Risk estimation for breast cancer development; a clinical perspective

Is using the Gail model to calculate the risk of breast cancer in the Venezuelan population justified?

Objective

To evaluate the accuracy of the Gail model (GM) in women who already have a diagnosis of breast cancer (BC) from the Breast Pathology Service, Hospital Oncology Department of the Venezuelan Social Security Institute (SOH-IVSS) in the period 2004-2014. To compare the accuracy of the GM in women aged above and below 40 years with a diagnosis of BC.

Method

Descriptive, retrospective, cross-sectional, 830 records of patients diagnosed with BC were reviewed between 2004 and 2014.

Results

The mean age for diagnosis of the disease was 46 ± 13 years; menarche age was 13 years ± 2; age at first birth 22 ± 5 years, with a history of biopsy 32 ± 11, the percentage of relatives with a primary history of BC reported (PHBC) 9.3%. Only 41% of women with a diagnosis of BC reported Gail >1.67 (positive Gail). In the dichotomous logistic regression that related positive Gail with the independent variables, it was observed: greater probability of positive Gail if menarche age <11 years (p < 0.036), PHBC (p = 0.005), previous biopsy (p = 0.007), age at first birth 25-29 years (p = 0.019). When stratifying by age, unlike the bivariate analysis, women over 40 years of age are more likely to have a positive Gail in menarche age <11 years (p = 0.008), PHBC (p = 0.001), previous biopsy (p = 0.025) when compared with younger women, the age at first birth between 25 and 29 years was statistically significant for both groups; however, the probability was higher in younger women (p = 0.008).

Conclusion

There is no conclusive evidence to consider that the GM is applicable to Venezuelan women due to its low precision since it only identified 41% of the patients who had BC as high risk; however, when the factors are analysed separately, we found a higher probability of a positive Gail with statistical significance in EM <11 years, PHBC, previous biopsy and age at first birth 25-29 years; When stratifying by age, we observed that the age at first birth 25-29 years in women aged 40 or less increases the probability of a positive Gail. It is necessary to develop new risk assessment models that are adapted to our female population.

Self-efficacy of the First-degree Relatives of Patients with Breast Cancer in the Prevention of Cancer: Using the Health Belief Model

Breast cancer is the most common type of cancer in women. The best method to fight this disease is early diagnosis. The aim of this study was to investigate the effect of education based on the health belief model on self-efficacy of the first-degree relatives of patients with breast cancer. This randomized clinical trial was conducted in Tehran in 2016 on 80 first-degree relatives of patients with breast cancer. After purposive sampling, the subjects were assigned to interventions and control groups using the randomized block design. The data collection tool was a questionnaire including questions about demographic data, health belief model, and self-efficacy. The educational intervention was held during four 90-min sessions. The questionnaires were completed before and 8 weeks after the intervention in both groups. The data were analyzed using the SPSS16 software. The educational intervention led to a significant increase in susceptibility (d = 1.17, 95%CI 0.69, 1.66), seriousness (d = 1.11, 95%CI 0.62, 1.59), benefits (d = 1.58, 95%CI 1.06, 2.09), and significant decrease in perceived barriers (d = - 0.73, 95%CI 0.27, 1.19) scores in the intervention group. The self-efficacy score in the intervention group was increased from 7.58 to 9.20, which was statistically significant (d = 1.72, 95%CI 1.19, 2.25). However, in the control group, there was no significant difference in self-efficacy score before and after the intervention (p = 0.45). The present study confirmed the effectiveness of the health belief model in promoting self-efficacy of the first-degree relatives of patients with breast cancer. Therefore, it is recommended that this education program is implemented for women, especially the first-degree relatives of patients with breast cancer.

Towards a more precise and individualized assessment of breast cancer risk

Many clinically based models are available for breast cancer risk assessment; however, these models are not particularly useful at the individual level, despite being designed with that intent. There is, therefore, a significant need for improved, precise individualized risk assessment. In this Research Perspective, we highlight commonly used clinical risk assessment models and recent scientific advances to individualize risk assessment using precision biomarkers. Genome-wide association studies have identified >100 single nucleotide polymorphisms (SNPs) associated with breast cancer risk, and polygenic risk scores (PRS) have been developed by several groups using this information. The ability of a PRS to improve risk assessment is promising; however, validation in both genetically and ethnically diverse populations is needed. Additionally, novel classes of biomarkers, such as microRNAs, may capture clinically relevant information based on epigenetic regulation of gene expression. Our group has recently identified a circulating-microRNA signature predictive of long-term breast cancer in a prospective cohort of high-risk women. While progress has been made, the importance of accurate risk assessment cannot be understated. Precision risk assessment will identify those women at greatest risk of developing breast cancer, thus avoiding overtreatment of women at average risk and identifying the most appropriate candidates for chemoprevention or surgical prevention.

Risk Assessment for Breast Cancer Development and Its Clinical Impact on Screening Performance in Iranian Women

Introduction

The aim of this study is to estimate the objective and subjective risk and to examine their associations with three forms of breast cancer screening.

Methods

This cross-sectional study was conducted with a sample of 800 women aged 35–85 years from the community setting and outpatient clinic in Babol, the north of Iran. The demographic, socio-economic characteristics and the risk factor profiles were collected through in-person interview. The health belief model (HBM) and visual analog scales were used to assess the women’s perceived risk of breast cancer. The practice of women regarding breast self-examination (BSE), breast clinical examination (BCE), and mammography were measured. We used the Gail model in estimating 5-year and lifetime risk. The logistic regression model was applied to determine the relationship of calculated and perceived risk on screening behaviors.

Results

The mean of estimated 5-year and lifetime risk were 0.89 ±0.89 and 8.87 ±3.84 percent respectively while the perceived personal risk on visual scale perception was much greater than the calculated risk. The high 5-year calculated risk was a predictor of mammography practice but not BSE and BCE; however, after adjusting the subscales of HBM and socio-demographic characteristics, its effect remained significant (adjusted OR=1.97(95% CI: 1.02–3.08)). The perceived risk from HBM in particular self-efficacy (p=0.001) remained positively significant on all forms of screening practice.

Conclusion

While the perceived risk from HBM scale was meaningful in screening performance, the calculated risk from the Gail model had a clinical impact on mammography behaviors independent of HBM scales.

Epirubicin-Vinorelbine Intravenous Combination Followed by Oral Vinorelbine as First-Line Treatment in Metastatic Breast Cancer

Epirubicin and vinorelbine are considered active drugs in metastatic breast cancer. The optimal duration of a chemotherapy regimen for metastatic breast cancer patients is still unknown. Nevertheless, epirubicin has a dose-limiting cardiotoxicity. Vinorelbine is also available as oral formulation. In a multicenter phase II study, we analyzed the feasibility and the efficacy of a maximum of six cycles of i.v. epirubicin plus vinorelbine, followed by oral vinorelbine. We enrolled 30 patients with metastatic breast cancer. Each patient received epirubicin (75 mg/m2 on day 1) and vinorelbine (25 mg/m2 on days 1–8), every 3 weeks, for three cycles or six cycles in case of objective response or stable disease. When a clinical benefit was obtained, patients received oral vinorelbine (60 mg/m2 on days 1–8 every 3 weeks for three cycles). The regimen demonstrated to be active and well tolerated in metastatic breast cancer, and 6–8 months represented the optimal treatment duration. Maintenance therapy with oral vinorelbine was feasible, effective, safe and well accepted by the patients.

The Urtica dioica extract enhances sensitivity of paclitaxel drug to MDA-MB-468 breast cancer cells

INTRODUCTION

Due to the chemo resistant nature of cancer cells and adverse effects of current therapies, researchers are looking for the most efficient therapeutic approach which has the lowest side effects and the highest toxicity on cancer cells. The aim of the present study was to investigate the synergic effect of Urtica dioica extract in combination with paclitaxel on cell death and invasion of human breast cancer MDA-MB-468 cell line.

MATERIALS AND METHODS

To determine the cytotoxic effects of Urtica dioica extract with paclitaxel, MTT assay was performed. The scratch test was exploited to assess the effects of Urtica dioica, Paclitaxel alone and combination on migration of cancer cells. The expression levels of snail-1, ZEB1, ZEB2, twist, Cdc2, cyclin B1 and Wee1 genes were quantified using qRT-PCR and western blot performed for snail-1expression. The effects of plant extract, Paclitaxel alone and combination on different phases of cell cycle was analyzed using flow cytometry.

RESULTS

Results of MTT assay showed that Urtica dioica significantly destroyed cancer cells. Interestingly, Concurrent use of Urtica dioica extract with paclitaxel resulted in decreased IC50 dose of paclitaxel. Moreover, findings of scratch assay exhibited the inhibitory effects of Urtica dioica, Paclitaxel alone and combination on migration of MDA-MB-468 cell line. Our findings also demonstrated that the extract substantially decreased the Snail-1 and related gene expression. Ultimately, Cell cycle arrest occurred at G2/M phase post-treatment by deregulating Cdc2 and wee1.

CONCLUSIONS

Our results demonstrated that the dichloromethane extract of Urtica dioica inhibit cell growth and migration. Also, Urtica dioica extract substantially increased sensitivity of breast cancer cells to paclitaxel. Therefore, it can be used as a potential candidate for treatment of breast cancer with paclitaxel.

Breast cancer risk assessment using the Gail model: a Turkish study

PURPOSE

This study was conducted to determine risk of developing of breast cancer among Turkish women.

MATERIALS AND METHODS

Using a descriptive and cross-sectional approach, data were collected from 231 women. Breast cancer risk was calculated using the National Cancer Institute's on-line verson of called as the Breast Cancer Risk Assessment Tool or the Gail Risk Assesment Tool.

RESULTS

The average age of women was 45.0±8.06 years. It was revealed that 6.1% of participants reported having first degree relatives who had had breast cancer, with only four women having more than one first-degree relative affected (1.7%). The mean five-year breast cancer risk for all women was 0.88±0.91%, and 7.4% of women had a five-year breast cancer risk >1.66% in this study. Mean lifetime breast cancer risk up to age 90 years was 9.3±5.2%.

CONCLUSIONS

The breast cancer risk assessment tool can help in the clinical management of patient seeking advice concerning screening and prevention. Healthcare providers in Turkey can use this approach to estimate an individual's probability of developing breast cancer.

Risk of developing breast cancer by utilizing Gail model

The Gail model has been widely used to quantify an individual woman's risk of developing breast cancer by using important clinical parameters, usually for clinical counselling purposes or to determine eligibility for mammography and genetic tests. The aim of the present study was to estimate the five-year and lifetime breast cancer risk among women in Rasht, Iran. In this cross-sectional study, 314 women were evaluated at Alzahra Women Hospital in 2007. Participants were ≥35 years of age without a history of breast cancer. Risk estimation was performed using the computerized Gail model. A five-year risk >1.66% was considered high-risk; 5.1% of women were high-risk. The mean five-year breast cancer risk was 0.8% (SD±1). Mean breast cancer risk up to the age of 90 years (lifetime risk) was 9.0% (SD±3.9%); 16.2% of the participants had a five-year risk higher than the average woman of the same age, and 18.2% had the same risk. Also for the lifetime risk, 11.1% of the women had higher risk and 1.6% had the same risk as the average woman. Routine use of the Gail model is recommended for identifying women at high average risk for increasing the survival of women from breast cancer.

Prophylactic mastectomy for the prevention of breast cancer

BACKGROUND

Recent progress in understanding the genetic basis of breast cancer has increased interest in prophylactic mastectomy (PM) as a method of preventing breast cancer.

OBJECTIVES

(i) To determine whether prophylactic mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of prophylactic mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2002), MEDLINE and Cancerlit (1966 to June 2006), EMBASE (1974 to June 2006), and the WHO International Clinical Trials Registry Platform (WHO ICTRP) search portal (until June 2006). Studies in English were included.

SELECTION CRITERIA

Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer.

DATA COLLECTION AND ANALYSIS

At least two authors independently abstracted data. Data were summarized descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. Data were analyzed separately for bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM).

MAIN RESULTS

All 39 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 7,384 women with a wide range of risk factors for breast cancer who underwent PM.BPM studies on the incidence of breast cancer and/or disease-specific mortality reported reductions after BPM particularly for those with BRCA1/2 mutations. For CPM, studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups and this study showed no overall survival advantage for CPM at 15 years. Another study showed significantly improved survival following CPM but after adjusting for bilateral prophylactic oophorectomy, the CPM effect on all-cause mortality was no longer significant.Sixteen studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have PM but more variable satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM.Case series reporting on adverse events from PM with or without reconstruction reported rates of unanticipated re-operations from 4% in those without reconstruction to 49% in patients with reconstruction.

AUTHORS' CONCLUSIONS

Sixteen studies have been published since the last version of the review, without altering our conclusions. While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. BPM should be considered only among those at very high risk of disease. There is insufficient evidence that CPM improves survival and studies that control for multiple confounding variables are needed.

Retrospective comparison of patient outcomes after in-person and telephone results disclosure counseling for BRCA1/2 genetic testing

Telephone disclosure of BRCA1/2 molecular genetic test results has been proposed as a feasible alternative to traditional in-person results disclosure. The purpose of this study was to investigate the relationship between method of result disclosure with the patient outcome variables of knowledge, cancer worry, cancer risk perception, satisfaction, and cancer screening and prophylactic surgery behaviors. Study participants included 228 women who completed retrospective, self-administered, mailed surveys regarding their pre-test genetic counseling and results disclosure. No significant relationships were found between result disclosure method and the outcome variables investigated. A majority (90%) of individuals who received positive results by telephone returned for follow up visits. Factors which genetic counselors believed influenced their clinical decision to offer telephone disclosure, such as history of breast cancer, a priori risk of genetic mutation and family history of known mutation were not shown to significantly impact the actual disclosure method. This study suggests that telephone results disclosure is clinically appropriate when counselors utilize their clinical judgment to determine which patients are appropriate candidates.

Pelvic organ prolapse and relationship with skeletal integrity

Health burden related to osteoporotic fractures in an aging female population far exceeds that imposed by other chronic disorders such as cardiovascular disease and breast cancer. Bone mineral density assessment and clinical risk factors provide independent insights into fracture risk in individuals. A finite list of clinical risk factors are identified as prognostic of fracture risk, namely among aging women, including low body mass, compromised reproductive physiology (e.g., prolonged periods of amenorrhea and early menopause), parental and personal histories of fracture, and alcohol and tobacco use. Pelvic organ prolapse is a common gynecologic entity and a contributor to age-related morbidities. The purpose of this review is to communicate data identifying pelvic organ prolapse as another clinical risk factor for fracture risk in postmenopausal women and to increase the caregiver's vigilance in anticipating and instituting preventive care strategies to a population (i.e., postmenopausal women with clinically appreciable pelvic organ prolapse) that may be at an enhanced lifetime risk for skeletal fractures.

Estimation of mammographic density on an interval scale by transillumination breast spectroscopy

Transillumination breast spectroscopy (TiBS) uses nonionizing optical radiation to gain information about breast tissue morphological and structural properties. TiBS spectra are obtained from 232 women and compared to mammographic density (MD) quantified using Cumulus. The ability of TiBS to estimate MD is assessed using partial least-squares (PLS) regression methods, which requires TiBS spectra as input (X) and Cumulus MD as target (Y) data. Multiple PLS models are considered to determine the optimal processing technique(s) for the input (X) and target (Y) data. For each model, the association between TiBS estimated MD (Y) and Cumulus MD (Y) is established using Spearman's rank correlation and linear regression analysis. The model that best estimates MD has the fewest assumptions regarding target (Y) and spectral (X) processing. The Spearman's correlation coefficient between predicted MD and Cumulus MD for this model is 0.88, with a regression slope (beta) of 0.93 (95% CI 0.83-1.02) and an R(2) of 0.78. The approximation of individual MD was within 10% of Cumulus MD for the majority of women (80%), without stratification on age, body mass index (BMI), and menopausal status. TiBS provides an alternative to mammography assessed MD enabling frequent and earlier use of MD as a risk marker in preventive oncology.

Advancing biocultural models by working with communities: a partnership approach

Culture and human behavior are recognized today as major forces acting on human biological variation around the world. Studies of the relationships between biology and processes, such as modernization, urbanization, and social stratification, are prominent in our journals and meetings. An ongoing study of the interrelationships between toxicant exposure (organochlorines, lead, and mercury), health, and culture among youth of the Mohawk Nation at Akwesasne is located within this context and is used to analyze the strengths and challenges of a partnership approach to biocultural research. To assist in modeling the complex relationships between health, behavior, and culture, we have employed concepts from contemporary social theory, integrated qualitative and quantitative research, and implemented community-based research principles to develop a partnership approach to research in human biology. The community is directly involved in identifying research goals, developing research protocols appropriate for local cultural sensitivities and complexities, implementing the protocols in the field, and collaborating in the analysis and publication of results. We show the utility of this approach for understanding the relationships of toxicants to behavior and biological outcomes (adolescent growth, sexual maturation, and endocrine system alteration); as well as how it facilitates the agency of participants and communities involved in research, and brings greater social engagement to the development of the new human biology.

Assessing breast tissue density by transillumination breast spectroscopy (TIBS): an intermediate indicator of cancer risk

Risk assessment by parenchymal density pattern, a strong physical indicator of future breast cancer risk, is available with the onset of mammographic screening programmes. However, due to the use of ionizing radiation, mammography is not recommended for use in younger women, thereby rendering risk assessment unattainable at an earlier age. Visible and near infrared light was used on 292 women with radiologically normal mammograms to determine whether transillumination breast spectroscopy (TIBS) can identify women with a high parenchymal density pattern as an intermediate indicator of breast cancer risk. Principal component analysis (PCA) was used to reduce the spectral data and generate density scores for each woman. To assess the accuracy of TIBS, logistic regression was used to calculate crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for each score. Receiver operator characteristic (ROC) curves and area under the curve (AUC) were also calculated for the crude and adjusted logistic models. Optical information relating to tissue chromophores, such as water, lipid and haemoglobin content, was sufficient to identify women with high parenchymal density. The resulting AUC for the final and most parsimonious multivariate logistic model was 0.922 (95% CI 0.878-0.967). TIBS provides information correlating to high parenchymal density and is a promising tool for risk assessment, particularly for younger women.

Predicting Metastasis in Breast Cancer: Comparing a Decision Tree with Domain Experts

Breast malignancy is the second most common cause of cancer death among women in Western countries. Identifying high-risk patients is vital in order to provide them with specialized treatment. In some situations, such as when access to experienced oncologists is not possible, decision support methods can be helpful in predicting the recurrence of cancer. Three thousand six hundred ninety-nine breast cancer patients admitted in south-east Sweden from 1986 to 1995 were studied. A decision tree was trained with all patients except for 100 cases and tested with those 100 cases. Two domain experts were asked for their opinions about the probability of recurrence of a certain outcome for these 100 patients. ROC curves, area under the ROC curves, and calibration for predictions were computed and compared. After comparing the predictions from a model built by data mining with predictions made by two domain experts, no significant differences were noted. In situations where experienced oncologists are not available, predictive models created with data mining techniques can be used to support physicians in decision making with acceptable accuracy.

Breast Cancer Risk and Immune Responses in Healthy Women

PURPOSE/OBJECTIVES

To summarize the findings of objective and subjective breast cancer risk assessments and their association with psychological distress and immune responses in healthy women with a family history of breast cancer.

DATA SOURCES

Published articles and book chapters.

DATA SYNTHESIS

Healthy women with a family history of breast cancer have shown decreased immune responses (i.e., low natural killer cell activity and low Th1 cytokine production), exaggerated biophysiologic reactivity to stimuli, and increased psychological distress.

CONCLUSIONS

Objective and subjective breast cancer risk is associated with impaired immune responses and exaggerated biophysiologic responses in healthy women with a family history of breast cancer. Increased psychological distress can contribute further to negative immune responses. Additional studies are warranted to substantiate and extend the findings based on more comprehensive assessments of objective and subjective breast cancer risk.

IMPLICATIONS FOR NURSING

Biophysiologic assessment is a useful approach for nurses in early identification of women at risk for breast cancer and developing appropriate strategies to reduce the risk.

"Why take it if you don't have anything?" breast cancer risk perceptions and prevention choices at a public hospital

BACKGROUND

Despite advances in breast cancer risk assessment and risk reduction technologies, little is still known about how high-risk women make sense of their risk and assess prevention options, particularly among minority and low-income women. Qualitative methods explore the complex meanings and logics of risk and prevention that quantitative approaches overlook.

OBJECTIVE

This study examined how women attending a high risk breast cancer clinic at a public hospital conceptualize their breast cancer risk and think about the prevention options available to them.

METHODS

Semi-structured interviews were used to gather data from 33 high-risk women (75% African American) between May and August 2004. Interview transcripts were analyzed for recurrent themes and patterns.

RESULTS

Despite general awareness of their objective risk status, many women in this study reported they did not feel "high risk" because they lacked signs and symptoms of cancer. Risk was described as an experienced acute problem rather than a statistical possibility. Women also frequently stated that thinking about cancer might cause it to happen and so it is better not to "dwell on it." While screening was welcomed, women were generally skeptical about primary prevention. In particular, preventive therapies were perceived to cause problems and were only acceptable as treatment options for a disease.

CONCLUSIONS

The body of ideas about risk and prevention expressed by this population differ from the medical model. These findings have implications for risk perception research as well as for the efficacy of risk communication and prevention counseling in clinical contexts.

Gynecological characteristics related to breast cancer in pre and postmenopausal women

BACKGROUND

The objective of this study was two fold: to identify gynecological characteristics that distinguish women diagnosed with early-stage breast cancer from those at more advanced stages; to identify distinguishing characteristics between premenopausal and postmenopausal women diagnosed with the same stage.

POPULATION AND METHOD

186 incident cases diagnosed with breast cancer were identified out of the 685 patients who were seen to in 2000-2001. The variables to be studied were obtained by means of a specific questionnaire which collected data concerning reproductive characteristics and contraceptive types.

RESULTS

Significant differences in the mean age were found, since the early-stage group was younger (57.01+/-12.82 vs. 65.06+/-15.11). Characteristic factors found in pre-menopausal women were: early menopause, they either had no children or a single child, no breastfeeding practice and a more extensive use of contraceptives. Postmenopausal women presented more advanced stages, more pregnancies and less abortions.

CONCLUSIONS

By taking the obtained results into consideration, it would be recommendable to bring forward the age at which women are to be included in early detection programmes, and to conduct a follow-up of those women who present such factors to favour an earlier diagnosis of the disease.

[Application of the Gail method of calculating risk in the population of Valencia]

BACKGROUND

The objective of this study was to verify whether the method defined by Gail is applicable and predictive in a population of women in Valencia (Spain).

POPULATION AND METHODS

Of the 685 patients diagnosed with breast cancer and attended-to in 2000-2001, 186 incident cases were identified. The variables studied were obtained from a specific questionnaire which included characteristics of reproductive history, number of biopsies and contraceptive pill consumption prior to the diagnosis. Using the model of the National Surgical Adjuvant Breast and Bowel Project (NSABP), an adaptation of the Gail model, the risk of developing breast cancer at 5 years was estimated.

RESULTS

Only 40% of those women diagnosed as having breast cancer would have been identified as a high-risk patient by the Gail method. With our population group, the method detected the elderly women with a medical history of breast cancer who developed advanced stage disease.

CONCLUSIONS

The Gail method does not adapt well to the study population of Valencia. It would be necessary to add other risk-factors to the Gail method so as to identify more patients in our area.

Computerized texture analysis of mammographic parenchymal patterns of digitized mammograms

RATIONALE AND OBJECTIVES

Mammographic density and parenchymal patterns have been shown to be related to the risk of developing breast cancer. Thus, computerized texture analysis of breast parenchymal patterns on mammograms may be useful in assessing breast cancer risk.

MATERIALS AND METHODS

A comparative evaluation was conducted of various computer-extracted texture features of mammographic parenchymal patterns of women with BRCA1/BRCA2 gene mutations and those of women at low risk of developing breast cancer. Mammograms from 172 subjects (30 women with either the BRCA1 or BRCA2 gene mutation and 142 low-risk women) were analyzed. Computerized texture features were extracted from regions-of-interest to assess the mammographic parenchymal patterns in the images. Receiver operating characteristic analysis was used to assess the performance of these features in the task of distinguishing between the two groups of women.

RESULTS

Quantitative texture analysis on digitized mammograms demonstrated that gene-mutation carriers and low-risk women have different mammographic parenchymal patterns. Gene-mutation carriers presented with parenchymal patterns that were denser, coarser, and lower in contrast than those of the low-risk group. For the gene-mutation carriers, their mammographic patterns appear to contain less high-frequency component as indicated by higher coarseness values, lower fractal dimensions, and smaller edge gradients, which yielded corresponding A(z) values of 0.79, 0.84, and 0.78, respectively, in the task of distinguishing between gene-mutation carriers and the low-risk group with the entire dataset. The contrast measure calculated from co-occurrence matrix method, which describes local image variation, yielded an A(z) value of 0.86 in distinguishing between the two groups of women.

CONCLUSION

Computerized texture analysis of mammograms provides radiographic descriptors of mammographic parenchymal patterns. The computer-extracted features may be useful for identifying women at high risk for breast cancer and for monitoring the treatment of breast cancer patients.

Strengths and limitations of breast cancer risk assessment

PURPOSE/OBJECTIVES

To evaluate current definitions of breast cancer risk and breast cancer risk assessment models, including the Gail, Claus, and BRCAPRO models, and discuss potential markers to enhance and standardize individual risk assessment.

DATA SOURCES

Published articles, conference proceedings, and textbooks.

DATA SYNTHESIS

Defining high risk for breast cancer development is explored, and options for high-risk women are discussed. The risk factors frequently used for risk evaluation, including age, age at menarche, age at first live birth, past history of breast biopsy, family history of breast cancer, and the presence of atypical hyperplasia, are reviewed.

CONCLUSIONS

Current models of breast cancer risk assessment are limited. Exploring the progression from healthy tissue to malignancy through techniques such as fine needle aspiration, ductal lavage, and nipple aspiration may lead to more precise individualized risk prediction.

IMPLICATIONS FOR NURSING

More accurate information regarding personal breast cancer risk is necessary. Oncology nurses may facilitate the use of appropriate tools that provide the most individualized risk assessment.

Two staged breast reconstruction following prophylactic bilateral subcutaneous mastectomy

The aim of this retrospective study was to evaluate the results in patients who underwent bilateral subcutaneous mastectomy (BSCM) for prophylaxis against invasive breast cancer. All patients were operated on with the same protocol regarding indications and surgical method. Reconstruction was completed in two stages with tissue expanders and permanent round or shaped rough textured gel filled silicone implants. The study includes 52 patients with a mean age of 39.5 years operated on in the period 1991-2000; the period of follow-up ranged between 3 and 12 years with a mean of 7. In this series, not a single case of invasive cancer developed, and the aesthetic results are considered very satisfactory. This data strengthens the case of subcutaneous mastectomy as a valid prophylactic operation.

Genetic alterations in hereditary breast cancer

Genetic linkage studies have led to the identification of highly penetrant genes as the possible cause of inherited cancer risk in many cancer-prone families. Most women with a family history of breast/ovarian cancer have tumors characterized by alterations in particular genes, mainly BRCA1 and BRCA2, but also CHK2, ATM, STK11 and others. This paper examines the BRCA1 and BRCA2 genes, focusing on the Italian pattern of mutations. The function of these two genes, classified as tumor suppressors, is linked with key metabolic mechanisms such as DNA damage repair, regulation of gene expression and cell cycle control. The pathological BRCA allelic variants may cause alteration of protein function, transcriptional activity and DNA repair; accumulation of the defects leads to widespread chromosome instability that may be directly responsible for cancer formation. In fact, mutations in BRCA1 and BRCA2, conferring a highly increased susceptibility to breast and ovarian cancer, do not lead to cancer by themselves. The current consensus is that these are 'caretaker' genes, which, when inactivated, allow other genetic defects to accumulate. The nature of these other molecular events may define the pathway through which BRCA1 and BRCA2 act. The BRCA mutation spectrum is complex, and the significance of most nucleotide alterations is difficult to understand. Moreover, the mutation pattern seems to be related to ethnicity. The Italian Consortium of Hereditary Breast and Ovarian Cancer has reviewed 1758 families; 23% have been found to be carriers of pathogenetic mutations in BRCA1 or BRCA2. Founder mutations have been described in geographically restricted areas of Italy; a regional founder effect has been demonstrated in Italy for the mutations BRCA1 5083del19 and BRCA2 8765delAG, and a probable new founder mutation has been characterized in Tuscany. The presence of founder mutations has practical implications for genetic testing.

[Mammography in younger women: interpretation of abnormal findings]

The aim of this paper is to report the mammographic predictive positive value by decade of age using the assessment categories described within the BI-RADS lexicon.

Prophylactic mastectomy for the prevention of breast cancer

BACKGROUND

Breast cancer is the most common cancer and the second most common cause of cancer-related death among North American and Western European women. Recent progress in understanding the genetic basis of breast cancer, along with rising incidence rates, have resulted in increased interest in prophylactic mastectomy as a method of preventing breast cancer, particularly in those with familial susceptibility.

OBJECTIVES

The primary objective was to determine whether prophylactic mastectomy reduces death from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast. The secondary objective was to examine the effect of prophylactic mastectomy on other endpoints including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes.

SEARCH STRATEGY

Electronic searches were performed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cancerlit, and the Science Citation Index.

SELECTION CRITERIA

Inclusion criteria were studies in English of any design type including randomized or nonrandomized controlled trials, cohort studies, case-control studies, and case series with at least ten participants. Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer, including subcutaneous mastectomy, total or simple mastectomy, modified radical mastectomy, and radical mastectomy.

DATA COLLECTION AND ANALYSIS

Information on patients, interventions, methods, and results were extracted by at least two independent reviewers. Methodological quality was assessed based on how well each study minimized potential selection bias, performance bias, detection bias, and attrition bias. Data for each study were summarized descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. Data were analyzed separately for bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM).

MAIN RESULTS

Twenty-three studies, including more than 4,000 patients, met inclusion criteria. No randomized or nonrandomized controlled trials were found. Most studies were either case series or cohort studies. All studies had methodological limitations, with the most common source of potential bias being systematic differences between the intervention and comparison groups that could potentially be associated with a particular outcome. Thirteen studies assessed the effectiveness of BPM. No study assessed all-cause mortality after BPM. All studies reporting on incidence of breast cancer and disease-specific mortality reported reductions after BPM. Nine studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have prophylactic mastectomy (PM) but more variable satisfaction with cosmetic results. Only one study assessed satisfaction with the psychological support provided by healthcare personnel during risk counseling and showed that more women were dissatisfied than satisfied with the support they received in the healthcare setting. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM. Three studies reported body image/feelings of femininity outcomes, and all reported that a substantial minority (about 20%) reported BPM had adverse effects on those domains. Six studies assessed contralateral prophylactic mastectomy. Studies consistently reported reductions in contralateral incidence of breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups, and this study showed no overall survival advantage for CPM at 15 years. Two case series were exclusively focused on adverse events from prophylactic mastectomy with reconstruction, and both reported rates of unanticipated re-operations from 30% to 49%.

REVIEWERS' CONCLUSIONS

While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. The studies need to be of sufficient duration and make better attempts to control for selection biases to arrive at better estimates of risk reduction. The state of the science is far from exact in predicting who will get or who will die from breast cancer. By one estimate, most of the women deemed high risk by family history (but not necessarily BRCA 1 or 2 mutation carriers) who underwent these procedures would not have died from breast cancer, even without prophylactic surgery. Therefore, women need to understand that this procedure should be considered only among those at very high risk of the disease. For women who had already been diagnosed with a primary tumor, the data were particularly lacking for indications for contralateral prophylactic mastectomy. While it appeared that contralateral mastectomy may reduce the incidence of cancer in the contralateral breast, there was insufficient evidence about whether, and for whom, CPM actually improved survival. Physical morbidity is not uncommon following PM, and many women underwent unanticipated re-operations (usually due to problems with reconstruction); however, these data need to be updated to reflect changes in surgical procedures and reconstruction. Regarding psychosocial outcomes, women generally reported satisfaction with their decisions to have PM but reported satisfaction less consistently for cosmetic outcomes, with diminished satisfaction often due to surgical complications. Therefore, physical morbidity and post-operative surgical complications were areas that should be considered when deciding about PM. With regard to emotional well-being, most women recovered well postoperatively, reporting reduced cancer worry and showing reduced psychological morbidity from their baseline measures; exceptions also have been noted. Of the psychosocial outcomes measured, body image and feelings of femininity were the most adversely affected.

Susceptibility of rats to mammary gland carcinogenesis by the food-derived carcinogen 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) varies with age and is associated with the induction of differential gene expression

2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP), a heterocyclic amine found in cooked meat, induces mammary gland cancer when administered to adolescent female rats (43-day-old). In contrast, mature virgin rats (150-day-old) were resistant to mammary carcinogenesis by PhIP. To explore the possible mechanisms for the age-related differences in susceptibility, PhIP-DNA adduct levels, mutations, and gene expression were examined in glands from 43-day and 150-day-old PhIP-treated rats. In rats of different ages, PhIP-DNA adduct levels detected by the (32)P-post-labeling assay and mutant frequency measured in the lacI reporter gene of Big Blue rats were not statistically different. PhIP-DNA adduct levels, adduct removal, and mutation burden did not appear to account for the variation in carcinogen susceptibility with age. However, cDNA microarray analysis indicated that PhIP treatment differentially altered the profile of gene expression in glands from 43-day-old and 150-day-old rats. In 150-day-old rats, PhIP enhanced the expression of genes associated with differentiation (eg, beta-casein, kappa-casein, whey acidic protein) and induced morphological differentiation. In contrast, in 43-day-old rats, PhIP inhibited the expression of differentiation genes and enhanced cellular proliferation. From 3 hours to 6 weeks after PhIP dosing, the number of clones showing altered expression declined more than 50% in 150-day-old rats but increased fourfold in 43-day-old rats (29 clones versus 194, respectively) suggesting that PhIP induced a cascade of gene expression alterations only in susceptible rats. Genes showing altered expression specifically in 43-day-old rats included the Ras superfamily genes and genes associated with protein synthesis/degradation (lysosomal proteins, heat shock proteins, and proteasomes). The microarray data support the notion that the mechanism of age-dependent susceptibility to mammary gland cancer is largely associated with differential responses in expression of genes involved in cellular differentiation, proliferation, and protein homeostasis.

Determining the Main Risk Factors and High-risk Groups of Breast Cancer Using a Predictive Model for Breast Cancer Risk Assessment in South Korea

This study was aimed at developing a predictive model for assessing the breast cancer risk of Korean women under the assumption of differences in the risk factors between Westerners and Koreans. The cohort comprised 384 breast cancer patients and 2 control groups: one comprising 166 hospitalized patients and the other comprising 104 nurses and teachers. Two initial models were produced by comparing cases and the 2 control groups, and the final equations were established by selecting highly significant variables of the initial models to test the accuracy of the models in terms of disease probability and predictability. Both the initial models and the final disease-probability models were confirmed to exhibit high degrees of accuracy and predictability. Major risk factors determined by comparing the patients with hospitalized controls were a family history, menstrual regularity, total menstrual duration, age at first full-term pregnancy, and duration of breastfeeding. Major risk factors determined by comparing patients with nurse/teacher controls were age, education level, menstrual regularity, drinking status, and smoking status. The predictive model developed here shows that risk factors for breast cancer differ between Korean and Western subjects in the aspect of breastfeeding behavior. However, identifying the relationship between genetic susceptibility and breast cancer will require further studies with larger samples. In a model with nurse/teacher controls, drinking and higher education were found to be protective variables, whereas smoking was a risk factor. Hence the predictive model in this group could not be generalized to the Korean population; instead, breast cancer incidence needs to be compared among nurses and teachers in a nurse-and-teacher cohort.

Gail model risk assessment and risk perceptions

Patients can benefit from accessible breast cancer risk information. The Gail model is a well-known means of providing risk information to patients and for guiding clinical decisions. Risk presentation often includes 5-year and life-time percent chances for a woman to develop breast cancer. How do women perceive their risks after Gail model risk assessment? This exploratory study used a randomized clinical trial design to address this question among women not previously selected for breast cancer risk. Results suggest a brief risk assessment intervention changes quantitative and comparative risk perceptions and improves accuracy. This study improves our understanding of risk perceptions by evaluating an intervention in a population not previously selected for high-risk status and measuring perceptions in a variety of formats.

Development and characterization of a nano-scale contrast agent

Agents injected parenterally must be less than approximately 8 microm diameter in order to traverse the capillaries in the pulmonary bed, but these agents remain in the vasculature until they are eliminated from the body by a variety of mechanisms. Targeting of cells outside the capillaries requires agent diameters of less than approximately 700 nm to enable escape through the larger-than-usual pores that have been noted in the leaky vasculature of a tumor. The objective of this study was to test the feasibility of creating a surfactant-stabilized nano-bubble with favorable acoustic properties, and identify the key parameters that influence size, yield and stability. Size distribution was characterized using laser light scattering. In vitro acoustic enhancement was assessed by generation of dose and time response curves. We previously developed a successful protocol to generate gas-filled microbubbles (containing perfluorocarbon, sulfur hexafluoride or air) with mean diameter of 1.5 microm, using sonication of carefully selected surfactant mixtures. This presentation describes generation of nano-bubbles with mean diameters ranging from 700 to 450 nm, depending on process variables. In all cases a centrifugation step was employed to separate the nano-sized particles. The in vitro dose response curves gave a maximum of 23-27 dB enhancement compared to buffer in the absence of agent, with the maximum enhancement and presence of shadowing at higher doses being dependent on the fabrication protocol. The effect of sonication time for solutions containing a mixture of the surfactants (Span 60 and Tween 80) was also tested, but was determined not to be an influencing factor. Future studies will involve development of a mathematical model characterizing the mean size as a function of centrifugal force, spin time and initial size distribution. Future work will also include imaging of tumor-bearing mice and measuring imaging potential in vivo in New Zealand white rabbits using power Doppler.

Comparing breast cancer risk between lesbians and their heterosexual sisters

PURPOSE

The purpose of this study was to explore the similarities and differences between lesbians and their heterosexual sisters in the established risks for developing breast cancer.

METHODS

The design for this study was a matched (lesbian with heterosexual sister) cross-sectional, mail-back, anonymous survey. We distributed the surveys throughout the state of California to English-speaking women who identified themselves as lesbians, age 40 and older, and their sisters. Using the modified Gail Breast Cancer Risk model as well as other well-established factors associated with the development of breast cancer, we compared the breast cancer risk potential for 324 sister pairs (N = 648). Data were analyzed using paired t-tests, analysis of covariance (ANCOVA), McNemar's chi(2), or the Bowker statistic, as appropriate for the level of data.

MAIN FINDINGS

The lesbians had significantly higher 5-year (p <.0001) and lifetime (p =.001) risk for developing breast cancer. The reasons for lesbians' predicted rate of breast cancer were most likely their higher scores on all pregnancy-related variables and the relatively high number of breast biopsies they reported. The lesbians had used birth control pills less (p <. 0001), had significantly fewer pregnancies (p <.0001), children (p <.0001), abortions (p <.0001), and miscarriages (p <.0001) as well as significantly more breast biopsies (p =.02) than did their heterosexual sisters.

CONCLUSIONS

A lesbian who comes out to her clinician is relying on the clinician to be informed and be open to discuss her life. When a lesbian has a lump or a suspicious mammogram, she needs her clinician to advocate for her within the health care system because she is at higher risk for having cancer than a heterosexual woman.

Evaluation of Oligonucleotide Arrays for Sequencing of the p53 Gene in DNA from Formalin-Fixed, Paraffin-Embedded Breast Cancer Specimens

Background: Routine tissue processing has generated banks of paraffin-embedded tissue that could be used in retrospective cohort studies to study the molecular changes that occur during cancer development. The purpose of this study was to determine whether a p53 microarray could be used to sequence the p53 gene in DNA extracted from formalin-fixed, paraffin-embedded (FFPE) tissues.

Methods: DNA was extracted from 70 FFPE breast cancer tissue specimens. p53 was sequenced with an oligonucleotide microarray (p53 GeneChip®; Affymetrix), and the results were compared with the results obtained from direct sequencing.

Results: DNA was extracted from 62 of 70 cases. We identified 26 mutations in 24 of the 62 cases by the p53 GeneChip. No polymorphisms were detected, and exon 4 could not be evaluated in 20 cases. There were 43 genetic alterations detected by direct sequencing in 35 of the 62 cases. These consisted of 26 polymorphisms and 17 mutations in exons or splice sites. Fifteen mutations were identified by both methods. Direct sequencing detected significantly more gene alterations (43 of 54) in DNA extracted from FFPE tissue than the p53 GeneChip (26 of 54; P = 0.018). However, if the changes in exon 4 were eliminated from this comparison, the p53 GeneChip detected 26 of 27 mutations compared with direct sequencing, which identified 16 of 27 mutations. (P = 0.016).

Conclusions: A combination of oligonucleotide microarray and direct sequencing may be necessary to accurately identify p53 gene alterations in FFPE breast cancer. The p53 GeneChip cannot be used to detect exon 4 polymorphisms (codon 72) in FFPE breast cancer tissue.

Long-term physical and psychological health consequences of induced abortion: review of the evidence

Induced abortion is a prevalent response to an unintended pregnancy. The long-term health consequences are poorly investigated and conclusions must be drawn from observational studies. Using strict inclusion criteria (study population >100 subjects, follow up >60 days) we reviewed an array of conditions in women's health. Induced abortion was not associated with changes in the prevalence of subsequent subfertility, spontaneous abortion, or ectopic pregnancy. Previous abortion was a risk factor for placenta previa. Moreover, induced abortion increased the risks for both a subsequent preterm delivery and mood disorders substantial enough to provoke attempts of self-harm. Preterm delivery and depression are important conditions in women's health and avoidance of induced abortion has potential as a strategy to reduce their prevalence. Only review articles including the single published meta-analysis exploring linkages between abortion and breast cancer were relied upon to draw conclusions. Reviewers were mixed on whether subsequent breast neoplasia can be linked to induced abortion, although the sole meta-analysis found a summary odds ratio of 1.2. Whatever the effect of induced abortion on breast cancer risk, a young woman with an unintended pregnancy clearly sacrifices the protective effect of a term delivery should she decide to abort and delay childbearing. That increase in risk can be quantified using the Gail Model. Thus, we conclude that informed consent before induced abortion should include information about the subsequent risk of preterm delivery and depression. Although it remains uncertain whether elective abortion increases subsequent breast cancer, it is clear that a decision to abort and delay pregnancy culminates in a loss of protection with the net effect being an increased risk.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to define the terms and, to outline the epidemiologic problems in studying the long-term consequences of abortion, and to list the associated long-term consequences of abortion.