000] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/16/2022] [Accepted: 03/02/2022] [Indexed: 12/24/2022]
Abstract
Breast cancer screening policies have been designed decades ago, but current screening strategies may not be optimal anymore. Next to that, screening capacity issues may restrict feasibility. This cost‐effectiveness study evaluates an extensive set of breast cancer screening strategies in the Netherlands. Using the Microsimulation Screening Analysis‐Breast (MISCAN‐Breast) model, the cost‐effectiveness of 920 breast cancer screening strategies with varying starting ages (40‐60), stopping ages (64‐84) and intervals (1‐4 years) were simulated. The number of quality adjusted life years (QALYs) gained and additional net costs (in €) per 1000 women were predicted (3.5% discounted) and incremental cost‐effectiveness ratios (ICERs) were calculated to compare screening scenarios. Sensitivity analyses were performed using different assumptions. In total, 26 strategies covering all four intervals were on the efficiency frontier. Using a willingness‐to‐pay threshold of €20 000/QALY gained, the biennial 40 to 76 screening strategy was optimal. However, this strategy resulted in more overdiagnoses and false positives, and required a high screening capacity. The current strategy in the Netherlands, biennial 50 to 74 years, was dominated. Triennial screening in the age range 44 to 71 (ICER 9364) or 44 to 74 (ICER 11144) resulted in slightly more QALYs gained and lower costs than the current Dutch strategy. Furthermore, these strategies were estimated to require a lower screening capacity. Findings were robust when varying attendance and effectiveness of treatment. In conclusion, switching from biennial to triennial screening while simultaneously lowering the starting age to 44 can increase benefits at lower costs and with a minor increase in harms compared to the current strategy.
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Affiliation(s)
- Lindy M. Kregting
- Department of Public Health, Erasmus MC University Medical Center Rotterdam The Netherlands
| | | | | | - Harry J. de Koning
- Department of Public Health, Erasmus MC University Medical Center Rotterdam The Netherlands
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7
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Clift AK, Dodwell D, Lord S, Petrou S, Brady SM, Collins GS, Hippisley-Cox J. The current status of risk-stratified breast screening. Br J Cancer 2022; 126:533-550. [PMID: 34703006 PMCID: PMC8854575 DOI: 10.1038/s41416-021-01550-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 08/25/2021] [Accepted: 09/14/2021] [Indexed: 12/23/2022] Open
Abstract
Apart from high-risk scenarios such as the presence of highly penetrant genetic mutations, breast screening typically comprises mammography or tomosynthesis strategies defined by age. However, age-based screening ignores the range of breast cancer risks that individual women may possess and is antithetical to the ambitions of personalised early detection. Whilst screening mammography reduces breast cancer mortality, this is at the risk of potentially significant harms including overdiagnosis with overtreatment, and psychological morbidity associated with false positives. In risk-stratified screening, individualised risk assessment may inform screening intensity/interval, starting age, imaging modality used, or even decisions not to screen. However, clear evidence for its benefits and harms needs to be established. In this scoping review, the authors summarise the established and emerging evidence regarding several critical dependencies for successful risk-stratified breast screening: risk prediction model performance, epidemiological studies, retrospective clinical evaluations, health economic evaluations and qualitative research on feasibility and acceptability. Family history, breast density or reproductive factors are not on their own suitable for precisely estimating risk and risk prediction models increasingly incorporate combinations of demographic, clinical, genetic and imaging-related parameters. Clinical evaluations of risk-stratified screening are currently limited. Epidemiological evidence is sparse, and randomised trials only began in recent years.
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Affiliation(s)
- Ash Kieran Clift
- Cancer Research UK Oxford Centre, Department of Oncology, University of Oxford, Oxford, UK.
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Simon Lord
- Department of Oncology, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Ahmed S, Lévesque E, Garland R, Knoppers B, Dorval M, Simard J, Loiselle CG. Women's perceptions of PERSPECTIVE: a breast cancer risk stratification e-platform. Hered Cancer Clin Pract 2022; 20:8. [PMID: 35209930 PMCID: PMC8867776 DOI: 10.1186/s13053-022-00214-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 02/03/2022] [Indexed: 12/14/2022] Open
Abstract
Background Breast cancer risk stratification categorizes a woman’s potential risk of developing the disease as near-population, intermediate, or high. In accordance, screening and follow up for breast cancer can readily be tailored following risk assessment. Recent efforts have focussed on developing more accessible means to convey this information to women. This study sought to document the relevance of an informational e-platform developed for these purposes. Objective To begin to assess a newly developed breast cancer risk stratification and decision support e-platform called PERSPECTIVE (PErsonalised Risk Stratification for Prevention and Early deteCTIon of breast cancer) among women who do not know their personal breast cancer risk (Phase 1). Changes (pre- and post- e-platform exposure) in knowledge of breast cancer risk and interest in undergoing genetic testing were assessed in addition to perceptions of platform usability and acceptability. Methods Using a pre-post design, women (N = 156) of differing literacy and education levels, aged 30 to 60, with no previous breast cancer diagnosis were recruited from the general population and completed self-report e-questionnaires. Results Mean e-platform viewing time was 18.67 min (SD 0.65) with the most frequently visited pages being breast cancer-related risk factors and risk assessment. Post-exposure, participants reported significantly higher breast cancer-related knowledge (p < .001). Increases in knowledge relating to obesity, alcohol, breast density, menstruation, and the risk estimation process remained even when sociodemographic variables age and education were controlled. There were no significant changes in genetic testing interest post-exposure. Mean ratings for e-platform acceptability and usability were high: 26.19 out of 30 (SD 0.157) and 42.85 out of 50 (SD 0.267), respectively. Conclusions An informative breast cancer risk stratification e-platform targeting healthy women in the general population can significantly increase knowledge as well as support decisions around breast cancer risk and assessment. Currently underway, Phase 2, called PERSPECTIVE, is seeking further content integration and broader implementation .
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Affiliation(s)
- Saima Ahmed
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada.,CIUSSS Centre-Ouest Montréal, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
| | | | - Rosalind Garland
- Medical Surgical Intensive Care Unit, Jewish General Hospital, Montreal, QC, Canada
| | - Bartha Knoppers
- McGill University Centre of Genomics and Policy, Montréal, QC, Canada
| | - Michel Dorval
- Université Laval, Québec City, QC, Canada.,CHU de Québec-Université Laval Research Centre, Québec City, QC, Canada
| | - Jacques Simard
- Université Laval, Québec City, QC, Canada.,CHU de Québec-Université Laval Research Centre, Québec City, QC, Canada
| | - Carmen G Loiselle
- CIUSSS Centre-Ouest Montréal, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada. .,Department of Oncology and Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, 680 Sherbrooke Ouest, Office 1812, Montréal, QC, H3A 2M7, Canada.
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Shah SK, McElfish PA. A Review of Cancer Screening Recommendations during the COVID-19 Pandemic. JMIR Cancer 2022; 8:e34392. [PMID: 35142621 PMCID: PMC8914792 DOI: 10.2196/34392] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cancer screening tests are recommended to prevent cancer-associated mortality by detecting precancerous and cancerous lesions in early stages. The COVID-19 pandemic disrupted the utilization of preventive health care services. While there was a rise in the number of cancer screening tests beginning in late 2020, screenings remained 29%-36% lower than in the pre-pandemic era. OBJECTIVE The objective of this review article was to assist health care providers in identifying approaches for prioritizing patients and increasing breast, cervical, and colorectal cancer screening during the uncertainty of the COVID-19 pandemic. METHODS We used the scoping review framework to identify articles on PubMed and EBSCO databases. A total of 403 articles were identified, and 23 articles were selected for this review. Literature review ranged from January 1st, 2020 to September 30th, 2021. RESULTS The articles included two primary categories of recommendations: (1) risk stratification and triage to prioritize screenings and (2) alternative methods to conduct cancer screenings. Risk stratification and triage recommendations focused on prioritizing high-risk patients with an abnormal or suspicious result on the previous screening test, of certain age group and sex, having personal medical or family history of cancers, currently symptomatic, predisposed to hereditary cancers, and cancer-causing mutations. Other recommended strategies included: identifying areas facing most disparities, creating algorithms and using artificial intelligence to create cancer-risk scores, leveraging in-person visits to assess cancer risk, and providing the option of open access screenings where patients can schedule screenings and can be assigned a priority category by health care staff. Some recommended using telemedicine to categorize patients and determine screening-eligibility for patients with new complaints. Several articles noted the importance of implementing preventive measures such as COVID-19 screening prior to the procedures, maintaining hygiene measures, and social distancing in waiting rooms. Alternative screening methods which do not require an in-person clinic visit and can effectively screen patients for cancers included mailing self-collection sampling kits for cervical and colorectal cancers and implementing or expanding mobile screening units. CONCLUSIONS Although the COVID-19 pandemic had devastating effects on population health globally, it could be an opportunity to adapt and evolve cancer screening methods. Disruption often creates innovation, and focus on alternative methods for cancer screenings may help reach rural and under-resourced areas after the pandemic has ended. CLINICALTRIAL
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Affiliation(s)
- Sumit K Shah
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, Fayetteville, US
| | - Pearl A McElfish
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Avenue, Fayetteville, US
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Rainey L, van der Waal D, Donnelly LS, Southworth J, French DP, Evans DG, Broeders MJM. Women's health behaviour change after receiving breast cancer risk estimates with tailored screening and prevention recommendations. BMC Cancer 2022; 22:69. [PMID: 35033023 PMCID: PMC8761310 DOI: 10.1186/s12885-022-09174-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022] Open
Abstract
Background The Predicting Risk of Cancer at Screening (PROCAS) study provided women who were eligible for breast cancer screening in Greater Manchester (United Kingdom) with their 10-year risk of breast cancer, i.e., low (≤1.5%), average (1.5–4.99%), moderate (5.-7.99%) or high (≥8%). The aim of this study is to explore which factors were associated with women’s uptake of screening and prevention recommendations. Additionally, we evaluated women’s organisational preferences regarding tailored screening. Methods A total of 325 women with a self-reported low (n = 60), average (n = 125), moderate (n = 80), or high (n = 60) risk completed a two-part web-based survey. The first part contained questions about personal characteristics. For the second part women were asked about uptake of early detection and preventive behaviours after breast cancer risk communication. Additional questions were posed to explore preferences regarding the organisation of risk-stratified screening and prevention. We performed exploratory univariable and multivariable regression analyses to assess which factors were associated with uptake of primary and secondary breast cancer preventive behaviours, stratified by breast cancer risk. Organisational preferences are presented using descriptive statistics. Results Self-reported breast cancer risk predicted uptake of (a) supplemental screening and breast self-examination, (b) risk-reducing medication and (c) preventive lifestyle behaviours. Further predictors were (a) having a first degree relative with breast cancer, (b) higher age, and (c) higher body mass index (BMI). Women’s organisational preferences for tailored screening emphasised a desire for more intensive screening for women at increased risk by further shortening the screening interval and moving the starting age forward. Conclusions Breast cancer risk communication predicts the uptake of key tailored primary and secondary preventive behaviours. Effective communication of breast cancer risk information is essential to optimise the population-wide impact of tailored screening. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09174-3.
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Affiliation(s)
- Linda Rainey
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | | | - Louise S Donnelly
- Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, England
| | - Jake Southworth
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - David P French
- Manchester Centre for Health Psychology, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, UK
| | - D Gareth Evans
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK.,Genomic Medicine, Division of Evolution and Genomic Sciences, Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,The Christie NHS Foundation Trust, Withington, Manchester, M20 4BX, UK
| | - Mireille J M Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Dutch Expert Centre for Screening, PO Box 6873, 6503 GJ, Nijmegen, The Netherlands
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11
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UK Women's Views of the Concepts of Personalised Breast Cancer Risk Assessment and Risk-Stratified Breast Screening: A Qualitative Interview Study. Cancers (Basel) 2021; 13:cancers13225813. [PMID: 34830965 PMCID: PMC8616436 DOI: 10.3390/cancers13225813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Risk-based breast screening will involve tailoring the amount of screening to women’s level of risk. Therefore, women at high-risk may be offered more frequent screening and over a longer period of time than those at low risk for whom less screening may be recommended. As this will involve considerable changes to the NHS Breast Screening Programme, it is important to explore what women in the UK think and feel about this approach. Analysis of in-depth interviews revealed that some women would find both high and low-risk screening options acceptable whereas others were resistant to the prospect of reduced screening if they were assessed as low-risk. We also found that the idea of risk-based screening had little influence on the attitudes of women who were already sceptical about breast screening. These findings highlight the communication challenges that will be faced by those introducing risk-based screening and suggest a need for tailored support and advice. Abstract Any introduction of risk-stratification within the NHS Breast Screening Programme needs to be considered acceptable by women. We conducted interviews to explore women’s attitudes to personalised risk assessment and risk-stratified breast screening. Twenty-five UK women were purposively sampled by screening experience and socioeconomic background. Interview transcripts were qualitatively analysed using Framework Analysis. Women expressed positive intentions for personal risk assessment and willingness to receive risk feedback to provide reassurance and certainty. Women responded to risk-stratified screening scenarios in three ways: ‘Overall acceptors’ considered both high- and low-risk options acceptable as a reasonable allocation of resources to clinical need, yet acceptability was subject to specified conditions including accuracy of risk estimates and availability of support throughout the screening pathway. Others who thought ‘more is better’ only supported high-risk scenarios where increased screening was proposed. ‘Screening sceptics’ found low-risk scenarios more aligned to their screening values than high-risk screening options. Consideration of screening recommendations for other risk groups had more influence on women’s responses than screening-related harms. These findings demonstrate high, but not universal, acceptability. Support and guidance, tailored to screening values and preferences, may be required by women at all levels of risk.
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12
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Wolfson M, Gribble S, Pashayan N, Easton DF, Antoniou AC, Lee A, van Katwyk S, Simard J. Potential of polygenic risk scores for improving population estimates of women's breast cancer genetic risks. Genet Med 2021; 23:2114-2121. [PMID: 34230637 PMCID: PMC8553614 DOI: 10.1038/s41436-021-01258-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Breast cancer risk has conventionally been assessed using family history (FH) and rare high/moderate penetrance pathogenic variants (PVs), notably in BRCA1/2, and more recently PALB2, CHEK2, and ATM. In addition to these PVs, it is now possible to use increasingly predictive polygenic risk scores (PRS) as well. The comparative population-level predictive capability of these three different indicators of genetic risk for risk stratification is, however, unknown. METHODS The Canadian heritable breast cancer risk distribution was estimated using a novel genetic mixing model (GMM). A realistically representative sample of women was synthesized based on empirically observed demographic patterns for appropriately correlated family history, inheritance of rare PVs, PRS, and residual risk from an unknown polygenotype. Risk assessment was simulated using the BOADICEA risk algorithm for 10-year absolute breast cancer incidence, and compared to heritable risks as if the overall polygene, including its measured PRS component, and PV risks were fully known. RESULTS Generally, the PRS was most predictive for identifying women at high risk, while family history was the weakest. Only the PRS identified any women at low risk of breast cancer. CONCLUSION PRS information would be the most important advance in enabling effective risk stratification for population-wide breast cancer screening.
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Affiliation(s)
- Michael Wolfson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
| | - Steve Gribble
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Nora Pashayan
- Department of Applied Health Research, University College London, London, UK
| | - Douglas F Easton
- Department of Public Health and Primary Care, Cambridge, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | | | - Andrew Lee
- Department of Public Health and Primary Care, Cambridge, UK
| | - Sasha van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Jacques Simard
- Department of Molecular Medicine, Université Laval, Quebec City, Canada
- CHU de Quebec-Université Laval Research Center, Quebec City, Canada
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13
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Effects of cancer screening restart strategies after COVID-19 disruption. Br J Cancer 2021; 124:1516-1523. [PMID: 33723386 PMCID: PMC7957464 DOI: 10.1038/s41416-021-01261-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/16/2020] [Accepted: 12/18/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Many breast, cervical, and colorectal cancer screening programmes were disrupted due to the COVID-19 pandemic. This study aimed to estimate the effects of five restart strategies after the disruption on required screening capacity and cancer burden. METHODS Microsimulation models simulated five restart strategies for breast, cervical, and colorectal cancer screening. The models estimated required screening capacity, cancer incidence, and cancer-specific mortality after a disruption of 6 months. The restart strategies varied in whether screens were caught up or not and, if so, immediately or delayed, and whether the upper age limit was increased. RESULTS The disruption in screening programmes without catch-up of missed screens led to an increase of 2.0, 0.3, and 2.5 cancer deaths per 100 000 individuals in 10 years in breast, cervical, and colorectal cancer, respectively. Immediately catching-up missed screens minimised the impact of the disruption but required a surge in screening capacity. Delaying screening, but still offering all screening rounds gave the best balance between required capacity, incidence, and mortality. CONCLUSIONS Strategies with the smallest loss in health effects were also the most burdensome for the screening organisations. Which strategy is preferred depends on the organisation and available capacity in a country.
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Khan SA, Hernandez-Villafuerte KV, Muchadeyi MT, Schlander M. Cost-effectiveness of risk-based breast cancer screening: A systematic review. Int J Cancer 2021; 149:790-810. [PMID: 33844853 DOI: 10.1002/ijc.33593] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/09/2021] [Accepted: 03/23/2021] [Indexed: 01/01/2023]
Abstract
To analyse published evidence on the economic evaluation of risk-based screening (RBS), a full systematic literature review was conducted. After a quality appraisal, we compared the cost-effectiveness of risk-based strategies (low-risk, medium-risk and high-risk) with no screening and age-based screening. Studies were also analysed for modelling, risk stratification methods, input parameters, data sources and harms and benefits. The 10 modelling papers analysed were based on screening performance of film-based mammography (FBM) (three); digital mammography (DM) and FBM (two); DM alone (three); DM, ultrasound (US) and magnetic resonance imaging (one) and DM and US (one). Seven studies did not include the cost of risk-stratification, and one did not consider the cost of diagnosis. Disutility was incorporated in only six studies (one for screening and five for diagnosis). None of the studies reported disutility of risk-stratification (being considered as high-risk). Risk-stratification methods varied from only breast density (BD) to the combination of familial risk, genetic susceptibility, lifestyle, previous biopsies, Jewish ancestry and reproductive history. Less or no screening in low-risk women and more frequent mammography screening in high-risk women was more cost-effective compared to no screening and age-based screening. High-risk women screened annually yielded a higher mortality rate reduction and more quality-adjusted life years at the expense of higher cost and false positives. RBS can be cost effective compared to the alternatives. However, heterogeneity among risk-stratification methods, input parameters, and weaknesses in the methodologies hinder the derivation of robust conclusions. Therefore, further studies are warranted to assess newer technologies and innovative risk-stratification methods.
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Affiliation(s)
- Shah Alam Khan
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Muchandifunga Trust Muchadeyi
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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