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Mullooly M, Fan S, Pfeiffer RM, Bowles EA, Duggan MA, Falk RT, Richert-Boe K, Glass AG, Kimes TM, Figueroa JD, Rohan TE, Abubakar M, Gierach GL. Temporal changes in mammographic breast density and breast cancer risk among women with benign breast disease. Breast Cancer Res 2024; 26:52. [PMID: 38532516 DOI: 10.1186/s13058-024-01764-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/06/2024] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION Benign breast disease (BBD) and high mammographic breast density (MBD) are prevalent and independent risk factors for invasive breast cancer. It has been suggested that temporal changes in MBD may impact future invasive breast cancer risk, but this has not been studied among women with BBD. METHODS We undertook a nested case-control study within a cohort of 15,395 women with BBD in Kaiser Permanente Northwest (KPNW; 1970-2012, followed through mid-2015). Cases (n = 261) developed invasive breast cancer > 1 year after BBD diagnosis, whereas controls (n = 249) did not have breast cancer by the case diagnosis date. Cases and controls were individually matched on BBD diagnosis age and plan membership duration. Standardized %MBD change (per 2 years), categorized as stable/any increase (≥ 0%), minimal decrease of less than 5% or a decrease greater than or equal to 5%, was determined from baseline and follow-up mammograms. Associations between MBD change and breast cancer risk were examined using adjusted unconditional logistic regression. RESULTS Overall, 64.5% (n = 329) of BBD patients had non-proliferative and 35.5% (n = 181) had proliferative disease with/without atypia. Women with an MBD decrease (≤ - 5%) were less likely to develop breast cancer (Odds Ratio (OR) 0.64; 95% Confidence Interval (CI) 0.38, 1.07) compared with women with minimal decreases. Associations were stronger among women ≥ 50 years at BBD diagnosis (OR 0.48; 95% CI 0.25, 0.92) and with proliferative BBD (OR 0.32; 95% CI 0.11, 0.99). DISCUSSION Assessment of temporal MBD changes may inform risk monitoring among women with BBD, and strategies to actively reduce MBD may help decrease future breast cancer risk.
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Affiliation(s)
- Maeve Mullooly
- School of Population Health, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Shaoqi Fan
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Erin Aiello Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Máire A Duggan
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, T2N2Y9, Canada
| | - Roni T Falk
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | | | - Andrew G Glass
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Teresa M Kimes
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Jonine D Figueroa
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Thomas E Rohan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mustapha Abubakar
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
| | - Gretchen L Gierach
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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Park HL, Ziogas A, Feig SA, Kirmizi RL, Lee CJ, Alvarez A, Lucia RM, Goodman D, Larsen KM, Kelly R, Anton-Culver H. Factors Associated with Longitudinal Changes in Mammographic Density in a Multiethnic Breast Screening Cohort of Postmenopausal Women. Breast J 2023; 2023:2794603. [PMID: 37881237 PMCID: PMC10597735 DOI: 10.1155/2023/2794603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 07/19/2023] [Accepted: 10/04/2023] [Indexed: 10/27/2023]
Abstract
Background Breast density is an important risk factor for breast cancer and is known to be associated with characteristics such as age, race, and hormone levels; however, it is unclear what factors contribute to changes in breast density in postmenopausal women over time. Understanding factors associated with density changes may enable a better understanding of breast cancer risk and facilitate potential strategies for prevention. Methods This study investigated potential associations between personal factors and changes in mammographic density in a cohort of 3,392 postmenopausal women with no personal history of breast cancer between 2011 and 2017. Self-reported information on demographics, breast and reproductive history, and lifestyle factors, including body mass index (BMI), alcohol intake, smoking, and physical activity, was collected by an electronic intake form, and breast imaging reporting and database system (BI-RADS) mammographic density scores were obtained from electronic medical records. Factors associated with a longitudinal increase or decrease in mammographic density were identified using Fisher's exact test and multivariate conditional logistic regression. Results 7.9% of women exhibited a longitudinal decrease in mammographic density, 6.7% exhibited an increase, and 85.4% exhibited no change. Longitudinal changes in mammographic density were correlated with age, race/ethnicity, and age at menopause in the univariate analysis. In the multivariate analysis, Asian women were more likely to exhibit a longitudinal increase in mammographic density and less likely to exhibit a decrease compared to White women. On the other hand, obese women were less likely to exhibit an increase and more likely to exhibit a decrease compared to normal weight women. Women who underwent menopause at age 55 years or older were less likely to exhibit a decrease in mammographic density compared to women who underwent menopause at a younger age. Besides obesity, lifestyle factors (alcohol intake, smoking, and physical activity) were not associated with longitudinal changes in mammographic density. Conclusions The associations we observed between Asian race/obesity and longitudinal changes in BI-RADS density in postmenopausal women are paradoxical in that breast cancer risk is lower in Asian women and higher in obese women. However, the association between later age at menopause and a decreased likelihood of decreasing in BI-RADS density over time is consistent with later age at menopause being a risk factor for breast cancer and suggests a potential relationship between greater cumulative lifetime estrogen exposure and relative stability in breast density after menopause. Our findings support the complexity of the relationships between breast density, BMI, hormone exposure, and breast cancer risk.
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Affiliation(s)
- Hannah Lui Park
- Department of Pathology and Laboratory Medicine, University of California, Irvine, CA, USA
- Department of Epidemiology and Biostatistics, University of California, Irvine, CA, USA
| | - Argyrios Ziogas
- Department of Medicine, University of California, Irvine, CA, USA
| | - Stephen A. Feig
- Department of Radiological Sciences, University of California, Irvine, CA, USA
| | - Roza Lorin Kirmizi
- Department of Biological Sciences, University of California, Irvine, CA, USA
| | - Christie Jiwon Lee
- Department of Pharmaceutical Sciences, University of California, Irvine, CA, USA
| | - Andrea Alvarez
- Department of Medicine, University of California, Irvine, CA, USA
| | | | - Deborah Goodman
- Department of Epidemiology and Biostatistics, University of California, Irvine, CA, USA
| | - Kathryn M. Larsen
- Department of Family Medicine, University of California, Irvine, CA, USA
| | - Richard Kelly
- Department of Clinical Informatics, University of California, Irvine, CA, USA
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3
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Illipse M, Czene K, Hall P, Humphreys K. Studying the association between longitudinal mammographic density measurements and breast cancer risk: a joint modelling approach. Breast Cancer Res 2023; 25:64. [PMID: 37296473 PMCID: PMC10257295 DOI: 10.1186/s13058-023-01667-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Researchers have suggested that longitudinal trajectories of mammographic breast density (MD) can be used to understand changes in breast cancer (BC) risk over a woman's lifetime. Some have suggested, based on biological arguments, that the cumulative trajectory of MD encapsulates the risk of BC across time. Others have tried to connect changes in MD to the risk of BC. METHODS To summarize the MD-BC association, we jointly model longitudinal trajectories of MD and time to diagnosis using data from a large ([Formula: see text]) mammography cohort of Swedish women aged 40-80 years. Five hundred eighteen women were diagnosed with BC during follow-up. We fitted three joint models (JMs) with different association structures; Cumulative, current value and slope, and current value association structures. RESULTS All models showed evidence of an association between MD trajectory and BC risk ([Formula: see text] for current value of MD, [Formula: see text] and [Formula: see text] for current value and slope of MD respectively, and [Formula: see text] for cumulative value of MD). Models with cumulative association structure and with current value and slope association structure had better goodness of fit than a model based only on current value. The JM with current value and slope structure suggested that a decrease in MD may be associated with an increased (instantaneous) BC risk. It is possible that this is because of increased screening sensitivity rather than being related to biology. CONCLUSION We argue that a JM with a cumulative association structure may be the most appropriate/biologically relevant model in this context.
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Affiliation(s)
- Maya Illipse
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Swedish eScience Research Centre (SeRC), Karolinska Institutet, Stockholm, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | - Keith Humphreys
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Swedish eScience Research Centre (SeRC), Karolinska Institutet, Stockholm, Sweden
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4
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Gastounioti A, Cohen EA, Pantalone L, Ehsan S, Vasudevan S, Kurudi A, Conant EF, Chen J, Kontos D, McCarthy AM. Changes in mammographic density and risk of breast cancer among a diverse cohort of women undergoing mammography screening. Breast Cancer Res Treat 2023; 198:535-544. [PMID: 36800118 DOI: 10.1007/s10549-023-06879-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 02/01/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Mammographic density (MD) is a strong breast cancer risk factor. MD may change over time, with potential implications for breast cancer risk. Few studies have assessed associations between MD change and breast cancer in racially diverse populations. We investigated the relationships between MD and MD change over time and breast cancer risk in a large, diverse screening cohort. MATERIALS AND METHODS We retrospectively analyzed data from 8462 women who underwent ≥ 2 screening mammograms from Sept. 2010 to Jan. 2015 (N = 20,766 exams); 185 breast cancers were diagnosed 1-7 years after screening. Breast percent density (PD) and dense area (DA) were estimated from raw digital mammograms (Hologic Inc.) using LIBRA (v1.0.4). For each MD measure, we modeled breast density change between two sequential visits as a function of demographic and risk covariates. We used Cox regression to examine whether varying degrees of breast density change were associated with breast cancer risk, accounting for multiple exams per woman. RESULTS PD at any screen was significantly associated with breast cancer risk (hazard ratio (HR) for PD = 1.03 (95% CI [1.01, 1.05], p < 0.0005), but neither change in breast density nor more extreme than expected changes in breast density were associated with breast cancer risk. We found no evidence of differences in density change or breast cancer risk due to density change by race. Results using DA were essentially identical. CONCLUSIONS Using a large racially diverse cohort, we found no evidence of association between short-term change in MD and risk of breast cancer, suggesting that short-term MD change is not a strong predictor for risk.
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Affiliation(s)
- Aimilia Gastounioti
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric A Cohen
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren Pantalone
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Ehsan
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sanjana Vasudevan
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Avinash Kurudi
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily F Conant
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jinbo Chen
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Despina Kontos
- Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne Marie McCarthy
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Short-term changes in ultrasound tomography measures of breast density and treatment-associated endocrine symptoms after tamoxifen therapy. NPJ Breast Cancer 2023; 9:12. [PMID: 36922547 PMCID: PMC10017770 DOI: 10.1038/s41523-023-00511-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 02/13/2023] [Indexed: 03/17/2023] Open
Abstract
Although breast density decline with tamoxifen therapy is associated with greater therapeutic benefit, limited data suggest that endocrine symptoms may also be associated with improved breast cancer outcomes. However, it is unknown whether endocrine symptoms are associated with reductions in breast density after tamoxifen initiation. We evaluated treatment-associated endocrine symptoms and breast density change among 74 women prescribed tamoxifen in a 12-month longitudinal study. Treatment-associated endocrine symptoms and sound speed measures of breast density, assessed via novel whole breast ultrasound tomography (m/s), were ascertained before tamoxifen (T0) and at 1-3 (T1), 4-6 (T2), and 12 months (T3) after initiation. CYP2D6 status was genotyped, and tamoxifen metabolites were measured at T3. Using multivariable linear regression, we estimated mean change in breast density by treatment-associated endocrine symptoms adjusting for age, race, menopausal status, body mass index, and baseline density. Significant breast density declines were observed in women with treatment-associated endocrine symptoms (mean change (95% confidence interval) at T1:-0.26 m/s (-2.17,1.65); T2:-2.12 m/s (-4.02,-0.22); T3:-3.73 m/s (-5.82,-1.63); p-trend = 0.004), but not among women without symptoms (p-trend = 0.18) (p-interaction = 0.02). Similar declines were observed with increasing symptom frequency (p-trends for no symptoms = 0.91; low/moderate symptoms = 0.03; high symptoms = 0.004). Density declines remained among women with detectable tamoxifen metabolites or intermediate/efficient CYP2D6 metabolizer status. Emergent/worsening endocrine symptoms are associated with significant, early declines in breast density after tamoxifen initiation. Further studies are needed to assess whether these observations predict clinical outcomes. If confirmed, endocrine symptoms may be a proxy for tamoxifen response and useful for patients and providers to encourage adherence.
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6
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Ohmaru A, Maeda K, Ono H, Kamimura S, Iwasaki K, Mori K, Kai M. Age-related change in mammographic breast density of women without history of breast cancer over a 10-year retrospective study. PeerJ 2023; 11:e14836. [PMID: 36815981 PMCID: PMC9936867 DOI: 10.7717/peerj.14836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/10/2023] [Indexed: 02/16/2023] Open
Abstract
Background Women with higher breast density are at higher risk of developing breast cancer. Breast density is known to affect sensitivity to mammography and to decrease with age. However, the age change and associated factors involved are still unknown. This study aimed to investigate changes in breast density and the associated factors over a 10-year period. Materials and Methods The study included 221 women who had undergone eight or more mammograms for 10 years (2011-2020), were between 25 and 65 years of age, and had no abnormalities as of 2011. Breast density on mammographic images was classified into four categories: fatty, scattered, heterogeneously dense, and extremely dense. Breast density was determined using an image classification program with a Microsoft Lobe's machine-learning model. The temporal changes in breast density over a 10-year period were classified into three categories: no change, decrease, and increase. An ordinal logistic analysis was performed with the three groups of temporal changes in breast density categories as the objective variable and the four items of breast density at the start, BMI, age, and changes in BMI as explanatory variables. Results As of 2011, the mean age of the 221 patients was 47 ± 7.3 years, and breast density category 3 scattered was the most common (67.0%). The 10-year change in breast density was 64.7% unchanged, 25.3% decreased, and 10% increased. BMI was increased by 64.7% of women. Breast density decreased in 76.6% of the category at the start: extremely dense breast density at the start was correlated with body mass index (BMI). The results of the ordinal logistic analysis indicated that contributing factors to breast density classification were higher breast density at the start (odds ratio = 0.044; 95% CI [0.025-0.076]), higher BMI at the start (odds ratio = 0.76; 95% CI [0.70-0.83]), increased BMI (odds ratio = 0.57; 95% CI [0.36-0.92]), and age in the 40s at the start (odds ratio = 0.49; 95% CI [0.24-0.99]). No statistically significant differences were found for medical history. Conclusion Breast density decreased in approximately 25% of women over a 10-year period. Women with decreased breast density tended to have higher breast density or higher BMI at the start. This effect was more pronounced among women in their 40s at the start. Women with these conditions may experience changes in breast density over time. The present study would be useful to consider effective screening mammography based on breast density.
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Affiliation(s)
- Aiko Ohmaru
- Department of Environmental Health Science, Oita University of Nursing and Health Sciences, Oita, Japan,Department of Radiological Science, Junshin Gakuen University, Fukuoka, Japan
| | - Kazuhiro Maeda
- Station Clinic, Medical Corporation Shin-ai, Fukuoka, Japan,Tenjin Clinic, Medical Corporation Shin-ai, Fukuoka, Japan
| | - Hiroyuki Ono
- Station Clinic, Medical Corporation Shin-ai, Fukuoka, Japan,Tenjin Clinic, Medical Corporation Shin-ai, Fukuoka, Japan
| | - Seiichiro Kamimura
- Station Clinic, Medical Corporation Shin-ai, Fukuoka, Japan,Tenjin Clinic, Medical Corporation Shin-ai, Fukuoka, Japan,Division of Total Health Care Unit, Chiyukai Shinkomonji Hospital, Fukuoka, Japan
| | - Kyoko Iwasaki
- Station Clinic, Medical Corporation Shin-ai, Fukuoka, Japan,Tenjin Clinic, Medical Corporation Shin-ai, Fukuoka, Japan
| | - Kazuhiro Mori
- Station Clinic, Medical Corporation Shin-ai, Fukuoka, Japan,Tenjin Clinic, Medical Corporation Shin-ai, Fukuoka, Japan
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7
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Assessing breast density using the chemical-shift encoding-based proton density fat fraction in 3-T MRI. Eur Radiol 2022; 33:3810-3818. [PMID: 36538074 PMCID: PMC10182116 DOI: 10.1007/s00330-022-09341-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Abstract
Objectives
There is a clinical need for a non-ionizing, quantitative assessment of breast density, as one of the strongest independent risk factors for breast cancer. This study aims to establish proton density fat fraction (PDFF) as a quantitative biomarker for fat tissue concentration in breast MRI and correlate mean breast PDFF to mammography.
Methods
In this retrospective study, 193 women were routinely subjected to 3-T MRI using a six-echo chemical shift encoding-based water-fat sequence. Water-fat separation was based on a signal model accounting for a single T2* decay and a pre-calibrated 7-peak fat spectrum resulting in volumetric fat-only, water-only images, PDFF- and T2*-values. After semi-automated breast segmentation, PDFF and T2* values were determined for the entire breast and fibroglandular tissue. The mammographic and MRI-based breast density was classified by visual estimation using the American College of Radiology Breast Imaging Reporting and Data System categories (ACR A-D).
Results
The PDFF negatively correlated with mammographic and MRI breast density measurements (Spearman rho: −0.74, p < .001) and revealed a significant distinction between all four ACR categories. Mean T2* of the fibroglandular tissue correlated with increasing ACR categories (Spearman rho: 0.34, p < .001). The PDFF of the fibroglandular tissue showed a correlation with age (Pearson rho: 0.56, p = .03).
Conclusion
The proposed breast PDFF as an automated tissue fat concentration measurement is comparable with mammographic breast density estimations. Therefore, it is a promising approach to an accurate, user-independent, and non-ionizing breast density assessment that could be easily incorporated into clinical routine breast MRI exams.
Key Points
• The proposed PDFF strongly negatively correlates with visually determined mammographic and MRI-based breast density estimations and therefore allows for an accurate, non-ionizing, and user-independent breast density measurement.
• In combination with T2*, the PDFF can be used to track structural alterations in the composition of breast tissue for an individualized risk assessment for breast cancer.
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8
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Factors Influencing Mammographic Density in Asian Women: A Retrospective Cohort Study in the Northeast Region of Peninsular Malaysia. Diagnostics (Basel) 2022; 12:diagnostics12040860. [PMID: 35453907 PMCID: PMC9032698 DOI: 10.3390/diagnostics12040860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 02/05/2023] Open
Abstract
Mammographic density is a significant risk factor for breast cancer. In this study, we identified the risk factors of mammographic density in Asian women and quantified the impact of breast density on the severity of breast cancer. We collected data from Hospital Universiti Sains Malaysia, a research- and university-based hospital located in Kelantan, Malaysia. Multivariable logistic regression was performed to analyse the data. Five significant factors were found to be associated with mammographic density: age (OR: 0.94; 95% CI: 0.92, 0.96), number of children (OR: 0.88; 95% CI: 0.81, 0.96), body mass index (OR: 0.88; 95% CI: 0.85, 0.92), menopause status (yes vs. no, OR: 0.59; 95% CI: 0.42, 0.82), and BI-RADS classification (2 vs. 1, OR: 1.87; 95% CI: 1.22, 2.84; 3 vs. 1, OR: 3.25; 95% CI: 1.86, 5.66; 4 vs. 1, OR: 3.75; 95% CI: 1.88, 7.46; 5 vs. 1, OR: 2.46; 95% CI: 1.21, 5.02; 6 vs. 1, OR: 2.50; 95% CI: 0.65, 9.56). Similarly, the average predicted probabilities were higher among BI-RADS 3 and 4 classified women. Understanding mammographic density and its influencing factors aids in accurately assessing and screening dense breast women.
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9
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Tice JA, Gard CC, Miglioretti DL, Sprague BL, Tosteson ANA, Joe BN, Ho TQH, Kerlikowske K. Comparing Mammographic Density Assessed by Digital Breast Tomosynthesis or Digital Mammography: The Breast Cancer Surveillance Consortium. Radiology 2022; 302:286-292. [PMID: 34812671 PMCID: PMC8805687 DOI: 10.1148/radiol.2021204579] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 08/13/2021] [Accepted: 09/10/2021] [Indexed: 02/03/2023]
Abstract
Background Consistency in reporting Breast Imaging Reporting and Data System (BI-RADS) breast density on mammograms is important because breast density is used for breast cancer risk assessment and is reported directly to women and clinicians to inform decisions about supplemental screening. Purpose To assess the consistency of BI-RADS density reporting between digital breast tomosynthesis (DBT) and digital mammography (DM) and evaluate density as a breast cancer risk factor when assessed using DM versus DBT. Materials and Methods The Breast Cancer Surveillance Consortium is a prospective cohort study of women undergoing mammography with DM or DBT. This secondary analysis included women aged 40-79 years who underwent at least two screening mammography examinations less than 36 months apart. Percentage agreement and κ statistic were estimated for pairs of BI-RADS density assessments. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of breast density as a risk factor for invasive breast cancer. Results A total of 403 326 pairs of mammograms from 342 149 women were evaluated. There were no significant differences in breast density assessment in pairs consisting of one DM and one DBT examination (57 516 of 74 729 [77%]; κ = 0.64), two DM examinations (238 678 of 301 743 [79%]; κ = 0.67), and two DBT examinations (20 763 of 26 854 [77%]; κ = 0.65). Results were similar when restricting the analyses to pairs read by the same radiologist. The breast cancer HRs for breast density were similar for DM and DBT (P = .45 for interaction). The HRs for density acquired using DM and DBT, respectively, were 0.55 (95% CI: 0.49, 0.63) and 0.37 (95% CI: 0.21, 0.66) for almost entirely fat, 1.47 (95% CI: 1.37, 1.58) and 1.36 (95% CI: 1.02, 1.82) for heterogeneously dense, and 1.72 (95% CI: 1.54, 1.93) and 2.05 (95% CI: 1.25, 3.36) for extremely dense breasts. Conclusion Radiologist reporting of Breast Imaging Reporting and Data System density obtained with digital breast tomosynthesis did not differ from that obtained with digital mammography. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Jeffrey A. Tice
- From the Division of General Internal Medicine, Department of
Medicine (J.A.T.), and Department of Radiology and Biomedical Imaging (B.N.J.),
University of California, San Francisco, 1545 Divisadero St, Suite 309, San
Francisco, CA 94143-0320; General Internal Medicine Section, Department of
Veterans Affairs and Departments of Medicine and Epidemiology and Biostatistics,
San Francisco, Calif (K.K.); Department of Economics, Applied Statistics, and
International Business, New Mexico State University, Las Cruces, NM (C.C.G.);
Department of Public Health Sciences, University of California, Davis, School of
Medicine, Davis, Calif (D.L.M., T.Q.H.H.); Kaiser Permanente Washington Health
Research Institute, Seattle, Wash (D.L.M.); Department of Surgery, University of
Vermont, Burlington, Vt (B.L.S.); The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
(A.N.A.T.); and Department of Training and Scientific Research, University
Medical Center, Ho Chi Minh City, Vietnam (T.Q.H.H.)
| | - Charlotte C. Gard
- From the Division of General Internal Medicine, Department of
Medicine (J.A.T.), and Department of Radiology and Biomedical Imaging (B.N.J.),
University of California, San Francisco, 1545 Divisadero St, Suite 309, San
Francisco, CA 94143-0320; General Internal Medicine Section, Department of
Veterans Affairs and Departments of Medicine and Epidemiology and Biostatistics,
San Francisco, Calif (K.K.); Department of Economics, Applied Statistics, and
International Business, New Mexico State University, Las Cruces, NM (C.C.G.);
Department of Public Health Sciences, University of California, Davis, School of
Medicine, Davis, Calif (D.L.M., T.Q.H.H.); Kaiser Permanente Washington Health
Research Institute, Seattle, Wash (D.L.M.); Department of Surgery, University of
Vermont, Burlington, Vt (B.L.S.); The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
(A.N.A.T.); and Department of Training and Scientific Research, University
Medical Center, Ho Chi Minh City, Vietnam (T.Q.H.H.)
| | - Diana L. Miglioretti
- From the Division of General Internal Medicine, Department of
Medicine (J.A.T.), and Department of Radiology and Biomedical Imaging (B.N.J.),
University of California, San Francisco, 1545 Divisadero St, Suite 309, San
Francisco, CA 94143-0320; General Internal Medicine Section, Department of
Veterans Affairs and Departments of Medicine and Epidemiology and Biostatistics,
San Francisco, Calif (K.K.); Department of Economics, Applied Statistics, and
International Business, New Mexico State University, Las Cruces, NM (C.C.G.);
Department of Public Health Sciences, University of California, Davis, School of
Medicine, Davis, Calif (D.L.M., T.Q.H.H.); Kaiser Permanente Washington Health
Research Institute, Seattle, Wash (D.L.M.); Department of Surgery, University of
Vermont, Burlington, Vt (B.L.S.); The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
(A.N.A.T.); and Department of Training and Scientific Research, University
Medical Center, Ho Chi Minh City, Vietnam (T.Q.H.H.)
| | - Brian L. Sprague
- From the Division of General Internal Medicine, Department of
Medicine (J.A.T.), and Department of Radiology and Biomedical Imaging (B.N.J.),
University of California, San Francisco, 1545 Divisadero St, Suite 309, San
Francisco, CA 94143-0320; General Internal Medicine Section, Department of
Veterans Affairs and Departments of Medicine and Epidemiology and Biostatistics,
San Francisco, Calif (K.K.); Department of Economics, Applied Statistics, and
International Business, New Mexico State University, Las Cruces, NM (C.C.G.);
Department of Public Health Sciences, University of California, Davis, School of
Medicine, Davis, Calif (D.L.M., T.Q.H.H.); Kaiser Permanente Washington Health
Research Institute, Seattle, Wash (D.L.M.); Department of Surgery, University of
Vermont, Burlington, Vt (B.L.S.); The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
(A.N.A.T.); and Department of Training and Scientific Research, University
Medical Center, Ho Chi Minh City, Vietnam (T.Q.H.H.)
| | - Anna N. A. Tosteson
- From the Division of General Internal Medicine, Department of
Medicine (J.A.T.), and Department of Radiology and Biomedical Imaging (B.N.J.),
University of California, San Francisco, 1545 Divisadero St, Suite 309, San
Francisco, CA 94143-0320; General Internal Medicine Section, Department of
Veterans Affairs and Departments of Medicine and Epidemiology and Biostatistics,
San Francisco, Calif (K.K.); Department of Economics, Applied Statistics, and
International Business, New Mexico State University, Las Cruces, NM (C.C.G.);
Department of Public Health Sciences, University of California, Davis, School of
Medicine, Davis, Calif (D.L.M., T.Q.H.H.); Kaiser Permanente Washington Health
Research Institute, Seattle, Wash (D.L.M.); Department of Surgery, University of
Vermont, Burlington, Vt (B.L.S.); The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
(A.N.A.T.); and Department of Training and Scientific Research, University
Medical Center, Ho Chi Minh City, Vietnam (T.Q.H.H.)
| | - Bonnie N. Joe
- From the Division of General Internal Medicine, Department of
Medicine (J.A.T.), and Department of Radiology and Biomedical Imaging (B.N.J.),
University of California, San Francisco, 1545 Divisadero St, Suite 309, San
Francisco, CA 94143-0320; General Internal Medicine Section, Department of
Veterans Affairs and Departments of Medicine and Epidemiology and Biostatistics,
San Francisco, Calif (K.K.); Department of Economics, Applied Statistics, and
International Business, New Mexico State University, Las Cruces, NM (C.C.G.);
Department of Public Health Sciences, University of California, Davis, School of
Medicine, Davis, Calif (D.L.M., T.Q.H.H.); Kaiser Permanente Washington Health
Research Institute, Seattle, Wash (D.L.M.); Department of Surgery, University of
Vermont, Burlington, Vt (B.L.S.); The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
(A.N.A.T.); and Department of Training and Scientific Research, University
Medical Center, Ho Chi Minh City, Vietnam (T.Q.H.H.)
| | - Thao-Quyen H. Ho
- From the Division of General Internal Medicine, Department of
Medicine (J.A.T.), and Department of Radiology and Biomedical Imaging (B.N.J.),
University of California, San Francisco, 1545 Divisadero St, Suite 309, San
Francisco, CA 94143-0320; General Internal Medicine Section, Department of
Veterans Affairs and Departments of Medicine and Epidemiology and Biostatistics,
San Francisco, Calif (K.K.); Department of Economics, Applied Statistics, and
International Business, New Mexico State University, Las Cruces, NM (C.C.G.);
Department of Public Health Sciences, University of California, Davis, School of
Medicine, Davis, Calif (D.L.M., T.Q.H.H.); Kaiser Permanente Washington Health
Research Institute, Seattle, Wash (D.L.M.); Department of Surgery, University of
Vermont, Burlington, Vt (B.L.S.); The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
(A.N.A.T.); and Department of Training and Scientific Research, University
Medical Center, Ho Chi Minh City, Vietnam (T.Q.H.H.)
| | - Karla Kerlikowske
- From the Division of General Internal Medicine, Department of
Medicine (J.A.T.), and Department of Radiology and Biomedical Imaging (B.N.J.),
University of California, San Francisco, 1545 Divisadero St, Suite 309, San
Francisco, CA 94143-0320; General Internal Medicine Section, Department of
Veterans Affairs and Departments of Medicine and Epidemiology and Biostatistics,
San Francisco, Calif (K.K.); Department of Economics, Applied Statistics, and
International Business, New Mexico State University, Las Cruces, NM (C.C.G.);
Department of Public Health Sciences, University of California, Davis, School of
Medicine, Davis, Calif (D.L.M., T.Q.H.H.); Kaiser Permanente Washington Health
Research Institute, Seattle, Wash (D.L.M.); Department of Surgery, University of
Vermont, Burlington, Vt (B.L.S.); The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
(A.N.A.T.); and Department of Training and Scientific Research, University
Medical Center, Ho Chi Minh City, Vietnam (T.Q.H.H.)
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10
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Yu T, Ye DM. The epidemiologic factors associated with breast density: A review. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2022; 27:53. [PMID: 36092490 PMCID: PMC9450246 DOI: 10.4103/jrms.jrms_962_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/14/2022] [Accepted: 01/26/2022] [Indexed: 11/04/2022]
Abstract
In recent years, some studies have evaluated the epidemiologic factors associated with breast density. However, the variant and inconsistent results exist. In addition, breast density has been proved to be a significant risk factor associated with breast cancer. Our review summarized the published studies and emphasized the crucial factors including epidemiological factors associated with breast density. In addition, we also discussed the potential reasons for the discrepant results with risk factors. To decrease the incidence and mortality rates for breast cancer, in clinical practice, breast density should be included for clinical risk models in addition to epidemiological factors, and physicians should get more concentrate on those women with risk factors and provide risk-based breast cancer screening regimens.
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11
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Shamsi U, Afzal S, Shamsi A, Azam I, Callen D. Factors associated with mammographic breast density among women in Karachi Pakistan. BMC Womens Health 2021; 21:438. [PMID: 34972514 PMCID: PMC8720218 DOI: 10.1186/s12905-021-01538-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 11/10/2021] [Indexed: 12/31/2022] Open
Abstract
Background There are no studies done to evaluate the distribution of mammographic breast density and factors associated with it among Pakistani women. Methods Participants included 477 women, who had received either diagnostic or screening mammography at two hospitals in Karachi Pakistan. Mammographic breast density was assessed using the Breast Imaging Reporting and Data System. In person interviews were conducted using a detailed questionnaire, to assess risk factors of interest, and venous blood was collected to measure serum vitamin D level at the end of the interview. To determine the association of potential factors with mammographic breast density, multivariable polytomous logistic regression was used. Results High-density mammographic breast density (heterogeneously and dense categories) was high and found in 62.4% of women. There was a significant association of both heterogeneously dense and dense breasts with women of a younger age group < 45 years (OR 2.68, 95% CI 1.60–4.49) and (OR 4.83, 95% CI 2.54–9.16) respectively. Women with heterogeneously dense and dense breasts versus fatty and fibroglandular breasts had a higher history of benign breast disease (OR 1.90, 95% CI 1.14–3.17) and (OR 3.61, 95% CI 1.90–6.86) respectively. There was an inverse relationship between breast density and body mass index. Women with dense breasts and heterogeneously dense breasts had lower body mass index (OR 0.94 95% CI 0.90–0.99) and (OR 0.81, 95% CI 0.76–0.87) respectively. There was no association of mammographic breast density with serum vitamin D levels, diet, and breast cancer. Conclusions The findings of a positive association of higher mammographic density with younger age and benign breast disease and a negative association between body mass index and breast density are important findings that need to be considered in developing screening guidelines for the Pakistani population.
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Affiliation(s)
- Uzma Shamsi
- School of Medicine, University of Adelaide, Adelaide, Australia.
| | - Shaista Afzal
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Azra Shamsi
- Department of Gynecology and Obstetrics, Combined Military Hospital, Karachi, Pakistan
| | - Iqbal Azam
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - David Callen
- School of Medicine, University of Adelaide, Adelaide, Australia
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12
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Bowles EJA, O'Neill SC, Li T, Knerr S, Mandelblatt JS, Schwartz MD, Jayasekera J, Leppig K, Ehrlich K, Farrell D, Gao H, Graham AL, Luta G, Wernli KJ. Effect of a Randomized Trial of a Web-Based Intervention on Patient-Provider Communication About Breast Density. J Womens Health (Larchmt) 2021; 30:1529-1537. [PMID: 34582721 PMCID: PMC8823670 DOI: 10.1089/jwh.2021.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Breast density increases breast cancer risk and decreases mammographic detection. We evaluated a personalized web-based intervention designed to improve breast cancer risk communication between women and their providers. Materials and Methods: This was a secondary outcome analysis of an online randomized trial. Women aged 40-69 years were randomized, February 2017-May 2018, to a control (n = 503) versus intervention website (n = 492). The intervention website included information about breast density, personalized breast cancer risk, chemoprevention, and magnetic resonance imaging. Participants self-reported communication about density with providers (yes/no) at 6 weeks and 12 months. We used logistic regression with generalized estimating equations to evaluate the association of study arm with density communication. In secondary analyses, we tested if the intervention was associated with indicators of patient activation (breast cancer worry, perceived risk, or health care use). Results: Women (mean age 62 years) in the intervention versus control arm were 2.39 times (95% confidence interval [CI] = 1.37-4.18) more likely to report density communication at 6 weeks; this effect persisted at 12 months (odds ratio [OR] = 1.71, 95% CI = 1.25-2.35). At 6 weeks, this effect was only significant among women who reported (OR = 3.23, 95% CI = 1.24-8.40) versus did not report any previous density discussions (OR = 1.64, 95% CI = 0.83-3.26). A quarter of women in each arm never had a density conversation at any time during the study. Conclusions: Despite providing personalized density and risk information, the intervention did not promote density discussions between women and their providers who had not had them previously. This intervention is unlikely to be used clinically to motivate density conversations in women who have not had them before. Clinical trial registration number NCT03029286.
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Affiliation(s)
- Erin J. Aiello Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA.,Address correspondence to: Erin J. Aiello Bowles, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA
| | - Suzanne C. O'Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Tengfei Li
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, District of Columbia, USA
| | - Sarah Knerr
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | - Jeanne S. Mandelblatt
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Marc D. Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Jinani Jayasekera
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Kathleen Leppig
- Clinical Genetics, Washington Permanente Medical Group, Seattle, Washington, USA
| | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | | | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Amanda L. Graham
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA.,Truth Initiative, Washington, District of Columbia, USA
| | - George Luta
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, District of Columbia, USA
| | - Karen J. Wernli
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
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13
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Menopausal Transition, Body Mass Index, and Prevalence of Mammographic Dense Breasts in Middle-Aged Women. J Clin Med 2020; 9:jcm9082434. [PMID: 32751482 PMCID: PMC7465213 DOI: 10.3390/jcm9082434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/24/2020] [Accepted: 07/28/2020] [Indexed: 12/12/2022] Open
Abstract
The interrelationship between menopausal stage, excessive adiposity and dense breasts remains unclear. We aimed to investigate the relationship between menopausal stage and dense-breast prevalence in midlife women while considering a possible effect modification of being overweight. The present cross-sectional study comprised 82,677 Korean women, aged 35–65 years, who attended a screening exam. Menopausal stages were categorized based on the Stages of Reproductive Aging Workshop (STRAW + 10) criteria. Mammographic breast density was categorized according to Breast Imaging Reporting and Data System (BI-RADS). Dense breasts were defined as BI-RADS Breast Density category D (extremely dense). The prevalence of dense breasts decreased as menopausal stage increased (p-trend < 0.001), and this pattern was pronounced in overweight women than non-overweight women (p-interaction = 0.016). Compared with pre-menopause, the multivariable-adjusted prevalence ratios (and 95% confidence intervals) for dense breasts were 0.98 (0.96–1.00) in early transition, 0.89 (0.86–0.92) in late transition, and 0.55 (0.52–0.59) in post-menopause, among non-overweight women, while corresponding prevalence ratios were 0.92 (0.87–0.98), 0.83 (0.77–0.90) and 0.36 (0.31–0.41) among overweight women. The prevalence of dense breasts was inversely associated with increasing menopausal stages and significantly decreased from the late menopausal transition, with stronger declines among overweight women.
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14
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Johnson HM, Shivalingappa H, Irish W, Wong JH, Muzaffar M, Verbanac K, Vohra NA. Race May Not Impact Endocrine Therapy-Related Changes in Breast Density. Cancer Epidemiol Biomarkers Prev 2020; 29:1049-1057. [PMID: 32098892 DOI: 10.1158/1055-9965.epi-19-1066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/03/2019] [Accepted: 02/21/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reduction in breast density may be a biomarker of endocrine therapy (ET) efficacy. Our objective was to assess the impact of race on ET-related changes in volumetric breast density (VBD). METHODS This retrospective cohort study assessed longitudinal changes in VBD measures in women with estrogen receptor-positive invasive breast cancer treated with ET. VBD, the ratio of fibroglandular volume (FGV) to breast volume (BV), was measured using Volpara software. Changes in measurements were evaluated using a multivariable linear mixed effects model. RESULTS Compared with white women (n = 191), black women (n = 107) had higher rates of obesity [mean ± SD body mass index (BMI) 34.5 ± 9.1 kg/m2 vs. 30.6 ± 7.0 kg/m2, P < 0.001] and premenopausal status (32.7% vs. 16.7%, P = 0.002). Age- and BMI-adjusted baseline FGV, BV, and VBD were similar between groups. Modeled longitudinal changes were also similar: During a follow-up of 30.7 ± 15.0 months (mean ± SD), FGV decreased over time in premenopausal women (slope = -0.323 cm3; SE = 0.093; P = 0.001), BV increased overall (slope = 2.475 cm3; SE = 0.483; P < 0.0001), and VBD decreased (premenopausal slope = -0.063%, SE = 0.011; postmenopausal slope = -0.016%, SE = 0.004; P < 0.0001). Race was not significantly associated with these longitudinal changes, nor did race modify the effect of time on these changes. Higher BMI was associated with lower baseline VBD (P < 0.0001). Among premenopausal women, VBD declined more steeply for women with lower BMI (time × BMI, P = 0.0098). CONCLUSIONS Race does not appear to impact ET-related longitudinal changes in VBD. IMPACT Racial disparities in estrogen receptor-positive breast cancer recurrence and mortality may not be explained by differential declines in breast density due to ET.
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Affiliation(s)
- Helen M Johnson
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina
| | - Hitesh Shivalingappa
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina.,Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - William Irish
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina
| | - Jan H Wong
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina
| | - Mahvish Muzaffar
- Division of Hematology Oncology, Department of Internal Medicine, East Carolina University Brody School of Medicine, Greenville, North Carolina
| | - Kathryn Verbanac
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina
| | - Nasreen A Vohra
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina.
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