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Hubbard RA, Su YR, Bowles EJA, Ichikawa L, Kerlikowske K, Lowry KP, Miglioretti DL, Tosteson ANA, Wernli KJ, Lee JM. Predicting five-year interval second breast cancer risk in women with prior breast cancer. J Natl Cancer Inst 2024; 116:929-937. [PMID: 38466940 PMCID: PMC11160498 DOI: 10.1093/jnci/djae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Annual surveillance mammography is recommended for women with a personal history of breast cancer. Risk prediction models that estimate mammography failures such as interval second breast cancers could help to tailor surveillance imaging regimens to women's individual risk profiles. METHODS In a cohort of women with a history of breast cancer receiving surveillance mammography in the Breast Cancer Surveillance Consortium in 1996-2019, we used Least Absolute Shrinkage and Selection Operator (LASSO)-penalized regression to estimate the probability of an interval second cancer (invasive cancer or ductal carcinoma in situ) in the 1 year after a negative surveillance mammogram. Based on predicted risks from this one-year risk model, we generated cumulative risks of an interval second cancer for the five-year period after each mammogram. Model performance was evaluated using cross-validation in the overall cohort and within race and ethnicity strata. RESULTS In 173 290 surveillance mammograms, we observed 496 interval cancers. One-year risk models were well-calibrated (expected/observed ratio = 1.00) with good accuracy (area under the receiver operating characteristic curve = 0.64). Model performance was similar across race and ethnicity groups. The median five-year cumulative risk was 1.20% (interquartile range 0.93%-1.63%). Median five-year risks were highest in women who were under age 40 or pre- or perimenopausal at diagnosis and those with estrogen receptor-negative primary breast cancers. CONCLUSIONS Our risk model identified women at high risk of interval second breast cancers who may benefit from additional surveillance imaging modalities. Risk models should be evaluated to determine if risk-guided supplemental surveillance imaging improves early detection and decreases surveillance failures.
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Affiliation(s)
- Rebecca A Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yu-Ru Su
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Erin J A Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Laura Ichikawa
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, CA, USA
| | - Kathryn P Lowry
- Department of Radiology, University of Washington and Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Diana L Miglioretti
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Davis, CA, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Janie M Lee
- Department of Radiology, University of Washington and Fred Hutchinson Cancer Center, Seattle, WA, USA
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2
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Klassen CL, Viers LD, Ghosh K. Following the High-Risk Patient: Breast Cancer Risk-Based Screening. Ann Surg Oncol 2024; 31:3154-3159. [PMID: 38302622 DOI: 10.1245/s10434-024-14957-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
Breast cancer (BC) is the most common cancer occurring in women in the USA today, and accounts for more than 40,000 deaths annually (Giaquinto in CA Cancer J Clin 72: 524-541, 2022). While breast cancer survival has improved over the past decades, incidence has increased, and diagnoses are being made at younger ages. This emphasizes the importance of risk evaluation, accurate prediction, and effective mitigation and risk reduction strategies. Enhanced screening can help detect cancers at an earlier stage, thus improving morbidity and mortality. This review addresses the recognition of women at high-risk for BC and monitoring strategies for those at high risk.
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Affiliation(s)
- Christine L Klassen
- Mayo School of Graduate Medical Education, Mayo Clinic- Rochester, Rochester, MN, USA.
| | - Lyndsay D Viers
- Mayo School of Graduate Medical Education, Mayo Clinic- Rochester, Rochester, MN, USA
| | - Karthik Ghosh
- Mayo School of Graduate Medical Education, Mayo Clinic- Rochester, Rochester, MN, USA
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3
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Gard CC, Tice JA, Miglioretti DL, Sprague BL, Bissell MC, Henderson LM, Kerlikowske K. Extending the Breast Cancer Surveillance Consortium Model of Invasive Breast Cancer. J Clin Oncol 2024; 42:779-789. [PMID: 37976443 PMCID: PMC10906584 DOI: 10.1200/jco.22.02470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 08/08/2023] [Accepted: 09/18/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE We extended the Breast Cancer Surveillance Consortium (BCSC) version 2 (v2) model of invasive breast cancer risk to include BMI, extended family history of breast cancer, and age at first live birth (version 3 [v3]) to better inform appropriate breast cancer prevention therapies and risk-based screening. METHODS We used Cox proportional hazards regression to estimate the age- and race- and ethnicity-specific relative hazards for family history of breast cancer, breast density, history of benign breast biopsy, BMI, and age at first live birth for invasive breast cancer in the BCSC cohort. We evaluated calibration using the ratio of expected-to-observed (E/O) invasive breast cancers in the cohort and discrimination using the area under the receiver operating characteristic curve (AUROC). RESULTS We analyzed data from 1,455,493 women age 35-79 years without a history of breast cancer. During a mean follow-up of 7.3 years, 30,266 women were diagnosed with invasive breast cancer. The BCSC v3 model had an E/O of 1.03 (95% CI, 1.01 to 1.04) and an AUROC of 0.646 for 5-year risk. Compared with the v2 model, discrimination of the v3 model improved most in Asian, White, and Black women. Among women with a BMI of 30.0-34.9 kg/m2, the true-positive rate in women with an estimated 5-year risk of 3% or higher increased from 10.0% (v2) to 19.8% (v3) and the improvement was greater among women with a BMI of ≥35 kg/m2 (7.6%-19.8%). CONCLUSION The BCSC v3 model updates an already well-calibrated and validated breast cancer risk assessment tool to include additional important risk factors. The inclusion of BMI was associated with the largest improvement in estimated risk for individual women.
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Affiliation(s)
- Charlotte C. Gard
- Department of Economics, Applied Statistics, and International Business, New Mexico State University, Las Cruces, NM
| | - Jeffrey A. Tice
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Diana L. Miglioretti
- University of California, Davis, Davis, CA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Brian L. Sprague
- Department of Surgery, University of Vermont Cancer Center, Burlington, VT
- Department of Radiology, University of Vermont Cancer Center, Burlington, VT
| | | | | | - Karla Kerlikowske
- General Internal Medicine Section, Department of Veteran Affairs, University of California, San Francisco, San Francisco, CA
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
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4
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Schopf CM, Ramwala OA, Lowry KP, Hofvind S, Marinovich ML, Houssami N, Elmore JG, Dontchos BN, Lee JM, Lee CI. Artificial Intelligence-Driven Mammography-Based Future Breast Cancer Risk Prediction: A Systematic Review. J Am Coll Radiol 2024; 21:319-328. [PMID: 37949155 PMCID: PMC10926179 DOI: 10.1016/j.jacr.2023.10.018] [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: 08/29/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE To summarize the literature regarding the performance of mammography-image based artificial intelligence (AI) algorithms, with and without additional clinical data, for future breast cancer risk prediction. MATERIALS AND METHODS A systematic literature review was performed using six databases (medRixiv, bioRxiv, Embase, Engineer Village, IEEE Xplore, and PubMed) from 2012 through September 30, 2022. Studies were included if they used real-world screening mammography examinations to validate AI algorithms for future risk prediction based on images alone or in combination with clinical risk factors. The quality of studies was assessed, and predictive accuracy was recorded as the area under the receiver operating characteristic curve (AUC). RESULTS Sixteen studies met inclusion and exclusion criteria, of which 14 studies provided AUC values. The median AUC performance of AI image-only models was 0.72 (range 0.62-0.90) compared with 0.61 for breast density or clinical risk factor-based tools (range 0.54-0.69). Of the seven studies that compared AI image-only performance directly to combined image + clinical risk factor performance, six demonstrated no significant improvement, and one study demonstrated increased improvement. CONCLUSIONS Early efforts for predicting future breast cancer risk based on mammography images alone demonstrate comparable or better accuracy to traditional risk tools with little or no improvement when adding clinical risk factor data. Transitioning from clinical risk factor-based to AI image-based risk models may lead to more accurate, personalized risk-based screening approaches.
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Affiliation(s)
- Cody M Schopf
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Ojas A Ramwala
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, Washington
| | - Kathryn P Lowry
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Solveig Hofvind
- Section Head of Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - M Luke Marinovich
- The Daffodil Centre, the University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Nehmat Houssami
- The Daffodil Centre, the University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia; National Breast Cancer Foundation Chair in Breast Cancer Prevention at the University of Sydney and Coeditor of The Breast
| | - Joann G Elmore
- David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California; Director of UCLA's National Clinician Scholars Program and Editor-in-Chief of Adult Primary Care at Up-To-Date. https://twitter.com/JoannElmoreMD
| | - Brian N Dontchos
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington; Clinical Director of Breast Imaging at Fred Hutchinson Cancer Center
| | - Janie M Lee
- Section Chief of Breast Imaging, Department of Radiology, University of Washington School of Medicine, Seattle, Washington; Director of Breast Imaging at Fred Hutchinson Cancer Center
| | - Christoph I Lee
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, and Department of Health Systems & Population Health, University of Washington School of Public Health, Seattle, WA; Director of the Northwest Screening and Cancer Outcomes Research Enterprise at the University of Washington and Deputy Editor of Journal of the American College of Radiology.
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5
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Wolfson EA, Schonberg MA, Eliassen AH, Bertrand KA, Shvetsov YB, Rosner BA, Palmer JR, LaCroix AZ, Chlebowski RT, Nelson RA, Ngo LH. Validating a model for predicting breast cancer and nonbreast cancer death in women aged 55 years and older. J Natl Cancer Inst 2024; 116:81-96. [PMID: 37676833 PMCID: PMC10777669 DOI: 10.1093/jnci/djad188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/24/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND To support mammography screening decision making, we developed a competing-risk model to estimate 5-year breast cancer risk and 10-year nonbreast cancer death for women aged 55 years and older using Nurses' Health Study data and examined model performance in the Black Women's Health Study (BWHS). Here, we examine model performance in predicting 10-year outcomes in the BWHS, Women's Health Initiative-Extension Study (WHI-ES), and Multiethnic Cohort (MEC) and compare model performance to existing breast cancer prediction models. METHODS We used competing-risk regression and Royston and Altman methods for validating survival models to calculate our model's calibration and discrimination (C index) in BWHS (n = 17 380), WHI-ES (n = 106 894), and MEC (n = 49 668). The Nurses' Health Study development cohort (n = 48 102) regression coefficients were applied to the validation cohorts. We compared our model's performance with breast cancer risk assessment tool (Gail) and International Breast Cancer Intervention Study (IBIS) models by computing breast cancer risk estimates and C statistics. RESULTS When predicting 10-year breast cancer risk, our model's C index was 0.569 in BWHS, 0.572 in WHI-ES, and 0.576 in MEC. The Gail model's C statistic was 0.554 in BWHS, 0.564 in WHI-ES, and 0.551 in MEC; IBIS's C statistic was 0.547 in BWHS, 0.552 in WHI-ES, and 0.562 in MEC. The Gail model underpredicted breast cancer risk in WHI-ES; IBIS underpredicted breast cancer risk in WHI-ES and in MEC but overpredicted breast cancer risk in BWHS. Our model calibrated well. Our model's C index for predicting 10-year nonbreast cancer death was 0.760 in WHI-ES and 0.763 in MEC. CONCLUSIONS Our competing-risk model performs as well as existing breast cancer prediction models in diverse cohorts and predicts nonbreast cancer death. We are developing a website to disseminate our model.
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Affiliation(s)
- Emily A Wolfson
- Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mara A Schonberg
- Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A Heather Eliassen
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Harvard School of Public Health, Boston, MA, USA
| | - Kimberly A Bertrand
- Slone Epidemiology Center at Boston University and Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Yurii B Shvetsov
- University of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Bernard A Rosner
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Harvard School of Public Health, Boston, MA, USA
| | - Julie R Palmer
- Slone Epidemiology Center at Boston University and Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Andrea Z LaCroix
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | | | - Rebecca A Nelson
- Department of Computational and Quantitative Medicine, City of Hope, Duarte, CA, USA
| | - Long H Ngo
- Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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6
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Kamil D, Wojcik KM, Smith L, Zhang J, Wilson OWA, Butera G, Jayasekera J. A Scoping Review of Personalized, Interactive, Web-Based Clinical Decision Tools Available for Breast Cancer Prevention and Screening in the United States. MDM Policy Pract 2024; 9:23814683241236511. [PMID: 38500600 PMCID: PMC10946080 DOI: 10.1177/23814683241236511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/04/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction. Personalized web-based clinical decision tools for breast cancer prevention and screening could address knowledge gaps, enhance patient autonomy in shared decision-making, and promote equitable care. The purpose of this review was to present evidence on the availability, usability, feasibility, acceptability, quality, and uptake of breast cancer prevention and screening tools to support their integration into clinical care. Methods. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to conduct this review. We searched 6 databases to identify literature on the development, validation, usability, feasibility, acceptability testing, and uptake of the tools into practice settings. Quality assessment for each tool was conducted using the International Patient Decision Aid Standard instrument, with quality scores ranging from 0 to 63 (lowest-highest). Results. We identified 10 tools for breast cancer prevention and 9 tools for screening. The tools included individual (e.g., age), clinical (e.g., genomic risk factors), and health behavior (e.g., alcohol use) characteristics. Fourteen tools included race/ethnicity, but no tool incorporated contextual factors (e.g., insurance, access) associated with breast cancer. All tools were internally or externally validated. Six tools had undergone usability testing in samples including White (median, 71%; range, 9%-96%), insured (99%; 97%-100%) women, with college education or higher (60%; 27%-100%). All of the tools were developed and tested in academic settings. Seven (37%) tools showed potential evidence of uptake in clinical practice. The tools had an average quality assessment score of 21 (range, 9-39). Conclusions. There is limited evidence on testing and uptake of breast cancer prevention and screening tools in diverse clinical settings. The development, testing, and integration of tools in academic and nonacademic settings could potentially improve uptake and equitable access to these tools. Highlights There were 19 personalized, interactive, Web-based decision tools for breast cancer prevention and screening.Breast cancer outcomes were personalized based on individual clinical characteristics (e.g., age, medical history), genomic risk factors (e.g., BRCA1/2), race and ethnicity, and health behaviors (e.g., smoking). The tools did not include contextual factors (e.g., insurance status, access to screening facilities) that could potentially contribute to breast cancer outcomes.Validation, usability, acceptability, and feasibility testing were conducted mostly among White and/or insured patients with some college education (or higher) in academic settings. There was limited evidence on testing and uptake of the tools in nonacademic clinical settings.
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Affiliation(s)
- Dalya Kamil
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Kaitlyn M. Wojcik
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Laney Smith
- Frederick P. Whiddon College of Medicine, Mobile, AL, USA
| | | | - Oliver W. A. Wilson
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Gisela Butera
- Office of Research Services, National Institutes of Health Library, Bethesda, MD, USA
| | - Jinani Jayasekera
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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7
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Lello S, Capozzi A, Scambia G, Franceschini G. Tibolone and Breast Tissue: a Review. Reprod Sci 2023; 30:3403-3409. [PMID: 37450250 DOI: 10.1007/s43032-023-01295-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
The safety profile of hormone replacement therapy (HRT) on breast is still controversial. Tibolone is an option of treatment for climacteric syndrome of postmenopausal women. Its risk profile on breast is debated. This is an updated narrative review focusing on the impact of tibolone on breast. Particularly, we will report data from major preclinical and clinical studies regarding the effects of the use of this compound on breast tissue and breast density. Moreover, we will analyze and discuss the most relevant findings of the principal studies evaluating the relationship between tibolone and breast cancer risk. Our purpose is making all clinicians who are particularly involved in women's health more aware of the effects of this compound on breast and, thus, more experienced in the management of menopausal symptoms with this drug. According to the available literature, tibolone seems to be characterized by an interesting safety profile on breast tissue.
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Affiliation(s)
- Stefano Lello
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Anna Capozzi
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Giovanni Scambia
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Gianluca Franceschini
- Multidisciplinary Breast Centre, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
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8
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Nyante SJ, Abraham L, Bowles EJA, Lee CI, Kerlikowske K, Miglioretti DL, Sprague BL, Henderson LM. Racial and Ethnic Variation in Diagnostic Mammography Performance among Women Reporting a Breast Lump. Cancer Epidemiol Biomarkers Prev 2023; 32:1542-1551. [PMID: 37440458 PMCID: PMC10790330 DOI: 10.1158/1055-9965.epi-23-0289] [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: 03/24/2023] [Revised: 06/12/2023] [Accepted: 07/11/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND We evaluated diagnostic mammography among women with a breast lump to determine whether performance varied across racial and ethnic groups. METHODS This study included 51,014 diagnostic mammograms performed between 2005 and 2018 in the Breast Cancer Surveillance Consortium among Asian/Pacific Islander (12%), Black (7%), Hispanic/Latina (6%), and White (75%) women reporting a lump. Breast cancers occurring within 1 year were ascertained from cancer registry linkages. Multivariable regression was used to adjust performance statistic comparisons for breast cancer risk factors, mammogram modality, demographics, additional imaging, and imaging facility. RESULTS Cancer detection rates were highest among Asian/Pacific Islander [per 1,000 exams, 84.2 (95% confidence interval (CI): 72.0-98.2)] and Black women [81.4 (95% CI: 69.4-95.2)] and lowest among Hispanic/Latina women [42.9 (95% CI: 34.2-53.6)]. Positive predictive values (PPV) were higher among Black [37.0% (95% CI: 31.2-43.3)] and White [37.0% (95% CI: 30.0-44.6)] women and lowest among Hispanic/Latina women [22.0% (95% CI: 17.2-27.7)]. False-positive results were most common among Asian/Pacific Islander women [per 1,000 exams, 183.9 (95% CI: 126.7-259.2)] and lowest among White women [112.4 (95% CI: 86.1-145.5)]. After adjustment, false-positive and cancer detection rates remained higher for Asian/Pacific Islander and Black women (vs. Hispanic/Latina and White). Adjusted PPV was highest among Asian/Pacific Islander women. CONCLUSIONS Among women with a lump, Asian/Pacific Islander and Black women were more likely to have cancer detected and more likely to receive a false-positive result compared with White and Hispanic/Latina women. IMPACT Strategies for optimizing diagnostic mammography among women with a lump may vary by racial/ethnic group, but additional factors that influence performance differences need to be identified. See related In the Spotlight, p. 1479.
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Affiliation(s)
- Sarah J. Nyante
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Linn Abraham
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Erin J. Aiello Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Christoph I. Lee
- Department of Radiology, University of Washington School of Medicine; Department of Health Services, University of Washington School of Public Health; Fred Hutchinson Cancer Center, Seattle, WA
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
- Department of Public Health Sciences, University of California, Davis, Davis, CA
| | - Brian L. Sprague
- Department of Surgery and University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - Louise M. Henderson
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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9
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Heine J, Fowler EEE, Weinfurtner RJ, Hume E, Tworoger SS. Breast density analysis of digital breast tomosynthesis. Sci Rep 2023; 13:18760. [PMID: 37907569 PMCID: PMC10618274 DOI: 10.1038/s41598-023-45402-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: 08/24/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023] Open
Abstract
Mammography shifted to digital breast tomosynthesis (DBT) in the US. An automated percentage of breast density (PD) technique designed for two-dimensional (2D) applications was evaluated with DBT using several breast cancer risk prediction measures: normalized-volumetric; dense volume; applied to the volume slices and averaged (slice-mean); and applied to synthetic 2D images. Volumetric measures were derived theoretically. PD was modeled as a function of compressed breast thickness (CBT). The mean and standard deviation of the pixel values were investigated. A matched case-control (CC) study (n = 426 pairs) was evaluated. Odd ratios (ORs) were estimated with 95% confidence intervals. ORs were significant for PD: identical for volumetric and slice-mean measures [OR = 1.43 (1.18, 1.72)] and [OR = 1.44 (1.18, 1.75)] for synthetic images. A 2nd degree polynomial (concave-down) was used to model PD as a function of CBT: location of the maximum PD value was similar across CCs, occurring at 0.41 × CBT, and PD was significant [OR = 1.47 (1.21, 1.78)]. The means from the volume and synthetic images were also significant [ORs ~ 1.31 (1.09, 1.57)]. An alternative standardized 2D synthetic image was constructed, where each pixel value represents the percentage of breast density above its location. Several measures were significant and an alternative method for constructing a standardized 2D synthetic image was produced.
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Affiliation(s)
- John Heine
- Cancer Epidemiology Department, Moffitt Cancer Center and Research Institute, 12902 Bruce B. Downs Blvd, Tampa, FL, 33612, USA.
| | - Erin E E Fowler
- Cancer Epidemiology Department, Moffitt Cancer Center and Research Institute, 12902 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - R Jared Weinfurtner
- Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center and Research Institute, 12902 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - Emma Hume
- Cancer Epidemiology Department, Moffitt Cancer Center and Research Institute, 12902 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - Shelley S Tworoger
- Cancer Epidemiology Department, Moffitt Cancer Center and Research Institute, 12902 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
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10
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Abstract
Multiple tools exist to assess a patient's breast cancer risk. The choice of risk model depends on the patient's risk factors and how the calculation will impact care. High-risk patients-those with a lifetime breast cancer risk of ≥20%-are, for instance, eligible for supplemental screening with breast magnetic resonance imaging. Those with an elevated short-term breast cancer risk (frequently defined as a 5-year risk ≥1.66%) should be offered endocrine prophylaxis. High-risk patients should also receive guidance on modification of lifestyle factors that affect breast cancer risk.
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Affiliation(s)
- Amy E Cyr
- Department of Medicine, Washington University, Box 8056, 660 South Euclid Avenue, Saint Louis, MO 63110, USA.
| | - Kaitlyn Kennard
- Department of Surgery, Washington University, Box 8051, 660 South Euclid Avenue, Saint louis, MO 63110, USA
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11
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Khan SA. Breast Cancer Risk Reduction: Current Status and Emerging Trends to Increase Efficacy and Reduce Toxicity of Preventive Medication. Surg Oncol Clin N Am 2023; 32:631-646. [PMID: 37714633 DOI: 10.1016/j.soc.2023.05.001] [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] [Indexed: 09/17/2023]
Abstract
The primary prevention of breast cancer is a worthwhile goal for which the efficacy of antiestrogens is well established. However, implementation has been problematic related to low prioritization by providers and the reluctance of high-risk women to experience medication side effects. Emerging solutions include improved risk estimation through the use of polygenic risk scores and the application of radiomics to screening mammograms; and optimization of medication dose to limit toxicity. The identification of agents to prevent estrogen receptor negative or HER2-positive tumors is being pursued, but personalization of medical risk reduction requires the prediction of tumor subtypes.
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Affiliation(s)
- Seema Ahsan Khan
- Department of Surgery, Feinberg School of Medicine of Northwestern University, 303 East Superior Street, Chicago, IL 60614, USA.
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12
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Jarm K, Zadnik V, Birk M, Vrhovec M, Hertl K, Klanecek Z, Studen A, Sval C, Krajc M. Breast cancer risk assessment and risk distribution in 3,491 Slovenian women invited for screening at the age of 50; a population-based cross-sectional study. Radiol Oncol 2023; 57:337-347. [PMID: 37665745 PMCID: PMC10476908 DOI: 10.2478/raon-2023-0039] [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: 06/01/2023] [Accepted: 07/06/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND The evidence shows that risk-based strategy could be implemented to avoid unnecessary harm in mammography screening for breast cancer (BC) using age-only criterium. Our study aimed at identifying the uptake of Slovenian women to the BC risk assessment invitation and assessing the number of screening mammographies in case of risk-based screening. PATIENTS AND METHODS A cross-sectional population-based study enrolled 11,898 women at the age of 50, invited to BC screening. The data on BC risk factors, including breast density from the first 3,491 study responders was collected and BC risk was assessed using the Tyrer-Cuzick algorithm (version 8) to classify women into risk groups (low, population, moderately increased, and high risk group). The number of screening mammographies according to risk stratification was simulated. RESULTS 57% (6,785) of women returned BC risk questionnaires. When stratifying 3,491 women into risk groups, 34.0% were assessed with low, 62.2% with population, 3.4% with moderately increased, and 0.4% with high 10-year BC risk. In the case of potential personalised screening, the number of screening mammographies would drop by 38.6% compared to the current screening policy. CONCLUSIONS The study uptake showed the feasibility of risk assessment when inviting women to regular BC screening. 3.8% of Slovenian women were recognised with higher than population 10-year BC risk. According to Slovenian BC guidelines they may be screened more often. Overall, personalised screening would decrease the number of screening mammographies in Slovenia. This information is to be considered when planning the pilot and assessing the feasibility of implementing population risk-based screening.
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Affiliation(s)
- Katja Jarm
- Sector for Cancer Screening and Clinical Genetics, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Health Sciences, University of Primorska, Izola, Slovenia
| | - Vesna Zadnik
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Health Sciences, University of Primorska, Izola, Slovenia
- Sector for Oncology Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Mojca Birk
- Sector for Oncology Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Milos Vrhovec
- Sector for Cancer Screening and Clinical Genetics, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Kristijana Hertl
- Sector for Cancer Screening and Clinical Genetics, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Zan Klanecek
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
| | - Andrej Studen
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
| | - Cveto Sval
- Sector for Cancer Screening and Clinical Genetics, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Mateja Krajc
- Sector for Cancer Screening and Clinical Genetics, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Health Sciences, University of Primorska, Izola, Slovenia
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13
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Terry MB, Colditz GA. Epidemiology and Risk Factors for Breast Cancer: 21st Century Advances, Gaps to Address through Interdisciplinary Science. Cold Spring Harb Perspect Med 2023; 13:a041317. [PMID: 36781224 PMCID: PMC10513162 DOI: 10.1101/cshperspect.a041317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Research methods to study risk factors and prevention of breast cancer have evolved rapidly. We focus on advances from epidemiologic studies reported over the past two decades addressing scientific discoveries, as well as their clinical and public health translation for breast cancer risk reduction. In addition to reviewing methodology advances such as widespread assessment of mammographic density and Mendelian randomization, we summarize the recent evidence with a focus on the timing of exposure and windows of susceptibility. We summarize the implications of the new evidence for application in risk stratification models and clinical translation to focus prevention-maximizing benefits and minimizing harm. We conclude our review identifying research gaps. These include: pathways for the inverse association of vegetable intake and estrogen receptor (ER)-ve tumors, prepubertal and adolescent diet and risk, early life adiposity reducing lifelong risk, and gaps from changes in habits (e.g., vaping, binge drinking), and environmental exposures.
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Affiliation(s)
- Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, Chronic Disease Unit Leader, Department of Epidemiology, Herbert Irving Comprehensive Cancer Center, Associate Director, New York, New York 10032, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine and Alvin J. Siteman Cancer Center at Washington University School of Medicine and Barnes-Jewish Hospital in St Louis, St. Louis, Missouri 63110, USA
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14
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Sprague BL, Ichikawa L, Eavey J, Lowry KP, Rauscher G, O’Meara ES, Miglioretti DL, Chen S, Lee JM, Stout NK, Mandelblatt JS, Alsheik N, Herschorn SD, Perry H, Weaver DL, Kerlikowske K. Breast cancer risk characteristics of women undergoing whole-breast ultrasound screening versus mammography alone. Cancer 2023; 129:2456-2468. [PMID: 37303202 PMCID: PMC10506533 DOI: 10.1002/cncr.34768] [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: 06/14/2022] [Revised: 02/06/2023] [Accepted: 02/24/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND There are no consensus guidelines for supplemental breast cancer screening with whole-breast ultrasound. However, criteria for women at high risk of mammography screening failures (interval invasive cancer or advanced cancer) have been identified. Mammography screening failure risk was evaluated among women undergoing supplemental ultrasound screening in clinical practice compared with women undergoing mammography alone. METHODS A total of 38,166 screening ultrasounds and 825,360 screening mammograms without supplemental screening were identified during 2014-2020 within three Breast Cancer Surveillance Consortium (BCSC) registries. Risk of interval invasive cancer and advanced cancer were determined using BCSC prediction models. High interval invasive breast cancer risk was defined as heterogeneously dense breasts and BCSC 5-year breast cancer risk ≥2.5% or extremely dense breasts and BCSC 5-year breast cancer risk ≥1.67%. Intermediate/high advanced cancer risk was defined as BCSC 6-year advanced breast cancer risk ≥0.38%. RESULTS A total of 95.3% of 38,166 ultrasounds were among women with heterogeneously or extremely dense breasts, compared with 41.8% of 825,360 screening mammograms without supplemental screening (p < .0001). Among women with dense breasts, high interval invasive breast cancer risk was prevalent in 23.7% of screening ultrasounds compared with 18.5% of screening mammograms without supplemental imaging (adjusted odds ratio, 1.35; 95% CI, 1.30-1.39); intermediate/high advanced cancer risk was prevalent in 32.0% of screening ultrasounds versus 30.5% of screening mammograms without supplemental screening (adjusted odds ratio, 0.91; 95% CI, 0.89-0.94). CONCLUSIONS Ultrasound screening was highly targeted to women with dense breasts, but only a modest proportion were at high mammography screening failure risk. A clinically significant proportion of women undergoing mammography screening alone were at high mammography screening failure risk.
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Affiliation(s)
- Brian L. Sprague
- Office of Health Promotion Research, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, VT
- University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT
| | - Laura Ichikawa
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente WA, Seattle, Washington
| | - Joanna Eavey
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente WA, Seattle, Washington
| | - Kathryn P. Lowry
- Department of Radiology, University of Washington and Seattle Cancer Care Alliance, Seattle, WA
| | - Garth Rauscher
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL
| | - Ellen S. O’Meara
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente WA, Seattle, Washington
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente WA, Seattle, Washington
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Davis, CA
| | - Shuai Chen
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Davis, CA
| | - Janie M. Lee
- Department of Radiology, University of Washington and Seattle Cancer Care Alliance, Seattle, WA
| | - Natasha K. Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Jeanne S. Mandelblatt
- Department of Oncology, Georgetown University Medical Center, Georgetown University, Washington, DC, USA
| | - Nila Alsheik
- Advocate Caldwell Breast Center, Advocate Lutheran General Hospital, 1700 Luther Lane, Park Ridge, IL
| | - Sally D. Herschorn
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, VT
- University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT
| | - Hannah Perry
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, VT
- University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT
| | - Donald L. Weaver
- University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT
- Department of Pathology & Laboratory Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, CA
- General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, CA
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15
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Nguyen AA, McCarthy AM, Kontos D. Combining Molecular and Radiomic Features for Risk Assessment in Breast Cancer. Annu Rev Biomed Data Sci 2023; 6:299-311. [PMID: 37159874 DOI: 10.1146/annurev-biodatasci-020722-092748] [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] [Indexed: 05/11/2023]
Abstract
Breast cancer risk is highly variable within the population and current research is leading the shift toward personalized medicine. By accurately assessing an individual woman's risk, we can reduce the risk of over/undertreatment by preventing unnecessary procedures or by elevating screening procedures. Breast density measured from conventional mammography has been established as one of the most dominant risk factors for breast cancer; however, it is currently limited by its ability to characterize more complex breast parenchymal patterns that have been shown to provide additional information to strengthen cancer risk models. Molecular factors ranging from high penetrance, or high likelihood that a mutation will show signs and symptoms of the disease, to combinations of gene mutations with low penetrance have shown promise for augmenting risk assessment. Although imaging biomarkers and molecular biomarkers have both individually demonstrated improved performance in risk assessment, few studies have evaluated them together. This review aims to highlight the current state of the art in breast cancer risk assessment using imaging and genetic biomarkers.
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Affiliation(s)
- Alex A Nguyen
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne Marie McCarthy
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Despina Kontos
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA;
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16
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Paige JS, Lee CI, Wang PC, Hsu W, Brentnall AR, Hoyt AC, Naeim A, Elmore JG. Variability Among Breast Cancer Risk Classification Models When Applied at the Level of the Individual Woman. J Gen Intern Med 2023; 38:2584-2592. [PMID: 36749434 PMCID: PMC10465429 DOI: 10.1007/s11606-023-08043-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/13/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Breast cancer risk models guide screening and chemoprevention decisions, but the extent and effect of variability among models, particularly at the individual level, is uncertain. OBJECTIVE To quantify the accuracy and disagreement between commonly used risk models in categorizing individual women as average vs. high risk for developing invasive breast cancer. DESIGN Comparison of three risk prediction models: Breast Cancer Risk Assessment Tool (BCRAT), Breast Cancer Surveillance Consortium (BCSC) model, and International Breast Intervention Study (IBIS) model. SUBJECTS Women 40 to 74 years of age presenting for screening mammography at a multisite health system between 2011 and 2015, with 5-year follow-up for cancer outcome. MAIN MEASURES Comparison of model discrimination and calibration at the population level and inter-model agreement for 5-year breast cancer risk at the individual level using two cutoffs (≥ 1.67% and ≥ 3.0%). KEY RESULTS A total of 31,115 women were included. When using the ≥ 1.67% threshold, more than 21% of women were classified as high risk for developing breast cancer in the next 5 years by one model, but average risk by another model. When using the ≥ 3.0% threshold, more than 5% of women had disagreements in risk severity between models. Almost half of the women (46.6%) were classified as high risk by at least one of the three models (e.g., if all three models were applied) for the threshold of ≥ 1.67%, and 11.1% were classified as high risk for ≥ 3.0%. All three models had similar accuracy at the population level. CONCLUSIONS Breast cancer risk estimates for individual women vary substantially, depending on which risk assessment model is used. The choice of cutoff used to define high risk can lead to adverse effects for screening, preventive care, and quality of life for misidentified individuals. Clinicians need to be aware of the high false-positive and false-negative rates and variation between models when talking with patients.
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Affiliation(s)
- Jeremy S Paige
- Department of Radiology, University of California, Los Angeles, CA, USA
| | - Christoph I Lee
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Pin-Chieh Wang
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, and Office of Health Informatics and Analytics, University of California, Los Angeles, Los Angeles, USA
| | - William Hsu
- Department of Radiology, University of California, Los Angeles, CA, USA
| | - Adam R Brentnall
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Charterhouse Square, Queen Mary University of London, London, UK
| | - Anne C Hoyt
- Department of Radiology, University of California, Los Angeles, CA, USA
| | - Arash Naeim
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Joann G Elmore
- Department of Medicine, Division of General Internal Medicine and Health Services Research and the National Clinician Scholars Program, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon Ave, Ste. 900, Los Angeles, CA, 90024, USA.
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17
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Arasu VA, Habel LA, Achacoso NS, Buist DSM, Cord JB, Esserman LJ, Hylton NM, Glymour MM, Kornak J, Kushi LH, Lewis DA, Liu VX, Lydon CM, Miglioretti DL, Navarro DA, Pu A, Shen L, Sieh W, Yoon HC, Lee C. Comparison of Mammography AI Algorithms with a Clinical Risk Model for 5-year Breast Cancer Risk Prediction: An Observational Study. Radiology 2023; 307:e222733. [PMID: 37278627 PMCID: PMC10315521 DOI: 10.1148/radiol.222733] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/05/2023] [Accepted: 04/18/2023] [Indexed: 06/07/2023]
Abstract
Background Although several clinical breast cancer risk models are used to guide screening and prevention, they have only moderate discrimination. Purpose To compare selected existing mammography artificial intelligence (AI) algorithms and the Breast Cancer Surveillance Consortium (BCSC) risk model for prediction of 5-year risk. Materials and Methods This retrospective case-cohort study included data in women with a negative screening mammographic examination (no visible evidence of cancer) in 2016, who were followed until 2021 at Kaiser Permanente Northern California. Women with prior breast cancer or a highly penetrant gene mutation were excluded. Of the 324 009 eligible women, a random subcohort was selected, regardless of cancer status, to which all additional patients with breast cancer were added. The index screening mammographic examination was used as input for five AI algorithms to generate continuous scores that were compared with the BCSC clinical risk score. Risk estimates for incident breast cancer 0 to 5 years after the initial mammographic examination were calculated using a time-dependent area under the receiver operating characteristic curve (AUC). Results The subcohort included 13 628 patients, of whom 193 had incident cancer. Incident cancers in eligible patients (additional 4391 of 324 009) were also included. For incident cancers at 0 to 5 years, the time-dependent AUC for BCSC was 0.61 (95% CI: 0.60, 0.62). AI algorithms had higher time-dependent AUCs than did BCSC, ranging from 0.63 to 0.67 (Bonferroni-adjusted P < .0016). Time-dependent AUCs for combined BCSC and AI models were slightly higher than AI alone (AI with BCSC time-dependent AUC range, 0.66-0.68; Bonferroni-adjusted P < .0016). Conclusion When using a negative screening examination, AI algorithms performed better than the BCSC risk model for predicting breast cancer risk at 0 to 5 years. Combined AI and BCSC models further improved prediction. © RSNA, 2023 Supplemental material is available for this article.
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Affiliation(s)
- Vignesh A. Arasu
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Laurel A. Habel
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Ninah S. Achacoso
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Diana S. M. Buist
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Jason B. Cord
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Laura J. Esserman
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Nola M. Hylton
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - M. Maria Glymour
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - John Kornak
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Lawrence H. Kushi
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Donald A. Lewis
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Vincent X. Liu
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Caitlin M. Lydon
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Diana L. Miglioretti
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Daniel A. Navarro
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Albert Pu
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Li Shen
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Weiva Sieh
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Hyo-Chun Yoon
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
| | - Catherine Lee
- From the Division of Research, Kaiser Permanente Northern California,
2000 Broadway, Oakland, CA 94612 (V.A.A., L.A.H., N.S.A., L.H.K., V.X.L.,
C.M.L., C.L.); Department of Radiology, Kaiser Permanente Northern California,
Vallejo Medical Center, Vallejo, Calif (V.A.A.); Kaiser Permanente Washington
Health Research Institute, Seattle, Wash (D.S.M.B.); Department of Radiology,
Southern California Permanente Medical Group, Orange County, Irvine, Calif
(J.B.C.); Department of Surgery (L.J.E.), Department of Radiology and Biomedical
Imaging (N.M.H.), and Department of Epidemiology and Biostatistics (M.M.G.,
J.K.), University of California–San Francisco, San Francisco, Calif;
Department of Medical Imaging Technology and Informatics, Southern California
Permanente Medical Group, Pasadena, Calif (D.A.L.); Department of Biostatistics,
University of California–Davis, Davis, Calif (D.L.M.); The Technology
Group, The Permanente Medical Group, Oakland, Calif (D.A.N.); KP Information
Technology, Kaiser Foundation Health Plan Inc and Kaiser Foundation Hospitals,
Oakland, Calif (A.P.); Department of Artificial Intelligence and Human Health
and Nash Family Department of Neuroscience (L.S.) and Department of Population
Health Science and Policy, Department of Genetics and Genomic Sciences (W.S.),
Icahn School of Medicine at Mount Sinai, New York, NY; and Department of
Radiology, Hawaii Permanente Medical Group, Moanalua Medical Center, Honolulu,
Hawaii (H.C.Y.)
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18
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Seitzman RL, Pushkin J, Berg WA. Effect of an Educational Intervention on Women's Health Care Provider Knowledge Gaps About Breast Cancer Risk Model Use and High-risk Screening Recommendations. JOURNAL OF BREAST IMAGING 2023; 5:30-39. [PMID: 38416962 DOI: 10.1093/jbi/wbac072] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Indexed: 03/01/2024]
Abstract
OBJECTIVE To assess effectiveness of a web-based educational intervention on women's health care provider knowledge of breast cancer risk models and high-risk screening recommendations. METHODS A web-based pre- and post-test study including 177 U.S.-based women's health care providers was conducted in 2019. Knowledge gaps were defined as fewer than 75% of respondents answering correctly. Pre- and post-test knowledge differences (McNemar test) and associations of baseline characteristics with pre-test knowledge gaps (logistic regression) were evaluated. RESULTS Respondents included 131/177 (74.0%) physicians; 127/177 (71.8%) practiced obstetrics/gynecology. Pre-test, 118/177 (66.7%) knew the Gail model predicts lifetime invasive breast cancer risk; this knowledge gap persisted post-test [(121/177, 68.4%); P = 0.77]. Just 39.0% (69/177) knew the Gail model identifies women eligible for risk-reducing medications; this knowledge gap resolved. Only 48.6% (86/177) knew the Gail model should not be used to identify women meeting high-risk MRI screening guidelines; this deficiency decreased to 66.1% (117/177) post-test (P = 0.001). Pre-test, 47.5% (84/177) knew the Tyrer-Cuzick model is used to identify women meeting high-risk screening MRI criteria, 42.9% (76/177) to predict BRCA1/2 pathogenic mutation risk, and 26.0% (46/177) to predict lifetime invasive breast cancer risk. These knowledge gaps persisted but improved. For a high-risk 30-year-old, 67.8% (120/177) and 54.2% (96/177) pre-test knew screening MRI and mammography/tomosynthesis are recommended, respectively; 19.2% (34/177) knew both are recommended; and 53% (94/177) knew US is not recommended. These knowledge gaps resolved or reduced. CONCLUSION Web-based education can reduce important provider knowledge gaps about breast cancer risk models and high-risk screening recommendations.
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Affiliation(s)
| | | | - Wendie A Berg
- DenseBreast-info, Inc, Deer Park, NY, USA
- University of Pittsburgh School of Medicine, Magee-Womens Hospital of UPMC, Department of Radiology, Pittsburgh, PA, USA
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19
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Zhang J, McGuinness JE, He X, Jones T, Silverman T, Guzman A, May BL, Kukafka R, Crew KD. Breast Cancer Risk and Screening Mammography Frequency Among Multiethnic Women. Am J Prev Med 2023; 64:51-60. [PMID: 36137818 DOI: 10.1016/j.amepre.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/19/2022] [Accepted: 08/02/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION In 2009, the U.S. Preventive Services Task Force updated recommended mammography screening frequency from annual to biennial for average-risk women aged 50-74 years. The association between estimated breast cancer risk and mammography screening frequency was evaluated. METHODS A single-center retrospective cohort study was conducted among racially/ethnically diverse women, aged 50-74 years, who underwent screening mammography from 2014 to 2018. Data on age, race/ethnicity, first-degree family history of breast cancer, previous benign breast biopsies, and mammographic density were extracted from the electronic health record to calculate Breast Cancer Surveillance Consortium 5-year risk of invasive breast cancer, with a 5-year risk ≥1.67% defined as high risk. Multivariable analyses were conducted to determine the association between breast cancer risk factors and mammography screening frequency (annual versus biennial). Data were analyzed from 2020 to 2022. RESULTS Among 12,929 women with a mean age of 61±6.9 years, 82.7% underwent annual screening mammography, and 30.7% met high-risk criteria for breast cancer. Hispanic women were more likely to screen annually than non-Hispanic Whites (85.0% vs 79.8%, respectively), despite fewer meeting high-risk criteria. In multivariable analyses adjusting for breast cancer risk factors, high- versus low/average-risk women (OR=1.17; 95% CI=1.04, 1.32) and Hispanic versus non-Hispanic White women (OR=1.46; 95% CI=1.29, 1.65) were more likely to undergo annual mammography. CONCLUSIONS A majority of women continue to undergo annual screening mammography despite only a minority meeting high-risk criteria, and Hispanic women were more likely to screen annually despite lower overall breast cancer risk. Future studies should focus on the implementation of risk-stratified breast cancer screening strategies.
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Affiliation(s)
- Jingwen Zhang
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Julia E McGuinness
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York.
| | - Xin He
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Tarsha Jones
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
| | - Thomas Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ashlee Guzman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Benjamin L May
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York; Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Katherine D Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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20
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Trapani D, Sandoval J, Aliaga PT, Ascione L, Maria Berton Giachetti PP, Curigliano G, Ginsburg O. Screening Programs for Breast Cancer: Toward Individualized, Risk-Adapted Strategies of Early Detection. Cancer Treat Res 2023; 188:63-88. [PMID: 38175342 DOI: 10.1007/978-3-031-33602-7_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] [Indexed: 01/05/2024]
Abstract
Early detection of breast cancer (BC) comprises two approaches: screening of asymptomatic women in a specified target population at risk (usually a target age range for women at average risk), and early diagnosis for women with BC signs and symptoms. Screening for BC is a key health intervention for early detection. While population-based screening programs have been implemented for age-selected women, the pivotal clinical trials have not addressed the global utility nor the improvement of screening performance by utilizing more refined parameters for patient eligibility, such as individualized risk stratification. In addition, with the exception of the subset of women known to carry germline pathogenetic mutations in (high- or moderately-penetrant) cancer predisposition genes, such as BRCA1 and BRCA2, there has been less success in outreach and service provision for the unaffected relatives of women found to carry a high-risk mutation (i.e., "cascade testing") as it is in these individuals for whom such actionable information can result in cancers (and/or cancer deaths) being averted. Moreover, even in the absence of clinical cancer genetics services, as is the case for the immediate and at least near-term in most countries globally, the capacity to stratify the risk of an individual to develop BC has existed for many years, is available for free online at various sites/platforms, and is increasingly being validated for non-Caucasian populations. Ultimately, a precision approach to BC screening is largely missing. In the present chapter, we aim to address the concept of risk-adapted screening of BC, in multiple facets, and understand if there is a value in the implementation of adapted screening strategies in selected women, outside the established screening prescriptions, in the terms of age-range, screening modality and schedules of imaging.
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Affiliation(s)
- Dario Trapani
- Division of New Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy.
| | - Josè Sandoval
- Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
- Unit of Population Epidemiology, Division and Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pamela Trillo Aliaga
- Division of New Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milan, Milan, Italy
| | - Liliana Ascione
- Division of New Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milan, Milan, Italy
| | - Pier Paolo Maria Berton Giachetti
- Division of New Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milan, Milan, Italy
| | - Giuseppe Curigliano
- Division of New Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, University of Milan, Milan, Italy
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21
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James JE, Joseph G. "It's personalized, but it's still bucket based": The promise of personalized medicine vs. the reality of genomic risk stratification in a breast cancer screening trial. NEW GENETICS AND SOCIETY 2022; 41:228-253. [PMID: 36936188 PMCID: PMC10021681 DOI: 10.1080/14636778.2022.2115348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/03/2022] [Indexed: 06/15/2023]
Abstract
Adaptive pragmatic clinical trials offer an innovative approach that integrates clinical care and research. Yet, blurring the boundaries between research and clinical care raises questions about how clinicians and investigators balance their caregiving and research roles and what types of knowledge and risk assessment are most valued. This paper presents findings from an ethnographic ELSI (Ethical, Legal, Social Implications) study of an innovative clinical trial of risk-based breast cancer screening that utilizes genomics to stratify risk and recommend a breast cancer screening commensurate with the assessed risk. We argue that the trial demonstrates a fundamental tension between the promissory ideals of personalized medicine, and the reality of implementing risk stratified care on a population scale. We examine the development of a Screening Assignment Review Board in response to this tension which allows clinician-investigators to negotiate, but never fully resolve, the inherent contradiction of 'precision population screening'.
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Affiliation(s)
| | - Galen Joseph
- Department of Humanities and Social Sciences, University of California, San Francisco
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22
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Nyante SJ, Abraham L, Bowles EJA, Lee CI, Kerlikowske K, Miglioretti DL, Sprague BL, Henderson LM. Diagnostic Mammography Performance across Racial and Ethnic Groups in a National Network of Community-Based Breast Imaging Facilities. Cancer Epidemiol Biomarkers Prev 2022; 31:1324-1333. [PMID: 35712862 PMCID: PMC9272467 DOI: 10.1158/1055-9965.epi-21-1379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/16/2022] [Accepted: 04/26/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND We evaluated differences in diagnostic mammography performance based on women's race/ethnicity. METHODS This cohort study included 267,868 diagnostic mammograms performed to evaluate screening mammogram findings at 98 facilities in the Breast Cancer Surveillance Consortium between 2005 and 2017. Mammogram assessments were recorded prospectively and breast cancers occurring within one year were ascertained. Performance statistics were calculated with 95% confidence intervals (CI) for each racial/ethnic group. Multivariable regression was used to control for personal characteristics and imaging facility. RESULTS Among non-Hispanic White (70%), non-Hispanic Black (13%), Asian/Pacific Islander (10%), and Hispanic (7%) women, the invasive cancer detection rate (iCDR, per 1,000 mammograms) and positive predictive value (PPV2) were highest among non-Hispanic White women (iCDR, 35.8; 95% CI, 35.0-36.7; PPV2, 27.8; 95% CI, 27.3-28.3) and lowest among Hispanic women (iCDR, 22.3; 95% CI, 20.2-24.6; PPV2, 19.4; 95% CI, 18.0-20.9). Short interval follow-up recommendations were most common among non-Hispanic Black women [(31.0%; 95% CI, 30.6%-31.5%) vs. other groups, range, 16.6%-23.6%]. False-positive biopsy recommendations were most common among Asian/Pacific Islander women [per 1,000 mammograms: 169.2; 95% CI, 164.8-173.7) vs. other groups, range, 126.5-136.1]. Some differences were explained by adjusting for receipt of diagnostic ultrasound or MRI for iCDR and imaging facility for short-interval follow-up. Other differences changed little after adjustment. CONCLUSIONS Diagnostic mammography performance varied across racial/ethnic groups. Addressing characteristics related to imaging facility and access, rather than personal characteristics, may help reduce some of these disparities. IMPACT Diagnostic mammography performance studies should include racially and ethnically diverse populations to provide an accurate view of the population-level effects.
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Affiliation(s)
- Sarah J. Nyante
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Linn Abraham
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Erin J. Aiello Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Christoph I. Lee
- Department of Radiology, University of Washington School of Medicine; Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA,Department of Public Health Sciences, University of California, Davis, Davis, CA
| | - Brian L. Sprague
- Department of Surgery and University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - Louise M. Henderson
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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23
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Tran TXM, Kim S, Song H, Park B. Mammographic breast density, body mass index and risk of breast cancer in Korean women aged 75 years and older. Int J Cancer 2022; 151:869-877. [PMID: 35460071 DOI: 10.1002/ijc.34038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/26/2022] [Accepted: 04/08/2022] [Indexed: 01/23/2023]
Abstract
Mammographic breast density and body mass index (BMI) are strong risk factors of breast cancer, but few studies have investigated these factors in older women. Our study assessed the association between breast density, BMI and the breast cancer risk among women aged ≥75 years. We included women who underwent breast cancer screening between 2009 and 2014 and were followed up until 2020. Breast density was measured using Breast Imaging Reporting and Data System. BMI was classified into three groups: <23, 23 to <25 and ≥25. Cox proportional hazards models were used to estimate the association of breast density and BMI with breast cancer risk. In 483 564 women, 1885 developed breast cancer. The 5-year incidence increased with an increase in breast density and BMI. Increase in breast density was associated with an increased breast cancer risk in all BMI categories: among women with BMI <23, those with heterogeneous/extreme density had a 2.98-fold (95% CI: 2.23-3.80) increased risk of breast cancer compared to those with entirely fatty breasts. An increase in BMI was associated with increased breast cancer risk in women with the same breast density in all density categories. When the combined associations of breast density and BMI on the risk of breast cancer were considered, women with a BMI ≥25 and heterogeneous/extreme breast density had a 5.35-fold (95% CI: 4.26-6.72) increased risk of breast cancer compared to women with a BMI <23 and fatty breasts. Women aged ≥75 years, with dense breasts, regardless of BMI status, might benefit from a tailored screening strategy for early detection of breast cancer.
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Affiliation(s)
- Thi Xuan Mai Tran
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Soyeoun Kim
- Department of Health Sciences, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Huiyeon Song
- Department of Epidemiology and Biostatistics, Graduate School of Public Health, Hanyang University, Seoul, Republic of Korea
| | - Boyoung Park
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
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24
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McGuinness JE, Zhang TM, Cooper K, Kelkar A, Dimond J, Lorenzi V, Crew KD, Kukafka R. Extraction of Electronic Health Record Data using Fast Healthcare Interoperability Resources for Automated Breast Cancer Risk Assessment. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2021:843-852. [PMID: 35308910 PMCID: PMC8861753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Women at high risk for breast cancer may benefit from enhanced screening and risk-reduction strategies. However, limited time during clinical encounters is one barrier to routine breast cancer risk assessment. We evaluated if electronic health record (EHR) data downloaded using Fast Healthcare Interoperability Resources (FHIR) is sufficient for breast cancer risk calculation in our decision support tools, RealRisks and BNAV. We accessed EHR data using FHIR for six patient advocates, and downloaded and parsed XML documents. We searched for relevant clinical variables, and evaluated if data was sufficient to calculate risk using validated models (Gail, Breast Cancer Screening Consortium [BCSC], BRCAPRO). While only one advocate had sufficient EHR data to calculate risk using the BCSC model only, we identified variables including age, race/ethnicity, mammographic density, and prior breast biopsy in most advocates. EHR data from FHIR could be incorporated into automated breast cancer risk calculation in clinical decision support tools.
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Affiliation(s)
- Julia E McGuinness
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Tianmai M Zhang
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | - Arusha Kelkar
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jill Dimond
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Virginia Lorenzi
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Katherine D Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rita Kukafka
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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25
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Schonberg MA, Karamourtopoulos M, Pinheiro A, Davis RB, Sternberg SB, Mehta TS, Gilliam EA, Tung NM. Variation in Breast Cancer Risk Model Estimates Among Women in Their 40s Seen in Primary Care. J Womens Health (Larchmt) 2022; 31:495-502. [PMID: 35073183 DOI: 10.1089/jwh.2021.0299] [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: 11/12/2022] Open
Abstract
Background: The Gail, Breast Cancer Surveillance Consortium (BCSC), and Tyrer-Cuzick breast cancer risk prediction models are recommended for use in primary care. Calculating breast cancer risk is particularly important for women in their 40s when deciding on mammography, with some guidelines recommending screening for those with 5-year risk similar to women age 50 (≥1.1%). Yet, little is known about risk estimate agreement among models for these women. Materials and Methods: Four hundred nine Boston-area women 40-49 years of age completed a risk questionnaire before a primary care visit to compute their breast cancer risk. The kappa statistic was used to examine when (1) Gail and BCSC agreed on 5-year risk ≥1.1%; (2) Gail estimated 5-year risk ≥1.7% and Tyrer-Cuzick estimated 10-year risk ≥5% (guideline thresholds for recommending prevention medications); and when (3) Gail and Tyrer-Cuzick agreed on lifetime risk ≥20% (threshold for breast MRI using Tyrer-Cuzick). Results: Participant mean age was 44.1 years, 56.7% were non-Hispanic white, and 7.8% had a first-degree relative with breast cancer. Of 266 with breast density information to estimate both Gail and BCSC, the models agreed on 5-year risk being ≥1.1% for 36 women, kappa = 0.34 (95% confidence interval: 0.23-0.45). Gail and Tyrer-Cuzick estimates led to agreement about prevention medications for 8 women, kappa 0.41 (0.20-0.61), and models agreed on lifetime risk ≥20% for 3 women, kappa 0.08 (-0.01 to 0.16). Conclusions: There is weak agreement on breast cancer risk estimates generated by risk models recommended for primary care. Using different models may lead to different clinical recommendations for women in their 40s.
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Affiliation(s)
- Mara A Schonberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Maria Karamourtopoulos
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Adlin Pinheiro
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Roger B Davis
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Scot B Sternberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tejas S Mehta
- Division of Breast Imaging, Department of Radiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Elizabeth A Gilliam
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nadine M Tung
- Department of Diagnostic Imaging, UMass Memorial Health, UMass Memorial Medical Center, Worcester, MA
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26
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Validation of Breast Cancer Risk Models by Race/Ethnicity, Family History and Molecular Subtypes. Cancers (Basel) 2021; 14:cancers14010045. [PMID: 35008209 PMCID: PMC8750569 DOI: 10.3390/cancers14010045] [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: 11/25/2021] [Revised: 12/09/2021] [Accepted: 12/20/2021] [Indexed: 12/28/2022] Open
Abstract
Simple Summary Several statistical models exist to predict a person’s risk of breast cancer. Risk assessment models can guide cancer screening approaches by identifying individuals who would benefit from additional screening. In this study, we compared the performance of four models in predicting the 5-year risk of breast cancer in a cohort of women aged 40–84 years who underwent screening mammography at three large health systems. Models showed comparable discrimination (ability to distinguish between cases and non-cases) and calibration (ability to accurately predict risk) overall, with no difference by race. Model discrimination was poorer for some cancer subtypes, and better for women with high BMI. The combined BRCAPRO+BCRAT model had improved calibration and discrimination among women with a family history of breast cancer. Our results can inform risk-based screening approaches by identifying women at a high risk of breast cancer. Abstract (1) Background: The purpose of this study is to compare the performance of four breast cancer risk prediction models by race, molecular subtype, family history of breast cancer, age, and BMI. (2) Methods: Using a cohort of women aged 40–84 without prior history of breast cancer who underwent screening mammography from 2006 to 2015, we generated breast cancer risk estimates using the Breast Cancer Risk Assessment tool (BCRAT), BRCAPRO, Breast Cancer Surveillance Consortium (BCSC) and combined BRCAPRO+BCRAT models. Model calibration and discrimination were compared using observed-to-expected ratios (O/E) and the area under the receiver operator curve (AUC) among patients with at least five years of follow-up. (3) Results: We observed comparable discrimination and calibration across models. There was no significant difference in model performance between Black and White women. Model discrimination was poorer for HER2+ and triple-negative subtypes compared with ER/PR+HER2−. The BRCAPRO+BCRAT model displayed improved calibration and discrimination compared to BRCAPRO among women with a family history of breast cancer. Across models, discriminatory accuracy was greater among obese than non-obese women. When defining high risk as a 5-year risk of 1.67% or greater, models demonstrated discordance in 2.9% to 19.7% of patients. (4) Conclusions: Our results can inform the implementation of risk assessment and risk-based screening among women undergoing screening mammography.
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27
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Palmer JR, Zirpoli G, Bertrand KA, Battaglia T, Bernstein L, Ambrosone CB, Bandera EV, Troester MA, Rosenberg L, Pfeiffer RM, Trinquart L. A Validated Risk Prediction Model for Breast Cancer in US Black Women. J Clin Oncol 2021; 39:3866-3877. [PMID: 34623926 DOI: 10.1200/jco.21.01236] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Breast cancer risk prediction models are used to identify high-risk women for early detection, targeted interventions, and enrollment into prevention trials. We sought to develop and evaluate a risk prediction model for breast cancer in US Black women, suitable for use in primary care settings. METHODS Breast cancer relative risks and attributable risks were estimated using data from Black women in three US population-based case-control studies (3,468 breast cancer cases; 3,578 controls age 30-69 years) and combined with SEER age- and race-specific incidence rates, with incorporation of competing mortality, to develop an absolute risk model. The model was validated in prospective data among 51,798 participants of the Black Women's Health Study, including 1,515 who developed invasive breast cancer. A second risk prediction model was developed on the basis of estrogen receptor (ER)-specific relative risks and attributable risks. Model performance was assessed by calibration (expected/observed cases) and discriminatory accuracy (C-statistic). RESULTS The expected/observed ratio was 1.01 (95% CI, 0.95 to 1.07). Age-adjusted C-statistics were 0.58 (95% CI, 0.56 to 0.59) overall and 0.63 (95% CI, 0.58 to 0.68) among women younger than 40 years. These measures were almost identical in the model based on estrogen receptor-specific relative risks and attributable risks. CONCLUSION Discriminatory accuracy of the new model was similar to that of the most frequently used questionnaire-based breast cancer risk prediction models in White women, suggesting that effective risk stratification for Black women is now possible. This model may be especially valuable for risk stratification of young Black women, who are below the ages at which breast cancer screening is typically begun.
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Affiliation(s)
- Julie R Palmer
- Slone Epidemiology Center at Boston University, Boston, MA.,Boston University School of Medicine, Boston, MA
| | - Gary Zirpoli
- Slone Epidemiology Center at Boston University, Boston, MA
| | - Kimberly A Bertrand
- Slone Epidemiology Center at Boston University, Boston, MA.,Boston University School of Medicine, Boston, MA
| | | | | | | | | | - Melissa A Troester
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Lynn Rosenberg
- Slone Epidemiology Center at Boston University, Boston, MA
| | - Ruth M Pfeiffer
- National Cancer Institute, Division of Cancer Epidemiology and Genetics, Bethesda, MD
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28
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James JE, Riddle L, Koenig BA, Joseph G. The limits of personalization in precision medicine: Polygenic risk scores and racial categorization in a precision breast cancer screening trial. PLoS One 2021; 16:e0258571. [PMID: 34714858 PMCID: PMC8555816 DOI: 10.1371/journal.pone.0258571] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 10/01/2021] [Indexed: 01/10/2023] Open
Abstract
Population-based genomic screening is at the forefront of a new approach to disease prevention. Yet the lack of diversity in genome wide association studies and ongoing debates about the appropriate use of racial and ethnic categories in genomics raise key questions about the translation of genomic knowledge into clinical practice. This article reports on an ethnographic study of a large pragmatic clinical trial of breast cancer screening called WISDOM (Women Informed to Screen Depending On Measures of Risk). Our ethnography illuminates the challenges of using race or ethnicity as a risk factor in the implementation of precision breast cancer risk assessment. Our analysis provides critical insights into how categories of race, ethnicity and ancestry are being deployed in the production of genomic knowledge and medical practice, and key challenges in the development and implementation of novel Polygenic Risk Scores in the research and clinical applications of this emerging science. Specifically, we show how the conflation of social and biological categories of difference can influence risk prediction for individuals who exist at the boundaries of these categories, affecting the perceptions and practices of scientists, clinicians, and research participants themselves. Our research highlights the potential harms of practicing genomic medicine using under-theorized and ambiguous categories of race, ethnicity, and ancestry, particularly in an adaptive, pragmatic trial where research findings are applied in the clinic as they emerge. We contribute to the expanding literature on categories of difference in post-genomic science by closely examining the implementation of a large breast cancer screening study that aims to personalize breast cancer risk using both common and rare genomic markers.
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Affiliation(s)
- Jennifer Elyse James
- Institute for Health and Aging, University of California, San Francisco, California, United States of America
| | - Leslie Riddle
- Department of Humanities and Social Sciences, University of California, San Francisco, California, United States of America
| | - Barbara Ann Koenig
- Institute for Health and Aging, University of California, San Francisco, California, United States of America
- Department of Humanities and Social Sciences, University of California, San Francisco, California, United States of America
| | - Galen Joseph
- Department of Humanities and Social Sciences, University of California, San Francisco, California, United States of America
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29
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Vegunta S, Bhatt AA, Choudhery SA, Pruthi S, Kaur AS. Identifying women with increased risk of breast cancer and implementing risk-reducing strategies and supplemental imaging. Breast Cancer 2021; 29:19-29. [PMID: 34665436 DOI: 10.1007/s12282-021-01298-x] [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: 10/21/2020] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
Breast cancer (BC) is the second most common cancer in women, affecting 1 in 8 women in the United States (12.5%) in their lifetime. However, some women have a higher lifetime risk of BC because of genetic and lifestyle factors, mammographic breast density, and reproductive and hormonal factors. Because BC risk is variable, screening and prevention strategies should be individualized after considering patient-specific risk factors. Thus, health care professionals need to be able to assess risk profiles, identify high-risk women, and individualize screening and prevention strategies through a shared decision-making process. In this article, we review the risk factors for BC, risk-assessment models that identify high-risk patients, and preventive medications and lifestyle modifications that may decrease risk. We also discuss the benefits and limitations of various supplemental screening methods.
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Affiliation(s)
- Suneela Vegunta
- Division of Women's Health Internal Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Asha A Bhatt
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sandhya Pruthi
- Division of General Internal Medicine, Breast Cancer Clinic, Mayo Clinic, Rochester, MN, USA
| | - Aparna S Kaur
- Division of General Internal Medicine, Breast Cancer Clinic, Mayo Clinic, Rochester, MN, USA
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30
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Huilgol YS, Keane H, Shieh Y, Hiatt RA, Tice JA, Madlensky L, Sabacan L, Fiscalini AS, Ziv E, Acerbi I, Che M, Anton-Culver H, Borowsky AD, Hunt S, Naeim A, Parker BA, van 't Veer LJ, Esserman LJ. Elevated risk thresholds predict endocrine risk-reducing medication use in the Athena screening registry. NPJ Breast Cancer 2021; 7:102. [PMID: 34344894 PMCID: PMC8333106 DOI: 10.1038/s41523-021-00306-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/24/2021] [Indexed: 11/09/2022] Open
Abstract
Risk-reducing endocrine therapy use, though the benefit is validated, is extremely low. The FDA has approved tamoxifen and raloxifene for a 5-year Breast Cancer Risk Assessment Tool (BCRAT) risk ≥ 1.67%. We examined the threshold at which high-risk women are likely to be using endocrine risk-reducing therapies among Athena Breast Health Network participants from 2011-2018. We identified high-risk women by a 5-year BCRAT risk ≥ 1.67% and those in the top 10% and 2.5% risk thresholds by age. We estimated the odds ratio (OR) of current medication use based on these thresholds using logistic regression. One thousand two hundred and one (1.2%) of 104,223 total participants used medication. Of the 33,082 participants with 5-year BCRAT risk ≥ 1.67%, 772 (2.3%) used medication. Of 2445 in the top 2.5% threshold, 209 (8.6%) used medication. Participants whose 5-year risk exceeded 1.67% were more likely to use medication than those whose risk was below this threshold, OR 3.94 (95% CI = 3.50-4.43). The top 2.5% was most strongly associated with medication usage, OR 9.50 (8.13-11.09) compared to the bottom 97.5%. Women exceeding a 5-year BCRAT ≥ 1.67% had modest medication use. We demonstrate that women in the top 2.5% have higher odds of medication use than those in the bottom 97.5% and compared to a risk of 1.67%. The top 2.5% threshold would more effectively target medication use and is being tested prospectively in a randomized control clinical trial.
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Affiliation(s)
- Yash S Huilgol
- University of California, San Francisco, San Francisco, CA, USA
- University of California, Berkeley, Berkeley, CA, USA
| | - Holly Keane
- University of California, San Francisco, San Francisco, CA, USA
- Peter MacCallum Cancer Centre, Melbourne, Melbourne, VIC, Australia
| | - Yiwey Shieh
- University of California, San Francisco, San Francisco, CA, USA
| | - Robert A Hiatt
- University of California, San Francisco, San Francisco, CA, USA
| | - Jeffrey A Tice
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Leah Sabacan
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Elad Ziv
- University of California, San Francisco, San Francisco, CA, USA
| | - Irene Acerbi
- University of California, San Francisco, San Francisco, CA, USA
| | - Mandy Che
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | - Arash Naeim
- University of California, Los Angeles, Los Angeles, CA, USA
| | | | | | - Laura J Esserman
- University of California, San Francisco, San Francisco, CA, USA.
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Advani SM, Zhu W, Demb J, Sprague BL, Onega T, Henderson LM, Buist DSM, Zhang D, Schousboe JT, Walter LC, Kerlikowske K, Miglioretti DL, Braithwaite D. Association of Breast Density With Breast Cancer Risk Among Women Aged 65 Years or Older by Age Group and Body Mass Index. JAMA Netw Open 2021; 4:e2122810. [PMID: 34436608 PMCID: PMC8391100 DOI: 10.1001/jamanetworkopen.2021.22810] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE Breast density is associated with breast cancer risk in women aged 40 to 65 years, but there is limited evidence of its association with risk of breast cancer among women aged 65 years or older. OBJECTIVE To compare the association between breast density and risk of invasive breast cancer among women aged 65 to 74 years vs women aged 75 years or older and to evaluate whether the association is modified by body mass index (BMI). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study used data from the Breast Cancer Surveillance Consortium from January 1, 1996, to December 31, 2012, for US women aged 65 years or older who underwent screening mammography. Data were analyzed from January 1, 2018, to December 31, 2020. EXPOSURES Breast Imaging Reporting and Data System breast density category, age, and BMI. MAIN OUTCOMES AND MEASURES The 5-year cumulative incidence of invasive breast cancer by level of breast density (almost entirely fat, scattered fibroglandular densities, or heterogeneous or extreme density) and age (65-74 vs ≥75 years) was calculated using weighted means. Cox proportional hazards models were fit to estimate the association of breast density with invasive breast cancer risk. The likelihood ratio test was used to test the interaction between BMI and breast density. RESULTS A total of 221 714 screening mammograms from 193 787 women were included in the study; a total of 38% of the study population was aged 75 years or older. Of the mammograms, most were from women aged 65 to 74 years (64.6%) and non-Hispanic White individuals (81.4%). The 5-year cumulative incidence of invasive breast cancer increased in association with increasing breast density among women aged 65 to 74 years (almost entirely fatty breasts: 11.3 per 1000 women [95% CI, 10.4-12.5 per 1000 women]; scattered fibroglandular densities: 17.2 per 1000 women [95% CI, 16.1-17.9 per 1000 women]; extremely or heterogeneously dense breasts: 23.7 per 1000 women [95% CI, 22.4-25.3 per 1000 women]) and among those aged 75 years or older (fatty breasts: 13.5 per 1000 women [95% CI, 11.6-15.5]; scattered fibroglandular densities: 18.4 per 1000 women [95% CI, 17.0-19.5 per 1000 women]; extremely or heterogeneously dense breasts: 22.5 per 1000 women [95% CI, 20.2-24.2 per 1000 women]). Extreme or heterogeneous breast density was associated with increased risk of breast cancer compared with scattered fibroglandular breast density in both age categories (65-74 years: hazard ratio [HR], 1.39 [95% CI, 1.28-1.50]; ≥75 years: HR, 1.23 [95% CI, 1.10-1.37]). Women with almost entirely fatty breasts had a decrease of approximately 30% (range, 27%-34%) in the risk of invasive breast cancer compared with women with scattered fibroglandular breast density (65-74 years: HR, 0.66 [95% CI, 0.58-0.75]; ≥75 years: HR, 0.73; 95% CI, 0.62-0.86). Associations between breast density and breast cancer risk were not significantly modified by BMI (for age 65-74 years: likelihood ratio test, 2.67; df, 2; P = .26; for age ≥75 years, 2.06; df, 2; P = .36). CONCLUSIONS AND RELEVANCE The findings suggest that breast density is associated with increased risk of invasive breast cancer among women aged 65 years or older. Breast density and life expectancy should be considered together when discussing the potential benefits vs harms of continued screening mammography in this population.
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Affiliation(s)
- Shailesh M. Advani
- Department of Oncology, Georgetown University, Washington, DC
- Terasaki Institute of Biomedical Innovation, Los Angeles, California
| | - Weiwei Zhu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joshua Demb
- Department of Medicine, University of California, San Diego
| | - Brian L. Sprague
- Department of Surgery, Larner College of Medicine, University of Vermont, Burlington
| | - Tracy Onega
- Department of Population Sciences, University of Utah, Salt Lake City
| | | | - Diana S. M. Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Dongyu Zhang
- Department of Epidemiology, University of Florida, Gainesville
| | - John T. Schousboe
- Division of Research, Health Partners Institute, Bloomington, Minnesota
| | | | - Karla Kerlikowske
- Department of Medicine, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Public Health Sciences, School of Medicine, University of California, Davis
| | - Dejana Braithwaite
- Terasaki Institute of Biomedical Innovation, Los Angeles, California
- Cancer Control and Population Sciences Program, University of Florida Health Cancer Center, Gainesville
- Department of Epidemiology, University of Florida, Gainesville
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Distribution of Estimated Lifetime Breast Cancer Risk Among Women Undergoing Screening Mammography. AJR Am J Roentgenol 2021; 217:48-55. [PMID: 33978450 DOI: 10.2214/ajr.20.23333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. Supplemental screening breast MRI is recommended for women with an estimated lifetime risk of breast cancer of greater than 20-25%. The performance of risk prediction models varies for each individual and across groups of women. The present study investigates the concordance of three breast cancer risk prediction models among women presenting for screening mammography. SUBJECTS AND METHODS. In this prospective study, we calculated the estimated lifetime risk of breast cancer using the modified Gail, Tyrer-Cuzick version 7, and BRCAPRO models for each woman who presented for screening mammography. Per American Cancer Society guidelines, for each woman the risk was categorized as less than 20% or 20% or greater as well as less than 25% or 25% or greater with use of each model. Venn diagrams were constructed to evaluate concordance across models. The McNemar test was used to test differences in risk group allocations between models, with p ≤ .05 considered to denote statistical significance. RESULTS. Of 3503 screening mammography patients who underwent risk stratification, 3219 (91.9%) were eligible for risk estimation using all three models. Using at least one model, 440 (13.7%) women had a lifetime risk of 20% or greater, including 390 women (12.1%) according to the Tyrer-Cuzick version 7 model, 18 (0.6%) according to the BRCAPRO model, and 141 (4.4%) according to the modified Gail model. Six women (0.2%) had a risk of 20% or greater according to all three models. Women were significantly more likely to be classified as having a high lifetime breast cancer risk by the Tyrer-Cuzick version 7 model compared with the modified Gail model, with thresholds of 20% or greater (odds ratio, 6.4; 95% CI, 4.7-8.7) or 25% or greater (odds ratio, 7.4; 95% CI, 4.7-11.9) used for both models. CONCLUSION. To identify women with a high lifetime breast cancer risk, practices should use estimates of lifetime breast cancer risk derived from multiple risk prediction models.
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Houghton SC, Hankinson SE. Cancer Progress and Priorities: Breast Cancer. Cancer Epidemiol Biomarkers Prev 2021; 30:822-844. [PMID: 33947744 DOI: 10.1158/1055-9965.epi-20-1193] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/13/2020] [Accepted: 02/19/2021] [Indexed: 12/24/2022] Open
Affiliation(s)
- Serena C Houghton
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, Massachusetts.
| | - Susan E Hankinson
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, Massachusetts
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Kim G, Bahl M. Assessing Risk of Breast Cancer: A Review of Risk Prediction Models. JOURNAL OF BREAST IMAGING 2021; 3:144-155. [PMID: 33778488 DOI: 10.1093/jbi/wbab001] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Indexed: 12/17/2022]
Abstract
Accurate and individualized breast cancer risk assessment can be used to guide personalized screening and prevention recommendations. Existing risk prediction models use genetic and nongenetic risk factors to provide an estimate of a woman's breast cancer risk and/or the likelihood that she has a BRCA1 or BRCA2 mutation. Each model is best suited for specific clinical scenarios and may have limited applicability in certain types of patients. For example, the Breast Cancer Risk Assessment Tool, which identifies women who would benefit from chemoprevention, is readily accessible and user-friendly but cannot be used in women under 35 years of age or those with prior breast cancer or lobular carcinoma in situ. Emerging research on deep learning-based artificial intelligence (AI) models suggests that mammographic images contain risk indicators that could be used to strengthen existing risk prediction models. This article reviews breast cancer risk factors, describes the appropriate use, strengths, and limitations of each risk prediction model, and discusses the emerging role of AI for risk assessment.
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Affiliation(s)
- Geunwon Kim
- Beth Israel Deaconess Medical Center, Department of Radiology, Boston, MA, USA
| | - Manisha Bahl
- Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
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Buist DSM. Factors to Consider in Developing Breast Cancer Risk Models to Implement into Clinical Care. CURR EPIDEMIOL REP 2021; 7:113-116. [PMID: 33552842 DOI: 10.1007/s40471-020-00230-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Purpose of the review This article outlines considerations for individuals interested in developing and implementing breast cancer risk models and has relevance for individuals developing risk-models with the goal of implementing them into health systems. Recent findings There has been increased focus on developing risk models for clinical use-often with less attention model implementation. Epidemiologists developing risk-models must think through model outcomes including stakeholder needs, time horizons, terminology and reference groups and clarity on what actionable steps are for health systems, providers and patients following its implementation. Summary Model performance needs to be evaluated relative to complexity of the model to be implemented-not just from the risk-prediction perspective, but also from the burden on patients, providers and systems for the amount and frequency of required data collection and with clear actionable steps to be taken with the information collected.
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Affiliation(s)
- Diana S M Buist
- Kaiser Permanente Washington Health Research Institute, Seattle WA
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Wernli KJ, Knerr S, Li T, Leppig K, Ehrlich K, Farrell D, Gao H, Bowles EJA, Graham AL, Luta G, Jayasekera J, Mandelblatt JS, Schwartz MD, O’Neill SC. Effect of Personalized Breast Cancer Risk Tool on Chemoprevention and Breast Imaging: ENGAGED-2 Trial. JNCI Cancer Spectr 2021; 5:pkaa114. [PMID: 33554037 PMCID: PMC7853161 DOI: 10.1093/jncics/pkaa114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/14/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background Limited evidence exists about how to communicate breast density-informed breast cancer risk to women at elevated risk to motivate cancer prevention. Methods We conducted a randomized controlled trial evaluating a web-based intervention incorporating personalized breast cancer risk, information on chemoprevention, and values clarification on chemoprevention uptake vs active control. Eligible women aged 40-69 years with normal mammograms and elevated 5-year breast cancer risk were recruited from Kaiser Permanente Washington from February 2017 to May 2018. Chemoprevention uptake was measured as any prescription for raloxifene or tamoxifen within 12 months from baseline in electronic health record pharmacy data. Secondary outcomes included breast magnetic resonance imaging (MRI), mammography use, self-reported distress, and communication with providers. We calculated unadjusted odds ratios (ORs) using logistic regression models and mean differences using analysis of covariance models with 95% confidence intervals (CIs) with generalized estimating equations. Results We randomly assigned 995 women to the intervention arm (n = 492) or control arm (n = 503). The intervention (vs control) had no effect on chemoprevention uptake (OR = 1.04, 95% CI = 0.07 to 16.62). The intervention increased breast MRI use (OR = 5.65, 95% CI = 1.61 to 19.74) while maintaining annual mammography (OR = 0.98, 95% CI = 0.75 to 1.28). Women in the intervention (vs control) arm had 5.67-times higher odds of having discussed chemoprevention or breast MRI with provider by 6 weeks (OR = 5.67, 95% CI = 2.47 to 13.03) and 2.36-times higher odds by 12 months (OR = 2.36, 95% CI = 1.65 to 3.37). No measurable differences in distress were detected. Conclusions A web-based, patient-level intervention activated women at elevated 5-year breast cancer risk to engage in clinical discussions about chemoprevention, but uptake remained low.
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Affiliation(s)
- Karen J Wernli
- Correspondence to: Karen J. Wernli, PhD, Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA (e-mail: )
| | - Sarah Knerr
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Tengfei Li
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | | | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Erin J A Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Amanda L Graham
- Truth Initiative, Washington, DC, USA,Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - George Luta
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | - Jinani Jayasekera
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Jeanne S Mandelblatt
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Suzanne C O’Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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Watt GP, Sung J, Morris EA, Buys SS, Bradbury AR, Brooks JD, Conant EF, Weinstein SP, Kontos D, Woods M, Colonna SV, Liang X, Stein MA, Pike MC, Bernstein JL. Association of breast cancer with MRI background parenchymal enhancement: the IMAGINE case-control study. Breast Cancer Res 2020; 22:138. [PMID: 33287857 PMCID: PMC7722419 DOI: 10.1186/s13058-020-01375-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/25/2020] [Indexed: 01/09/2023] Open
Abstract
Background Background parenchymal enhancement (BPE) on breast magnetic resonance imaging (MRI) may be associated with breast cancer risk, but previous studies of the association are equivocal and limited by incomplete blinding of BPE assessment. In this study, we evaluated the association between BPE and breast cancer based on fully blinded assessments of BPE in the unaffected breast. Methods The Imaging and Epidemiology (IMAGINE) study is a multicenter breast cancer case-control study of women receiving diagnostic, screening, or follow-up breast MRI, recruited from three comprehensive cancer centers in the USA. Cases had a first diagnosis of unilateral breast cancer and controls had no history of or current breast cancer. A single board-certified breast radiologist with 12 years’ experience, blinded to case-control status and clinical information, assessed the unaffected breast for BPE without view of the affected breast of cases (or the corresponding breast laterality of controls). The association between BPE and breast cancer was estimated by multivariable logistic regression separately for premenopausal and postmenopausal women. Results The analytic dataset included 835 cases and 963 controls. Adjusting for fibroglandular tissue (breast density), age, race/ethnicity, BMI, parity, family history of breast cancer, BRCA1/BRCA2 mutations, and other confounders, moderate/marked BPE (vs minimal/mild BPE) was associated with breast cancer among premenopausal women [odds ratio (OR) 1.49, 95% CI 1.05–2.11; p = 0.02]. Among postmenopausal women, mild/moderate/marked vs minimal BPE had a similar, but statistically non-significant, association with breast cancer (OR 1.45, 95% CI 0.92–2.27; p = 0.1). Conclusions BPE is associated with breast cancer in premenopausal women, and possibly postmenopausal women, after adjustment for breast density and confounders. Our results suggest that BPE should be evaluated alongside breast density for inclusion in models predicting breast cancer risk.
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Affiliation(s)
- Gordon P Watt
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave., Second Floor, New York, NY, 10017, USA.
| | - Janice Sung
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Elizabeth A Morris
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Saundra S Buys
- Huntsman Cancer Institute, University of Utah, Salt Lake City, USA
| | - Angela R Bradbury
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Jennifer D Brooks
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Emily F Conant
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Susan P Weinstein
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Despina Kontos
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Meghan Woods
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave., Second Floor, New York, NY, 10017, USA
| | - Sarah V Colonna
- Huntsman Cancer Institute, University of Utah, Salt Lake City, USA
| | - Xiaolin Liang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave., Second Floor, New York, NY, 10017, USA
| | - Matthew A Stein
- Huntsman Cancer Institute, University of Utah, Salt Lake City, USA
| | - Malcolm C Pike
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave., Second Floor, New York, NY, 10017, USA
| | - Jonine L Bernstein
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave., Second Floor, New York, NY, 10017, USA
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Evans DG, van Veen EM, Howell A, Astley S. Heritability of mammographic breast density. Quant Imaging Med Surg 2020; 10:2387-2391. [PMID: 33269237 DOI: 10.21037/qims-2020-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- D Gareth Evans
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, 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 Universities Foundation Trust, Wythenshawe, Manchester, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, UK
| | - Elke M van Veen
- NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, 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
| | - Anthony Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Wythenshawe, Manchester, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, UK
| | - Susan Astley
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Wythenshawe, Manchester, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, UK.,Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Wernli KJ, Bowles EA, Knerr S, Leppig KA, Ehrlich K, Gao H, Schwartz MD, O’Neill SC. Characteristics Associated with Participation in ENGAGED 2 - A Web-based Breast Cancer Risk Communication and Decision Support Trial. Perm J 2020; 24:1-4. [PMID: 33482952 PMCID: PMC7849258 DOI: 10.7812/tpp/19.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 10/14/2020] [Accepted: 03/01/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE We evaluated demographic and clinical characteristics associated with participation in a clinical trial testing the efficacy of an online tool to support breast cancer risk communication and decision support for risk mitigation to determine the generalizability of trial results. METHODS Eligible women were members of Kaiser Permanente Washington aged 40-69 years with a recent normal screening mammogram, heterogeneously or extremely dense breasts and a calculated risk of > 1.67% based on the Breast Cancer Surveillance Consortium 5-year breast cancer risk model. Trial outcomes were chemoprevention and breast magnetic resonance imaging by 12-months post-baseline. Women were recruited via mail with phone follow-up using plain language materials notifying them of their density status and higher than average breast cancer risk. Multivariable logistic regression calculated independent odds ratios (ORs) for associations between demographic and clinical characteristics with trial participation. RESULTS Of 2,569 eligible women contacted, 995 (38.7%) participated. Women with some college (OR = 1.99, 95% confidence interval [CI] 1.34-2.96) or college degree (OR = 3.35, 95% CI 2.29-4.90) were more likely to participate than high school-educated women. Race/ethnicity also was associated with participation (African-American OR = 0.50, 95% CI 0.29-0.87; Asian OR = 0.22, 95% CI 0.12-0.41). Multivariate adjusted ORs for family history of breast/ovarian cancer were not associated with trial participation. DISCUSSION Use of plain language and potential access to a website providing personal breast cancer risk information and education were insufficient in achieving representative participation in a breast cancer prevention trial. Additional methods of targeting and tailoring, potentially facilitated by clinical and community outreach, are needed to facilitate equitable engagement for all women.
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Affiliation(s)
- Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Erin A Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | | | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Suzanne C O’Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
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Screening Strategy Modification Based on Personalized Breast Cancer Risk Stratification and its Implementation in the National Guidelines - Pilot Study. Zdr Varst 2020; 59:211-218. [PMID: 33133277 PMCID: PMC7583429 DOI: 10.2478/sjph-2020-0027] [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: 03/24/2020] [Accepted: 08/31/2020] [Indexed: 12/24/2022] Open
Abstract
Background One of the most consistent models for estimating personalized breast cancer (BC) risk is the Tyrer-Cuzick algorithm that is incorporated into the International Breast Cancer Intervention Study (IBIS) software. Our main objective was to provide criteria for the classification of the Slovenian population, which has BC incidence below the European average, into risk groups, and to evaluate the integration of the criteria in Slovenian guidelines. Our main focus was on women age <50 with higher BC risk, since no organized BC screening is available for these women. Methods Slovenian age-specific BC risks were incorporated into IBIS software and threshold values of risk categories were determined. Risk categories were assigned according to the individual’s ten-year risk for women aged 40 and older, and lifetime risk for women between 20 and 39. To test the software, we compared screening strategies with the use vs. no use of IBIS. Results Of the 197 women included in the study IBIS assigned 75.1% to the BC risk group, and the rest to the moderately increased risk. Without IBIS 80 women were offered mammographic and 33 ultrasound screening. In contrast, 28 instead of 80 would have been offered mammographic screening and there would have been no referrals for ultrasound if IBIS had been used. Conclusions The Slovenian IBIS has been developed, tested and suggested for personalized breast cancer risk assessment. The implementation of the software with the consideration of Slovenian risk thresholds enables a more accurate and nationally unified assessment.
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Kim DY, Park HL. Breast Cancer Risk Prediction in Korean Women: Review and Perspectives on Personalized Breast Cancer Screening. J Breast Cancer 2020; 23:331-342. [PMID: 32908785 PMCID: PMC7462811 DOI: 10.4048/jbc.2020.23.e40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/22/2020] [Indexed: 01/20/2023] Open
Abstract
Due to an increasing proportion of older individuals and the adoption of a westernized lifestyle, the incidence rate of breast cancer is expected to rapidly increase within the next 10 years in Korea. The National Cancer Screening Program (NCSP) of Korea recommends biennial breast cancer screening through mammography for women aged 40-69 years old and according to individual risk and preference for women above 70 years old. There is an ongoing debate on how to most effectively screen for breast cancer, with many proponents of personalized screening, or screening according to individual risk, for women under 70 years old as well. However, to accurately stratify women into risk categories, further study using more refined personalized characteristics, including potentially incorporating a polygenic risk score (PRS), may be needed. While most breast cancer risk prediction models were developed in Western countries, the Korean Breast Cancer Risk Assessment Tool (KoBCRAT) was developed in 2013, and several other risk models have been developed for Asian women specifically. This paper reviews these models compared to commonly used models developed using primarily Caucasian women, namely, the modified Gail, Breast Cancer Surveillance Consortium, Rosner and Colditz, and Tyrer-Cuzick models. In addition, this paper reviews studies in which PRS is included in risk prediction in Asian women. Finally, this paper discusses and explores strategies toward development and implementation of personalized screening for breast cancer in Korea.
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Affiliation(s)
- Do Yeun Kim
- Division of Medical Oncology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hannah Lui Park
- Department of Epidemiology, School of Medicine, University of California, Irvine, CA, USA
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Seitzman RL, Pushkin J, Berg WA. Radiologic Technologist and Radiologist Knowledge Gaps about Breast Density Revealed by an Online Continuing Education Course. JOURNAL OF BREAST IMAGING 2020; 2:315-329. [PMID: 38424967 DOI: 10.1093/jbi/wbaa039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Indexed: 03/02/2024]
Abstract
OBJECTIVE We sought to identify provider knowledge gaps and their predictors, as revealed by a breast density continuing education course marketed to the radiology community. METHODS The course, continually available online during the study period of November 2, 2016 and December 31, 2018, includes demographics collection; a monograph on breast density, breast cancer risk, and screening; and a post-test. Four post-test questions were modified during the study period, resulting in different sample sizes pre- and postmodification. Multiple logistic regression was used to identify predictors of knowledge gaps (defined as > 25% of responses incorrect). RESULTS Of 1649 analyzable registrants, 1363 (82.7%) were radiologic technologists, 226 (13.7%) were physicians, and 60 (3.6%) were other nonphysicians; over 90% of physicians and over 90% of technologists/nonphysicians specialized in radiology. Sixteen of 49 physicians (32.7%) and 80/233 (34.3%) technologists/nonphysicians mistakenly thought the Gail model should be used to determine "high-risk" status for recommending MRI or genetic testing. Ninety-nine of 226 (43.8%) physicians and 682/1423 (47.9%) technologists/nonphysicians misunderstood the inverse relationship between increasing age and lifetime breast cancer risk. Fifty-two of 166 (31.3%) physicians and 549/1151 (47.7%) technologists/nonphysicians were unaware that MRI should be recommended for women with a family history of BRCA1/BRCA2 mutations. Tomosynthesis effectiveness was overestimated, with 18/60 (30.0%) physicians and 95/272 (34.9%) technologists/nonphysicians believing sensitivity nearly equaled MRI. Knowledge gaps were more common in technologists/nonphysicians. CONCLUSIONS Important knowledge gaps about breast density, breast cancer risk assessment, and screening exist among radiologic technologists and radiologists. Continued education efforts may improve appropriate breast cancer screening recommendations.
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Affiliation(s)
- Robin L Seitzman
- Seitzman Consulting, San Diego, CA
- DenseBreast-info, Inc., Deer Park, NY
| | | | - Wendie A Berg
- DenseBreast-info, Inc., Deer Park, NY
- University of Pittsburgh School of Medicine, Magee-Womens Hospital of UPMC, Department of Radiology, Pittsburgh, PA
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Breast cancer risk based on adapted IBIS prediction model in Slovenian women aged 40-49 years - could it be better? Radiol Oncol 2020; 54:335-340. [PMID: 32614783 PMCID: PMC7409597 DOI: 10.2478/raon-2020-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/07/2020] [Indexed: 01/30/2023] Open
Abstract
Background The aim of the study was to assess the proportion of women that would be classified as at above-average risk of breast cancer based on the 10 year-risk prediction of the Slovenian breast cancer incidence rate (S-IBIS) program in two presumably above-average breast cancer risk populations in age group 40-49 years: (i) women referred for any reason to diagnostic breast centres and (ii) women who were diagnosed with breast cancer aged 40-49 years. Breast cancer is the commonest female cancer in Slovenia, with an incidence rate below European average. The Tyrer-Cuzick breast cancer risk assessment algorithm was recently adapted to S-IBIS. In Slovenia a tailored mammographic screening for women at above average risk in age group 40-49 years is considered in the future. S-IBIS is a possible tool to select population at above-average risk of breast cancer for tailored screening. Patients and methods In 357 healthy women aged 40-49 years referred for any reason to diagnostic breast centres and in 367 female breast cancer patients aged 40-49 years at time of diagnosis 10-years breast cancer risk was calculated using the S-IBIS software. The proportion of women classified as above-average risk of breast cancer was calculated for each subgroup of the study population. Results 48.7% of women in the Breast centre group and 39.2% of patients in the breast cancer group had above-average 10-year breast cancer risk. Positive family history of breast cancer was more prevalent in the Breast centre group (p < 0.05). Conclusions Inclusion of additional risk factors into the S-IBIS is warranted in the populations with breast cancer incidence below European average to reliably stratify women into breast cancer risk groups.
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McClintock AH, Golob AL, Laya MB. Breast Cancer Risk Assessment: A Step-Wise Approach for Primary Care Providers on the Front Lines of Shared Decision Making. Mayo Clin Proc 2020; 95:1268-1275. [PMID: 32498779 DOI: 10.1016/j.mayocp.2020.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/23/2020] [Accepted: 04/01/2020] [Indexed: 12/31/2022]
Abstract
Breast cancer-screening guidelines increasingly recommend that clinicians perform a risk assessment for breast cancer to inform shared decision making for screening. Precision medicine is quickly becoming the preferred approach to cancer screening, with the aim of increased surveillance in high-risk women, while sparing lower-risk women the burden of unnecessary imaging. Risk assessment also informs clinical care by refining screening recommendations for younger women, identifying women who should be referred to genetic counseling, and identifying candidates for risk-reducing medications. Several breast cancer risk-assessment models are currently available to help clinicians categorize a woman's risk for breast cancer. However, choosing the appropriate model for a given patient requires a working knowledge of the strengths, weaknesses, and performance characteristics of each. The aim of this article is to provide a stepwise approach for clinicians to assess an individual woman's risk for breast cancer and describe the features, appropriate use, and performance characteristics of commonly encountered risk-prediction models. This approach will help primary care providers engage in shared decision making by efficiently generating an accurate risk assessment and make clear, evidence-based screening and prevention recommendations that are appropriately matched to a woman's risk for breast cancer.
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Affiliation(s)
- Adelaide H McClintock
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington; Women's Health Care Center, Seattle, Washington.
| | - Anna L Golob
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington; Seattle Veterans Affairs Medical Center, Seattle, Washington
| | - Mary B Laya
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington; Women's Health Care Center, Seattle, Washington
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Harkness EF, Astley SM, Evans D. Risk-based breast cancer screening strategies in women. Best Pract Res Clin Obstet Gynaecol 2020; 65:3-17. [DOI: 10.1016/j.bpobgyn.2019.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/14/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022]
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Mahorter SS, Knerr S, Bowles EJA, Wernli KJ, Gao H, Schwartz MD, O'Neill SC. Prior breast density awareness, knowledge, and communication in a health system-embedded behavioral intervention trial. Cancer 2020; 126:1614-1621. [PMID: 31977078 DOI: 10.1002/cncr.32711] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/22/2019] [Accepted: 12/16/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Breast density is an important breast cancer risk factor and a focus of recent national and state health policy efforts. This article describes breast density awareness, knowledge, and communication among participants in a health system-embedded trial with clinically elevated breast cancer risk 1 year before state-mandated density disclosure. METHODS Trial participants' demographics and prior health history were ascertained from electronic health records. The proportions of women reporting prior breast density awareness, knowledge of density's masking effect, and communication with a provider about their own breast density were calculated using baseline interview data collected from 2017 to 2018. Multiple logistic regression was used to estimate associations between women's characteristics and density awareness, knowledge, and communication. RESULTS Although the overwhelming majority of participants had heard of breast density (91%) and were aware of breast density's masking effect (87%), only 60% had ever discussed their breast density with a provider. Annual mammography screening was associated with prior breast density awareness (odds ratio [OR], 2.97; 95% confidence interval [CI], 1.29-6.81), knowledge (OR, 2.83; 95% CI, 1.20-6.66), and communication (OR, 2.87; 95% CI, 1.34-6.16) compared with an infrequent or unknown screening interval. Receipt of breast biopsy was also associated with prior knowledge (OR, 1.60; 95% CI, 1.04-2.45) and communication (OR, 1.36; 95% CI, 1.00-1.85). CONCLUSIONS Breast density awareness and knowledge are high among insured women participating in clinical research, even in the absence of mandated density disclosure. Patient-provider communication about personal density status is less common, particularly among women with fewer interactions with breast health specialists.
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Affiliation(s)
- Siobhan S Mahorter
- Department of Health Services, University of Washington, Seattle, Washington
| | - Sarah Knerr
- Department of Health Services, University of Washington, Seattle, Washington
| | | | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Suzanne C O'Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
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Nyante SJ, Marsh MW, Benefield T, Earnhardt K, Lee SS, Henderson LM. Supplemental Breast Imaging Utilization After Breast Density Legislation in North Carolina. J Am Coll Radiol 2020; 17:6-14. [PMID: 31271735 PMCID: PMC6938553 DOI: 10.1016/j.jacr.2019.05.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Breast density notification laws are increasingly common but little is known of how they affect supplemental screening use. The aim of this study was to investigate supplemental screening before and after density notification in North Carolina, where notification has been required since 2014. METHODS Breast screening data from Carolina Mammography Registry participants aged 40 to 79 years with no personal histories of breast cancer or breast implants were evaluated. Supplemental screening was defined as a nondiagnostic digital breast tomosynthesis (DBT), whole-breast ultrasound, or breast MRI performed within 3 months of negative or benign results on screening mammography (2-D or DBT). Supplemental screening before (2012-2013) and after (2014-2016) the notification law was compared using logistic regression. RESULTS During the study period, 78,967 women underwent 145,279 index screening mammographic examinations. Supplemental screening use was similar before and after the notification law, regardless of breast density (dense breasts: adjusted odds ratio [aOR], 1.01; 95% confidence interval [CI], 0.58-1.75; nondense breasts: aOR, 0.63; 95% CI, 0.38-1.04). Although there was no change in supplemental screening, new use of any screening DBT from 2014 to 2016 was greater for women with dense breasts (versus nondense breasts; aOR, 1.15; 95% CI, 1.08-1.23). CONCLUSIONS Data suggest that supplemental screening use in North Carolina did not change after enactment of a breast density notification law, though the increase in new use of any screening DBT was greater for women with dense breasts. The short-term lack of change in supplemental screening should be considered as additional notification laws are developed.
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Affiliation(s)
- Sarah J Nyante
- Department of Radiology and the Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Mary W Marsh
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Thad Benefield
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kathryn Earnhardt
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sheila S Lee
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Louise M Henderson
- Department of Radiology and the Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Thorat MA, Balasubramanian R. Breast cancer prevention in high-risk women. Best Pract Res Clin Obstet Gynaecol 2019; 65:18-31. [PMID: 31862315 DOI: 10.1016/j.bpobgyn.2019.11.006] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/10/2019] [Accepted: 11/11/2019] [Indexed: 12/24/2022]
Abstract
Women at high risk of developing breast cancer are a heterogeneous group of women including those with and without high-risk germline mutation/s. Prevention in these women requires a personalised and multidisciplinary approach. Preventive therapy with selective oestrogen receptor modulators (SERMs) like tamoxifen and aromatase inhibitors (AIs) substantially reduces breast cancer risk well beyond the active treatment period. The importance of benign breast disease as a marker of increased breast cancer risk remains underappreciated, and although the benefit of preventive therapy may be greater in such women, preventive therapy remains underutilised in these and other high-risk women. Bilateral Risk-Reducing Mastectomy (BRRM) reduces the risk of developing breast cancer by 90% in high-risk women such as carriers of BRCA mutations. It also improves breast cancer-specific survival in BRCA1 carriers. Bilateral risk-reducing salpingo-oophorectomy may also reduce risk in premenopausal BRCA2 carriers. Further research to improve risk models, to identify surrogate biomarkers of preventive therapy benefit and to develop newer preventive agents is needed.
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Affiliation(s)
- Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, United Kingdom; School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, United Kingdom; Breast Services, Guy's Hospital, Great Maze Pond, London, SE1 9RT, United Kingdom.
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Kerlikowske K, Miglioretti DL, Vachon CM. Discussions of Dense Breasts, Breast Cancer Risk, and Screening Choices in 2019. JAMA 2019; 322:69-70. [PMID: 31150040 PMCID: PMC7153958 DOI: 10.1001/jama.2019.6247] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Karla Kerlikowske
- Department of Medicine, University of California, San Francisco
- General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco
| | - Diana L Miglioretti
- Department of Public Health Sciences, University of California, Davis
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Celine M Vachon
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic, Rochester, Minnesota
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