Practice Bulletin Number 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women

The science and practice of imaging-based screening: What the radiologist needs to know

Imaging-based screening is an important public health focus and a fundamental part of Diagnostic Radiology. Hence, radiologists should be familiar with the concepts that drive imaging-based screening practice including goals, risks, biases and clinical trials. This review article discusses an array of imaging-based screening exams including the key epidemiology and evidence that drive screening guidelines for abdominal aortic aneurysm, breast cancer, carotid artery disease, colorectal cancer, coronary artery disease, lung cancer, osteoporosis, and thyroid cancer. We will provide an overview on societal interests in screening, screening-related inequities, and opportunities to address them. Emerging evidence for opportunistic screening and the role of AI in imaging-based screening will be explored. In-depth knowledge and formalized training in imaging-based screening strengthens radiologists as clinician scientists and has the potential to broaden our public health leadership opportunities. SUMMARY SENTENCE: An overview of key screening concepts, the evidence that drives today's imaging-based screening practices, and the need for radiologist leadership in screening policies and evidence development.

Trends in Cancer and Heart Failure related mortality in adult US population: A CDC WONDER database analysis from 1999 to 2020

BACKGROUND

With the advent of novel chemotherapy, survival of patients with cancer has improved. However, people with cancer have an increased risk of heart failure (HF). Conversely, HF-related mortality may undermine survival among people with cancer. We aim to analyze the trends of mortality in people with HF and cancer in the adult US population.

METHODS

We conducted an examination of death certificates sourced from the CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) database, from the years 1999 to 2020. Mortality in adults with HF and cancer was assessed. Age-adjusted mortality rates (AAMRs) per 100,000 persons and annual percent change were reported.

RESULTS

Between 1999 and 2020, 621,783 deaths occurred from HF in people with cancer. The AAMR declined from 16.4 in 1999 to 11.9 in 2017, after which an increase to 14.5 was observed in 2020. Men had consistently higher overall AAMR as compared to women (men = 18.1 vs women = 9.9). Similar AAMR was observed between non-Hispanic (NH) Blacks/African Americans (13.9) and NH Whites (13.3), with lower in American Indian/Alaska Native (9.6) and Hispanics (7.4). Asian/Pacific Islanders reported the lowest AAMR (5.7). The Midwestern region reported the highest AAMR (14.8). We observed the highest AAMR amongst the older population (61.4).

CONCLUSION

The mortality rates of people with HF and cancer are increasing in the adult U.S.

POPULATION

This underscores the need for increased screening, aggressive management, and subsequent surveillance of people at risk or with manifested HF in people with cancer.

Optimizing the Patient Experience in Breast Imaging Facilities: AJR Expert Panel Narrative Review

Breast imaging studies are complex examinations for patients and providers. Breast imaging providers and organizations invest significant resources in educating patients and referring physicians to address variability in changing breast cancer screening recommendations, cultural biases, and socioeconomic barriers for patients. The breast imaging examination frequently involves multiple imaging modalities, including interventional procedures, thus requiring multiple room types. Practices need to consider the variables that affect workflow efficiency throughout the process of examination scheduling, performance, interpretation, and results delivery, as well as options in facilities design for creating inviting yet functional environments for patients. Breast imaging appointments provide an opportunity to capture individual breast cancer risk and to engage patients in health education and breast screening awareness. This AJR Expert Panel Narrative Review discusses ways in which breast imaging facilities can optimize a patient's experience throughout the complex process of a breast imaging examination, based on the authors' observations and opinions informed by private and academic breast imaging experience.

Comparative morphology of tumour microenvironment in claudin-low and claudin-high breast cancers

BACKGROUND

Claudin-low breast cancers (BCs) exhibit more aggressive behaviour compared to claudin-high types. Claudin-low BCs are often characterized by features such as a higher grade, enrichment of stemness characteristics, and a propensity for metastasis. Tumour microenvironment (TME) defined as the intricate network of surrounding cells, blood vessels, and extracellular matrix components influences the behaviour of cancer cells within the breast tissue. Understanding the TME is crucial for comprehending the aggressive characteristics of claudin-low BCs.

METHODS

In this study, we have studied the morphology of immune and non-immune TME using Haematoxylin and eosin (H&E)-stained slides of 15 claudin-low and 12 claudin-high tissue samples of BC.

RESULTS

TME of claudin-low BCs was observed to have a significantly higher frequency of retraction clefts (66.6 %; n = 10/15), immature desmoplastic response (40 %; n = 6/15), higher stromal cellularity (60 %; n = 9/15); and fibroblastic proliferation (53.3 %; n = 8/15) with a low prevalence of elastosis (66.6 %; n = 10/15). The immune microenvironment revealed a higher frequency of total (80 %; n = 12/15) as well as stromal (86.67 %; n = 13/15) and intra-tumoural TILs (60 %; n = 9/15) in them.

CONCLUSION

The above morphology-based study revealed that claudin-low tumours have unique immune and non-immune TME as compared to claudin-high tumours. Future studies exploring the molecular correlates of each of the above morphological features can help in identifying novel therapeutic targets for the treatment of claudin-low BCs.

Tumor Doubling Time and Screening Interval

The goal of screening is to detect breast cancers when still curable to decrease breast cancer-specific mortality. Breast cancer screening in the United States is routinely performed with digital mammography and digital breast tomosynthesis. This article reviews breast cancer doubling time by tumor subtype and examines the impact of doubling time on breast cancer screening intervals. By the article's end, the reader will be better equipped to have informed discussions with patients and medical professionals regarding the benefits and disadvantages of the currently recommended screening mammography intervals.

Screening for Breast Cancer: A Comparative Review of Guidelines

Breast cancer is the most common malignancy diagnosed in the female population worldwide and the leading cause of death among perimenopausal women. Screening is essential, since earlier detection in combination with improvements in breast cancer treatment can reduce the associated mortality. The aim of this study was to review and compare the recommendations from published guidelines on breast cancer screening. A total of 14 guidelines on breast cancer screening issued between 2014 and 2022 were identified. A descriptive review of relevant guidelines by the World Health Organization (WHO), the U.S. Preventive Services Task Force (USPSTF), the American Cancer Society (ACS), the National Comprehensive Cancer Network (NCCN), the American College of Obstetricians and Gynecologists (ACOG), the American Society of Breast Surgeons (ASBrS), the American College of Radiology (ACR), the Task Force on Preventive Health Care (CTFPHC), the European Commission Initiative on Breast Cancer (ECIBC), the European Society for Medical Oncology (ESMO), the Royal Australian College of General Practitioners (RACGP) and the Japanese Journal of Clinical Oncology (JJCO) for women both at average and high-risk was carried out. There is a consensus among all the reviewed guidelines that mammography is the gold standard screening modality for average-risk women. For this risk group, most of the guidelines suggest annual or biennial mammographic screening at 40-74 years, while screening should particularly focus at 50-69 years. Most of the guidelines suggest that the age limit to stop screening should be determined based on the women's health status and life expectancy. For women at high-risk, most guidelines recommend the use of annual mammography or magnetic resonance imaging, while the starting age should be earlier than the average-risk group, depending on the risk factor. There is discrepancy among the recommendations regarding the age at onset of screening in the various high-risk categories. The development of consistent international practice protocols for the most appropriate breast cancer screening programs seems of major importance to reduce mortality rates and safely guide everyday clinical practice.

Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement

Importance

Among all US women, breast cancer is the second most common cancer and the second most common cause of cancer death. In 2023, an estimated 43 170 women died of breast cancer. Non-Hispanic White women have the highest incidence of breast cancer and non-Hispanic Black women have the highest mortality rate.

Objective

The USPSTF commissioned a systematic review to evaluate the comparative effectiveness of different mammography-based breast cancer screening strategies by age to start and stop screening, screening interval, modality, use of supplemental imaging, or personalization of screening for breast cancer on the incidence of and progression to advanced breast cancer, breast cancer morbidity, and breast cancer-specific or all-cause mortality, and collaborative modeling studies to complement the evidence from the review.

Population

Cisgender women and all other persons assigned female at birth aged 40 years or older at average risk of breast cancer.

Evidence Assessment

The USPSTF concludes with moderate certainty that biennial screening mammography in women aged 40 to 74 years has a moderate net benefit. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of screening mammography in women 75 years or older and the balance of benefits and harms of supplemental screening for breast cancer with breast ultrasound or magnetic resonance imaging (MRI), regardless of breast density.

Recommendation

The USPSTF recommends biennial screening mammography for women aged 40 to 74 years. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women 75 years or older. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasonography or MRI in women identified to have dense breasts on an otherwise negative screening mammogram. (I statement).

Increasing Access to Medical Care for Hispanic Women Without Insurance: A Mobile Clinic Approach

The purpose of this study was to describe the health status and barriers of people who sought care on a free mobile health clinic for women without insurance in California. Participants were 221 women who attended the Salud para Mujeres (Women's Health) mobile medical clinic between 2019 and 2021. Medical chart abstractions provided data on sociodemographic factors, medical history, barriers to care, depressive symptoms, and dietary factors. Anthropometric measure, blood pressure, and biomarkers of cardiometabolic disease risk were also abstracted. Participants were young adult (29.1 [SD 9.3] years), Hispanic (97.6%), farm-working (62.2%) women from Mexico (87.0%). Prevalent barriers to accessing (non-mobile) medical care included high cost (74.5%), language (47.6%), hours of operation (36.2%), and transportation (31.4%). The majority (89.5%) of patients had overweight (34.0%) or obesity (55.5%), and 27% had hypertension. Among those (n = 127) receiving a lipid panel, 60.3% had higher than recommended levels of low-density lipoprotein and 89% had lower than recommended levels of high-density lipoprotein. Point-of-care HbA1c tests (n = 133) indicated that 9.0% had diabetes and 24.8% had prediabetes. Over half (53.1%) of patients reported prevalent occupational exposure to pesticides and 19% had moderate to severe depressive symptoms. Weekly or more frequent consumption of sugar sweetened beverages (70.9%) and fast food (43.5%) were also prevalent. Mobile health units have potential for reaching women who face several barriers to care and experience major risk factors for cardometabolic disease. Findings suggest a compelling need to assure that Hispanic and Indigenous women and farmworkers have access to healthcare.

BECN1 mRNA expression in breast cancer tissue; significant correlation to tumor grade

Breast cancer (BC) is a heterogenous disease with multiple pathways implicated in its development, progression, and drug resistance. Autophagy, a cellular process responsible for self-digestion of damaged organelles, had been recognized as eminent player in cancer progression and chemotherapeutic resistance. The haploinsufficiency of Beclin 1 (BECN1), autophagy protein, is believed to contribute to cancer pathogenesis and progression. In our study, we investigated the expression of BECN1 in a BC female Egyptian patient cohort, as well as its prognostic role through evaluating its association with disease free survival (DFS) after 2 years follow up and association of tumor clinicopathological features. Twenty frozen female BC tissue samples and 17 adjacent normal tissue were included and examined for the expression levels of BECN1. Although the tumor tissues showed lower expression 0.73 (0-8.95) than their corresponding normal tissues 1.02 (0.04-19.59), it was not statistically significant, p: 0.463. BECN1 expression was not associated with stage, nodal metastasis or tumor size, p:0.435, 0.541, 0.296, respectively. However, statistically significant negative correlation was found between grade and BECN1 mRNA expression in the studied cases, p:0.028. BECN1 expression had no statistically significant association with DFS, P = 0.944. However, we observed that triple negative (TNBC) cases had significantly lower DFS rate than luminal BC patients, p: 0.022, with mean DFS 19.0 months, while luminal BC patients had mean DFS of 23.41 months. Our study highlights the potential role of BECN1 in BC pathogenesis, showing that BECN1 expression correlates with poorer differentiation of BC, indicating its probable link with disease aggressiveness. DFS two years follow up showed that TNBC subtype remains associated with less favorable prognosis.

Canadian Association of Radiologists Breast Disease Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Breast Disease Expert Panel consists of breast imaging radiologists, a high-risk breast clinician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 69 recommendation statements across the 20 scenarios. This guideline presents the methods of development and the recommendations for referring asymptomatic individuals, symptomatic patients, and other scenarios requiring imaging of the breast.

Following the High-Risk Patient: Breast Cancer Risk-Based Screening

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.

Breast Cancer Screening Referral Patterns and Compliance in Transgender Male Patients

Purpose

Screening guidelines for breast cancer (BC) in transgender male (TM) patients are not well defined. This study describes referral patterns and compliance with referral for BC screening among TM patients receiving care at a tertiary care center.

Methods

This was a retrospective cohort study of TM patients, 40-74 years of age, presenting for care between 2017 and 2020. The electronic medical record was queried for medical history and cancer screening data. Compliance with referral and screening was defined as occurring within 2 years of when screening would be expected.

Results

Of the 266 patients identified, 45 met inclusion criteria. One (2.2%) had a history of BC, 0 (0%) had hereditary BC risk, and 11 (24.4%) had a family history of BC. Of the patients, 18 (40%) were referred for BC screening, of whom 13 (72.2%) were compliant with screening. Ten (55.6%) were referred by a primary care provider, 2 (11.1%) were referred by a transgender medicine specialist, and 6 (33.3%) were referred by both. Of the cohort, 27 (60%) had undergone masculinizing mastectomy. Six (22.2%) of these patients were referred for screening, of whom 0 (0%) had pre-screening clinical findings indicating need for screening. Of the 18 (40%) patients who had not undergone masculinizing mastectomy, 12 (66.7%) were referred for BC screening.

Conclusions

There was heterogeneity in referral patterns for BC screening between TM patients who had undergone masculinizing mastectomy and those who had not. BC screening guidelines should be established for TM patients who have undergone masculinizing mastectomy.

The influence of chronic renal insufficiency on multi-therapeutic modalities for breast cancer: a single-center experience

BACKGROUND

Due to the presence of other comorbidities and multi-therapeutic modalities in breast cancer, renally cleared chemotherapeutic regimens may cause nephrotoxicity. The aim of this retrospective study is to compare the chemotherapy types and outcomes in breast cancer patients with or without chronic renal disease.

PATIENTS AND METHODS

We retrospectively enrolled 62 female patients with breast cancer and underlying late stages (stage 3b, 4, and 5) of chronic kidney disease (CKD) treated from 2000 to 2017. They were propensity score-matched 1:1 with patients in our database with breast cancer and normal renal function (total n = 124).

RESULTS

The main subtype of breast cancer was luminal A and relatively few patients with renal impairment received chemotherapy and anti-Her-2 treatment. The breast cancer patients with late-stage CKD had a slightly higher recurrent rate, especially at the locally advanced stage. The 5-year overall survival was 90.1 and 71.2% for patients without and with late-stage CKD, but the breast cancer-related mortality rate was 88.9 and 24.1%, respectively. In multivariate analyses, dose-reduced chemotherapy was an independent negative predictor of 5-year recurrence-free survival and late-stage CKD was associated with lower 5-year overall survival rate.

CONCLUSIONS

Breast cancer patients with late-stage CKD may receive insufficient therapeutic modalities. Although the recurrence-free survival rate did not differ significantly by the status of CKD, patients with breast cancer and late-stage CKD had shorter overall survival time but a lower breast cancer-related mortality rate, indicated that the mortality was related to underlying disease.

A Public Health Emergency: Breast Cancer Among Black Communities in the United States

While Black people have a similar incidence of breast cancer compared to White people, they have a 40% increased death rate. Black people are more likely to be diagnosed with aggressive subtypes such as triple-negative breast cancer. However, despite biological factors, systemic racism and social determinants of health create delays in care and barriers to treatment. While genetic testing holds incredible promise for Black people, uptake remains low and results may be challenging to interpret. There is a need for more robust, multidisciplinary, and antiracist interventions to reverse breast cancer-related racial disparities.

Gynecologic Care of Transgender and Gender-Diverse People

The visibility and care of transgender and gender-diverse (TGD) people is an important component of gynecology. Transmasculine individuals require routine gynecologic and preventative care. Guidelines can be extrapolated from the cisgender female population, and using affirming language, acknowledging the challenges patients face with pelvic examination, and discussing individual gynecologic needs are important components of care. Transmasculine patients may seek hysterectomy for gender affirmation from gynecologists. Unique nuances exist in the considerations needed when preparing for hysterectomy, and patients should be thoroughly counseled with regard to concurrent vaginectomy or oophorectomy or both. Transfeminine patients often seek gynecologic care after gender-affirming surgery, and, unlike transmasculine patients, the gynecology visit is often very affirming and welcomed by patients. Becoming familiar with the perioperative and delayed postoperative care needs of transfeminine patients undergoing vaginoplasty can help improve the care provided by gynecologists. In general, prospective data on the outcomes of gender-affirming care in large cohorts of TGD patients are limited, but the body of literature is growing. Gynecologists remain central to the care of TGD patients, the academic advancement of the field of transgender health, and the advocacy needed to support this vulnerable patient population.

Benefits and Harms of Mammography Screening in 75 + Women to Inform Shared Decision-making: a Simulation Modeling Study

BACKGROUND

Guidelines recommend shared decision-making (SDM) around mammography screening for women ≥ 75 years old.

OBJECTIVE

To use microsimulation modeling to estimate the lifetime benefits and harms of screening women aged 75, 80, and 85 years based on their individual risk factors (family history, breast density, prior biopsy) and comorbidity level to support SDM in clinical practice.

DESIGN, SETTING, AND PARTICIPANTS

We adapted two established Cancer Intervention and Surveillance Modeling Network (CISNET) models to evaluate the remaining lifetime benefits and harms of screening U.S. women born in 1940, at decision ages 75, 80, and 85 years considering their individual risk factors and comorbidity levels. Results were summarized for average- and higher-risk women (defined as having breast cancer family history, heterogeneously dense breasts, and no prior biopsy, 5% of the population).

MAIN OUTCOMES AND MEASURES

Remaining lifetime breast cancers detected, deaths (breast cancer/other causes), false positives, and overdiagnoses for average- and higher-risk women by age and comorbidity level for screening (one or five screens) vs. no screening per 1000 women.

RESULTS

Compared to stopping, one additional screen at 75 years old resulted in six and eight more breast cancers detected (10% overdiagnoses), one and two fewer breast cancer deaths, and 52 and 59 false positives per 1000 average- and higher-risk women without comorbidities, respectively. Five additional screens over 10 years led to 23 and 31 additional breast cancer cases (29-31% overdiagnoses), four and 15 breast cancer deaths avoided, and 238 and 268 false positives per 1000 average- and higher-risk screened women without comorbidities, respectively. Screening women at older ages (80 and 85 years old) and high comorbidity levels led to fewer breast cancer deaths and a higher percentage of overdiagnoses.

CONCLUSIONS

Simulation models show that continuing screening in women ≥ 75 years old results in fewer breast cancer deaths but more false positive tests and overdiagnoses. Together, clinicians and 75 + women may use model output to weigh the benefits and harms of continued screening.

Eradicating Atherosclerotic Events by Targeting Early Subclinical Disease: It Is Time to Retire the Therapeutic Paradigm of Too Much, Too Late

Recent decades have seen spectacular advances in understanding and managing atherosclerotic cardiovascular disease, but paradoxically, clinical progress has stalled. Residual risk of atherosclerotic cardiovascular disease events is particularly vexing, given recognized lifestyle interventions and powerful modern medications. Why? Atherosclerosis begins early in life, yet clinical trials and mechanistic studies often emphasize terminal, end-stage plaques, meaning on the verge of causing heart attacks and strokes. Thus, current clinical evidence drives us to emphasize aggressive treatments that are delayed until patients already have advanced arterial disease. I call this paradigm "too much, too late." This brief review covers exciting efforts that focus on preventing, or finding and treating, arterial disease before its end-stage. Also included are specific proposals to establish a new evidence base that could justify intensive short-term interventions (induction-phase therapy) to treat subclinical plaques that are early enough perhaps to heal. If we can establish that such plaques are actionable, then broad screening to find them in early midlife individuals would become imperative-and achievable. You have a lump in your coronaries! can motivate patients and clinicians. We must stop thinking of a heart attack as a disease. The real disease is atherosclerosis. In my opinion, an atherosclerotic heart attack is a medical failure. It is a manifestation of longstanding arterial disease that we had allowed to progress to its end-stage, despite knowing that atherosclerosis begins early in life and despite the availability of remarkably safe and highly effective therapies. The field needs a transformational advance to shift the paradigm out of end-stage management and into early interventions that hold the possibility of eradicating the clinical burden of atherosclerotic cardiovascular disease, currently the biggest killer in the world. We urgently need a new evidence base to redirect our main focus from terminal, end-stage atherosclerosis to earlier, and likely reversible, human arterial disease.

Persistence of patient-detected breast cancer over time: 1990-2019

BACKGROUND

The continued presentation of patient-detected breast cancer (BC) and associated characteristics over time is understudied.

METHODS

In a large institutional cohort of first primary stage 0-IV patients with BC in 1990-2019 (n = 15,827), diagnostic method (patient-detected [PtDBC] [n = 5844]; mammography-detected [MamDBC] [nondiagnostic] [n = 9248]; and physician-detected [PhysDBC] [n = 736]) and patient and tumor characteristics including age, race, TNM stage, and hormone-receptor status were reviewed. Pearson χ2 tests for bivariate comparisons and logistic regression for patient detection-associated factors were used.

RESULTS

In a cohort from 1990 to 2019, the proportion aged 50-74 years (55%-63%; p < .001) and non-White race (9%-37%; p < .001) increased over time. Percentage PtDBC decreased over time but case numbers increased (1990-1999: 44% [n = 1399]; 2010-2019: 34% [n = 2349]; p < .001). Excluding stage 0, PtDBC declined from 47% to 41% over time (p < .001). In 2010-2019, 21% of cases were stage 0, 91% of which were mammography detected (n = 1439). Seventy percent of patient-detected cases were stage II-IV (stage II, 44%; stage III, 20%; stage IV, 6%; p < .001). In adjusted logistic regression, the odds of PtDBC decreased over time (2000-2009: odds ratio [OR], .65 [95% CI, .58-.72]; 2010-2019: OR, .54 [95% CI, .49-.60]), with age <40 years OR, 15.81, and Black and non-White other at 50% increased risk.

CONCLUSIONS

The relative proportion of PtDBC decreased to a constant 34%-40% of total cases after 1990-1999. PtDBC case numbers increased in subsequent years (2000-2019), and were consistently higher stage. Interval cancers, mammography-screening uptake, breast health awareness of age groups outside screening guidelines, and underserved socioeconomic groups may be related to the continued significant PtDBC incidence.

PLAIN LANGUAGE SUMMARY

After decades of mammography-screening availability, symptomatic patient-detected breast cancer declined over time from 44% to a persistent rate of 34% in our institutional cohort. The persistence of patient-detected breast cancer over time presents a difficult situation for patients and care givers without clear diagnosis pathways for younger and older women outside recommended screening guidelines, who often present with higher stage and more lethal characteristics. More timely diagnosis and treatment including breast health awareness, prompt presentation of breast problems, outreach to younger age and minority groups, and provision of specialized training and care delivery for symptomatic patient-detected breast cancer are needed.

Effects of exposure to media messages about limiting breast cancer screening: A qualitative experimental study

OBJECTIVE

Examine how women aged 35-50 respond to messages about limiting cancer screening.

METHODS

A national sample of women aged 35-50 (n = 983) were randomly assigned to read one of four media vignettes: three provided information about potential harms of mammograms using evidence, norms, or an anecdote strategy, and one provided no such information. Participants listed thoughts they had about the message, and after coding these themes, we tested for associations between the themes evoked, message exposure, and mammogram history.

RESULTS

Thematic categories included emotions (8 %); behavioral intentions (14 %); and cognitions, attitudes, and beliefs (67 %). Pro-screening attitudes, questioning, and cues to get screened were most prevalent. The anecdote message often elicited pro-screening attitudes, while the evidence message often elicited negative emotions and anger, as well as questioning or skeptical responses. Those with a history of mammograms expressed more pro-screening attitudes and disagreed with the message more often.

CONCLUSIONS

Media messaging about guideline-supported care, especially when it involves reducing a clinical service that is routine and valued by patients, may evoke counterarguing, skepticism, and other negative responses.

PRACTICE IMPLICATIONS

Clinicians should recognize the role of the media in potentially shaping women's attitudes, beliefs, and intentions when it comes to breast cancer screening.

Talking numbers: how women and providers use risk scores during and after risk counseling - a qualitative investigation from the NRG Oncology/NSABP DMP-1 study

OBJECTIVES

Little research exists on how risk scores are used in counselling. We examined (a) how Breast Cancer Risk Assessment Tool (BCRAT) scores are presented during counselling; (b) how women react and (c) discuss them afterwards.

DESIGN

Consultations were video-recorded and participants were interviewed after the consultation as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1 (NSABP DMP-1).

SETTING

Two NSABP DMP-1 breast cancer care centres in the USA: one large comprehensive cancer centre serving a high-risk population and an academic safety-net medical centre in an urban setting.

PARTICIPANTS

Thirty women evaluated for breast cancer risk and their counselling providers were included.

METHODS

Participants who were identified as at increased risk of breast cancer were recruited to participate in qualitative study with a video-recorded consultation and subsequent semi-structured interview that included giving feedback and input after viewing their own consultation. Consultation videos were summarised jointly and inductively as a team.tThe interview material was searched deductively for text segments that contained the inductively derived themes related to risk assessment. Subgroup analysis according to demographic variables such as age and Gail score were conducted, investigating reactions to risk scores and contrasting and comparing them with the pertinent video analysis data. From this, four descriptive categories of reactions to risk scores emerged. The descriptive categories were clearly defined after 19 interviews; all 30 interviews fit principally into one of the four descriptive categories.

RESULTS

Risk scores were individualised and given meaning by providers through: (a) presenting thresholds, (b) making comparisons and (c) emphasising or minimising the calculated risk. The risk score information elicited little reaction from participants during consultations, though some added to, agreed with or qualified the provider's information. During interviews, participants reacted to the numbers in four primary ways: (a) engaging easily with numbers; (b) expressing greater anxiety after discussing the risk score; (c) accepting the risk score and (d) not talking about the risk score.

CONCLUSIONS

Our study highlights the necessity that patients' experiences must be understood and put into relation to risk assessment information to become a meaningful treatment decision-making tool, for instance by categorising patients' information engagement into types.

TRIAL REGISTRATION NUMBER

NCT01399359.

Breast Cancer Screening and Prevention

Breast cancer is the most common cancer among U.S. women and its incidence increases with age. Endogenous estrogen exposure, proliferative benign breast disease, breast density, and family history may also indicate increased risk for breast cancer. Early detection with screening mammography reduces breast cancer mortality, but the net benefits vary by age. Assessing a patient's individual breast cancer risk can guide decisions regarding breast cancer screening. All women benefit from healthy behaviors which may reduce breast cancer risk. Some women at increased risk for breast cancer may benefit from risk-reducing medications. Use of screening measures remains suboptimal, especially for uninsured women.

Breast Cancer Screening and Diagnosis: Recent Advances in Imaging and Current Limitations

Breast cancer detection has a significant impact on population health. Although there are many breast imaging modalities, mammography is the predominant tool for breast cancer screening. The introduction of digital breast tomosynthesis to mammography has contributed to increased cancer detection rates and decreased recall rates. In average-risk women, starting annual screening mammography at age 40 years has demonstrated the highest mortality reduction. In intermediate- and high-risk women as well as in those with dense breasts, additional modalities, including MRI, ultrasound, and molecular breast imaging, can also be considered for adjunct screening to improve the detection of mammographically occult malignancy.

PROSPECTIVE POSTMORTEM ASSESSMENT OF THE INCIDENCE OF MAMMARY NEOPLASIA IN CHIMPANZEES (PAN TROGLODYTES)

When evaluating the last 25 yr of morbidity and mortality from adult chimpanzees managed within the Association of Zoo and Aquarium Chimpanzee Species Survival Plan® for North American zoos, only two female chimpanzees were diagnosed with mammary neoplasia: one incidentally antemortem and one with a terminal metastatic neoplasia. When comparing this observation of prevalence of mammary neoplasia to humans, a substantial disparity is apparent. Mammary neoplasia is the second most common cancer in adult female humans, with a lifetime risk of 1:8 in the United States. The reason for the disparity between humans and chimpanzees, as closely related species, is unknown. The true prevalence in chimpanzees may be higher than currently noted, because routine examination of mammary tissue in chimpanzees is generally less complete than for other tissues postmortem, and antemortem assessment is generally limited to mammary palpation. This study was performed on intact, bilateral mammary glands harvested at postmortem examination of adult female chimpanzees (n = 7) from six institutions. With mammography, complete histopathologic sectioning, and genetic evaluation, the risk of mammary neoplasia was evaluated more thoroughly than during a typical postmortem exam in zoo populations during 2017-2019. No chimpanzees in the study were diagnosed with mammary neoplasia. Overall, this study supports the previous impression that chimpanzees do not develop mammary neoplasia at a similar rate as humans, even when comparable diagnostic modalities for evaluation are used.

New Approaches and Recommendations for Risk-Adapted Breast Cancer Screening

Population-based breast cancer screening using mammography as the gold standard imaging modality has been in clinical practice for over 40 years. However, the limitations of mammography in terms of sensitivity and high false-positive rates, particularly in high-risk women, challenge the indiscriminate nature of population-based screening. Additionally, in light of expanding research on new breast cancer risk factors, there is a growing consensus that breast cancer screening should move toward a risk-adapted approach. Recent advancements in breast imaging technology, including contrast material-enhanced mammography (CEM), ultrasound (US) (automated-breast US, Doppler, elastography US), and especially magnetic resonance imaging (MRI) (abbreviated, ultrafast, and contrast-agent free), may provide new opportunities for risk-adapted personalized screening strategies. Moreover, the integration of artificial intelligence and radiomics techniques has the potential to enhance the performance of risk-adapted screening. This review article summarizes the current evidence and challenges in breast cancer screening and highlights potential future perspectives for various imaging techniques in a risk-adapted breast cancer screening approach. EVIDENCE LEVEL: 1. TECHNICAL EFFICACY: Stage 5.

Early breast cancer risk detection: a novel framework leveraging polygenic risk scores and machine learning

BACKGROUND

Breast cancer (BC) is the most common cancer and the second leading cause of cancer death in women; an estimated one in eight women in the USA will develop BC during her lifetime. However, current methods of BC screening, including clinical breast exams, mammograms, biopsies and others, are often underused due to limited access, expense and a lack of risk awareness, causing 30% (up to 80% in low-income and middle-income countries) of patients with BC to miss the precious early detection phase.

METHODS

This study creates a key step to supplement the current BC diagnostic pipeline: a prescreening platform, prior to traditional detection and diagnostic steps. We have developed BREast CAncer Risk Detection Application (BRECARDA), a novel framework that personalises BC risk assessment using artificial intelligence neural networks to incorporate relevant genetic and non-genetic risk factors. A polygenic risk score (PRS) was enhanced by employing AnnoPred and validated by fivefolds cross-validation, outperforming three existing state-of-the-art PRS methods.

RESULTS

We used data from 97 597 female participants of the UK BioBank to train our algorithm. Using the enhanced PRS thus trained together with non-genetic information, BRECARDA was evaluated in a testing dataset with 48 074 UK Biobank female participants and achieved a high accuracy of 94.28% and area under the curve of 0.7861. Our optimised AnnoPred outperformed other state-of-the-art methods on quantifying genetic risk, indicating its potential for supplementing the current BC detection tests, population screening and risk evaluation.

CONCLUSION

BRECARDA can enhance disease risk prediction, identify high-risk individuals for BC screening, facilitate disease diagnosis and improve population-level screening efficiency. It can serve as a valuable and supplemental platform to assist doctors in BC diagnosis and evaluation.

Breast Self-Examination Practice and Its Determinants among Women in Indonesia: A Systematic Review, Meta-Analysis, and Meta-Regression

Breast cancer (BC) is a heavy burden for Indonesian healthcare, but there is still no thorough evaluation for Breast self-examination (BSE) practice as routine BC screening. In this study, we aimed to synthesize the pooled prevalence data of BSE practice, compare BSE practice prevalence between Java Island and non-Java Islands in Indonesia, and identify the determinants that we thought could affect the BSE practice in the Indonesian population. Intensive searches were conducted in Cochrane Library, PubMed, Google Scholar, and SINTA (Indonesian Web of Science and Technology Index) from September 2017-2022. We utilized Review Manager 5.4 for conducting the meta-analysis. We found the overall national prevalence of BSE practice was 43.14% (95% CI: 36.08, 50.20, p < 0.00001). BSE practice in Java Island was higher compared to non-Java Island (44.58% vs. 41.62%). The highest prevalence of BSE practice was found among university students, with a 49.90% prevalence. Good knowledge, good attitude toward BSE, family history of BC, family support, and BC information exposure were all statistically associated with a higher determinant of BSE practice. We concluded that BSE practice in Indonesia is still low, especially in non-Java Islands. Integrative and collaborative programs should be established to promote BSE as routine screening for BC.

Application of SHAP for Explainable Machine Learning on Age-Based Subgrouping Mammography Questionnaire Data for Positive Mammography Prediction and Risk Factor Identification

Mammography is considered the gold standard for breast cancer screening. Multiple risk factors that affect breast cancer development have been identified; however, there is an ongoing debate regarding the significance of these factors. Machine learning (ML) models and Shapley Additive Explanation (SHAP) methodology can rank risk factors and provide explanatory model results. This study used ML algorithms with SHAP to analyze the risk factors between two different age groups and evaluate the impact of each factor in predicting positive mammography. The ML model was built using data from the risk factor questionnaires of women participating in a breast cancer screening program from 2017 to 2021. Three ML models, least absolute shrinkage and selection operator (lasso) logistic regression, extreme gradient boosting (XGBoost), and random forest (RF), were applied. RF generated the best performance. The SHAP values were then applied to the RF model for further analysis. The model identified age at menarche, education level, parity, breast self-examination, and BMI as the top five significant risk factors affecting mammography outcomes. The differences between age groups ranked by reproductive lifespan and BMI were higher in the younger and older age groups, respectively. The use of SHAP frameworks allows us to understand the relationships between risk factors and generate individualized risk factor rankings. This study provides avenues for further research and individualized medicine.

Predictors of nonadherence to breast cancer screening guidelines in a United States urban comprehensive cancer center

BACKGROUND

This study aimed to identify predictors of nonadherence to breast cancer screening guidelines in an urban screening clinic among high- and average-risk women in the United States.

METHODS

We reviewed records of 6090 women who received ≥2 screening mammograms over 2 years at the Karmanos Cancer Institute to examine how breast cancer risk and breast density were associated with guideline-concordant screening. Incongruent screening was defined as receiving supplemental imaging between screening mammograms for average-risk women, and as not receiving recommended supplemental imaging for high-risk women. We used t-tests and chi-square tests to examine bivariate associations with guideline-congruent screening, and probit regression to regress guideline-congruence unto breast cancer risk, breast density, and their interaction, controlling for age and race.

RESULTS

Incongruent screening was more likely among high- versus average-risk women (97.7% vs. 0.9%, p < 0.01). Among average-risk women, incongruent screening was more likely among those with dense versus nondense breasts (2.0% vs. 0.1%, p < 0.01). Among high-risk women, incongruent screening was more likely among those with nondense versus dense breasts (99.5% vs. 95.2%, p < 0.01). The significant main effects of density and high-risk on increased incongruent screening were qualified by a density by high-risk interaction, showing a weaker association between risk and incongruent screening among women with dense breasts (simple slope = 3.71, p < 0.01) versus nondense breasts (simple slope = 5.79, p < 0.01). Age and race were not associated with incongruent screening.

CONCLUSIONS

Lack of adherence to evidence-based screening guidelines has led to underutilization of supplementary imaging for high-risk women and potential overutilization for women with dense breasts without other risk factors.

Women's health issues in solid organ transplantation: Breast and gynecologic cancers in the post-transplant population

The success of solid organ transplant has steadily improved which has led to a unique set of post-transplant issues. The rates of de novo cancer in the solid organ transplant recipient population are higher than those in the general population. There is growing evidence that breast and gynecologic cancers may have a higher mortality rate in post-transplant patients. Cervical and vulvovaginal cancers specifically have a significantly higher mortality in this population. Despite this increased mortality risk, there is currently no consistent standard in screening and identifying these cancers in post-transplant patients. Breast, ovarian and endometrial cancers do not appear to have significantly increased incidence. However, the data on these cancers remains limited. Further studies are needed to determine if more aggressive screening strategies would be of benefit for these cancers. Here we review the cancer incidence, mortality risk and current screening methods associated with breast and gynecologic cancers in the post-solid organ transplant population.

A Rational and Standardized Prenatal Examination

Importance

As prenatal care is in transition after the COVID-19 pandemic, reviewing fundamental physical examination approaches is necessary for providers examining obstetrical patients.

Objective

The objective of this review is 3-fold: (1) convey why the age of telemedicine necessitates reconsideration of the standardized physical examination in routine prenatal care; (2) identify the screening efficacy of examination maneuvers used within a standard prenatal examination of the neck, heart, lungs, abdomen, breasts, skin, lower extremities, pelvis, and fetal growth; and (3) propose an evidence-based prenatal physical examination.

Evidence Acquisition

A comprehensive literature review identified relevant research, review articles, textbook chapters, databases, and societal guidelines.

Results

We conclude that an evidence-based prenatal examination for asymptomatic patients includes the following maneuvers: inspection and palpation for thyromegaly and cervical lymphadenopathy, cardiac auscultation, fundal height measurement, and a pelvic examination for purposes including testing for gonorrhea and chlamydia, assessing pelvimetry, and assessing cervical dilation later in the pregnancy, intrapartum, or in the setting of ultrasonogram-detected prelabor preterm cervical shortening.

Conclusions and Relevance

Although not true of all physical examination maneuvers, this article demonstrates that there are maneuvers that continue to play important screening roles in asymptomatic patients. With the increase in virtual visits and fewer in-person prenatal appointments, the rational basis for maneuvers recommended in this review should inform decision making around the prenatal examination performed.

Different Types of Patient Health Information Associated With Physician Decision-making Regarding Cancer Screening Cessation for Older Adults

Importance

Although guidelines use limited life expectancy to guide physician decision-making regarding cessation of cancer screening, many physicians recommend screening for older adults with limited life expectancies. Different ways of presenting information may influence older adults' screening decision-making; whether the same is true for physicians is unknown.

Objective

To examine how different ways of presenting patient health information are associated with physician decision-making about cancer screening cessation for older adults.

Design, Setting, and Participants

A national survey was mailed from April 29 to November 8, 2021, to a random sample of 1800 primary care physicians and 600 gynecologists from the American Medical Association Physician Masterfile. Primary care physicians were surveyed about breast, colorectal, or prostate cancer screenings. Gynecologists were surveyed about breast cancer screening.

Main Outcomes and Measures

Using vignettes of 2 older patients with limited life expectancies, 4 pieces of information about each patient were presented: (1) description of health conditions and functional status, (2) life expectancy, (3) equivalent physiological age, and (4) risk of dying from the specific cancer in the patient's remaining lifetime. The primary outcome was which information was perceived to be the most influential in screening cessation.

Results

The final sample included 776 participants (adjusted response rate, 52.8%; mean age, 51.4 years [range, 27-91 years]; 402 of 775 participants were men [51.9%]; 508 of 746 participants were White [68.1%]). The 2 types of information that were most often chosen as the factors most influential in cancer screening cessation were description of the patient's health or functional status (36.7% of vignettes [569 of 1552]) and risk of death from cancer in the patient's remaining lifetime (34.9% of vignettes [542 of 1552]). Life expectancy was chosen as the most influential factor in 23.1% of vignettes (358 of 1552). Physiological age was the least often chosen (5.3% of vignettes [83 of 1552]) as the most influential factor. Description of patient's health or functional status was the most influential factor among primary care physicians (estimated probability, 40.2%; 95% CI, 36.2%-44.2%), whereas risk of death from cancer was the most influential factor among gynecologists (estimated probability, 43.1%; 95% CI, 34.0%-52.1%). Life expectancy was perceived as a more influential factor in the vignette with more limited life expectancy (estimated probability, 27.9%; 95% CI, 24.5%-31.3%) and for colorectal cancer (estimated probability, 33.9%; 95% CI, 27.3%-40.5%) or prostate cancer (28.0%; 95% CI, 21.7%-34.2%) screening than for breast cancer screening (estimated probability, 14.5%; 95% CI, 10.9%-18.0%).

Conclusions and Relevance

Findings from this national survey study of physicians suggest that, in addition to the patient's health and functional status, the cancer risk in the patient's remaining lifetime and life expectancy were the factors most associated with physician decision-making regarding cancer screening cessation; information on cancer risk in the patient's remaining lifetime and life expectancy is not readily available during clinical encounters. Decision support tools that present a patient's cancer risk and/or limited life expectancy may help reduce overscreening among older adults.

Will Absolute Risk Estimation for Time to Next Screen Work for an Asian Mammography Screening Population?

Personalized breast cancer risk profiling has the potential to promote shared decision-making and improve compliance with routine screening. We assessed the Gail model's performance in predicting the short-term (2- and 5-year) and the long-term (10- and 15-year) absolute risks in 28,234 asymptomatic Asian women. Absolute risks were calculated using different relative risk estimates and Breast cancer incidence and mortality rates (White, Asian-American, or the Singapore Asian population). Using linear models, we tested the association of absolute risk and age at breast cancer occurrence. Model discrimination was moderate (AUC range: 0.580-0.628). Calibration was better for longer-term prediction horizons (E/O_{long-term ranges}: 0.86-1.71; E/O_{short-term ranges}:1.24-3.36). Subgroup analyses show that the model underestimates risk in women with breast cancer family history, positive recall status, and prior breast biopsy, and overestimates risk in underweight women. The Gail model absolute risk does not predict the age of breast cancer occurrence. Breast cancer risk prediction tools performed better with population-specific parameters. Two-year absolute risk estimation is attractive for breast cancer screening programs, but the models tested are not suitable for identifying Asian women at increased risk within this short interval.

Black Women's Perspectives on Breast Cancer Risk Assessment

PURPOSE

The aim of this study was to gather the perspectives of Black women on breast cancer risk assessment through a series of one-on-one interviews.

METHODS

The authors conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with Black women in Tennessee between September 2020 and November 2020. Guided by the Health Belief Model, qualitative analysis of interview data was performed in an iterative inductive and deductive approach and resulted in the development of a conceptual framework to depict influences on a woman's decision to engage with breast cancer risk assessment.

RESULTS

A total of 37 interviews were completed, and a framework of influences on a woman's decision to engage in breast cancer risk assessment was developed. Study participants identified several emerging themes regarding women's perspectives on breast cancer risk assessment and potential influences on women's decisions to engage with risk assessment. Much of women's decision context was based on risk appraisal (perceived severity of cancer and susceptibility of cancer), emotions (fear and trust), and perceived risks and benefits of having risk assessment. The decision was further influenced by modifiers such as communication, the risk assessment protocol, access to health care, knowledge, and health status. Perceived challenges to follow-up if identified as high risk also influenced women's decisions to pursue risk assessment.

CONCLUSIONS

Black women in this study identified several barriers to engagement with breast cancer risk assessment. Efforts to overcome these barriers and increase the use of breast cancer risk assessment can potentially serve as a catalyst to address existing breast cancer disparities. Continued work is needed to develop patient-centric strategies to overcome identified barriers.

Breast Cancer Mode of Detection in a Population-Based Cohort

OBJECTIVE

To evaluate how breast cancers come to clinical attention (mode of detection [MOD]) in a population-based cohort, determine the relative frequency of different MODs, and characterize patient and tumor characteristics associated with MOD.

PATIENTS AND METHODS

We used the Rochester Epidemiology Project to identify women ages 40 to 75 years with a first-time diagnosis of breast cancer from May 9, 2017, to May 9, 2019 (n=500) in a 9-county region in Minnesota. We conducted a retrospective medical record review to ascertain the relative frequency of MODs, evaluating differences between screening mammography vs all other MODs by breast density and cancer characteristics. Multiple logistic regression was conducted to examine the likelihood of MOD for breast density and stage of disease.

RESULTS

In our population-based cohort, 162 of 500 breast cancers (32.4%) were detected by MODs other than screening mammography, including 124 (24.8%) self-detected cancers. Compared with women with mammography-detected cancers, those with MODs other than screening mammography were more frequently younger than 50 years of age (P=.004) and had higher-grade tumors (P=.007), higher number of positive lymph nodes (P<.001), and larger tumor size (P<.001). Relative to women with mammography-detected cancers, those with MODs other than screening mammography were more likely to have dense breasts (odds ratio, 1.87; 95% CI, 1.20 to 2.92; P=.006) and advanced cancer at diagnosis (odds ratio, 3.58; 95% CI, 2.29 to 5.58; P<.001).

CONCLUSION

One-third of all breast cancers in this population were detected by MODs other than screening mammography. Increased likelihood of nonmammographic MODs was observed among women with dense breasts and advanced cancer.

A model for predicting both breast cancer risk and non-breast cancer death among women > 55 years old

BACKGROUND

Guidelines recommend shared decision making (SDM) for mammography screening for women ≥ 75 and not screening women with < 10-year life expectancy. High-quality SDM requires consideration of women's breast cancer (BC) risk, life expectancy, and values but is hard to implement because no models simultaneously estimate older women's individualized BC risk and life expectancy.

METHODS

Using competing risk regression and data from 83,330 women > 55 years who completed the 2004 Nurses' Health Study (NHS) questionnaire, we developed (in 2/3 of the cohort, n = 55,533) a model to predict 10-year non-breast cancer (BC) death. We considered 60 mortality risk factors and used best-subsets regression, the Akaike information criterion, and c-index, to identify the best-fitting model. We examined model performance in the remaining 1/3 of the NHS cohort (n = 27,777) and among 17,380 Black Women's Health Study (BWHS) participants, ≥ 55 years, who completed the 2009 questionnaire. We then included the identified mortality predictors in a previously developed competing risk BC prediction model and examined model performance for predicting BC risk.

RESULTS

Mean age of NHS development cohort participants was 70.1 years (± 7.0); over 10 years, 3.1% developed BC, 0.3% died of BC, and 20.1% died of other causes; NHS validation cohort participants were similar. BWHS participants were younger (mean age 63.7 years [± 6.7]); over 10-years 3.1% developed BC, 0.4% died of BC, and 11.1% died of other causes. The final non-BC death prediction model included 21 variables (age; body mass index [BMI]; physical function [3 measures]; comorbidities [12]; alcohol; smoking; age at menopause; and mammography use). The final BC prediction model included age, BMI, alcohol and hormone use, family history, age at menopause, age at first birth/parity, and breast biopsy history. When risk factor regression coefficients were applied in the validation cohorts, the c-index for predicting 10-year non-BC death was 0.790 (0.784-0.796) in NHS and 0.768 (0.757-0.780) in BWHS; for predicting 5-year BC risk, the c-index was 0.612 (0.538-0.641) in NHS and 0.573 (0.536-0.611) in BWHS.

CONCLUSIONS

We developed and validated a novel competing-risk model that predicts 10-year non-BC death and 5-year BC risk. Model risk estimates may help inform SDM around mammography screening.

Perceptions of Breast Cancer Risks Among Women Receiving Mammograph Screening

Importance

Breast density is an independent risk factor for breast cancer. Despite the proliferation of mandated written notifications about breast density following mammography, there is little understanding of how women perceive the relative breast cancer risk associated with breast density.

Objective

To assess women's perception of breast density compared with other breast cancer risks and explore their understanding of risk reduction.

Design, Setting, and Participants

This mixed-methods qualitative study used telephone surveys and semistructured interviews to investigate perceptions about breast cancer risk among a nationally representative, population-based sample of women. Eligible study participants were aged 40 to 76 years, reported having recently undergone mammography, had no history of prior breast cancer, and had heard of breast density. Survey participants who had been informed of their personal breast density were invited for a qualitative interview. Survey administration spanned July 1, 2019, to April 30, 2020, with 2306 women completing the survey. Qualitative interviews were conducted from February 1 to May 30, 2020.

Main Outcomes and Measures

Respondents compared the breast cancer risk associated with breast density with 5 other risk factors. Participants qualitatively described what they thought contributed to breast cancer risk and ways to reduce risk.

Results

Of the 2306 women who completed the survey, 1858 (166 [9%] Asian, 503 [27%] Black, 268 [14%] Hispanic, 792 [43%] White, and 128 [7%] other race or ethnicity; 358 [19%] aged 40-49 years, 906 [49%] aged 50-64 years, and 594 [32%] aged ≥65 years) completed the revised risk perception questions and were included in the analysis. Half of respondents thought breast density to be a greater risk than not having children (957 [52%]), having more than 1 alcoholic drink per day (975 [53%]), or having a prior breast biopsy (867 [48%]). Most respondents felt breast density was a lesser risk than having a first-degree relative with breast cancer (1706 [93%]) or being overweight or obese (1188 [65%]). Of the 61 women who were interviewed, 6 (10%) described breast density as contributing to breast cancer risk, and 43 (70%) emphasized family history as a breast cancer risk factor. Of the interviewed women, 17 (28%) stated they did not know whether it was possible to reduce their breast cancer risk.

Conclusions and Relevance

In this qualitative study of women of breast cancer screening age, family history was perceived as the primary breast cancer risk factor. Most interviewees did not identify breast density as a risk factor and did not feel confident about actions to mitigate breast cancer risk. Comprehensive education about breast cancer risks and prevention strategies is needed.

Breast Cancer Risk and Screening Mammography Frequency Among Multiethnic Women

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.

Screening Programs for Breast Cancer: Toward Individualized, Risk-Adapted Strategies of Early Detection

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.

The Landmark Series-Addressing Disparities in Breast Cancer Screening: New Recommendations for Black Women

Randomized, clinical trials have established the efficacy of screening mammography in improving survival from breast cancer for women through detection of early, asymptomatic disease. However, disparities in survival rates between black women and women from other racial and ethnic groups following breast cancer diagnosis persist. Various professional groups have different, somewhat conflicting, guidelines with regards to recommended age for commencing screening as well as recommended frequency of screening exams, but the trials upon which these recommendations are based were not specifically designed to examine benefit among black women. Furthermore, these recommendations do not appear to incorporate the unique epidemiological circumstances of breast cancer among black women, including higher rates of diagnosis before age 40 years and greater likelihood of advanced stage at diagnosis, into their formulation. In this review, we examined the epidemiologic and socioeconomic factors that are associated with breast cancer among black women and assess the implications of these factors for screening in this population. Specifically, we recommend that by no later than age 25 years, all black women should undergo baseline assessment for future risk of breast cancer utilizing a model that incorporates race (e.g., Breast Cancer Risk Assessment Tool [BCRAT], formerly the Gail model) and that this assessment should be conducted by a breast specialist or a healthcare provider (e.g., primary care physician or gynecologist) who is trained to assess breast cancer risk and is aware of the increased risks of early (i.e., premenopausal) and biologically aggressive (e.g., late-stage, triple-negative) breast cancer among black women.

An Assessment of the Predictive Performance of Current Machine Learning-Based Breast Cancer Risk Prediction Models: Systematic Review

BACKGROUND

Several studies have explored the predictive performance of machine learning-based breast cancer risk prediction models and have shown controversial conclusions. Thus, the performance of the current machine learning-based breast cancer risk prediction models and their benefits and weakness need to be evaluated for the future development of feasible and efficient risk prediction models.

OBJECTIVE

The aim of this review was to assess the performance and the clinical feasibility of the currently available machine learning-based breast cancer risk prediction models.

METHODS

We searched for papers published until June 9, 2021, on machine learning-based breast cancer risk prediction models in PubMed, Embase, and Web of Science. Studies describing the development or validation models for predicting future breast cancer risk were included. The Prediction Model Risk of Bias Assessment Tool (PROBAST) was used to assess the risk of bias and the clinical applicability of the included studies. The pooled area under the curve (AUC) was calculated using the DerSimonian and Laird random-effects model.

RESULTS

A total of 8 studies with 10 data sets were included. Neural network was the most common machine learning method for the development of breast cancer risk prediction models. The pooled AUC of the machine learning-based optimal risk prediction model reported in each study was 0.73 (95% CI 0.66-0.80; approximate 95% prediction interval 0.56-0.96), with a high level of heterogeneity between studies (Q=576.07, I²=98.44%; P<.001). The results of head-to-head comparison of the performance difference between the 2 types of models trained by the same data set showed that machine learning models had a slightly higher advantage than traditional risk factor-based models in predicting future breast cancer risk. The pooled AUC of the neural network-based risk prediction model was higher than that of the nonneural network-based optimal risk prediction model (0.71 vs 0.68, respectively). Subgroup analysis showed that the incorporation of imaging features in risk models resulted in a higher pooled AUC than the nonincorporation of imaging features in risk models (0.73 vs 0.61; P_{heterogeneity}=.001, respectively). The PROBAST analysis indicated that many machine learning models had high risk of bias and poorly reported calibration analysis.

CONCLUSIONS

Our review shows that the current machine learning-based breast cancer risk prediction models have some technical pitfalls and that their clinical feasibility and reliability are unsatisfactory.

Evaluation of Harms Reporting in U.S. Cancer Screening Guidelines

BACKGROUND

Cancer screening should be recommended only when the balance between benefits and harms is favorable. This review evaluated how U.S. cancer screening guidelines reported harms, within and across organ-specific processes to screen for cancer.

OBJECTIVE

To describe current reporting practices and identify opportunities for improvement.

DESIGN

Review of guidelines.

SETTING

United States.

PATIENTS

Patients eligible for screening for breast, cervical, colorectal, lung, or prostate cancer according to U.S. guidelines.

MEASUREMENTS

Information was abstracted on reporting of patient-level harms associated with screening, diagnostic follow-up, and treatment. The authors classified harms reporting as not mentioned, conceptual, qualitative, or quantitative and noted whether literature was cited when harms were described. Frequency of harms reporting was summarized by organ type.

RESULTS

Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines. Conceptualization of harms and use of quantitative evidence also differed by organ type.

LIMITATIONS

This review considers only patient-level harms. The authors did not verify accuracy of harms information presented in the guidelines.

CONCLUSION

The review identified opportunities for improving conceptualization, assessment, and reporting of screening process-related harms in guidelines. Future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. Improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Breast Cancer Screening: An Overview of Risk-specific Screening and Risk Assessment

Breast cancer screening decreases stage at diagnosis, treatment morbidity, and disease mortality. A comprehensive risk assessment is critical to determine an individual's most appropriate screening regimen. Multiple guidelines exist for screening mammography in average-risk individuals, which differ on age and frequency of screening. Annual mammography starting at age 40 is associated with the greatest reduction in breast cancer mortality and greatest number of life-years saved. A formal risk calculator is helpful to assess one's lifetime risk of breast cancer and assess eligibility for high-risk screening. Screening guidelines exist for genetic mutations that increase breast cancer risk.

Medicaid Expansion Associated With Reduction in Geospatial Breast Cancer Stage at Diagnosis Disparities

CONTEXT

Prior studies demonstrate that Medicaid expansion has been associated with earlier-stage breast cancer diagnosis among women with low income, likely through increased access to cancer screening services. However, how this policy change has impacted geospatial disparities in breast cancer stage at diagnosis is unclear.

OBJECTIVE

To examine whether there were reductions in geospatial disparities in advanced stage breast cancer at diagnosis in Ohio after Medicaid expansion.

DESIGN

The study included 33 537 women aged 40 to 64 years diagnosed with invasive breast cancer from the Ohio Cancer Incidence Surveillance System between 2010 and 2017. The space-time scan statistic was used to detect clusters of advanced stage at diagnosis before and after Medicaid expansion. Block group variables from the Census were used to describe the contextual characteristics of detected clusters.

RESULTS

The percentage of local stage diagnosis among women with breast cancer increased from 60.2% in the pre-expansion period (2010-2013) to 62.6% in the post-expansion period (2014-2017), while the uninsured rate among those women decreased from 13.7% to 7.5% during the same period. Two statistically significant ( P < .05) and 6 nonsignificant spatial clusters ( P > .05) of advanced stage breast cancer cases were found in the pre-expansion period, while none were found in the post-expansion period. These clusters were in the 4 largest metropolitan areas in Ohio, and individuals inside the clusters were more likely to be disadvantaged along numerous socioeconomic factors.

CONCLUSIONS

Medicaid expansion has played an important role in reducing geospatial disparities in breast cancer stage at diagnosis, likely through the reduction of advanced stage disease among women living in socioeconomically disadvantaged communities.

The impact of Angiopoietin-2 genetic polymorphisms on susceptibility for malignant breast neoplasms

Breast cancer causes morbidity and mortality among women worldwide, despite much research illuminating the genetic basis of this disease. Anti-angiogenesis therapies have been widely studied, although the association between angiopoietin-2 (ANGPT2) single nucleotide polymorphisms (SNPs) and breast cancer subtypes remains unclear. This case-control study included 464 patients with malignant breast neoplasms and 539 cancer-free females. We explored the effects of ANGPT2 SNPs on the susceptibility for a malignant breast neoplasm in a Chinese Han population. Five ANGPT2 SNPs (rs2442598, rs734701, rs1823375, 11,137,037, and rs12674822) were analyzed using TaqMan SNP genotyping. Carriers of the variant GG allele of rs1823375 were less likely than wild-type carriers to be diagnosed with clinically staged breast cancer, while females with human epidermal growth factor receptor 2 (HER2)-enriched disease carrying the CG or the CG+GG genotype at rs1823375 were significantly less likely than CC genotype carriers to be of lymph node status N1-N3. We also found that the T-T-C-A-T ANGPT2 haplotype significantly increased the risk for developing a malignant breast neoplasm by 1.385-fold (95% CI: 1.025-1.871; p < 0.05). Our study is the first to document a correlation between ANGPT2 polymorphisms and the development and progression of a malignant breast neoplasm in females of Chinese Han ethnicity.

Global guidelines for breast cancer screening: A systematic review

Objectives

Breast cancer screening guidelines could provide valuable tools for clinical decision making by reviewing the available evidence and providing recommendations. Little information is known about how many countries have issued breast cancer screening guidelines and the differences among existing guidelines. We systematically reviewed current guidelines and summarized corresponding recommendations, to provide references for good clinical practice in different countries.

Methods

Systematic searches of MEDLINE, EMBASE, Web of Science, and Scopus from inception to March 27th, 2021 were conducted and supplemented by reviewing the guideline development organizations. The quality of screening guidelines was assessed from six domains of the Appraisal of Guidelines for Research and Evaluation Ⅱ (AGREE Ⅱ) instrument by two appraisers. The basic information and recommendations of the issued guidelines were extracted and summarized.

Results

A total of 23 guidelines issued between 2010 and 2021 in 11 countries or regions were identified for further review. The content and quality varied across the guidelines. The average AGREE Ⅱ scores of the guidelines ranged from 33.3% to 87.5%. The highest domain score was "clarity of presentation" while the domain with the lowest score was "applicability". For average-risk women, most of the guidelines recommended mammographic screening for those aged 40–74 years, specifically, those aged 50–69 years were regarded as the optimal age group for screening. Nine of 23 guidelines recommended against an upper age limit for breast cancer screening. Mammography (MAM) was recommended as the primary screening modality for average-risk women by all included guidelines. Most guidelines suggested annual or biennial mammographic screening. Risk factors of breast cancer identified in the guidelines mainly fell within five categories which could be broadly summarized as the personal history of pre-cancerous lesions and/or breast cancer; the family history of breast cancer; the known genetic predisposition of breast cancer; the history of mantle or chest radiation therapy; and dense breasts. For women at higher risk, there was a consensus among most guidelines that annual MAM or annual magnetic resonance imaging (MRI) should be given, and the screening should begin earlier than the average-risk group.

Conclusions

The majority of 23 included international guidelines were issued by developed countries which contained roughly the same but not identical recommendations on breast cancer screening age, methods, and intervals. Most guidelines recommended annual or biennial mammographic screening between 40 and 74 years for average-risk populations and annual MAM or annual MRI starting from a younger age for high-risk populations. Current guidelines varied in quality and increased efforts are needed to improve the methodological quality of guidance documents. Due to lacking clinical practice guidelines tailored to different economic levels, low- and middle-income countries (LMICs) should apply and implement the evidence-based guidelines with higher AGREE Ⅱ scores considering local adaption.

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This systematic review comprehensively maps the recommendations of the latest international breast screening guidelines, providing valuable tools for clinical decision making in different settings.

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Most guidelines recommend annual or biennial mammographic screening between 40 and 74 years for the average-risk populations and annual MAM or annual MRI starting from a younger age for the high-risk populations. However, there are indeed discrepancies in screening age, methods, and intervals among countries.

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High-quality evidence and rigorous methodology are the keys to guidance development, but current guidelines vary in methodological quality.

Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA

BACKGROUND

After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources.

OBJECTIVE

To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening.

DESIGN

Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits.

PARTICIPANTS

Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543).

MAIN MEASURES

Cancer screening procedures were coded as low value using USPSTF age thresholds.

KEY RESULTS

Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians.

CONCLUSIONS

Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.

Pilot Study: Increasing Medical Student Comfort in Transgender Gynecology

Background: The purpose of this study was to use survey data to better understand medical students’ comfort in taking care of transgender patients and to determine whether this is an area that needs to be expanded upon in their curriculum.

Methods : Eight pre-clerkship medical students participated in a virtual two-week course about gynecologic transgender care which included a mix of self-paced learning combined with two days of interactive faculty-led sessions. Students were asked to complete a pre and post course survey evaluating their comfort in caring for transgender individuals. 

Results: We had an 100% response rate to our pre and post course survey. Students’ knowledge about the gynecologic needs of transgender individuals significantly improved after taking the course with the average student rating before and after the course being 2.38 ± 0.74 (p<0.05) and 4.25 ± 0.46 (p<0.05), respectively. In addition, 100% of students “agreed” or “strongly agreed” that this course built their confidence in taking care of transgender patients in the clinical setting.

Conclusions: This study highlights a potential gap in medical education while also emphasizing that knowledge on this special population can enhance physician confidence when caring for transgender individuals.