An Update on Breast Cancer Screening and Prevention

In silico guided in vitro study of traditionally used medicinal plants reveal the alleviation of post-menopausal symptoms through ERβ binding and MAO-A inhibition

The slumping level of estrogen and serotonin in menopausal women is directly associated with the occurrence of menopausal symptoms where, estrogen receptor-β (ERβ) and monoamine oxidase-A (MAO-A) are directly involved. The present investigation aimed for validation of promising plants traditionally used to alleviate menopausal symptoms with ERβ mediated MAO-A inhibition potential through in silico disease-target network construction using Cytoscape plugins followed by molecular docking of phytomolecules through AutoDock vina. ADMET parameters of identified bioactive phytomolecules were analysed through swissADME and ProTox II. The efficacy of promising plant leads was further established through in vitro ERβ competitive binding, MAO-A inhibition, enzyme kinetics and free radical quenching assays. In silico analysis suggested glabrene (ΔG = -9.7 Kcal/mol) as most promising against ERβ in comparison to 17β-estradiol (ΔG = -11.4 Kcal/mol) whereas liquiritigenin (ΔG = -9.4 Kcal/mol) showed potential binding with MAO-A in comparison to standard harmine (ΔG = -8.8 Kcal/mol). In vitro analysis of promising plants segregated Glycyrrhiza glabra (IC50 = 0.052 ± 0.007 μg/ml) as most promising, followed by Hypericum perforatum (IC50 = 0.084 ± 0.01 μg/ml), Trifolium pratense (IC50 = 0.514 ± 0.01 μg/ml) and Rumex nepalensis (IC50 = 2.568 ± 0.11 μg/ml). The enzyme kinetics of promising plant leads showed reversible and competitive nature of inhibition against MAO-A. The potency of plant extracts in quenching free radicals was at par with ascorbic acid. The identified four potent medicinal plants with ERβ selective, MAO-A inhibitory and free radical quenching abilities could be used against menopausal symptoms however, finding needs to be validated further for menopausal symptoms in in vivo conditions for drug development.Communicated by Ramaswamy H. Sarma.

Isolation and elucidation of two isoflavonoids from an American Indian plant, Amorpha canescens Pursh, using Magnetic Microbead Affinity Selection Screening (MagMASS) for estrogen receptor alpha ligands

A new isoflavonoid, xanthocerin J, along with previously described xanthocerin A, were isolated from a methanol extract of aerial parts of a traditional American Indian herb, Amorpha canescens Pursh (Asteraceae). The structures of these compounds were characterized using mass spectrometry and NMR based on an isolation protocol using magnetic microbead affinity selection screening (MagMASS) for ligands to the estrogen receptor alpha (ERα). These compounds bound to ERα from an active fraction that exhibited dose-dependent antiestrogenic activity in the in vitro Ishikawa assay. However, these compounds did not exhibit antiestrogenic activity in the cell-based Ishikawa assay. Xanthocerin A and J may exhibit synergistic or additive activity with other compounds found in A. canescens which needs further exploration. This work highlights the potential of A. canescens as a prospect for the future discovery of compounds for women's health related to estrogen pathways.

A systematic review of recommendations on screening strategies for breast cancer due to hereditary predisposition: Who, When, and How?

BACKGROUND

Breast cancer is a global health problem that cannot be underestimated. Many studies have shown that breast cancer is related to pathogenic mutations in hereditary predisposition genes. Clinical practice guidelines play a vital role in guiding the selection of breast cancer screening. Little is known about the quality and consistency of guidelines' recommendations and their changes over these years.

METHODS

We reviewed the existing screening guidelines for genetic susceptibility to breast cancer and assessed the methodological quality, and summarized the recommendations to aid clinicians to make decisions. We conducted a systematic search in PubMed, Embase, Web of Science, and guideline-specific databases, aiming to find the guidelines of breast cancer due to hereditary predisposition. The necessary information was exacted by Excel. We also summarized different evidence grading systems. The qualities of the guidelines were assessed by the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument.

RESULTS

A total of 54 recommendations from 13 guidelines were extracted. Generally speaking, the recommendations were consistent, mainly focusing on mammography and MRI.

CONCLUSIONS

The recommendations differ in details. Moreover, different guidelines are based on different grading systems, and some guidelines are not divided for age limits, which may limit the promotion and implementation of the guidelines. It is suggested that improvement can be made in this regard in the future.

Impact of Educational Level and Family income on Breast Cancer Awareness among College-Going Girls in Shillong (Meghalaya), India

Background:

Breast cancer (BC) is the most common cancer among women in India and shows an increasing trend. The mammography screening seems unfeasible as a public health service in India. Thus, breast self-examination (BSE), followed by clinical breast examination (CBE), is the affordable method to downstage BC. A cross-sectional study was conducted with senior school and college-going girls in Shillong (Meghalaya) to study the impact of girls’ academic level and family income on breast cancer knowledge and the prevalence of BC’s known risk factors in girls.

Methods:

A self-administered questionnaire was employed to collect relevant information. The data were analysed using statistical software SPSS version 22. The categorical data presented as frequency (%) and the comparison made using Chi-square or Fisher exact test.

Results:

(i) 78.2% girls knew about breast cancer, 19.2% of these were aware of BSE, and 22.9% of BSE knowing ever performed it (ii) Awareness of breast cancer and BSE, and its practice is significantly associated with their academic level and family income (iii) The consumption of alcohol beverages and physical activity of girls was positively associated with educational level and family income (iv) Body mass index (BMI) was weakly associated with family income with an insignificant relationship with academic level (v) oily food consumption related inversely with the level of education irrespective of family income (vi) there was a positive correlation between parents education and family income.

Conclusions:

The results show a severe lack of breast cancer knowledge in senior school and college-going girls under the survey. To spread community awareness, we suggest a public health policy-driven educational intervention through culturally relevant mass/social media on the risk factors of breast cancer and practice of BSE. It is also recommended that dedicated facilities be created for breast cancer early diagnosis in the public health system.

Systematic Patient Navigation Strategies to Scale Breast Cancer Disparity Reduction by Improved Cancer Prevention and Care Delivery Processes

PURPOSE

Patient navigation uses trained personnel to eliminate barriers to timely care across all phases of the health care continuum, thereby reducing health disparities. However, patient navigation has yet to be systematized in implementation models to improve processes of care at scale rather than remain a band-aid approach focused solely on improving care for the individual patient. The 4R systems engineering approach (right information and right treatment to the right patient at the right time) uses project management discipline principles to develop care sequence templates that serve as patient-centered project plans guiding patients and their care team.

METHODS

A case-study approach focused on the underserved patient shows how facilitators to timely breast cancer screening and care pragmatically identified as emergent data by patient navigators can be actionized by iteratively revising 4R care sequence templates to incorporate new insights as they emerge.

RESULTS

Using a case study of breast cancer screening of a low-income patient, we illustrate how 4R care sequence templates can be revised to incorporate emergent facilitators to care identified through patient navigation.

CONCLUSION

Use of care sequence templates can inform the care team to optimize a particular patient's care, while functioning as a learning health care system for process improvement of patient care and patient navigation scaling. A learning health care system approach that systematically integrates data patterns emerging from multiple patient navigation experiences through in-person navigators and 4R care sequence templates may improve processes of care and allow patient navigation scaling to reduce cancer disparities.

Risk-reducing medications for primary breast cancer: a network meta-analysis

BACKGROUND

Breast cancer is the most frequently occurring malignancy and the second cause of death for cancer in women. Cancer prevention agents (CPAs) are a promising approach to reduce the burden of breast cancer. Currently, two main types of CPAs are available: selective estrogen receptor modulators (SERMs, such as tamoxifen and raloxifene) and aromatase inhibitors (AIs, such as exemestane and anastrozole).

OBJECTIVES

To assess the efficacy and acceptability of single CPAs for the prevention of primary breast cancer, in unaffected women, at an above-average risk of developing breast cancer.Using a network meta-analysis, to rank single CPAs, based on their efficacy and acceptability (an endpoint that is defined as the inverse of CPA-related toxicity).

SEARCH METHODS

We searched the Cochrane Breast Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov on 17 August 2018. We handsearched reference lists to identify additional relevant studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that enrolled women without a personal history of breast cancer but with an above-average risk of developing a tumor. Women had to be treated with a CPA and followed up to record the occurrence of breast cancer and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and conducted risk of bias assessments of the included studies, and assessed the certainty of the evidence using GRADE. Outcome data included incidence of breast carcinoma (both invasive and in situ carcinoma) and adverse events (both overall and severe toxicity). We performed a conventional meta-analysis (for direct comparisons of a single CPA with placebo or a different CPA) and network meta-analysis (for indirect comparisons).

MAIN RESULTS

We included six studies enrolling 50,927 women randomized to receive one CPA (SERMs: tamoxifen or raloxifene, or AIs: exemestane or anastrozole) or placebo. Three studies compared tamoxifen and placebo, two studies compared AIs (exemestane or anastrozole) versus placebo, and one study compared tamoxifen versus raloxifene. The risk of bias was low for all RCTs.For the tamoxifen versus placebo comparison, tamoxifen likely resulted in a lower risk of developing breast cancer compared to placebo (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.62 to 0.76; 3 studies, 22,832 women; moderate-certainty evidence). In terms of adverse events, tamoxifen likely increased the risk of severe toxicity compared to placebo (RR 1.28, 95% CI 1.12 to 1.47; 2 studies, 20,361 women; moderate-certainty evidence). In particular, women randomized to receive tamoxifen experienced a higher incidence of both endometrial carcinoma (RR 2.26, 95% CI 1.52 to 3.38; high-certainty evidence) and thromboembolism (RR 2.10, 95% CI 1.14 to 3.89; high-certainty evidence) compared to women who received placebo.For the AIs versus placebo comparison, AIs (exemestane or anastrozole) reduced the risk of breast cancer by 53% (RR 0.47, 95% CI 0.35 to 0.63; 2 studies, 8424 women; high-certainty evidence). In terms of adverse events, AIs increased the risk of severe toxicity by 18% (RR 1.18, 95% CI 1.09 to 1.28; 2 studies, 8352 women; high-certainty evidence). These differences were sustained especially by endocrine (e.g. hot flashes), gastrointestinal (e.g. diarrhea), and musculoskeletal (e.g. arthralgia) adverse events, while there were no differences in endometrial cancer or thromboembolism rates between AIs and placebo.For the tamoxifen versus raloxifene comparison, raloxifene probably performed worse than tamoxifen in terms of breast cancer incidence reduction (RR 1.25, 95% CI 1.09 to 1.43; 1 study, 19,490 women; moderate-certainty evidence), but its use was associated with lower toxicity rates (RR 0.87, 95% CI 0.80 to 0.95; 1 study, 19,490 women; moderate-certainty evidence), particularly relating to incidence of endometrial cancer and thromboembolism.An indirect comparison of treatment effects allowed us to compare the SERMs and AIs in this review. In terms of efficacy, AIs (exemestane or anastrozole) may have reduced breast cancer incidence slightly compared to tamoxifen (RR 0.67, 95% CI 0.46 to 0.98; 5 RCTs, 31,256 women); however, the certainty of evidence was low. A lack of model convergence did not allow us to analyze toxicity data.

AUTHORS' CONCLUSIONS

For women with an above-average risk of developing breast cancer, CPAs can reduce the incidence of this disease. AIs appear to be more effective than SERMs (tamoxifen) in reducing the risk of developing breast cancer. AIs are not associated with an increased risk of endometrial cancer and thromboembolic events. However, long-term data on toxicities from tamoxifen are available while the follow-up toxicity data on unaffected women taking AIs is relatively short. Additional data from direct comparisons are needed to fully address the issues of breast cancer prevention by risk-reducing medications, with special regards to acceptability (i.e. the benefit/harm ratio).

Challenges With Identifying Indication for Examination in Breast Imaging as a Key Clinical Attribute in Practice, Research, and Policy

PURPOSE

To assess indication for examination for four breast imaging modalities and describe the complexity and heterogeneity of data sources and ascertainment methods.

METHODS

Indication was evaluated among the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) breast cancer research centers (PRCs). Indication data were reported overall and separately for four breast imaging modalities: digital mammography (DM), digital breast tomosynthesis (DBT), ultrasound (US), and magnetic resonance imaging (MRI).

RESULTS

The breast PRCs contributed 236,262 women with 607,735 breast imaging records from 31 radiology facilities. We found a high degree of heterogeneity for indication within and across six data sources. Structured codes within a data source were used most often to identify indication for mammography (59% DM, 85% DBT) and text analytics for US (45%) and MRI (44%). Indication could not be identified for 17% of US and 26% of MRI compared with 2% of mammography examinations (1% DM, 3% DBT).

CONCLUSIONS

Multiple and diverse data sources, heterogeneity of ascertainment methods, and nonstandardization of codes within and across data systems for determining indication were found. Consideration of data sources and standardized methodology for determining indication is needed to assure accurate measurement of cancer screening rates and performance in clinical practice and research.

Utilization of screening mammography in older women according to comorbidity and age: protocol for a systematic review

BACKGROUND

Approximately half of new invasive breast cancer cases diagnosed each year in the United States occur among women aged 65 years and older. The increasing life expectancy coupled with the attendant rise in breast cancer incidence and elimination of out-of-pocket expenses for screening mammography as a result of the Affordable Care Act could lead to higher utilization rates of screening mammography. Although research indicates that life expectancy should be a strong consideration when making screening decisions among older women, the extent to which screening mammography utilization is tailored to comorbidity and life expectancy is not well established.

METHODS/DESIGN

To identify relevant studies, a systematic search of the literature will be conducted using PubMed and EMBASE between January 1, 1991, and March 1, 2016. Additional studies will be found through citation review or by contacting experts in the field. The inclusion criteria will be any study design comprised of women aged 65 and older, assessing women's comorbidity, functional impairments, and/or health status, and reporting outcome measures that addressed mammography utilization within the last 1-5 years. For each study, two authors will independently abstract data regarding study eligibility and outcomes to determine relevance. Quantitative results will be extracted from text and tables, choosing preferably those adjusted for important confounders.

DISCUSSION

The review will provide evidence on the impact of comorbidity, functional limitations, and health status on screening mammography utilization in older women and inform decision aids in this area.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016032661.

Botanicals and Their Bioactive Phytochemicals for Women's Health

Botanical dietary supplements are increasingly popular for women's health, particularly for older women. The specific botanicals women take vary as a function of age. Younger women will use botanicals for urinary tract infections, especially Vaccinium macrocarpon (cranberry), where there is evidence for efficacy. Botanical dietary supplements for premenstrual syndrome (PMS) are less commonly used, and rigorous clinical trials have not been done. Some examples include Vitex agnus-castus (chasteberry), Angelica sinensis (dong quai), Viburnum opulus/prunifolium (cramp bark and black haw), and Zingiber officinale (ginger). Pregnant women have also used ginger for relief from nausea. Natural galactagogues for lactating women include Trigonella foenum-graecum (fenugreek) and Silybum marianum (milk thistle); however, rigorous safety and efficacy studies are lacking. Older women suffering menopausal symptoms are increasingly likely to use botanicals, especially since the Women's Health Initiative showed an increased risk for breast cancer associated with traditional hormone therapy. Serotonergic mechanisms similar to antidepressants have been proposed for Actaea/Cimicifuga racemosa (black cohosh) and Valeriana officinalis (valerian). Plant extracts with estrogenic activities for menopausal symptom relief include Glycine max (soy), Trifolium pratense (red clover), Pueraria lobata (kudzu), Humulus lupulus (hops), Glycyrrhiza species (licorice), Rheum rhaponticum (rhubarb), Vitex agnus-castus (chasteberry), Linum usitatissimum (flaxseed), Epimedium species (herba Epimedii, horny goat weed), and Medicago sativa (alfalfa). Some of the estrogenic botanicals have also been shown to have protective effects against osteoporosis. Several of these botanicals could have additional breast cancer preventive effects linked to hormonal, chemical, inflammatory, and/or epigenetic pathways. Finally, although botanicals are perceived as natural safe remedies, it is important for women and their healthcare providers to realize that they have not been rigorously tested for potential toxic effects and/or drug/botanical interactions. Understanding the mechanism of action of these supplements used for women's health will ultimately lead to standardized botanical products with higher efficacy, safety, and chemopreventive properties.

Assessing the Key Attributes of Low Utilization of Mammography Screening and Breast-self Exam among African-American Women

PURPOSE

African-American (AA) women living in four Black Belt Counties (BBC) of Alabama; consisting of Barbour, Macon, Green and Wilcox are known to have lower mammogram utilization and breast self-exam rates when compared to their white female counterparts. The influence of socioeconomic and demographic factors on these disparities has not been clearly defined so far. Our study was designed to determine whether these observed disparities can be predicted with the socioeconomic and other demographic attributes.

METHODS

Health Disparity Questionnaires data (n = 516) for BBC of Alabama was analyzed using a logistic regression model to examine the association of breast cancer screening rates and breast self-exam with income, the level of education, family doctor, type of health insurance, obesity, and age.

RESULTS

Income, education, family doctor, age and health insurance were independent predictors for the low utilization rate of mammography and breast self-exam (BSE).

CONCLUSION

Improving socioeconomic conditions such as level of education and availability of health care are essential to increase the rates of breast cancer screening test and breast self-exam in the BBC of Alabama.

Anti-influenza neuraminidase inhibitor oseltamivir phosphate induces canine mammary cancer cell aggressiveness

Oseltamivir phosphate is a widely used anti-influenza sialidase inhibitor. Sialylation, governed by sialyltransferases and sialidases, is strongly implicated in the oncogenesis and progression of breast cancer. In this study we evaluated the biological behavior of canine mammary tumor cells upon oseltamivir phosphate treatment (a sialidase inhibitor) in vitro and in vivo. Our in vitro results showed that oseltamivir phosphate impairs sialidase activity leading to increased sialylation in CMA07 and CMT-U27 canine mammary cancer cells. Surprisingly, oseltamivir phosphate stimulated, CMT-U27 cell migration and invasion capacity in vitro, in a dose-dependent manner. CMT-U27 tumors xenograft of oseltamivir phosphate-treated nude mice showed increased sialylation, namely α2,6 terminal structures and SLe(x) expression. Remarkably, a trend towards increased lung metastases was observed in oseltamivir phosphate-treated nude mice. Taken together, our findings revealed that oseltamivir impairs canine mammary cancer cell sialidase activity, altering the sialylation pattern of canine mammary tumors, and leading, surprisingly, to in vitro and in vivo increased mammary tumor aggressiveness.