Five-year and lifetime risk of breast cancer among U.S. subpopulations: implications for magnetic resonance imaging screening

Distribution of Estimated Lifetime Breast Cancer Risk Among Women Undergoing Screening Mammography

OBJECTIVE. Supplemental screening breast MRI is recommended for women with an estimated lifetime risk of breast cancer of greater than 20-25%. The performance of risk prediction models varies for each individual and across groups of women. The present study investigates the concordance of three breast cancer risk prediction models among women presenting for screening mammography. SUBJECTS AND METHODS. In this prospective study, we calculated the estimated lifetime risk of breast cancer using the modified Gail, Tyrer-Cuzick version 7, and BRCAPRO models for each woman who presented for screening mammography. Per American Cancer Society guidelines, for each woman the risk was categorized as less than 20% or 20% or greater as well as less than 25% or 25% or greater with use of each model. Venn diagrams were constructed to evaluate concordance across models. The McNemar test was used to test differences in risk group allocations between models, with p ≤ .05 considered to denote statistical significance. RESULTS. Of 3503 screening mammography patients who underwent risk stratification, 3219 (91.9%) were eligible for risk estimation using all three models. Using at least one model, 440 (13.7%) women had a lifetime risk of 20% or greater, including 390 women (12.1%) according to the Tyrer-Cuzick version 7 model, 18 (0.6%) according to the BRCAPRO model, and 141 (4.4%) according to the modified Gail model. Six women (0.2%) had a risk of 20% or greater according to all three models. Women were significantly more likely to be classified as having a high lifetime breast cancer risk by the Tyrer-Cuzick version 7 model compared with the modified Gail model, with thresholds of 20% or greater (odds ratio, 6.4; 95% CI, 4.7-8.7) or 25% or greater (odds ratio, 7.4; 95% CI, 4.7-11.9) used for both models. CONCLUSION. To identify women with a high lifetime breast cancer risk, practices should use estimates of lifetime breast cancer risk derived from multiple risk prediction models.

COVID-19: Safe Guidelines for Breast Imaging During the Pandemic

During the COVID-19 pandemic, breast imaging must be performed using safe practices. Balancing the need to avoid delays in the diagnosis of breast cancer while avoiding infection requires careful attention to personal protective equipment and physical distancing and vigilance to maintain these practices. The Canadian Society of Breast Imaging/Canadian Association of Radiologists guideline for breast imaging during COVID-19 is provided based on priority according to risk of breast cancer and impact of delaying treatment. A review of the best practices is presented that allow breast imaging during COVID-19 to maximize protection of patients, technologists, residents, fellows, and radiologists and minimize spread of the infection. The collateral damage of delaying diagnosis of breast cancer due to COVID-19 should be avoided when possible.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening

Each year, the American Cancer Society publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, the current American Cancer Society cancer screening guidelines are summarized, and the most current data from the National Health Interview Survey are provided on the utilization of cancer screening for men and women and on the adherence of men and women to multiple recommended screening tests.

The Sister Study Cohort: Baseline Methods and Participant Characteristics

BACKGROUND

The Sister Study was designed to address gaps in the study of environment and breast cancer by taking advantage of more frequent breast cancer diagnoses among women with a sister history of breast cancer and the presumed enrichment of shared environmental and genetic exposures.

OBJECTIVE

The Sister Study sought a large cohort of women never diagnosed with breast cancer but who had a sister (full or half) diagnosed with breast cancer.

METHODS

A multifaceted national effort employed novel strategies to recruit a diverse cohort, and collected biological and environmental samples and extensive data on potential breast cancer risk factors.

RESULTS

The Sister Study enrolled 50,884 U.S. and Puerto Rican women 35-74y of age (median 56 y). Although the majority were non-Hispanic white, well educated, and economically well off, substantial numbers of harder-to-recruit women also enrolled (race/ethnicity other than non-Hispanic white: 16%; no college degree: 35%; household income <$50,000: 26%). Although all had a biologic sister with breast cancer, 16.5% had average or lower risk of breast cancer according to the Breast Cancer Risk Assessment Tool (Gail score). Most were postmenopausal (66%), parous with a first full-term pregnancy <30y of age (79%), never-smokers (56%) with body mass indexes (BMIs) of <29.9kg/m² (70%). Few (5%) reported any cancer prior to enrollment.

CONCLUSIONS

The Sister Study is a unique cohort designed to efficiently study environmental and genetic risk factors for breast cancer. Extensive exposure data over the life-course and baseline specimens provide important opportunities for studying breast cancer and other health outcomes in women. Collaborations are welcome. https://doi.org/10.1289/EHP1923.

Using an Internet-Based Breast Cancer Risk Assessment Tool to Improve Social-Cognitive Precursors of Physical Activity

BACKGROUND

Internet-based cancer risk assessment tools might serve as a strategy for translating epidemiological risk prediction research into public health practice. Understanding how such tools affect key social-cognitive precursors of behavior change is crucial for leveraging their potential into effective interventions.

PURPOSE

To test the effects of a publicly available, Internet-based, breast cancer risk assessment tool on social-cognitive precursors of physical activity.

METHODS

Women (N = 132) aged 40-78 with no personal cancer history indicated their perceived risk of breast cancer and were randomly assigned to receive personalized ( www.yourdiseaserisk.wustl.edu ) or nonpersonalized breast cancer risk information. Immediately thereafter, breast cancer risk perceptions and physical activity-related behavioral intentions, self-efficacy, and response efficacy were assessed.

RESULTS

Personalized information elicited higher intentions, self-efficacy, and response efficacy than nonpersonalized information, P values < 0.05. Self-efficacy and response efficacy mediated the effect of personalizing information on intentions. Women who received personalized information corrected their inaccurate risk perceptions to some extent, P values < 0.05, but few fully accepted the information.

CONCLUSION

Internet-based risk assessment tools can produce beneficial effects on important social-cognitive precursors of behavior change, but lingering skepticism, possibly due to defensive processing, needs to be addressed before the effects can be maximized.

Travel Burden to Breast MRI and Utilization: Are Risk and Sociodemographics Related?

PURPOSE

Mammography, unlike MRI, is relatively geographically accessible. Additional travel time is often required to access breast MRI. However, the amount of additional travel time and whether it varies on the basis of sociodemographic or breast cancer risk factors is unknown.

METHODS

The investigators examined screening mammography and MRI between 2005 and 2012 in the Breast Cancer Surveillance Consortium by (1) travel time to the closest and actual mammography facility used and the difference between the two, (2) women's breast cancer risk factors, and (3) sociodemographic characteristics. Logistic regression was used to examine the odds of traveling farther than the closest facility in relation to women's characteristics.

RESULTS

Among 821,683 screening mammographic examinations, 76.6% occurred at the closest facility, compared with 51.9% of screening MRI studies (n = 3,687). The median differential travel time among women not using the closest facility for mammography was 14 min (interquartile range, 8-25 min) versus 20 min (interquartile range, 11-40 min) for breast MRI. Differential travel time for both imaging modalities did not vary notably by breast cancer risk factors but was significantly longer for nonurban residents. For non-Hispanic black compared with non-Hispanic white women, the adjusted odds of traveling farther than the closest facility were 9% lower for mammography (odds ratio, 0.91; 95% confidence interval, 0.87-0.95) but more than two times higher for MRI (odds ratio, 2.64; 95% confidence interval, 1.36-5.13).

CONCLUSIONS

Breast cancer risk factors were not related to excess travel time for screening MRI, but sociodemographic factors were, suggesting the possibility that geographic distribution of advanced imaging may exacerbated disparities for some vulnerable populations.

The role of dynamic contrast-enhanced screening breast MRI in populations at increased risk for breast cancer

Breast MRI is more sensitive than mammography in detecting breast cancer. However, MRI as a screening tool is limited to high-risk patients due to cost, low specificity and insufficient evidence for its use in intermediate-risk populations. Nonetheless, in the past decade, there has been a dramatic increase in the use of breast-screening MRI in the community setting. In this review, we set to describe the current literature on the use of screening MRI in high- and intermediate-risk populations. We will also describe novel applications of breast MRI including abbreviated breast MRI protocols, background parenchymal enhancement and diffusion-weighted imaging.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Breast cancer risk scores in a standard screening population

SUMMARY Aim: Information regarding the characteristics and breast cancer risk factors of British women in the standard population attending breast cancer screening is limited. Such information could be useful in personalizing screening and care, and informing and educating women about their risk. Materials & methods: Information about various breast cancer risk factors was obtained from 355 women aged between 46 and 74 years at a UK inner-city breast cancer screening clinic using questionnaires. The risk of breast cancer was calculated using the modified Gail model and analyzed using descriptive and regression statistics. Results: There were 26 women recalled for further assessment and two cases confirmed as invasive breast cancer. Forty-seven women reported first-degree relatives with breast cancer. A total of 58% of our sample was overweight or obese, although 84% reported meeting the recommended target of ≥150 min of exercise per week. A total of 44% were smokers and 23% reported consuming alcohol on a regular basis. The mean lifetime risk score was 9.0% and the mean 5-year risk score was 1.5%. Various non-Gail model risk factors were found to be correlated with risk scores, but the only factor that was significantly different between women recalled for further assessment and those who were not was age of menarche. Conclusion: The results suggest that determining risk factor data in a standard screening population could be useful both to the women, who may have modifiable lifestyle factors that can be changed to improve their risk, and to the clinics, which can identify women at a higher risk who may be unaware and not present themselves as candidates for risk assessment.

Evaluation of quality of life of breast cancer patient next- of-kin in Turkey

INTRODUCTION

Quality of life (QoL) issues are of importance in relatives of women with breast cancer (BC)as caregivers in neglecting their own needs due to care of a patient and also as women regarding the potential risk of themselves developing BC. The objectives in the present study were to compare the QoL of female relatives of women in treatment for breast cancer. To date, no study had examined multi-dimensional QoL in accompanying people as compared them into two groups of female relatives whose first degree and second degree.

METHODS

QoL of female relatives was assessed using the Quality of Life-Family Version (QOL-FV) scale. Relationships between socio-demographic characteristics and QoL scores were analyzed using the Mann-Whitney U, Kruskal Wallis and Crosstabs tests.

RESULTS

The mean age of the female relatives was 37.6 years, and nearly 48% had a university education. It was found that first degree relatives had worse QoL in all domains except physical well- being than second degree relatives.

CONCLUSION

This study showed that being female relatives of BC, especially first-degree, affect QoL negatively. Health care providers are of an important role in the stage of information related to genetic influence of BC.

Results from a randomized trial of a web-based, tailored decision aid for women at high risk for breast cancer

OBJECTIVE

To assess the impact of Guide to Decide (GtD), a web-based, personally-tailored decision aid designed to inform women's decisions about prophylactic tamoxifen and raloxifene use.

METHODS

Postmenopausal women, age 46-74, with BCRAT 5-year risk ≥ 1.66% and no prior history of breast cancer were randomized to one of three study arms:intervention (n=690), Time 1 control (n=160), or 3-month control (n=162). Intervention participants viewed GtD prior to completing a post-test and 3 month follow-up assessment. Controls did not. We assessed the impact of GtD on women's decisional conflict levels and treatment decision behavior at post-test and at 3 months, respectively.

RESULTS

Intervention participants had significantly lower decisional conflict levels at post-test (p<0.001) and significantly higher odds of making a decision about whether or not to take prophylactic tamoxifen or raloxifene at 3-month follow-up (p<0.001) compared to control participants.

CONCLUSION

GtD lowered decisional conflict and helped women at high risk of breast cancer decide whether to take prophylactic tamoxifen or raloxifene to reduce their cancer risk.

PRACTICE IMPLICATIONS

Web-based, tailored decision aids should be used more routinely to facilitate informed medical decisions, reduce patients' decisional conflict, and empower patients to choose the treatment strategy that best reflects their own values.

The risk of developing invasive breast cancer in Hispanic women : a look across Hispanic subgroups

BACKGROUND

Current evidence on breast cancer among US Hispanic women indicates a significant public health threat, although few studies have assessed the heterogeneity in breast cancer risk among Hispanics of different origin.

METHODS

The 2000 and 2005 National Health Interview Survey Cancer Control Modules were used to examine the Breast Cancer Risk Assessment Tool (BCRAT) 5-year risk and lifetime risk of invasive breast cancer among Mexican/Mexican American, Puerto Rican, Cuban/Cuban American, Dominican (Republic), Central/South American, Other Hispanic, and non-Hispanic white (NHW) women ages 35 to 84 years. Multiple linear regression models were used to compare the BCRAT 5-year and lifetime breast cancer risk between 1) Hispanics and NHWs and 2) Hispanic subgroups.

RESULTS

Hispanic women had significantly lower mean BCRAT 5-year and lifetime breast cancer risk compared with NHW women (P < .001). Among Hispanic subgroups, Cuban/Cuban Americans had a higher BCRAT 5-year risk (P < .05), whereas Dominicans had a higher lifetime risk (P < .001) compared with Mexican/Mexican Americans. Approximately 2.6% of Hispanic women were at high risk for breast cancer (BCRAT 5-year risk ≥1.67%), ranging from 1% of Central/South Americans to 3.7% of Puerto Ricans; few Hispanics (0.2%) had a lifetime risk ≥20%.

CONCLUSIONS

The current findings indicate that Hispanic women have a significantly lower risk of breast cancer compared with NHW women, although the risk according to BCRAT differed significantly between specific Hispanic subgroups. We provide estimates of the number of US Hispanic women from six subgroups who may be eligible for prophylactic breast cancer chemoprevention. The authors concluded that future studies should further investigate the heterogeneity in breast cancer risk and risk factors between Hispanic women of different origins.

Breast MRI use uncommon among U.S. women

BACKGROUND

The goal of breast cancer screening is to reduce breast cancer mortality. Mammography is the standard screening method for detecting breast cancer early. Breast MRI is recommended to be used in conjunction with mammography for screening subsets of women at high risk for breast cancer. We offer the first study to provide national estimates of breast MRI use among women in the United States.

METHODS

We analyzed data from women who responded to questions about having a breast MRI on the 2010 National Health Interview Survey. We assessed report of having a breast MRI and reasons for it by sociodemographic characteristics and access to health care and computed five-year and lifetime breast cancer risk using the Gail model.

RESULTS

Among 11,222 women who responded, almost 5% reported ever having a breast MRI and 2% reported having an MRI within the 2 years preceding the survey. Less than half of the women who reported having a breast MRI were at increased risk. Approximately 60% of women reported having the breast MRI for diagnostic reasons. Women who ever had a breast MRI were more likely to be older, Black, and insured and to report a usual source of health care as compared with women who reported no MRI.

CONCLUSIONS

Breast MRI use may be underused or overused in certain subgroups of women.

IMPACT

As access to health care improves, the use of breast MRI and the appropriateness of its use for breast cancer detection will be important to monitor.

Factors associated with breast MRI use: a population-based analysis

INTRODUCTION

Although controversial, the use of breast magnetic resonance imaging (MRI) is widespread. We sought to determine factors that influenced its use in a population-based sample.

METHODS

The National Health Interview Survey is conducted annually by the Centers for Disease Control and is designed to be representative of the American population. Data from 2010 were queried for the use of breast MRI and associated sociodemographic and risk characteristics.

RESULTS

Of the 11,222 women aged ≥30 years who were surveyed, 4.7 % reported ever having a breast MRI. Nearly a quarter were done as part of a "routine exam" and <5 % were done for "family history" or for "high risk." Factors correlating with MRI use on univariate analysis included age, race, personal and/or family history of breast cancer, history of benign breast biopsy, perceived risk, and insurance. On multivariate analysis, African-American race (p = 0.001), personal history (p < 0.001), history of benign biopsy (p < 0.001), and high perceived risk (p < 0.001) were significantly associated with increased MRI use. In a cohort without a personal history of breast cancer, race, history of benign biopsy, and perceived risk were independent correlates of breast MRI, whereas family history, age, and insurance were no longer significant.

CONCLUSIONS

Personal history is the strongest factor associated with breast MRI use. However, whereas race, history of benign biopsy, and perceived risk were independently associated with MRI use, family history was not. These findings call into question whether current practice patterns follow evidence-based guidelines.

Effectiveness of a multidimensional physical therapy program on pain, pressure hypersensitivity, and trigger points in breast cancer survivors: a randomized controlled clinical trial

OBJECTIVE

To evaluate the effects of an 8-week multidimensional physical therapy program, including strengthening exercises and recovery massage, on neck and shoulder pain, pressure hypersensitivity, and the presence of active trigger points (TrPs) in breast cancer survivors.

METHODS

In this randomized controlled clinical trial, 44 breast cancer survivors were randomly assigned into 2 groups: CUIDATE group who received a multidimensional physical therapy program; or CONTROL group who received usual care treatment for breast cancer. CUIDATE program consisted of 24 hours of individual physical training (aerobic, mobility, stretching, and strengthening exercises) and 12 hours of physical therapy recovery (stretching, massage) interventions (3 times/wk, 90 min). Outcomes included neck and shoulder pain (visual analog scale, 0 to 100), pressure pain thresholds over the C5-C6 zygapophyseal joints, deltoid muscles, second metacarpal and tibialis anterior muscles, and the presence of active TrPs in shoulder muscles. Outcomes were assessed at baseline and after the 8-week program by a blinded assessor.

RESULTS

The CUIDATE group showed an estimated improvement for neck pain of -56 mm [95% confidence interval (CI), -71--40, P<0.001; effect size 2.72, 1.94 to 3.44] and for shoulder/axillary of -56 mm (95% CI, -74--38, P<0.001; effect size 2.45, 1.66 to 3.23). Improvements were also noted for pressure pain thresholds levels: C5-C6 zygapophyseal joints (between-group differences 101 kPa, 95% CI, 60-143; effect size 1.68, 1.00 to 2.35; 92 kPa 55 to 129; d: 1.98, 1.18 to 2.77), deltoid muscles (98 kPa, 45 to 149; d: 1.34, 0.62 to 2.04; 75 kPa 18 to 132; d: 1.12, 0.27 to 1.96), second metacarpal (93 kPa, 45 to 134; d: 1.30, 0.63 to 1.86; 99 kPa 59 to 139; d: 1.60, 0.96 to 2.24), and tibialis anterior muscles (71 kPa, 40 to 144; d: 1.16, 0.65 to 2.34; 118 kPa 57 to 178; d: 1.17, 0.56 to 1.77). Finally, patients within the CUIDATE program showed a greater reduction of active muscle TrPs compared with the CONTROL group (P<0.01).

CONCLUSIONS

An 8-week multidimensional program including strengthening exercises, and massage as major components was effective for improving neck and shoulder pain and reducing widespread pressure hyperalgesia in breast cancer survivors compared with usual care treatment.

Performing breast cancer risk assessments in a community setting

This article describes the implementation of a risk assessment program for women having screening mammography at a community center. The program used the National Cancer Institute's Breast Cancer Risk Assessment Tool to raise awareness in high-risk women. An evidence-based process is essential when implementing changes in clinical practice to overcome challenges and barriers.

Widespread mechanical pain hypersensitivity as a sign of central sensitization after breast cancer surgery: comparison between mastectomy and lumpectomy

OBJECTIVE

To investigate the differences in widespread pressure pain hypersensitivity after two surgery approaches for breast cancer: mastectomy or lumpectomy.

DESIGN

A cross-sectional blinded study.

SETTING

Widespread pressure pain hypersensitivity has been suggested as a sign of central sensitization. No study has previously investigated the presence of widespread pain pressure hypersensitivity after breast cancer surgery.

PATIENTS

Twenty-one women (age: 52±9 years old) who had received lumpectomy after breast cancer, 21 women (mean age: 50±10 years old) who had received mastectomy surgery after breast cancer, and 21 healthy women (age: 51±10 years old) participated.

OUTCOME MEASURES

Pressure pain thresholds (PPT) were bilaterally assessed over C5-C6 zygapophyseal joint, deltoid muscle, second metacarpal, and the tibialis anterior muscle.

RESULTS

Women with mastectomy had greater intensity of neck (t= -2.897; P=0.006) and shoulder/axillary (t= -2.609; P=0.013) pain as compared with those who received lumpectomy. The results showed that PPT were significantly decreased bilaterally over the C5-C6 zygapophyseal joint, deltoid muscle, second metacarpal, and tibialis anterior muscle in both lumpectomy and mastectomy groups as compared with healthy women in all points (P<0.001), without differences between both breast cancer groups (P=0.954). No significant differences in the magnitude of PPT levels between both breast cancer groups were found (all, P>0.450). PPT levels over some areas were negatively associated with the intensity of pain in the mastectomy, but not lumpectomy, group.

CONCLUSION

The current study found widespread pressure pain hyperalgesia in women who received breast cancer surgery suggesting central spreading sensitization. The degree of central sensitization was similar between lumpectomy and mastectomy surgery.