Breast cancer risk assessments comparing Gail and CARE models in African-American women

Impact of Affordable Care Act Provisions on the Racial Makeup of Patients Enrolled at a Deep South, High-Risk Breast Cancer Clinic

PURPOSE

Black women are less likely to receive screening mammograms, are more likely to develop breast cancer at an earlier age, and more likely to die from breast cancer when compared to White women. Affordable Care Act (ACA) provisions decreased cost sharing for women's preventive screening, potentially mitigating screening disparities. We examined enrollment of a high-risk screening program before and after ACA implementation stratified by race.

METHODS

This retrospective, quasi-experimental study examined the ACA's impact on patient demographics at a high-risk breast cancer screening clinic from 02/28/2003 to 02/28/2019. Patient demographic data were abstracted from electronic medical records and descriptively compared in the pre- and post-ACA time periods. Interrupted time series (ITS) analysis using Poisson regression assessed yearly clinic enrollment rates by race using incidence rate ratios (IRR) and 95% confidence intervals (CI).

RESULTS

Two thousand seven hundred and sixty-seven patients enrolled in the clinic. On average, patients were 46 years old (SD, ± 12), 82% were commercially insured, and 8% lived in a highly disadvantaged neighborhood. In ITS models accounting for trends over time, prior to ACA implementation, White patient enrollment was stable (IRR 1.01, 95% CI 1.00-1.02) while Black patient enrollment increased at 13% per year (IRR 1.13, 95% CI 1.05-1.22). Compared to the pre-ACA enrollment period, the post-ACA enrollment rate remained unchanged for White patients (IRR 0.99, 95% CI 0.97-1.01) but decreased by 17% per year for Black patients (IRR 0.83, 95% CI 0.74-0.92).

CONCLUSION

Black patient enrollment decreased at a high-risk breast cancer screening clinic post-ACA compared to the pre-ACA period, indicating a need to identify factors contributing to racial disparities in clinic enrollment.

Assessment of breast cancer risk among Iraqi women in 2019

Background

Breast cancer is one of the most common cancers among women worldwide and the leading cause of death among Iraqi women. Breast cancer cases in Iraq were found to have increased from 26.6/100,000 in 2000 to 31.5/100,000 in 2009. The present study aims to assess the established risk factors of breast cancer among Iraqi women and to highlight strategies that can aid in reducing the incidence.

Methods

1093 Iraqi females were enrolled in this cross-sectional study by purposive sampling methods. Data collection occurred from July 2019 to September 2019. 1500 women participated in the study, and 407 women were ultimately excluded. The questionnaire was conducted as a self-administrated form in an online survey. Ethical approval was obtained from the College of Medicine in the University of Baghdad. The Gail Model risk was calculated for each woman by the Breast Cancer Risk Assessment Tool (BCRAT), an interactive model developed by Mitchell Gail that was designed to estimate a woman’s absolute risk of developing breast cancer in the upcoming five years of her life and in her lifetime.

Results

The ages of the participants ranged from 35 to 84 years old. The mean 5–year risk of breast cancer was found to be 1.3, with 75.3% of women at low risk and 24.7% of women at high risk. The mean lifetime risk of breast cancer was found to be 13.4, with 64.7% of women at low risk, 30.3% at moderate risk, and 5.0% at high risk. The results show that geographically Baghdad presented the highest 5-year risk, followed by Dhi Qar, Maysan, and Nineveh. However, the highest lifetime risk was found in Najaf, followed by Dhi Qar, Baghdad, and Nineveh, successively.

Conclusion

Breast cancer is a wide-spreading problem in the world and particularly in Iraq, with Gail Model estimations of high risk in several governorates. Prevention programs need to be implemented and awareness campaigns organized in order to highlight the importance of early detection and treatment.

A Validated Risk Prediction Model for Breast Cancer in US Black Women

PURPOSE

Breast cancer risk prediction models are used to identify high-risk women for early detection, targeted interventions, and enrollment into prevention trials. We sought to develop and evaluate a risk prediction model for breast cancer in US Black women, suitable for use in primary care settings.

METHODS

Breast cancer relative risks and attributable risks were estimated using data from Black women in three US population-based case-control studies (3,468 breast cancer cases; 3,578 controls age 30-69 years) and combined with SEER age- and race-specific incidence rates, with incorporation of competing mortality, to develop an absolute risk model. The model was validated in prospective data among 51,798 participants of the Black Women's Health Study, including 1,515 who developed invasive breast cancer. A second risk prediction model was developed on the basis of estrogen receptor (ER)-specific relative risks and attributable risks. Model performance was assessed by calibration (expected/observed cases) and discriminatory accuracy (C-statistic).

RESULTS

The expected/observed ratio was 1.01 (95% CI, 0.95 to 1.07). Age-adjusted C-statistics were 0.58 (95% CI, 0.56 to 0.59) overall and 0.63 (95% CI, 0.58 to 0.68) among women younger than 40 years. These measures were almost identical in the model based on estrogen receptor-specific relative risks and attributable risks.

CONCLUSION

Discriminatory accuracy of the new model was similar to that of the most frequently used questionnaire-based breast cancer risk prediction models in White women, suggesting that effective risk stratification for Black women is now possible. This model may be especially valuable for risk stratification of young Black women, who are below the ages at which breast cancer screening is typically begun.

Performance of the IBIS/Tyrer-Cuzick model of breast cancer risk by race and ethnicity in the Women's Health Initiative

BACKGROUND

The IBIS/Tyrer-Cuzick model is used clinically to guide breast cancer screening and prevention, but was developed primarily in non-Hispanic White women. Little is known about its long-term performance in a racially/ethnically diverse population.

METHODS

The Women's Health Initiative study enrolled postmenopausal women from 1993-1998. Women were included who were aged <80 years at enrollment with no prior breast cancer or mastectomy and with data required for IBIS/Tyrer-Cuzick calculation (weight; height; ages at menarche, first birth, and menopause; menopausal hormone therapy use; and family history of breast or ovarian cancer). Calibration was assessed by the ratio of observed breast cancer cases to the number expected by the IBIS/Tyrer-Cuzick model (O/E; calculated as the sum of cumulative hazards). Differential discrimination was tested for by self-reported race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, Asian or Pacific Islander, and American Indian or Alaskan Native) using Cox regression. Exploratory analyses, including simulation of a protective single-nucleotide polymorphism (SNP), rs140068132 at 6q25, were performed.

RESULTS

During follow-up (median 18.9 years, maximum 23.4 years), 6783 breast cancer cases occurred among 90,967 women. IBIS/Tyrer-Cuzick was well calibrated overall (O/E ratio = 0.95; 95% CI, 0.93-0.97) and in most racial/ethnic groups, but overestimated risk for Hispanic women (O/E ratio = 0.75; 95% CI, 0.62-0.90). Discrimination did not differ by race/ethnicity. Exploratory simulation of the protective SNP suggested improved IBIS/Tyrer-Cuzick calibration for Hispanic women (O/E ratio = 0.80; 95% CI, 0.66-0.96).

CONCLUSIONS

The IBIS/Tyrer-Cuzick model is well calibrated for several racial/ethnic groups over 2 decades of follow-up. Studies that incorporate genetic and other risk factors, particularly among Hispanic women, are essential to improve breast cancer-risk prediction.

Inflammation markers on benign breast biopsy are associated with risk of invasive breast cancer in African American women

PURPOSE

Markers of inflammation, including crown-like structures of the breast (CLS-B) and infiltrating lymphocytes (IL), have been identified in breast tissue and associated with increased risk of breast cancer (BrCa), however most of this work has been performed in primarily non-Hispanic white women. Here, we examined whether CLS-B and IL are associated with invasive BrCa in African American (AA) women.

METHODS

We assessed breast biopsies from three 5-year age-matched groups: BrCa-free AA women (50 Volunteer) from the Komen Normal Tissue Bank (KTB) and AA women with a clinically-indicated biopsy diagnosed with benign breast disease (BBD) from our Detroit cohort who developed BrCa (55 BBD-cancer) or did not develop BrCa (47 BBD only, year of biopsy matched to BBD-cancer). Mean adipocyte diameter and total adipose area were estimated from digital images using the Adiposoft plugin from ImageJ. Associations between CLS-B, IL, and BrCa among KTB and Detroit biopsies were assessed using multivariable multinomial and conditional logistic regression models.

RESULTS

Among all biopsies, Volunteer and BBD only biopsies did not harbor CLS-B or IL at significantly different rates after adjusting for logarithm of adipocyte area, adipocyte diameter, and BMI. Among clinically-indicated BBD biopsies, BBD-cancer biopsies were more likely to exhibit CLS-B (odds ratio (OR) = 3.36, 95% Confidence Interval (CI): 1.33-8.48) or IL (OR = 4.95, 95% CI 1.76-13.9) than BBD only biopsies after adjusting for total adipocyte area, adipocyte diameter, proliferative disease, and BMI.

CONCLUSIONS

CLS-B and IL may serve as histological markers of BrCa risk in benign breast biopsies from AA women.

Assessment of the risk of developing breast cancer using the Gail model in Asian females: A systematic review

Introduction

Currently, the Breast Cancer Risk Assessment Tool (BCRAT), also known as the Gail model (GM) has been widely recognized and adapted for to study disparity in racial and ethnic groups in America including Asian and Pacific Islander American females. However, its applicability outside America remains uncertain due to diversity in epidemiology and risk factors of breast cancer in populations especially in Asian females. We sought to evaluate the performance of the GM to predict breast cancer risk in Asian countries.

Material and methods

This study identified articles published from 2010 by searching PubMed, MEDLINE, Scopus, Web of Science, Google Scholar and gray literature. The initial search terms were breast cancer, mammary, carcinoma, tumor, neoplasm, risk assessment tool, BCRAT, breast cancer prediction, Gail model, Asia, and Asian.

Results

The search yielded 20 articles, with 7 articles addressing the AUC and/or the expected (E) to observed (O) ratio of predicted breast cancer risk, representing the accuracy of the GM in the Asian population. One publication reported the sensitivity and specificity but no AUC. None of the studies were accepted as the standard for reporting prognostic models. Several studies reported good prognostic testing and likely developed a new model modifying the items in the instrument.

Conclusion

The results are not strong enough to develop breast cancer risk in the setting of Asian countries. Involving the breast cancer risk of the Asian population in developing a prognostic model with good statistical understanding is particularly important and can reduce flawed or biased models. Identifying the best methods to achieve well-suited prognostic models in the Asian population should be a priority.

Assessment of the Gail Model in Estimating the Risk of Breast Cancer: Effect of Cancer Worry and Risk in Healthy Women

Background: There has been substantial interest in developing methods to predict the risk of breast cancer. The Gail model is one the first model have been widely used to identify women at higher risk of breast cancer. Aim: This study aimed to determine the 5-year and the general life-time risk of breast cancer and also to determine breast cancer predictors in women using the Gail model. Methods: We used the Gail model to estimate the risk of breast cancer in female Turkish outpatients aged above 35 years in this cross-sectional study. Age, life-style habits, breast-feeding duration, family history of breast cancer, and body mass index were compared between high and low-risk subjects. We have performed the Patient Health Questionnaire 9-item (PHQ-9) and the Generalized Anxiety Disorder 7-item (GAD-7) tools on patients regarding depression and anxiety. We also assessed the association of these covariates with the estimated risk of breast cancer in multivariate linear regression analysis. Results: We enrolled 1065 subjects with a mean age of 52.9 ± 8.4 years. The mean of the five-year risk for breast cancer was 1.33%±0.6. Meanwhile, the mean of lifetime risks for breast cancer was 10.15%±3.18, respectively. Nearly one-third of the participants had one child, 55.9% had breast-fed their children more than six months. Meanwhile, 18.5% of the subjects had a high depression score, 15.2% had a high anxiety score. Higher age, age at first birth, and parity; lower age at menarche; presence of menopause and family history of breast cancer were higher in the high-risk group. Higher age, and age at first birth; lower age at menarche; family history of breast cancer, presence of menopause, and parity were independently associated with higher breast cancer risk. Conclusion: We identified certain risk factors for breast cancer in our study population and Gail model is a reliable and useful breast cancer risk prediction model for clinical decision-making. This study contributes to the body of evidence in order to facilitate early detection and better plan for possible malignancies in Turkish population.

Association of Combined Estrogen-Progestogen and Progestogen-Only Contraceptives with the Development of Cancer

Combined estrogen-progestogen contraceptives (oral contraceptives or OCs) and progestogen-only contraceptives (POCs) are synthetic steroids that bind to steroid hormone receptors, which are widespread throughout the body. They have a profound effect on cellular physiology. Combined OCs have been classified by the International Agency for Research on Cancer (IARC) as Group 1 carcinogens, but their findings have not been updated recently. In order to update the information and better understand the impact that OCs and POCs have on the risk of development of cancers, a comprehensive literature search was undertaken, focusing on more recently published papers. In agreement with the IARC, the recent literature confirms an increased risk of breast cancer and cervical cancer with the use of OCs. The recent literature also confirms the IARC conclusion that OCs decrease the risk of ovarian and endometrial cancers. However, there is little support from recent studies for the IARC conclusion that OCs decrease the risk of colorectal cancer or increase the risk of liver cancer. For liver cancer, this may be due to the recent studies having been performed in areas where hepatitis is endemic. In one large observational study, POCs also appear to increase the overall risk of developing cancer. OCs and POCs appear to increase the overall risk of cancer when carefully performed studies with the least intrinsic bias are considered.

Summary

OCs have been classified as cancer-causing agents, especially leading to increases in breast cancer and cervical cancer. A review of the recent scientific literature was performed to see whether this still appears to be the case. The recent literature supports the cancer-causing role of OCs especially for breast cancer and cervical cancer. Studies also indicate that progesterone-only contraceptives (such as implants and vaginal rings) also can cause cancer. This is especially true for breast cancer and cervical cancer.

Validation of a genetic risk score for Arkansas women of color

African American women in the state of Arkansas have high breast cancer mortality rates. Breast cancer risk assessment tools developed for African American underestimate breast cancer risk. Combining African American breast cancer associated single-nucleotide polymorphisms (SNPs) into breast cancer risk algorithms may improve individualized estimates of a woman's risk of developing breast cancer and enable improved recommendation of screening and chemoprevention for women at high risk. The goal of this study was to confirm with an independent dataset consisting of Arkansas women of color, whether a genetic risk score derived from common breast cancer susceptibility SNPs can be combined with a clinical risk estimate provided by the Breast Cancer Risk Assessment Tool (BCRAT) to produce a more accurate individualized breast cancer risk estimate. A population-based cohort of African American women representative of Arkansas consisted of 319 cases and 559 controls for this study. Five-year and lifetime risks from the BCRAT were measured and combined with a risk score based on 75 independent susceptibility SNPs in African American women. We used the odds ratio (OR) per adjusted standard deviation to evaluate the improvement in risk estimates produced by combining the polygenic risk score (PRS) with 5-year and lifetime risk scores estimated using BCRAT. For 5-year risk OR per standard deviation increased from 1.84 to 2.08 with the addition of the polygenic risk score and from 1.79 to 2.07 for the lifetime risk score. Reclassification analysis indicated that 13% of cases had their 5-year risk increased above the 1.66% guideline threshold (NRI = 0.020 (95% CI -0.040, 0.080)) and 6.3% of cases had their lifetime risk increased above the 20% guideline threshold by the addition of the polygenic risk score (NRI = 0.034 (95% CI 0.000, 0.070)). Our data confirmed that discriminatory accuracy of BCRAT is improved for African American women in Arkansas with the inclusion of specific SNP breast cancer risk alleles.

Effect of exercise on metabolic syndrome in black women by family history and predicted risk of breast cancer: The FIERCE Study

BACKGROUND

This study examined the effects of supervised and home-based exercise interventions on changes in metabolic syndrome (MetS) according to breast cancer risk (high vs low) in black women enrolled in the Focused Intervention on Exercise to Reduce Cancer (FIERCE) trial.

METHODS

Postmenopausal, obese, metabolically unhealthy black women, 45 to 65 years old, were randomized to supervised aerobic exercise (73 women), home-based walking-based exercise (69 women), or a control arm (71 women). Participants in the exercise arms underwent a 6-month intervention with study assessments conducted at the baseline and 6 months. The primary outcome measure was MetS (fasting glucose, waist circumference, blood pressure, serum triglycerides, and high-density lipoprotein [HDL]). The intervention effects on MetS, stratified by breast cancer risk as measured by the family history of breast cancer and model-based projected breast cancer risk, were examined with intent-to-treat analyses using generalized estimating equation models.

RESULTS

Among women with a family history of breast cancer, the exercise arms had lower mean MetS z scores, which suggested an improvement in the metabolic profile, than controls at 6 months (controls, + 0.55; home-based arm, -0.97, P < .01; supervised arm, -0.89, P < .01). Stratified analyses by projected breast cancer risk suggested similar but statistically nonsignificant findings, with those at high risk having more favorable changes in the MetS z score in the exercise arms versus the control arm. These changes were primarily attributable to changes in blood pressure, triglycerides, and HDL.

CONCLUSIONS

Short-term aerobic activity regimens may improve the metabolic profile and thereby reduce breast cancer risk in obese, metabolically unhealthy black women at high risk for cancer. © 2018 American Cancer Society.

Evaluation of 2 breast cancer risk models in a benign breast disease cohort

BACKGROUND

More than 1.5 million women per year have a benign breast biopsy resulting in concern about their future breast cancer (BC) risk. This study examined the performance of 2 BC risk models that integrate clinical and histologic findings in this population.

METHODS

The BC risk at 5 and 10 years was estimated with the Breast Cancer Surveillance Consortium (BCSC) and Benign Breast Disease to Breast Cancer (BBD-BC) models for women diagnosed with benign breast disease (BBD) at the Mayo Clinic from 1997 to 2001. Women with BBD were eligible for the BBD-BC model, but the BCSC model also required a screening mammogram. Calibration and discrimination were assessed.

RESULTS

Fifty-six cases of BC were diagnosed among the 2142 women with BBD (median age, 50 years) within 5 years (118 were diagnosed within 10 years). The BBD-BC model had slightly better calibration at 5 years (0.89; 95% confidence interval [CI], 0.71-1.21) versus 10 years (0.81; 95% CI, 0.70-1.00) but similar discrimination in the 2 time periods: 0.68 (95% CI, 0.60-0.75) and 0.66 (95% CI, 0.60-0.71), respectively. In contrast, among the 1089 women with screening mammograms (98 cases of BC within 10 years), the BCSC model had better calibration (0.94; 95% CI, 0.85-1.43) and discrimination (0.63; 95% CI, 0.56-0.71) at 10 years versus 5 years (calibration, 1.31; 95% CI, 0.94-2.25; discrimination, 0.59; 95% CI, 0.46-0.71) where discrimination was not different from chance.

CONCLUSIONS

The BCSC and BBD-BC models were validated in the Mayo BBD cohort, although their performance differed by 5-year risk versus 10-year risk. Further enhancement of these models is needed to provide accurate BC risk estimates for women with BBD.

Assessing Breast Cancer Risk Estimates Based on the Gail Model and Its Predictors in Qatari Women

Background: The Gail model is the most widely used breast cancer risk assessment tool. An accurate assessment of individual’s breast cancer risk is very important for prevention of the disease and for the health care providers to make decision on taking chemoprevention for high-risk women in clinical practice in Qatar. Aim: To assess the breast cancer risk among Arab women population in Qatar using the Gail model and provide a global comparison of risk assessment. Subjects and Methods: In this cross-sectional study of 1488 women (aged 35 years and older), we used the Gail Risk Assessment Tool to assess the risk of developing breast cancer. Sociodemographic features such as age, lifestyle habits, body mass index, breast-feeding duration, consanguinity among parents, and family history of breast cancer were considered as possible risks. Results: The mean age of the study population was 47.8 ± 10.8 years. Qatari women and Arab women constituted 64.7% and 35.3% of the study population, respectively. The mean 5-year and lifetime breast cancer risks were 1.12 ± 0.52 and 10.57 ± 3.1, respectively. Consanguineous marriage among parents was seen in 30.6% of participants. We found a relationship between the 5-year and lifetime risks of breast cancer and variables such as age, age at menarche, gravidity, parity, body mass index, family history of cancer, menopause age, occupation, and level of education. The linear regression analysis identified the predictors for breast cancer in women such as age, age at menarche, age of first birth, family history and age of menopausal were considered the strong predictors and significant contributing risk factors for breast cancer after adjusting for ethnicity, parity and other variables. Conclusion: The current study is the first to evaluate the performance of the Gail model for Arab women population in the Gulf Cooperation Council. Gail model is an appropriate breast cancer risk assessment tool for female population in Qatar.

SNPs and breast cancer risk prediction for African American and Hispanic women

For African American or Hispanic women, the extent to which clinical breast cancer risk prediction models are improved by including information on susceptibility single nucleotide polymorphisms (SNPs) is unknown, even though these women comprise increasing proportions of the US population and represent a large proportion of the world’s population. We studied 7539 African American and 3363 Hispanic women from the Women’s Health Initiative. The age-adjusted 5-year risks from the BCRAT and IBIS risk prediction models were measured and combined with a risk score based on >70 independent susceptibility SNPs. Logistic regression, adjusting for age group, was used to estimate risk associations with log-transformed age-adjusted 5-year risks. Discrimination was measured by the odds ratio (OR) per standard deviation (SD) and the area under the receiver operator curve (AUC). When considered alone, the ORs for African American women were 1.28 for BCRAT, and 1.04 for IBIS. When combined with the SNP risk score (OR 1.23), the corresponding ORs were 1.39 and 1.22. For Hispanic women the corresponding ORs were 1.25 for BCRAT, and 1.15 for IBIS. When combined with the SNP risk score (OR 1.39), the corresponding ORs were 1.48 and 1.42. There was no evidence that any of the combined models were not well calibrated. Including information on known breast cancer susceptibility loci provides approximately 10 and 19 % improvement in risk prediction using BCRAT for African Americans and Hispanics, respectively. The corresponding figures for IBIS are approximately 18 and 26 %, respectively.

An exercise trial targeting African-American women with metabolic syndrome and at high risk for breast cancer: Rationale, design, and methods

BACKGROUND

Metabolic syndrome and obesity are known risk factors for breast cancers. Exercise interventions can potentially modify circulating biomarkers of breast cancer risk but evidence in African-Americans and women with metabolic syndrome is lacking.

METHODS/DESIGN

The Focused Intervention on Exercise to Reduce CancEr (FIERCE) trial is a prospective, 6-month, 3-arm, randomized controlled trial to examine the effect of exercise on obesity, metabolic syndrome components, and breast cancer biomarkers among African-American women at high risk of breast cancer. Two hundred-forty inactive women with metabolic syndrome and absolute risk of breast cancer ≥ 1.40 will be randomized to one of the three trial arms: 1) a supervised, facility-based exercise arm; 2) a home-based exercise arm; and 3) a control group that maintains physical activity levels through the course of the trial. Assessments will be conducted at baseline, 3 months, and 6 months. The primary outcome variables are anthropometric indicators of obesity, metabolic syndrome components, and inflammatory, insulin-pathway, and hormonal biomarkers of breast cancer risk.

DISCUSSION

The FIERCE trial will provide evidence on whether a short-term exercise intervention might be effective in reducing breast cancer risk among African-American women with comorbidities and high breast cancer risk--a group traditionally under-represented in non-therapeutic breast cancer trials.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02103140.

Prospective approach to breast cancer risk prediction in African American women: the black women's health study model

PURPOSE

Breast cancer risk prediction models have underestimated risk for African American women, contributing to lower recruitment rates in prevention trials. A model previously developed for African American women was found to underestimate risk in the Black Women's Health Study (BWHS).

METHODS

We developed a breast cancer risk model for African American women using relative risks derived from 10 years of follow-up of BWHS participants age 30 to 69 years at baseline. Using the subsequent 5 years of follow-up data, we evaluated calibration as the ratio of expected to observed number of breast cancers and assessed discriminatory accuracy using the concordance statistic.

RESULTS

The BWHS model included family history, previous biopsy, body mass index at age 18 years, age at menarche, age at first birth, oral contraceptive use, bilateral oophorectomy, estrogen plus progestin use, and height. There was good agreement between predicted and observed number of breast cancers overall (expected-to-observed ratio, 0.96; 95% CI, 0.88 to 1.05) and in most risk factor categories. Discriminatory accuracy was higher for women younger than age 50 years (area under the curve [AUC], 0.62; 95% CI, 0.58 to 0.65) than for women age ≥ 50 years (AUC, 0.56; 95% CI, 0.53 to 0.59). Using a 5-year predicted risk of 1.66% or greater as a cut point, 2.8% of women younger than 50 years old and 32.2% of women ≥ 50 years old were classified as being at elevated risk of invasive breast cancer.

CONCLUSION

The BWHS model was well calibrated overall, and the predictive ability was best for younger women. The proportion of women predicted to meet the 1.66% cut point commonly used to determine eligibility for breast cancer prevention trials was greatly increased relative to previous models.

Breast cancer risk and early diagnosis applications in Turkish women aged 50 and over

BACKGROUND

The aim of the study was to determine breast cancer risk and early diagnosis applications in women aged ≥50.

MATERIALS AND METHODS

This cross-sectional, descriptive field study focused on a population of 4,815 in Mansurog?lu with a 55.1% participation rate in screening. In the study, body mass index (BMI) was also evaluated in the calculation of breast cancer risk by the Breast Cancer Risk Assessment Tool (BCRA) (also called the "Gail Risk Assessment Tool") . The interviewers had a three-hour training provided by the researchers, during which interactive training methods were used and applications were supported with role-plays.

RESULTS

The mean age of the women participating in the study was 60.1±8.80. Of these women, 57.3% were in the 50-59 age group, 71.7% were married, 57.3% were primary school graduates and 61.7% were housewives. Breast-cancer development rate was 7.4% in the women participating in the study. When they were evaluated according to their relationship with those with breast cancer, it was determined that 73.0% of them had first- degree relatives with breast cancer. According to the assessment based on the Gail method, the women's breast cancer development risk within the next 5 years was 17.6%, whereas their calculated lifetime risk was found to be as low as 0.2%. Statistically significant differences (P=0.000) were determined between performing BSE - CBE and socio-demographic factors.

CONCLUSIONS

It was determined that 17.6% of the participants had breast cancer risk. There was no statistically significant difference between the women with and without breast cancer risk in terms of early diagnosis practices, which can be regarded as a remarkable finding. It was planned to provide training about the early diagnosis and treatment of breast cancer for people with high-risk scores, and to conduct population-based breast cancer screening programs.

Personalized medicine and access to health care: potential for inequitable access?

Personalized medicine promises that an individual's genetic information will be increasingly used to prioritize access to health care. Use of genetic information to inform medical decision making, however, raises questions as to whether such use could be inequitable. Using breast cancer genetic risk prediction models as an example, on the surface clinical use of genetic information is consistent with the tools provided by evidence-based medicine, representing a means to equitably distribute limited health-care resources. However, at present, given limitations inherent to the tools themselves, and the mechanisms surrounding their implementation, it becomes clear that reliance on an individual's genetic information as part of medical decision making could serve as a vehicle through which disparities are perpetuated under public and private health-care delivery models. The potential for inequities arising from using genetic information to determine access to health care has been rarely discussed. Yet, it raises legal and ethical questions distinct from those raised surrounding genetic discrimination in employment or access to private insurance. Given the increasing role personalized medicine is forecast to play in the provision of health care, addressing a broader view of what constitutes genetic discrimination, one that occurs along a continuum and includes inequitable access, will be needed during the implementation of new applications based on individual genetic profiles. Only by anticipating and addressing the potential for inequitable access to health care occurring from using genetic information will we move closer to realizing the goal of personalized medicine: to improve the health of individuals.

National Surgical Adjuvant Breast and Bowel Project Study of Tamoxifen and Raloxifene trial: advancing the science of recruitment and breast cancer risk assessment in minority communities

BACKGROUND

One of the first chemoprevention trials conducted in the western hemisphere, the National Surgical Adjuvant Breast and Bowel Project's (NSABP) Breast Cancer Prevention Trial (BCPT), demonstrated the need to evaluate all aspects of recruitment in real time and to implement strategies to enroll racial and ethnic minority women.

PURPOSE

The purpose of this report is to review various patient recruitment efforts the NSABP developed to enhance the participation of racial and ethnic minority women in the Study of Tamoxifen and Raloxifene (STAR) trial and to describe the role that the recruitment process played in the implementation and understanding of breast cancer risk assessment in minority communities.

METHODS

The NSABP STAR trial was a randomized, double-blinded study comparing the use of tamoxifen 20 mg/day to raloxifene 60 mg/day, for a 5-year period, to reduce the risk of developing invasive breast cancer. Eligible postmenopausal women were required to have a 5-year predicted breast cancer risk of 1.66% based on the modified Gail Model. For the current report, eligibility and enrollment data were tabulated by race/ethnicity for women who submitted STAR risk assessment forms (RAFs).

RESULTS

A total of 184,460 RAFs were received, 145,550 (78.9%) from white women and 38,910 (21.1%) from minority women. Of the latter group, 21,444 (11.6%) were from African Americans/blacks, 7913 (4.5%) from Hispanics/Latinas, and 9553 (5.2%) from other racial or ethnic groups. The percentages of risk-eligible women among African Americans, Hispanics/Latinas, others, and whites were 14.2%, 23.3%, 13.7%, and 57.4%, respectively. Programs targeting minority enrollment submitted large numbers of RAFs, but the eligibility rates of the women referred from those groups tended to be lower than the rates among women referred outside of those programs. The average number of completed risk assessments increased among minority women over the course of the recruitment period compared to those from whites.

LIMITATIONS

We have not addressed all identified barriers to the recruitment of minorities in clinical research. Our risk assessments and recruitment results do not reflect the modified Gail Model for African Americans.

CONCLUSIONS

Recruitment strategies used in STAR for racial and ethnic minorities contributed to doubling the minority enrollment compared to that in the BCPT and increased the awareness of breast cancer risk assessment in minority communities. Incorporation of new information into models to improve the risk estimation of diverse populations should prove beneficial.

Cancer risk models and preselection for screening

OBJECTIVE

The invitation to population screening is based on age criteria in many countries. Screening is not offered to younger or older participants, because the benefits in these age groups do not outweigh the harms. One could argue that it is not so much age that determines the benefits but the risk of developing preclinical and treatable cancer. Cancer risk varies with age but is also affected by other factors.

METHODS

We performed a systematic review for risk models for the three types of cancer for which population screening programs exist: breast, cervical and colon cancer. We used an evaluation scheme that distinguishes three phases of model development: model derivation, validation and impact analysis. Data were collected in August 2010.

RESULTS

We identified two colorectal, four breast and three cervix cancer risk models. One colorectal, four breast and none of the cervix cancer models have been externally validated. We could not identify evaluations of the impact on population screening effectiveness.

CONCLUSION

We conclude that risk models for the pre-selection of screening have been developed. These models could improve the pre-selection for screening, help in making personal decisions about participation, and reduce adverse effects of population screening. The validity of this hypothesis, as well as practicalities and issues of equity and reliability, have to be tested in further studies.

Correlates of unrealistic risk beliefs in a nationally representative sample

Unrealistically optimistic or pessimistic risk perceptions may be associated with maladaptive health behaviors. This study characterized factors associated with unrealistic optimism (UO) and unrealistic pessimism (UP) about breast cancer. Data from the 2005 National Health Interview Survey were analyzed (N = 14,426 women). After accounting for objective risk status, many (43.8%) women displayed UO, 12.3% displayed UP, 34.5% had accurate risk perceptions (their perceived risk matched their calculated risk), and 9.5% indicated "don't know/no response." Multivariate multinomial logistic regression indicated that UO was associated with higher education and never smoking. UP was associated with lower education, lower income, being non-Hispanic Black, having ≥3 comorbidities, current smoking, and being overweight. UO was more likely to emerge in younger and older than in middle-aged individuals. UO and UP are associated with different demographic, health, and behavioral characteristics. Population segments that are already vulnerable to negative health outcomes displayed more UP than less vulnerable populations.

A review of body size and breast cancer risk in Hispanic and African American women

Obesity is an epidemic in the United States, especially among Hispanics and African Americans. Studies of obesity and breast cancer risk have been conducted primarily in non-Hispanic whites. There have been few studies of the association between body mass index (BMI) or weight gain and the risk of breast cancer in minorities, and the results have been inconsistent. Because most studies are conducted primarily in non-Hispanic whites, the etiology of breast cancer in minorities is not well understood. The authors of the current report reviewed the literature on the association between obesity, weight, and weight gain and breast cancer in minorities using a combination of the Medical Subject Heading (MeSH) terms "obesity," "body mass index," "weight," "weight gain," "Hispanic," and "African American." Only publications in English and with both risk estimates and 95% confidence intervals were considered. Forty-five studies of body size and breast cancer risk in non-Hispanic whites were identified. After an exhaustive search of the literature, only 3 studies of body size and breast cancer were conducted in Hispanic women were identified, and only 8 such studies in African American women were identified. The results were inconsistent in both race/ethnicity groups, with studies reporting positive, inverse, and null results. Thus, as obesity rates among Hispanics and African Americans continue to rise, there is an urgent need to identify the roles that both obesity and adult weight gain play in the development of breast cancer in these minorities. Additional studies are needed to provide more understanding of the etiology of this disease and to explain some of the disparities in incidence and mortality.