1
|
Youngs A, Forman A, Elms M, Kohut K, Hlaing MT, Short J, Hanson H, Snape K. Digital innovation for cancer risk assessment allows large-scale service redevelopment of regional cancer genetics service delivery. Fam Cancer 2024:10.1007/s10689-024-00407-x. [PMID: 38954285 DOI: 10.1007/s10689-024-00407-x] [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: 01/22/2024] [Accepted: 06/01/2024] [Indexed: 07/04/2024]
Abstract
Family-history assessment can identify individuals above population-risk for cancer to enable targeted Screening, Prevention and Early Detection (SPED). The online patient-facing cancer Family History Questionnaire Service (cFHQS) is a digitalised, resource efficient tool for family history data capture to facilitate this. The capturing of digital data from cFHQS allows for data interrogation of patients referred to Clinical Genetics for the purposes of service improvement. Digital data from 4,044 cFHQS respondents over a three-year period was collected and interrogated with respect to the number and type of familial tumour diagnoses to enable service improvement and streamlining of referral pathways. 81% of colorectal and 71% of breast screening assessments were population- or moderate-risk. Most patients who completed cFHQS reported more than one diagnosis of cancer/tumour/polyps in their family. 2.5% of family history assessment patients had a second indication that required assessment that would have been missed if single tumour type assessment was undertaken. Implementation of an innovative, digital family history data collection pathway has allowed large scale interrogation of referral patterns and assessment outcomes to enable service development. The high volume of inappropriate referrals to Clinical Genetics for population and moderate risk patients highlighted the need for dedicated secondary care pathway provision for these patients. The use of cFHQS streamlined family history assessment allows for redistribution of resources to improve equity and access to genetic cancer risk assessment.
Collapse
Affiliation(s)
- Alice Youngs
- South West Thames Centre for Genomics, St George's University Hospitals NHS Foundation Trust, SW17 0QT, London, England
| | - Andrea Forman
- South West Thames Centre for Genomics, St George's University Hospitals NHS Foundation Trust, SW17 0QT, London, England
| | - Marisa Elms
- South West Thames Centre for Genomics, St George's University Hospitals NHS Foundation Trust, SW17 0QT, London, England
| | - Kelly Kohut
- South West Thames Centre for Genomics, St George's University Hospitals NHS Foundation Trust, SW17 0QT, London, England
| | - Min Theik Hlaing
- South West Thames Centre for Genomics, St George's University Hospitals NHS Foundation Trust, SW17 0QT, London, England
| | - John Short
- South West Thames Centre for Genomics, St George's University Hospitals NHS Foundation Trust, SW17 0QT, London, England
| | - Helen Hanson
- Peninsula Clinical Genetics Service, Royal Devon University Healthcare NHS Foundation Trust, EX1 2ED, Exeter, England
| | - Katie Snape
- South West Thames Centre for Genomics, St George's University Hospitals NHS Foundation Trust, SW17 0QT, London, England.
- St George's University, London, UK.
| |
Collapse
|
2
|
Hindmarch S, Howell SJ, Usher-Smith JA, Gorman L, Evans DG, French DP. Feasibility and acceptability of offering breast cancer risk assessment to general population women aged 30-39 years: a mixed-methods study protocol. BMJ Open 2024; 14:e078555. [PMID: 38199637 PMCID: PMC10806663 DOI: 10.1136/bmjopen-2023-078555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Breast cancer incidence starts to increase exponentially when women reach 30-39 years, hence before they are eligible for breast cancer screening. The introduction of breast cancer risk assessment for this age group could lead to those at higher risk receiving benefits of earlier screening and preventive strategies. Currently, risk assessment is limited to women with a family history of breast cancer only. The Breast CANcer Risk Assessment in Younger women (BCAN-RAY) study is evaluating a comprehensive breast cancer risk assessment strategy for women aged 30-39 years incorporating a questionnaire of breast cancer risk factors, low-dose mammography to assess breast density and polygenic risk. This study will assess the feasibility and acceptability of the BCAN-RAY risk assessment strategy. METHODS AND ANALYSIS This study involves women undergoing risk assessment as part of the BCAN-RAY case-control study (n=750). They will be aged 30-39 years without a strong family history of breast cancer and invited to participate via general practice. A comparison of uptake rates by socioeconomic status and ethnicity between women who participated in the BCAN-RAY study and women who declined participation will be conducted. All participants will be asked to complete self-report questionnaires to assess key potential harms including increased state anxiety (State Trait Anxiety Inventory), cancer worry (Lerman Cancer Worry Scale) and satisfaction with the decision to participate (Decision Regret Scale), alongside potential benefits such as feeling more informed about breast cancer risk. A subsample of approximately 24 women (12 at average risk and 12 at increased risk) will additionally participate in semistructured interviews to understand the acceptability of the risk assessment strategy and identify any changes needed to it to increase uptake. ETHICS AND DISSEMINATION Ethical approval was granted by North West-Greater Manchester West Research Ethics Committee (reference: 22/NW/0268). Study results will be disseminated through peer-reviewed journals, conference presentations and charitable organisations. TRIAL REGISTRATION NUMBER NCT05305963.
Collapse
Affiliation(s)
- Sarah Hindmarch
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Sacha J Howell
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Louise Gorman
- NIHR Greater Manchester Patient Safety Research Collaboration, Division of Population Health, Health Services Research & Primary Care, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - D Gareth Evans
- Manchester Academic Health Science Centre, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - David P French
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| |
Collapse
|
3
|
Atakpa EC, Buist DSM, Aiello Bowles EJ, Cuzick J, Brentnall AR. Development and evaluation of a method to assess breast cancer risk using a longitudinal history of mammographic density: a cohort study. Breast Cancer Res 2023; 25:147. [PMID: 38001476 PMCID: PMC10668455 DOI: 10.1186/s13058-023-01744-y] [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: 07/25/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Women with dense breasts have an increased risk of breast cancer. However, breast density is measured with variability, which may reduce the reliability and accuracy of its association with breast cancer risk. This is particularly relevant when visually assessing breast density due to variation in inter- and intra-reader assessments. To address this issue, we developed a longitudinal breast density measure which uses an individual woman's entire history of mammographic density, and we evaluated its association with breast cancer risk as well as its predictive ability. METHODS In total, 132,439 women, aged 40-73 yr, who were enrolled in Kaiser Permanente Washington and had multiple screening mammograms taken between 1996 and 2013 were followed up for invasive breast cancer through 2014. Breast Imaging Reporting and Data System (BI-RADS) density was assessed at each screen. Continuous and derived categorical longitudinal density measures were developed using a linear mixed model that allowed for longitudinal density to be updated at each screen. Predictive ability was assessed using (1) age and body mass index-adjusted hazard ratios (HR) for breast density (time-varying covariate), (2) likelihood-ratio statistics (ΔLR-χ2) and (3) concordance indices. RESULTS In total, 2704 invasive breast cancers were diagnosed during follow-up (median = 5.2 yr; median mammograms per woman = 3). When compared with an age- and body mass index-only model, the gain in statistical information provided by the continuous longitudinal density measure was 23% greater than that provided by BI-RADS density (follow-up after baseline mammogram: ΔLR-χ2 = 379.6 (degrees of freedom (df) = 2) vs. 307.7 (df = 3)), which increased to 35% (ΔLR-χ2 = 251.2 vs. 186.7) for follow-up after three mammograms (n = 76,313, 2169 cancers). There was a sixfold difference in observed risk between densest and fattiest eight-category longitudinal density (HR = 6.3, 95% CI 4.7-8.7), versus a fourfold difference with BI-RADS density (HR = 4.3, 95% CI 3.4-5.5). Discriminatory accuracy was marginally greater for longitudinal versus BI-RADS density (c-index = 0.64 vs. 0.63, mean difference = 0.008, 95% CI 0.003-0.012). CONCLUSIONS Estimating mammographic density using a woman's history of breast density is likely to be more reliable than using the most recent observation only, which may lead to more reliable and accurate estimates of individual breast cancer risk. Longitudinal breast density has the potential to improve personal breast cancer risk estimation in women attending mammography screening.
Collapse
Affiliation(s)
- Emma C Atakpa
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK.
| | - Diana S M Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, USA
| | | | - Jack Cuzick
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Adam R Brentnall
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| |
Collapse
|
4
|
Woof VG, McWilliams L, Howell A, Evans DG, French DP. How do women at increased risk of breast cancer make sense of their risk? An interpretative phenomenological analysis. Br J Health Psychol 2023; 28:1169-1184. [PMID: 37395149 PMCID: PMC10947456 DOI: 10.1111/bjhp.12678] [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: 03/20/2023] [Revised: 06/08/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVES Offering breast cancer risk prediction for all women of screening age is being considered globally. For women who have received a clinically derived estimate, risk appraisals are often inaccurate. This study aimed to gain an in-depth understanding of women's lived experiences of receiving an increased breast cancer risk. DESIGN One-to-one semi-structured telephone interviews. METHODS Eight women informed that they were at a 10-year above-average (moderate) or high risk in a breast cancer risk study (BC-Predict) were interviewed about their views on breast cancer, personal breast cancer risk and risk prevention. Interviews lasted between 40 and 70 min. Data were analysed using Interpretative Phenomenological Analysis. RESULTS Four themes were generated: (i) encounters with breast cancer and perceived personal significance, where the nature of women's lived experiences of others with breast cancer impacted their views on the significance of the disease, (ii) 'It's random really': difficulty in seeking causal attributions, where women encountered contradictions and confusion in attributing causes to breast cancer, (iii) believing versus identifying with a clinically-derived breast cancer risk, where personal risk appraisals and expectations influenced women's ability to internalize their clinically derived risk and pursue preventative action and (iv) perceived utility of breast cancer risk notification, where women reflected on the usefulness of knowing their risk. CONCLUSIONS Providing (numerical) risk estimates appear to have little impact on stable yet internally contradictory beliefs about breast cancer risk. Given this, discussions with healthcare professionals are needed to help women form more accurate appraisals and make informed decisions.
Collapse
Affiliation(s)
| | | | - Anthony Howell
- University of ManchesterManchesterUK
- The Nightingale Centre, Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | - D. Gareth Evans
- University of ManchesterManchesterUK
- The Nightingale Centre, Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | | |
Collapse
|
5
|
del Valle Peña Colmenares J, García CC, Velásquez YJV, Pino LAC, Rodríguez ÁG, Rodríguez WJV, Vargas DJG, Herrera DJA. Is using the Gail model to calculate the risk of breast cancer in the Venezuelan population justified? Ecancermedicalscience 2023; 17:1590. [PMID: 37799948 PMCID: PMC10550297 DOI: 10.3332/ecancer.2023.1590] [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: 03/27/2023] [Indexed: 10/07/2023] Open
Abstract
Objective To evaluate the accuracy of the Gail model (GM) in women who already have a diagnosis of breast cancer (BC) from the Breast Pathology Service, Hospital Oncology Department of the Venezuelan Social Security Institute (SOH-IVSS) in the period 2004-2014. To compare the accuracy of the GM in women aged above and below 40 years with a diagnosis of BC. Method Descriptive, retrospective, cross-sectional, 830 records of patients diagnosed with BC were reviewed between 2004 and 2014. Results The mean age for diagnosis of the disease was 46 ± 13 years; menarche age was 13 years ± 2; age at first birth 22 ± 5 years, with a history of biopsy 32 ± 11, the percentage of relatives with a primary history of BC reported (PHBC) 9.3%. Only 41% of women with a diagnosis of BC reported Gail >1.67 (positive Gail). In the dichotomous logistic regression that related positive Gail with the independent variables, it was observed: greater probability of positive Gail if menarche age <11 years (p < 0.036), PHBC (p = 0.005), previous biopsy (p = 0.007), age at first birth 25-29 years (p = 0.019). When stratifying by age, unlike the bivariate analysis, women over 40 years of age are more likely to have a positive Gail in menarche age <11 years (p = 0.008), PHBC (p = 0.001), previous biopsy (p = 0.025) when compared with younger women, the age at first birth between 25 and 29 years was statistically significant for both groups; however, the probability was higher in younger women (p = 0.008). Conclusion There is no conclusive evidence to consider that the GM is applicable to Venezuelan women due to its low precision since it only identified 41% of the patients who had BC as high risk; however, when the factors are analysed separately, we found a higher probability of a positive Gail with statistical significance in EM <11 years, PHBC, previous biopsy and age at first birth 25-29 years; When stratifying by age, we observed that the age at first birth 25-29 years in women aged 40 or less increases the probability of a positive Gail. It is necessary to develop new risk assessment models that are adapted to our female population.
Collapse
Affiliation(s)
- Josepmilly del Valle Peña Colmenares
- Servicio Patología Mamaria del Servicio Oncológico Hospitalario (SOH), Instituto Venezolano del Seguro Social (IVSS), Caracas 1040, Venezuela
- https://orcid.org/0000-0002-1114-6289
| | - Carmen Cristina García
- Cátedra de Patología General y Fisiopatología, Escuela Luis Razetti, Facultad de Medicina, Caracas 1050, Venezuela
- https://orcid.org/0000-0002-7889-9445
| | - Yazmin José Velásquez Velásquez
- Servicio Patología Mamaria del Servicio Oncológico Hospitalario (SOH), Instituto Venezolano del Seguro Social (IVSS), Caracas 1040, Venezuela
- https://orcid.org/0000-0003-3307-2564
| | - Leider Arelis Campos Pino
- Servicio Patología Mamaria del Servicio Oncológico Hospitalario (SOH), Instituto Venezolano del Seguro Social (IVSS), Caracas 1040, Venezuela
- https://orcid.org/0000-0002-0907-8467
| | - Álvaro Gómez Rodríguez
- Servicio Patología Mamaria del Servicio Oncológico Hospitalario (SOH), Instituto Venezolano del Seguro Social (IVSS), Caracas 1040, Venezuela
- https://orcid.org/0000-0003-3740-0238
| | - Wladimir José Villegas Rodríguez
- Servicio Patología Mamaria del Servicio Oncológico Hospitalario (SOH), Instituto Venezolano del Seguro Social (IVSS), Caracas 1040, Venezuela
- https://orcid.org/0000-0001-8999-9751
| | - David José González Vargas
- Servicio Oncológico Hospitalario (SOH), Instituto Venezolano del Seguro Social (IVSS), Caracas 1040, Venezuela
- https://orcid.org/0000-0001-8071-3139
| | - Douglas José Angulo Herrera
- Escuela de Estadística y Ciencias Actuariales, Universidad Central de Venezuela, Caracas 1050, Venezuela
- https://orcid.org/0009-0003-5506-0297
| |
Collapse
|
6
|
Gareth Evans D, McWilliams L, Astley S, Brentnall AR, Cuzick J, Dobrashian R, Duffy SW, Gorman LS, Harkness EF, Harrison F, Harvie M, Jerrison A, Machin M, Maxwell AJ, Howell SJ, Wright SJ, Payne K, Qureshi N, Ruane H, Southworth J, Fox L, Bowers S, Hutchinson G, Thorpe E, Ulph F, Woof V, Howell A, French DP. Quantifying the effects of risk-stratified breast cancer screening when delivered in real time as routine practice versus usual screening: the BC-Predict non-randomised controlled study (NCT04359420). Br J Cancer 2023; 128:2063-2071. [PMID: 37005486 PMCID: PMC10066938 DOI: 10.1038/s41416-023-02250-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/28/2023] [Accepted: 03/20/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Risk stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) could provide a better balance of benefits and harms. We developed BC-Predict, to offer women when invited to the NHSBSP, which collects standard risk factor information; mammographic density; and in a sub-sample, a Polygenic Risk Score (PRS). METHODS Risk prediction was estimated primarily from self-reported questionnaires and mammographic density using the Tyrer-Cuzick risk model. Women eligible for NHSBSP were recruited. BC-Predict produced risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5-<8% 10-year) to have appointments to discuss prevention and additional screening. RESULTS Overall uptake of BC-Predict in screening attendees was 16.9% with 2472 consenting to the study; 76.8% of those received risk feedback within the 8-week timeframe. Recruitment was 63.2% with an onsite recruiter and paper questionnaire compared to <10% with BC-Predict only (P < 0.0001). Risk appointment attendance was highest for those at high risk (40.6%); 77.5% of those opted for preventive medication. DISCUSSION We have shown that a real-time offer of breast cancer risk information (including both mammographic density and PRS) is feasible and can be delivered in reasonable time, although uptake requires personal contact. Preventive medication uptake in women newly identified at high risk is high and could improve the cost-effectiveness of risk stratification. TRIAL REGISTRATION Retrospectively registered with clinicaltrials.gov (NCT04359420).
Collapse
Affiliation(s)
- D Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England.
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England.
- Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, England.
| | - Lorna McWilliams
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - Susan Astley
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Adam R Brentnall
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, England
| | - Jack Cuzick
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, England
| | - Richard Dobrashian
- East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital, Haslingden Road, Lancashire, BB2 3HH, Manchester, England
| | - Stephen W Duffy
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, England
| | - Louise S Gorman
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, M13 9PL, England
| | - Elaine F Harkness
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | | | - Michelle Harvie
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
| | - Andrew Jerrison
- Research IT, IT Services, University of Manchester, Manchester, M13 9PL, England
| | - Matthew Machin
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Anthony J Maxwell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
| | - Sacha J Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, England
| | - Stuart J Wright
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, England
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, England
| | - Nadeem Qureshi
- Primary Care Stratified Medicine research group, Centre for Academic Primary Care, University of Nottingham, University Park, Nottingham, NG7 2RD, England
| | - Helen Ruane
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Jake Southworth
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Lynne Fox
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Sarah Bowers
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Gillian Hutchinson
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Emma Thorpe
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Fiona Ulph
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - Victoria Woof
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - Anthony Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, England
| | - David P French
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| |
Collapse
|
7
|
French DP, McWilliams L, Bowers S, Woof VG, Harrison F, Ruane H, Hendy A, Evans DG. Psychological impact of risk-stratified screening as part of the NHS Breast Screening Programme: multi-site non-randomised comparison of BC-Predict versus usual screening (NCT04359420). Br J Cancer 2023; 128:1548-1558. [PMID: 36774447 PMCID: PMC9922101 DOI: 10.1038/s41416-023-02156-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Adding risk stratification to standard screening via the NHS Breast Screening Programme (NHSBSP) allows women at higher risk to be offered additional prevention and screening options. It may, however, introduce new harms such as increasing cancer worry. The present study aimed to assess whether there were differences in self-reported harms and benefits between women offered risk stratification (BC-Predict) compared to women offered standard NHSBSP, controlling for baseline values. METHODS As part of the larger PROCAS2 study (NCT04359420), 5901 women were offered standard NHSBSP or BC-Predict at the invitation to NHSBSP. Women who took up BC-Predict received 10-year risk estimates: "high" (≥8%), "above average (moderate)" (5-7.99%), "average" (2-4.99%) or "below average (low)" (<2%) risk. A subset of 662 women completed questionnaires at baseline and at 3 months (n = 511) and 6 months (n = 473). RESULTS State anxiety and cancer worry scores were low with no differences between women offered BC-Predict or NHSBSP. Women offered BC-Predict and informed of being at higher risk reported higher risk perceptions and cancer worry than other women, but without reaching clinical levels. CONCLUSIONS Concerns that risk-stratified screening will produce harm due to increases in general anxiety or cancer worry are unfounded, even for women informed that they are at high risk.
Collapse
Affiliation(s)
- David P. French
- grid.5379.80000000121662407Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL England ,grid.498924.a0000 0004 0430 9101NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England ,grid.5379.80000000121662407Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ England
| | - Lorna McWilliams
- grid.5379.80000000121662407Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL England ,grid.498924.a0000 0004 0430 9101NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Sarah Bowers
- grid.498924.a0000 0004 0430 9101The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT England
| | - Victoria G. Woof
- grid.5379.80000000121662407Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL England
| | | | - Helen Ruane
- grid.498924.a0000 0004 0430 9101The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT England
| | - Alice Hendy
- grid.498924.a0000 0004 0430 9101The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT England
| | - D. Gareth Evans
- grid.498924.a0000 0004 0430 9101NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England ,grid.5379.80000000121662407Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ England ,grid.498924.a0000 0004 0430 9101The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT England ,grid.5379.80000000121662407Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL England
| |
Collapse
|
8
|
Usher-Smith JA, Hindmarch S, French DP, Tischkowitz M, Moorthie S, Walter FM, Dennison RA, Stutzin Donoso F, Archer S, Taylor L, Emery J, Morris S, Easton DF, Antoniou AC. Proactive breast cancer risk assessment in primary care: a review based on the principles of screening. Br J Cancer 2023; 128:1636-1646. [PMID: 36737659 PMCID: PMC9897164 DOI: 10.1038/s41416-023-02145-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that women at moderate or high risk of breast cancer be offered risk-reducing medication and enhanced breast screening/surveillance. In June 2022, NICE withdrew a statement recommending assessment of risk in primary care only when women present with concerns. This shift to the proactive assessment of risk substantially changes the role of primary care, in effect paving the way for a primary care-based screening programme to identify those at moderate or high risk of breast cancer. In this article, we review the literature surrounding proactive breast cancer risk assessment within primary care against the consolidated framework for screening. We find that risk assessment for women under 50 years currently satisfies many of the standard principles for screening. Most notably, there are large numbers of women at moderate or high risk currently unidentified, risk models exist that can identify those women with reasonable accuracy, and management options offer the opportunity to reduce breast cancer incidence and mortality in that group. However, there remain a number of uncertainties and research gaps, particularly around the programme/system requirements, that need to be addressed before these benefits can be realised.
Collapse
Affiliation(s)
- Juliet A. Usher-Smith
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hindmarch
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Marc Tischkowitz
- grid.5335.00000000121885934Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Sowmiya Moorthie
- grid.5335.00000000121885934PHG Foundation, University of Cambridge, Cambridge, UK
| | - Fiona M. Walter
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca A. Dennison
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francisca Stutzin Donoso
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Psychology, University of Cambridge, Cambridge, UK
| | - Lily Taylor
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- grid.1008.90000 0001 2179 088XCentre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC Australia
| | - Stephen Morris
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Antonis C. Antoniou
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
9
|
Gorman LS, Ruane H, Woof VG, Southworth J, Ulph F, Evans DG, French DP. The co-development of personalised 10-year breast cancer risk communications: a 'think-aloud' study. BMC Cancer 2022; 22:1264. [PMID: 36471302 PMCID: PMC9721070 DOI: 10.1186/s12885-022-10347-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/21/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Risk stratified breast cancer screening is being considered as a means of improving the balance of benefits and harms of mammography. Stratified screening requires the communication of risk estimates. We aimed to co-develop personalised 10-year breast cancer risk communications for women attending routine mammography. METHODS We conducted think-aloud interviews on prototype breast cancer risk letters and accompanying information leaflets with women receiving breast screening through the UK National Breast Screening Programme. Risk information was redesigned following feedback from 55 women in three iterations. A deductive thematic analysis of participants' speech is presented. RESULTS Overall, participants appreciated receiving their breast cancer risk. Their comments focused on positive framing and presentation of the risk estimate, a desire for detail on the contribution of individual risk factors to overall risk and effective risk management strategies, and clearly signposted support pathways. CONCLUSION Provision of breast cancer risk information should strive to be personal, understandable and meaningful. Risk information should be continually refined to reflect developments in risk management. Receipt of risk via letter is welcomed but concerns remain around the acceptability of informing women at higher risk in this way, highlighting a need for co-development of risk dissemination and support pathways.
Collapse
Affiliation(s)
- Louise S. Gorman
- grid.498924.a0000 0004 0430 9101The Nightingale Centre and Prevent Breast Cancer Centre Research Unit, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT UK
| | - Helen Ruane
- grid.498924.a0000 0004 0430 9101The Nightingale Centre and Prevent Breast Cancer Centre Research Unit, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT UK
| | - Victoria G. Woof
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, The University of Manchester, MAHSC, Oxford Road, Manchester, M13 9PL UK
| | - Jake Southworth
- grid.498924.a0000 0004 0430 9101The Nightingale Centre and Prevent Breast Cancer Centre Research Unit, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT UK
| | - Fiona Ulph
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, The University of Manchester, MAHSC, Oxford Road, Manchester, M13 9PL UK
| | - D. Gareth Evans
- grid.498924.a0000 0004 0430 9101The Nightingale Centre and Prevent Breast Cancer Centre Research Unit, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT UK ,grid.498924.a0000 0004 0430 9101Department of Genomic Medicine, Division of Evolution and Genomic Science, MAHSC, University of Manchester, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL, Manchester, UK ,grid.498924.a0000 0004 0430 9101NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, The University of Manchester, MAHSC, Oxford Road, Manchester, M13 9PL UK ,grid.498924.a0000 0004 0430 9101NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England UK
| |
Collapse
|
10
|
Taylor G, McWilliams L, Woof VG, Evans DG, French DP. What are the views of three key stakeholder groups on extending the breast screening interval for low-risk women? A secondary qualitative analysis. Health Expect 2022; 25:3287-3296. [PMID: 36305519 PMCID: PMC9700144 DOI: 10.1111/hex.13637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/14/2022] [Accepted: 10/16/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION There is increasing interest in risk-stratified breast screening, whereby the prevention and early detection offers vary by a woman's estimated risk of breast cancer. To date, more focus has been directed towards high-risk screening pathways rather than considering women at lower risk, who may be eligible for extended screening intervals. This secondary data analysis aimed to compare the views of three key stakeholder groups on how extending screening intervals for low-risk women should be implemented and communicated as part of a national breast screening programme. METHODS Secondary data analysis of three qualitative studies exploring the views of distinct stakeholder groups was conducted. Interviews took place with 23 low-risk women (identified from the BC-Predict study) and 17 national screening figures, who were involved in policy-making and implementation. In addition, three focus groups and two interviews were conducted with 26 healthcare professionals. A multiperspective thematic analysis was conducted to identify similarities and differences between stakeholders. FINDINGS Three themes were produced: Questionable assumptions about negative consequences, highlighting how other stakeholders lack trust in how women are likely to understand extended screening intervals; Preserving the integrity of the programme, centring on decision-making and maintaining a positive reputation of breast screening and Negotiating a communication pathway highlighting communication expectations and public campaign importance. CONCLUSIONS A risk-stratified screening programme should consider how best to engage women assessed as having a low risk of breast cancer to ensure mutual trust, balance the practicality of change whilst ensuring acceptability, and carefully develop multilevel inclusive communication strategies. PATIENT AND PUBLIC CONTRIBUTION The research within this paper involved patient/public contributors throughout including study design and materials input.
Collapse
Affiliation(s)
- Grace Taylor
- School of Health Sciences, Manchester Centre of Health Psychology, Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK
| | - Lorna McWilliams
- School of Health Sciences, Manchester Centre of Health Psychology, Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science CentreCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
| | - Victoria G. Woof
- School of Health Sciences, Manchester Centre of Health Psychology, Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK
| | - D. Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science CentreCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
- The Nightingale and Prevent Breast Cancer CentreManchester University NHS Foundation TrustManchesterUK
- Manchester Breast Centre, Manchester Cancer Research CentreUniversity of ManchesterManchesterUK
- Genomic Medicine, Division of Evolution and Genomic Sciences, St Mary's Hospital, Manchester University NHS Foundation TrustThe University of ManchesterManchesterUK
| | - David P. French
- School of Health Sciences, Manchester Centre of Health Psychology, Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science CentreCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
- Manchester Breast Centre, Manchester Cancer Research CentreUniversity of ManchesterManchesterUK
| |
Collapse
|
11
|
Platt S, Montgomery GH, Schnur JH, Margolies L. BI-RADS 0 Screening Mammography: Risk Factors That Prevent or Delay Follow-Up Time to Diagnostic Evaluation. J Am Coll Radiol 2022; 19:1262-1268. [PMID: 35985631 DOI: 10.1016/j.jacr.2022.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/27/2022] [Accepted: 07/06/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE BI-RADS 0 screening mammograms require follow-up diagnostic imaging, optimally within 60 days. Our study aims to identify risk factors for delayed follow-up. METHODS We conducted a retrospective case-control study of individuals who had a nondiagnostic BI-RADS 0 screening mammogram between March 19, 2018, and March 19, 2020. Sociodemographic information was collected from self-reported questionnaire. We aimed to identify factors associated with <60-day follow-up, >60-day follow-up, or no follow-up outcomes. The χ2 test and univariate logistic regressions were performed. Significant variables were included in multinomial logistic regression. We also aimed to identify risk factors that lead to delayed follow-up times among individuals with follow-up. Spearman's correlation and Mann-Whitney Wilcoxon tests and Kruskal-Wallis tests were performed. RESULTS Review returned 5,034 screening mammograms. Of 4,552 individuals included, 904 (19.9%) had no follow-up. Of the 3,648 (80.1%) with follow-up, 2,797 (76.7%) had a follow-up <60 days (median 20 days) and 851 (23.3%) had follow-up >60 days (median 176 days). Multinomial regression found that Asian (P = .022), Black (P < .0001), and individuals who identified their race as other (P < .0001) were independently more likely to have no or >60-day follow-up. Individuals who did not report their race (P = .001) or completed the questionnaire in Spanish (P = .025) were more likely to have no or >60-day follow-up. Amongst individuals with follow-up, Black individuals (P < .0001), those who identified their race as other (P < .0001), Hispanic individuals (P = .04), and those who completed the questionnaire in Spanish (P < .0001) had follow-up delays. BRCA-positive individuals had shorter follow-up times (P = .021). DISCUSSION Follow-up time is affected by cancer risk factors such as BRCA status in addition to race, preferred language, and Hispanic ethnicity.
Collapse
Affiliation(s)
- Samantha Platt
- Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Guy H Montgomery
- Professor, Department of Population Health Science and Policy and Director, Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Julie H Schnur
- Assistant Professor, Department of Population Health Science and Policy, Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laurie Margolies
- Professor of Diagnostic, Molecular and Interventional Radiology and Professor and Director, Dubin Breast Center, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
12
|
Clift AK, Dodwell D, Lord S, Petrou S, Brady SM, Collins GS, Hippisley-Cox J. The current status of risk-stratified breast screening. Br J Cancer 2022; 126:533-550. [PMID: 34703006 PMCID: PMC8854575 DOI: 10.1038/s41416-021-01550-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 08/25/2021] [Accepted: 09/14/2021] [Indexed: 12/23/2022] Open
Abstract
Apart from high-risk scenarios such as the presence of highly penetrant genetic mutations, breast screening typically comprises mammography or tomosynthesis strategies defined by age. However, age-based screening ignores the range of breast cancer risks that individual women may possess and is antithetical to the ambitions of personalised early detection. Whilst screening mammography reduces breast cancer mortality, this is at the risk of potentially significant harms including overdiagnosis with overtreatment, and psychological morbidity associated with false positives. In risk-stratified screening, individualised risk assessment may inform screening intensity/interval, starting age, imaging modality used, or even decisions not to screen. However, clear evidence for its benefits and harms needs to be established. In this scoping review, the authors summarise the established and emerging evidence regarding several critical dependencies for successful risk-stratified breast screening: risk prediction model performance, epidemiological studies, retrospective clinical evaluations, health economic evaluations and qualitative research on feasibility and acceptability. Family history, breast density or reproductive factors are not on their own suitable for precisely estimating risk and risk prediction models increasingly incorporate combinations of demographic, clinical, genetic and imaging-related parameters. Clinical evaluations of risk-stratified screening are currently limited. Epidemiological evidence is sparse, and randomised trials only began in recent years.
Collapse
Affiliation(s)
- Ash Kieran Clift
- Cancer Research UK Oxford Centre, Department of Oncology, University of Oxford, Oxford, UK.
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Simon Lord
- Department of Oncology, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
13
|
Burnside ES, Warren LM, Myles J, Wilkinson LS, Wallis MG, Patel M, Smith RA, Young KC, Massat NJ, Duffy SW. Quantitative breast density analysis to predict interval and node-positive cancers in pursuit of improved screening protocols: a case-control study. Br J Cancer 2021; 125:884-892. [PMID: 34168297 PMCID: PMC8438060 DOI: 10.1038/s41416-021-01466-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 05/18/2021] [Accepted: 06/10/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This study investigates whether quantitative breast density (BD) serves as an imaging biomarker for more intensive breast cancer screening by predicting interval, and node-positive cancers. METHODS This case-control study of 1204 women aged 47-73 includes 599 cancer cases (302 screen-detected, 297 interval; 239 node-positive, 360 node-negative) and 605 controls. Automated BD software calculated fibroglandular volume (FGV), volumetric breast density (VBD) and density grade (DG). A radiologist assessed BD using a visual analogue scale (VAS) from 0 to 100. Logistic regression and area under the receiver operating characteristic curves (AUC) determined whether BD could predict mode of detection (screen-detected or interval); node-negative cancers; node-positive cancers, and all cancers vs. controls. RESULTS FGV, VBD, VAS, and DG all discriminated interval cancers (all p < 0.01) from controls. Only FGV-quartile discriminated screen-detected cancers (p < 0.01). Based on AUC, FGV discriminated all cancer types better than VBD or VAS. FGV showed a significantly greater discrimination of interval cancers, AUC = 0.65, than of screen-detected cancers, AUC = 0.61 (p < 0.01) as did VBD (0.63 and 0.53, respectively, p < 0.001). CONCLUSION FGV, VBD, VAS and DG discriminate interval cancers from controls, reflecting some masking risk. Only FGV discriminates screen-detected cancers perhaps adding a unique component of breast cancer risk.
Collapse
Affiliation(s)
- Elizabeth S Burnside
- Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, WI, USA.
| | - Lucy M Warren
- National Co-ordinating Centre for the Physics of Mammography (NCCPM), Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | - Jonathan Myles
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
| | | | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Mishal Patel
- Scientific Computing, Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | | | - Kenneth C Young
- National Co-ordinating Centre for the Physics of Mammography (NCCPM), Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | - Nathalie J Massat
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
| |
Collapse
|
14
|
Long-Term Evaluation of Women Referred to a Breast Cancer Family History Clinic (Manchester UK 1987-2020). Cancers (Basel) 2020; 12:cancers12123697. [PMID: 33317064 PMCID: PMC7763143 DOI: 10.3390/cancers12123697] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022] Open
Abstract
Simple Summary This study reports the management of women at high risk for breast cancer over a 33 years period. The aim was to summarize the numbers seen and to report the results of our studies on gene testing, the outcomes of screening and the success of preventive methods including lifestyle change, chemoprevention and risk-reducing mastectomy. We also discuss how the clinical Family History Service may be improved in the future. Abstract Clinics for women concerned about their family history of breast cancer are widely established. A Family History Clinic was set-up in Manchester, UK, in 1987 in a Breast Unit serving a population of 1.8 million. In this review, we report the outcome of risk assessment, screening and prevention strategies in the clinic and propose future approaches. Between 1987–2020, 14,311 women were referred, of whom 6.4% were from known gene families, 38.2% were at high risk (≥30% lifetime risk), 37.7% at moderate risk (17–29%), and 17.7% at an average/population risk who were discharged. A total of 4168 (29.1%) women were eligible for genetic testing and 736 carried pathogenic variants, predominantly in BRCA1 and BRCA2 but also other genes (5.1% of direct referrals). All women at high or moderate risk were offered annual mammographic screening between ages 30 and 40 years old: 646 cancers were detected in women at high and moderate risk (5.5%) with a detection rate of 5 per 1000 screens. Incident breast cancers were largely of good prognosis and resulted in a predicted survival advantage. All high/moderate-risk women were offered lifestyle prevention advice and 14–27% entered various lifestyle studies. From 1992–2003, women were offered entry into IBIS-I (tamoxifen) and IBIS-II (anastrozole) trials (12.5% of invitees joined). The NICE guidelines ratified the use of tamoxifen and raloxifene (2013) and subsequently anastrozole (2017) for prevention; 10.8% women took up the offer of such treatment between 2013–2020. Since 1994, 7164 eligible women at ≥25% lifetime risk of breast cancer were offered a discussion of risk-reducing breast surgery and 451 (6.2%) had surgery. New approaches in all aspects of the service are needed to build on these results.
Collapse
|
15
|
Screening Strategy Modification Based on Personalized Breast Cancer Risk Stratification and its Implementation in the National Guidelines - Pilot Study. Zdr Varst 2020; 59:211-218. [PMID: 33133277 PMCID: PMC7583429 DOI: 10.2478/sjph-2020-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/31/2020] [Indexed: 12/24/2022] Open
Abstract
Background One of the most consistent models for estimating personalized breast cancer (BC) risk is the Tyrer-Cuzick algorithm that is incorporated into the International Breast Cancer Intervention Study (IBIS) software. Our main objective was to provide criteria for the classification of the Slovenian population, which has BC incidence below the European average, into risk groups, and to evaluate the integration of the criteria in Slovenian guidelines. Our main focus was on women age <50 with higher BC risk, since no organized BC screening is available for these women. Methods Slovenian age-specific BC risks were incorporated into IBIS software and threshold values of risk categories were determined. Risk categories were assigned according to the individual’s ten-year risk for women aged 40 and older, and lifetime risk for women between 20 and 39. To test the software, we compared screening strategies with the use vs. no use of IBIS. Results Of the 197 women included in the study IBIS assigned 75.1% to the BC risk group, and the rest to the moderately increased risk. Without IBIS 80 women were offered mammographic and 33 ultrasound screening. In contrast, 28 instead of 80 would have been offered mammographic screening and there would have been no referrals for ultrasound if IBIS had been used. Conclusions The Slovenian IBIS has been developed, tested and suggested for personalized breast cancer risk assessment. The implementation of the software with the consideration of Slovenian risk thresholds enables a more accurate and nationally unified assessment.
Collapse
|
16
|
French DP, Astley S, Brentnall AR, Cuzick J, Dobrashian R, Duffy SW, Gorman LS, Harkness EF, Harrison F, Harvie M, Howell A, Jerrison A, Machin M, Maxwell AJ, McWilliams L, Payne K, Qureshi N, Ruane H, Sampson S, Stavrinos P, Thorpe E, Ulph F, van Staa T, Woof V, Evans DG. What are the benefits and harms of risk stratified screening as part of the NHS breast screening Programme? Study protocol for a multi-site non-randomised comparison of BC-predict versus usual screening (NCT04359420). BMC Cancer 2020; 20:570. [PMID: 32552763 PMCID: PMC7302349 DOI: 10.1186/s12885-020-07054-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/09/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND In principle, risk-stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) should produce a better balance of benefits and harms. The main benefit is the offer of NICE-approved more frequent screening and/ or chemoprevention for women who are at increased risk, but are unaware of this. We have developed BC-Predict, to be offered to women when invited to NHSBSP which collects information on risk factors (self-reported information on family history and hormone-related factors via questionnaire; mammographic density; and in a sub-sample, Single Nucleotide Polymorphisms). BC-Predict produces risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5 to < 8% 10-year) to have discussion of prevention and early detection options at Family History, Risk and Prevention Clinics. Despite the promise of systems such as BC-Predict, there are still too many uncertainties for a fully-powered definitive trial to be appropriate or ethical. The present research aims to identify these key uncertainties regarding the feasibility of integrating BC-Predict into the NHSBSP. Key objectives of the present research are to quantify important potential benefits and harms, and identify key drivers of the relative cost-effectiveness of embedding BC-Predict into NHSBSP. METHODS A non-randomised fully counterbalanced study design will be used, to include approximately equal numbers of women offered NHSBSP (n = 18,700) and BC-Predict (n = 18,700) from selected screening sites (n = 7). In the initial 8-month time period, women eligible for NHSBSP will be offered BC-Predict in four screening sites. Three screening sites will offer women usual NHSBSP. In the following 8-months the study sites offering usual NHSBSP switch to BC-Predict and vice versa. Key potential benefits including uptake of risk consultations, chemoprevention and additional screening will be obtained for both groups. Key potential harms such as increased anxiety will be obtained via self-report questionnaires, with embedded qualitative process analysis. A decision-analytic model-based cost-effectiveness analysis will identify the key uncertainties underpinning the relative cost-effectiveness of embedding BC-Predict into NHSBSP. DISCUSSION We will assess the feasibility of integrating BC-Predict into the NHSBSP, and identify the main uncertainties for a definitive evaluation of the clinical and cost-effectiveness of BC-Predict. TRIAL REGISTRATION Retrospectively registered with clinicaltrials.gov (NCT04359420).
Collapse
Affiliation(s)
- David P French
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England.
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.
| | - Susan Astley
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Adam R Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, England
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, England
| | - Richard Dobrashian
- East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital, Haslingden Road, Lancashire, BB2 3HH, England
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, England
| | - Louise S Gorman
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, M13 9PL, England
| | - Elaine F Harkness
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | | | - Michelle Harvie
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England
| | - Anthony Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, England
| | - Andrew Jerrison
- Research IT, IT Services, University of Manchester, Manchester, M13 9PL, England
| | - Matthew Machin
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Anthony J Maxwell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Lorna McWilliams
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Katherine Payne
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, England
| | - Nadeem Qureshi
- School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, England
| | - Helen Ruane
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Sarah Sampson
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Paula Stavrinos
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Emma Thorpe
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Fiona Ulph
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Tjeerd van Staa
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Victoria Woof
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - D Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England
- Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, England
| |
Collapse
|
17
|
Qureshi N, Dutton B, Weng S, Sheehan C, Chorley W, Robertson JFR, Kendrick D, Kai J. Improving primary care identification of familial breast cancer risk using proactive invitation and decision support. Fam Cancer 2020; 20:13-21. [PMID: 32524330 PMCID: PMC7870768 DOI: 10.1007/s10689-020-00188-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/18/2020] [Indexed: 01/28/2023]
Abstract
Family history of breast cancer is a key risk factor, accounting for up to 10% of cancers. We evaluated the proactive assessment of familial breast cancer (FBC) risk in primary care. Eligible women (30 to 60 years) were recruited from eight English general practices. Practices were trained on FBC risk assessment. In four randomly-assigned practices, women were invited to complete a validated, postal family history questionnaire, which practice staff inputted into decision support software to determine cancer risk. Those with increased risk were offered specialist referral. Usual care was observed in the other four practices. In intervention practices, 1127/7012 women (16.1%) returned family history questionnaires, comprising 1105 (98%) self-reported white ethnicity and 446 (39.6%) educated to University undergraduate or equivalent qualification, with 119 (10.6%) identified at increased breast cancer risk and offered referral. Sixty-seven (56%) women recommended referral were less than 50 years old. From 66 women attending specialists, 26 (39.4%) were confirmed to have high risk and recommended annual surveillance (40–60 years) and surgical prevention; while 30 (45.5%) were confirmed at moderate risk, with 19 offered annual surveillance (40–50 years). The remaining 10 (15.2%) managed in primary care. None were recommended chemoprevention. In usual care practices, only ten women consulted with concerns about breast cancer family history. This study demonstrated proactive risk assessment in primary care enables accurate identification of women, including many younger women, at increased risk of breast cancer. To improve generalisability across the population, more active methods of engagement need to be explored. Trial registration: CRUK Clinical Trials Database 11779.
Collapse
Affiliation(s)
- Nadeem Qureshi
- Division of Primary Care, NIHR School for Primary Care Research, School of Medicine, University of Nottingham, 13th Floor, Tower Building, Nottingham, NG7 2RD, UK.
| | - Brittany Dutton
- Division of Primary Care, NIHR School for Primary Care Research, School of Medicine, University of Nottingham, 13th Floor, Tower Building, Nottingham, NG7 2RD, UK
| | - Stephen Weng
- Division of Primary Care, NIHR School for Primary Care Research, School of Medicine, University of Nottingham, 13th Floor, Tower Building, Nottingham, NG7 2RD, UK
| | - Christina Sheehan
- Division of Primary Care, NIHR School for Primary Care Research, School of Medicine, University of Nottingham, 13th Floor, Tower Building, Nottingham, NG7 2RD, UK
| | - Wendy Chorley
- University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, UK
| | | | - Denise Kendrick
- Division of Primary Care, NIHR School for Primary Care Research, School of Medicine, University of Nottingham, 13th Floor, Tower Building, Nottingham, NG7 2RD, UK
| | - Joe Kai
- Division of Primary Care, NIHR School for Primary Care Research, School of Medicine, University of Nottingham, 13th Floor, Tower Building, Nottingham, NG7 2RD, UK
| |
Collapse
|
18
|
Rainey L, van der Waal D, Jervaeus A, Donnelly LS, Evans DG, Hammarström M, Hall P, Wengström Y, Broeders MJM. European women's perceptions of the implementation and organisation of risk-based breast cancer screening and prevention: a qualitative study. BMC Cancer 2020; 20:247. [PMID: 32209062 PMCID: PMC7092605 DOI: 10.1186/s12885-020-06745-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/12/2020] [Indexed: 01/28/2023] Open
Abstract
Background Increased knowledge of breast cancer risk factors has meant that we are currently exploring risk-based screening, i.e. determining screening strategies based on women’s varying levels of risk. This also enables risk management through primary prevention strategies, e.g. a lifestyle programme or risk-reducing medication. However, future implementation of risk-based screening and prevention will warrant significant changes in current practice and policy. The present study explores women’s perceptions of the implementation and organisation of risk-based breast cancer screening and prevention to optimise acceptability and uptake. Methods A total of 143 women eligible for breast cancer screening in the Netherlands, the United Kingdom, and Sweden participated in focus group discussions. The focus group discussions were transcribed verbatim and the qualitative data was analysed using thematic analysis. Results Women from all three countries generally agreed on the overall proceedings, e.g. a risk assessment after which the risk estimate is communicated via letter (for below average and average risk) or consultation (for moderate and high risk). However, discrepancies in information needs, preferred risk communication format and risk counselling professional were identified between countries. Additionally, a need to educate healthcare professionals on all aspects of the risk-based screening and prevention programme was established. Conclusion Women’s insights identified the need for country-specific standardised protocols regarding the assessment and communication of risk, and the provision of heterogeneous screening and prevention recommendations, monitoring the principle of solidarity in healthcare policy.
Collapse
Affiliation(s)
- Linda Rainey
- Radboud Institute for Health Sciences, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Daniëlle van der Waal
- Radboud Institute for Health Sciences, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Anna Jervaeus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Alfred, Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - Louise S Donnelly
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - D Gareth Evans
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK.,Genomic Medicine, Division of Evolution and Genomic Sciences, Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,The Christie NHS Foundation Trust, Withington, Manchester, M20 4BX, UK
| | - Mattias Hammarström
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 77, Stockholm, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 77, Stockholm, Sweden.,Department of Oncology, Södersjukhuset, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Alfred, Nobels allé 23, 23300, 14183, Huddinge, Sweden.,Theme Cancer, Karolinska University Hospital, Alfred Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - Mireille J M Broeders
- Radboud Institute for Health Sciences, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Dutch Expert Centre for Screening, PO Box 6873, 6503 GJ, Nijmegen, The Netherlands
| |
Collapse
|
19
|
Characteristics predicting recommendation for familial breast cancer referral in a cohort of women from primary care. J Community Genet 2020; 11:331-338. [PMID: 31965555 PMCID: PMC7295867 DOI: 10.1007/s12687-020-00452-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/14/2020] [Indexed: 11/03/2022] Open
Abstract
Family history of breast and related cancers can indicate increased breast cancer (BC) risk. In national familial breast cancer (FBC) guidelines, the risk is stratified to guide referral decisions. We aimed to identify characteristics associated with the recommendation for referral in a large cohort of women undergoing FBC risk assessment in a recent primary care study. Demographic, family history, psychological and behavioural factors were collected with family history questionnaires, psychological questionnaires and manual data extraction from general practice electronic health records. Participants were women aged 30–60 with no previous history of breast or ovarian cancer. Data from 1127 women were analysed with stepwise logistic regression. Two multivariable logistic models were developed to predict recommendations for referral: using the entire cohort (n = 1127) and in a subgroup with uncertain risks (n = 168). Model performance was assessed by the area under the receiver operating curve (AUC). In all 1127 women, a multivariable model incorporating five family history components (BC aged < 40, bilateral BC, prostate cancer, first degree relative with ovarian cancer, paternal family history of BC) and having a mammogram in the last 3 years, performed well (AUC = 0.86). For the 168 uncertain risk women, only paternal family history of BC remained significant (AUC = 0.71). Clinicians should pay particular attention to these five family history components when assessing FBC risk, especially prostate cancer which is not in the current national guidelines.
Collapse
|
20
|
Harvie M, Pegington M, French D, Cooper G, McDiarmid S, Howell A, Donnelly L, Ruane H, Sellers K, Foden P, Evans DG. Breast cancer risk status influences uptake, retention and efficacy of a weight loss programme amongst breast cancer screening attendees: two randomised controlled feasibility trials. BMC Cancer 2019; 19:1089. [PMID: 31795966 PMCID: PMC6892016 DOI: 10.1186/s12885-019-6279-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 10/21/2019] [Indexed: 01/01/2023] Open
Abstract
Background Excess body weight and sub-optimal lifestyle are modifiable causes of breast cancer and other diseases. There is little evidence that behaviour change is possible within screening programmes and whether this is influenced by prior knowledge of disease risk. We determined whether breast cancer risk influences uptake, retention and efficacy of a weight control programme in the UK National Health Service Breast Screening Programme, and whether additional cardiovascular disease and type 2 diabetes risk information improves uptake and retention further. Method Overweight/obese women in the UK National Health Service Breast Screening Programme identified at high, moderately increased, average and low-risk of breast cancer were randomised to receive individualised breast cancer risk information (breast cancer prevention programme), or individualised breast cancer, cardiovascular disease (QRISK2) and type 2 diabetes (QDiabetes, HbA1c) information (multiple disease prevention programme). Personalised breast cancer risk feedback was given before randomisation in Study-1, and after randomisation in Study-2. Results Recruitment was 9% (126/1356) in Study-1 and 7% (52/738) in Study-2. With respect to breast cancer risk, odds ratio of uptake for high/moderately increased vs low risk women was 1.99 (95% CI 1.24–3.17, P = 0.004) in Study-1 and 3.58 (95% CI 1.59–8.07, P = 0.002) in Study-2. Odds ratio of retention for high/moderately increased -risk vs. low risk women was 2.98 (95% CI 1.05–8.47, P = 0.041) in Study-1 and 3.88 (95% CI 1.07–14.04, P = 0.039) in Study-2. Weight loss of ≥5% at 12 months was achieved by 63% high/moderate vs. 43% low-risk women in Study-1 (P = 0.083) and 39% vs. 8% in Study-2 (P = 0.008). Uptake, retention and weight loss were equivalent in both the breast cancer prevention programme and the multiple disease prevention programme in both studies. Conclusions Women who are informed that they are at increased breast cancer risk were significantly more likely to join and remain in the programmes and consequently lose more weight across both studies. High risk women are more likely engage in a lifetyle prevention programme and also have the greatest potential benefit fom risk reduction strategies. Trial registration ISRCTN91372184 Registered 28 September 2014.
Collapse
Affiliation(s)
- Michelle Harvie
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England. .,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England. .,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.
| | - Mary Pegington
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England.,Division of Cancer Sciences, The University of Manchester, Wilmslow Road, Manchester, M20 4BX, England.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - David French
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.,Manchester Centre for Health Psychology, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - Grace Cooper
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Sarah McDiarmid
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Anthony Howell
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.,Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, England
| | - Louise Donnelly
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Helen Ruane
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Katharine Sellers
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Philip Foden
- Department of Medical Statistics, Education and Research Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - D Gareth Evans
- The Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.,Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, England
| |
Collapse
|
21
|
New evidence confirms that reproductive risk factors can be used to stratify breast cancer risks: Implications for a new population screening paradigm. Eur J Cancer 2019; 124:204-206. [PMID: 31784063 DOI: 10.1016/j.ejca.2019.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 10/18/2019] [Indexed: 11/20/2022]
|
22
|
Sporadic implementation of UK familial mammographic surveillance guidelines 15 years after original publication. Br J Cancer 2019; 122:329-332. [PMID: 31761901 PMCID: PMC7000386 DOI: 10.1038/s41416-019-0631-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/14/2019] [Indexed: 11/25/2022] Open
Abstract
The National Institute of health and Care Excellence issued guidelines on familial breast cancer screening in 2004. Such guidelines should be uniformly implemented to ensure that members of the same family with the same level of risk, but living in different areas, have the same access to screening. We assessed uptake by creating a short, six question online survey designed to assess compliance in each regional area. We used this to conduct a survey of all 22 regional genetics services. There was a 100% response to the survey allowing a complete map to be created. The devolved nations had near complete compliance with the sole exception of SW Scotland, but in England the picture was fragmented with regions representing a combined population of 26.6 million (48%) not implementing the full NICE recommendations. Fifteen years after the publication of the original guidelines, major inequity in provision for screening still occurs and a postcode lottery exists for the management of women from families with a history of breast cancer. We estimate that up to 73 preventable breast cancer deaths occur each year due to the current inequity of access. It may be time to consider alternative funding and implementation models to ensure consistent access across the country.
Collapse
|
23
|
Breast Cancer in Young Women: Status Quo and Advanced Disease Management by a Predictive, Preventive, and Personalized Approach. Cancers (Basel) 2019; 11:cancers11111791. [PMID: 31739537 PMCID: PMC6896106 DOI: 10.3390/cancers11111791] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 12/24/2022] Open
Abstract
Why does healthcare of breast cancer (BC) patients, especially in a young population, matter and why are innovative strategies by predictive, preventive, and personalized medicine (PPPM) strongly recommended to replace current reactive medical approach in BC management? Permanent increase in annual numbers of new BC cases with particularly quick growth of premenopausal BC patients, an absence of clearly described risk factors for those patients, as well as established screening tools and programs represent important reasons to focus on BC in young women. Moreover, "young" BC cases are frequently "asymptomatic", difficult to diagnose, and to treat effectively on time. The objective of this article is to update the knowledge on BC in young females, its unique molecular signature, newest concepts in diagnostics and therapy, and to highlight the concepts of predictive, preventive, and personalized medicine with a well-acknowledged potential to advance the overall disease management.
Collapse
|
24
|
Evans D, Thomas S, Caunt J, Burch A, Brentnall A, Roberts L, Howell A, Wilson M, Fox R, Hillier S, Sibbering D, Moss S, Wallis M, Eccles D, Duffy S. Final Results of the Prospective FH02 Mammographic Surveillance Study of Women Aged 35-39 at Increased Familial Risk of Breast Cancer. EClinicalMedicine 2019; 7:39-46. [PMID: 31008449 PMCID: PMC6472550 DOI: 10.1016/j.eclinm.2019.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/24/2018] [Accepted: 01/16/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Many women who are at increased risk of breast cancer due to a mother or sister diagnosed with breast cancer aged under 40 do not currently qualify for surveillance before 40 years of age. There are almost no available data to assess whether mammography screening aged 35-39 years would be effective in this group, in terms of detection of breast cancer at an early stage or cost effective. METHODS A cohort screening study (FH02) with annual mammography was devised for women aged 35-39 to assess the sensitivity and screening performance and potential survival of women with identified tumours. FINDINGS 2899 women were recruited from 12/2006-12/2015. These women underwent 12,086 annual screening mammograms and were followed for 13,365.8 years. A total of 55 breast cancers in 54 women occurred during the study period (one bilateral) with 50 cancers (49 women) (15 CIS) adherent to the screening. Eighty percent (28/35) of invasive cancers were ≤ 2 cm and 80% also lymph node negative. Invasive cancers diagnosed in FH02 were significantly smaller than the comparable (POSH-unscreened prospective) study group (45% (131/293) ≤ 2 cm in POSH vs 80% (28/35) in FH02 p < 0.0001), and were less likely to be lymph-node positive (54% (158/290, 3 unknown) in POSH vs 20% (7/35) in FH02: p = 0.0002. Projected and actual survival were also better than POSH. Overall radiation dose was not higher than in an older screened population at mean dose on study per standard sized breast of 1.5 mGy. INTERPRETATION Mammography screening aged 35-39 years detects breast cancer at an early stage and is likely to be as effective in reducing mortality as in women at increased breast cancer risk aged 40-49 years.
Collapse
Affiliation(s)
- D.G. Evans
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Wythenshawe, Manchester M23 9LT, UK
- Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester Universities Foundation Trust, St. Mary's Hospital, Oxford Road, Manchester M13 9WL, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Christie Hospital, Withington, Manchester M20 4BX, UK
| | - S. Thomas
- Breast Test Wales, 18 Cathedral Road, Cardiff CF11 9LJ, UK
| | - J. Caunt
- Breast Test Wales, 18 Cathedral Road, Cardiff CF11 9LJ, UK
| | - A. Burch
- Breast Test Wales, 18 Cathedral Road, Cardiff CF11 9LJ, UK
| | - A.R. Brentnall
- Cancer Research UK Centre for Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine' Charterhouse Square, London EC1M 6BQ, UK
| | - L. Roberts
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Wythenshawe, Manchester M23 9LT, UK
| | - A. Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Christie Hospital, Withington, Manchester M20 4BX, UK
| | - M. Wilson
- Breast Screening Unit, Nightingale Centre, Wythenshawe Hospital, Manchester University Foundation Trust, Wythenshawe, Manchester M23 9LT, UK
| | - R. Fox
- Breast Test Wales, 18 Cathedral Road, Cardiff CF11 9LJ, UK
| | - S. Hillier
- Breast Test Wales, 18 Cathedral Road, Cardiff CF11 9LJ, UK
| | | | - S. Moss
- Cancer Research UK Centre for Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine' Charterhouse Square, London EC1M 6BQ, UK
| | - M.G. Wallis
- Cambridge Breast Unit, NIHR Cambridge Biomedical Research Unit, Box 97, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - D.M. Eccles
- Faculty of Medicine, University of Southampton, University Road, Southampton, SO17 1BJ, UK
| | | | - S. Duffy
- Cancer Research UK Centre for Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine' Charterhouse Square, London EC1M 6BQ, UK
| |
Collapse
|
25
|
Frank RD, Winham SJ, Vierkant RA, Frost MH, Radisky DC, Ghosh K, Brandt KR, Sherman ME, Visscher DW, Hartmann LC, Degnim AC, Vachon CM. Evaluation of 2 breast cancer risk models in a benign breast disease cohort. Cancer 2018; 124:3319-3328. [PMID: 29932456 PMCID: PMC6108911 DOI: 10.1002/cncr.31528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/02/2018] [Accepted: 03/18/2018] [Indexed: 11/06/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ryan D. Frank
- Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Stacey J. Winham
- Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Robert A. Vierkant
- Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Marlene H. Frost
- Woman’s Cancer Program, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Derek C. Radisky
- Cancer Biology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL. 322245
- General Internal Medicine, Breast Diagnostic Clinic, Mayo Clinic, 200 First Street SW
| | - Karthik Ghosh
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Kathleen R. Brandt
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Mark E. Sherman
- Health Sciences Research, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL
| | | | - Lynn C. Hartmann
- Woman’s Cancer Program, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Amy C. Degnim
- Woman’s Cancer Program, Mayo Clinic, 200 First Street SW, Rochester, MN
- Breast, Endocrine, Metabolic, and GI Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Celine M. Vachon
- Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN
| |
Collapse
|
26
|
Curtis HJ, Walker AJ, Goldacre B. Impact of NICE guidance on tamoxifen prescribing in England 2011-2017: an interrupted time series analysis. Br J Cancer 2018; 118:1268-1275. [PMID: 29681615 PMCID: PMC5943266 DOI: 10.1038/s41416-018-0065-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 02/28/2018] [Accepted: 03/05/2018] [Indexed: 11/30/2022] Open
Abstract
Background Tamoxifen was recommended by NICE in 2013 for chemoprevention of breast cancer, but a recent survey suggested only a quarter of GPs are aware of this. We set out to measure the uptake of tamoxifen, and the alternative raloxifene, in national prescribing data sets. Methods Tamoxifen and raloxifene data were extracted from England’s monthly prescribing data sets, October 2010–October 2017. We used interrupted time series analysis to reveal national and local responses to guidelines. We investigated variation between practices by calculating percentiles for prescribing rates and ratios of change. Results We found an increase in monthly tamoxifen prescribing following release of the guidelines, with an increase in gradient (p = 0.001) but no step change (p = 0.342). Alongside a small change in raloxifene prescribing we estimate 8450 women took up chemoprevention between 2013 and 2016. We did not find evidence that this was limited to a small group of practices. Conclusions Our results suggest that the uptake of new guidance on chemoprevention has been slow and has potentially left women exposed to avoidable risk. Improving dissemination of guidance to healthcare professionals and routinely monitoring implementation could help reduce this risk.
Collapse
Affiliation(s)
- Helen J Curtis
- Evidence Based Medicine DataLab, Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom
| | - Alex J Walker
- Evidence Based Medicine DataLab, Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom
| | - Ben Goldacre
- Evidence Based Medicine DataLab, Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom.
| |
Collapse
|
27
|
Evans DG, Howell SJ, Howell A. Personalized prevention in high risk individuals: Managing hormones and beyond. Breast 2018; 39:139-147. [PMID: 29610032 DOI: 10.1016/j.breast.2018.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/17/2018] [Accepted: 03/24/2018] [Indexed: 12/01/2022] Open
Abstract
Increasing numbers of women are being identified at 'high-risk' of breast cancer, defined by The National Institute of Health and Care Excellence (NICE) as a 10-year risk of ≥8%. Classically women have been so identified through family history based risk algorithms or genetic testing of high-risk genes. Recent research has shown that assessment of mammographic density and single nucleotide polymorphisms (SNPs), when combined with established risk factors, trebles the number of women reaching the high risk threshold. The options for risk reduction in such women include endocrine chemoprevention with the selective estrogen receptor modulators tamoxifen and raloxifene or the aromatase inhibitors anastrozole or exemestane. NICE recommends offering anastrozole to postmenopausal women at high-risk of breast cancer as cost effectiveness analysis showed this to be cost saving to the National Health Service. Overall uptake to chemoprevention has been disappointingly low but this may improve with the improved efficacy of aromatase inhibitors, particularly the lack of toxicity to the endometrium and thrombogenic risks. Novel approaches to chemoprevention under investigation include lower dose and topical tamoxifen, denosumab, anti-progestins and metformin. Although oophorectomy is usually only recommended to women at increased risk of ovarian cancer it has been shown in numerous studies to reduce breast cancer risks in the general population and in those with mutations in BRCA1/2. However, recent evidence from studies that have confined analysis to true prospective follow up have cast doubt on the efficacy of oophorectomy to reduce breast cancer risk in BRCA1 mutation carriers, at least in the short-term.
Collapse
Affiliation(s)
- D Gareth Evans
- Manchester Centre for Genomic Medicine, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK.
| | - Sacha J Howell
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Anthony Howell
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| |
Collapse
|
28
|
Cuzick J, Brentnall AR, Segal C, Byers H, Reuter C, Detre S, Lopez-Knowles E, Sestak I, Howell A, Powles TJ, Newman WG, Dowsett M. Impact of a Panel of 88 Single Nucleotide Polymorphisms on the Risk of Breast Cancer in High-Risk Women: Results From Two Randomized Tamoxifen Prevention Trials. J Clin Oncol 2017; 35:743-750. [PMID: 28029312 PMCID: PMC5455424 DOI: 10.1200/jco.2016.69.8944] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Purpose At least 94 common single nucleotide polymorphisms (SNPs) are associated with breast cancer. The extent to which an SNP panel can refine risk in women who receive preventive therapy has not been directly assessed previously. Materials and Methods A risk score on the basis of 88 SNPs (SNP88) was investigated in a nested case-control study of women enrolled in the International Breast Intervention Study (IBIS-I) or the Royal Marsden study. A total of 359 women who developed cancer were matched to 636 controls by age, trial, follow-up time, and treatment arm. Genotyping was done using the OncoArray. Conditional logistic regression and matched concordance indices (mC) were used to measure the performance of SNP88 alone and with other breast cancer risk factors assessed using the Tyrer-Cuzick (TC) model. Results SNP88 was predictive of breast cancer risk overall (interquartile range odds ratio [IQ-OR], 1.37; 95% CI, 1.14 to 1.66; mC, 0.55), but mainly for estrogen receptor-positive disease (IQ-OR, 1.44; 95% CI, 1.16 to 1.79; P for heterogeneity = .10) versus estrogen receptor-negative disease. However, the observed risk of SNP88 was only 46% (95% CI, 19% to 74%) of expected. No significant interaction was observed with treatment arm (placebo IQ-OR, 1.46; 95% CI, 1.13 to 1.87; tamoxifen IQ-OR, 1.25; 95% CI, 0.96 to 1.64; P for heterogeneity = .5). The predictive power was similar to the TC model (IQ-OR, 1.45; 95% CI, 1.21 to 1.73; mC, 0.55), but SNP88 was independent of TC (Spearman rank-order correlation, 0.012; P = .7), and when combined multiplicatively, a substantial improvement was seen (IQ-OR, 1.64; 95% CI, 1.36 to 1.97; mC, 0.60). Conclusion A polygenic risk score may be used to refine risk from the TC or similar models in women who are at an elevated risk of breast cancer and considering preventive therapy. Recalibration may be necessary for accurate risk assessment.
Collapse
Affiliation(s)
- Jack Cuzick
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Adam R. Brentnall
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Corrinne Segal
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Helen Byers
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Caroline Reuter
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Simone Detre
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Elena Lopez-Knowles
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ivana Sestak
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Anthony Howell
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Trevor J. Powles
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - William G. Newman
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Mitchell Dowsett
- Jack Cuzick, Adam R. Brentnall, Caroline Reuter, and Ivana Sestak, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; Corrinne Segal, The Institute of Cancer Research; Corrinne Segal, Simone Detre, Elena Lopez-Knowles, and Mitchell Dowsett, Royal Marsden Hospital; Trevor J. Powles, Cancer Centre London, London; Helen Byers and William G. Newman, University of Manchester and Central Manchester Foundation Trust; and Anthony Howell, The Christie NHS Foundation Trust, Manchester, United Kingdom
| |
Collapse
|
29
|
Evans DG, Astley S, Stavrinos P, Harkness E, Donnelly LS, Dawe S, Jacob I, Harvie M, Cuzick J, Brentnall A, Wilson M, Harrison F, Payne K, Howell A. Improvement in risk prediction, early detection and prevention of breast cancer in the NHS Breast Screening Programme and family history clinics: a dual cohort study. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04110] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BackgroundIn the UK, women are invited for 3-yearly mammography screening, through the NHS Breast Screening Programme (NHSBSP), from the ages of 47–50 years to the ages of 69–73 years. Women with family histories of breast cancer can, from the age of 40 years, obtain enhanced surveillance and, in exceptionally high-risk cases, magnetic resonance imaging. However, no NHSBSP risk assessment is undertaken. Risk prediction models are able to categorise women by risk using known risk factors, although accurate individual risk prediction remains elusive. The identification of mammographic breast density (MD) and common genetic risk variants [single nucleotide polymorphisms (SNPs)] has presaged the improved precision of risk models.ObjectivesTo (1) identify the best performing model to assess breast cancer risk in family history clinic (FHC) and population settings; (2) use information from MD/SNPs to improve risk prediction; (3) assess the acceptability and feasibility of offering risk assessment in the NHSBSP; and (4) identify the incremental costs and benefits of risk stratified screening in a preliminary cost-effectiveness analysis.DesignTwo cohort studies assessing breast cancer incidence.SettingHigh-risk FHC and the NHSBSP Greater Manchester, UK.ParticipantsA total of 10,000 women aged 20–79 years [Family History Risk Study (FH-Risk); UK Clinical Research Network identification number (UKCRN-ID) 8611] and 53,000 women from the NHSBSP [aged 46–73 years; Predicting the Risk of Cancer At Screening (PROCAS) study; UKCRN-ID 8080].InterventionsQuestionnaires collected standard risk information, and mammograms were assessed for breast density by a number of techniques. All FH-Risk and 10,000 PROCAS participants participated in deoxyribonucleic acid (DNA) studies. The risk prediction models Manual method, Tyrer–Cuzick (TC), BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm) and Gail were used to assess risk, with modelling based on MD and SNPs. A preliminary model-based cost-effectiveness analysis of risk stratified screening was conducted.Main outcome measuresBreast cancer incidence.Data sourcesThe NHSBSP; cancer registration.ResultsA total of 446 women developed incident breast cancers in FH-Risk in 97,958 years of follow-up. All risk models accurately stratified women into risk categories. TC had better risk precision than Gail, and BOADICEA accurately predicted risk in the 6268 single probands. The Manual model was also accurate in the whole cohort. In PROCAS, TC had better risk precision than Gail [area under the curve (AUC) 0.58 vs. 0.54], identifying 547 prospective breast cancers. The addition of SNPs in the FH-Risk case–control study improved risk precision but was not useful inBRCA1(breast cancer 1 gene) families. Risk modelling of SNPs in PROCAS showed an incremental improvement from using SNP18 used in PROCAS to SNP67. MD measured by visual assessment score provided better risk stratification than automatic measures, despite wide intra- and inter-reader variability. Using a MD-adjusted TC model in PROCAS improved risk stratification (AUC = 0.6) and identified significantly higher rates (4.7 per 10,000 vs. 1.3 per 10,000;p < 0.001) of high-stage cancers in women with above-average breast cancer risks. It is not possible to provide estimates of the incremental costs and benefits of risk stratified screening because of lack of data inputs for key parameters in the model-based cost-effectiveness analysis.ConclusionsRisk precision can be improved by using DNA and MD, and can potentially be used to stratify NHSBSP screening. It may also identify those at greater risk of high-stage cancers for enhanced screening. The cost-effectiveness of risk stratified screening is currently associated with extensive uncertainty. Additional research is needed to identify data needed for key inputs into model-based cost-effectiveness analyses to identify the impact on health-care resource use and patient benefits.Future workA pilot of real-time NHSBSP risk prediction to identify women for chemoprevention and enhanced screening is required.FundingThe National Institute for Health Research Programme Grants for Applied Research programme. The DNA saliva collection for SNP analysis for PROCAS was funded by the Genesis Breast Cancer Prevention Appeal.
Collapse
Affiliation(s)
- D Gareth Evans
- Department of Genomic Medicine, Institute of Human Development, Manchester Academic Health Science Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Susan Astley
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
| | - Paula Stavrinos
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Elaine Harkness
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
| | - Louise S Donnelly
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Sarah Dawe
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Ian Jacob
- Department of Health Economics, University of Manchester, Manchester, UK
| | - Michelle Harvie
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Adam Brentnall
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Mary Wilson
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | | | - Katherine Payne
- Department of Health Economics, University of Manchester, Manchester, UK
| | - Anthony Howell
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| |
Collapse
|
30
|
Evans DGR, Donnelly LS, Harkness EF, Astley SM, Stavrinos P, Dawe S, Watterson D, Fox L, Sergeant JC, Ingham S, Harvie MN, Wilson M, Beetles U, Buchan I, Brentnall AR, French DP, Cuzick J, Howell A. Breast cancer risk feedback to women in the UK NHS breast screening population. Br J Cancer 2016; 114:1045-52. [PMID: 27022688 PMCID: PMC4984905 DOI: 10.1038/bjc.2016.56] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 01/20/2016] [Accepted: 02/11/2016] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION There are widespread moves to develop risk-stratified approaches to population-based breast screening. The public needs to favour receiving breast cancer risk information, which ideally should produce no detrimental effects. This study investigates risk perception, the proportion wishing to know their 10-year risk and whether subsequent screening attendance is affected. METHODS Fifty thousand women attending the NHS Breast Screening Programme completed a risk assessment questionnaire. Ten-year breast cancer risks were estimated using a validated algorithm (Tyrer-Cuzick) adjusted for visually assessed mammographic density. Women at high risk (⩾8%) and low risk (<1%) were invited for face-to-face or telephone risk feedback and counselling. RESULTS Of those invited to receive risk feedback, more high-risk women, 500 out of 673 (74.3%), opted to receive a consultation than low-risk women, 106 out of 193 (54.9%) (P<0.001). Women at high risk were significantly more likely to perceive their risk as high (P<0.001) and to attend their subsequent mammogram (94.4%) compared with low-risk women (84.2%; P=0.04) and all attendees (84.3%; ⩽0.0001). CONCLUSIONS Population-based assessment of breast cancer risk is feasible. The majority of women wished to receive risk information. Perception of general population breast cancer risk is poor. There were no apparent adverse effects on screening attendance for high-risk women whose subsequent screening attendance was increased.
Collapse
Affiliation(s)
- D Gareth R Evans
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Genomic Medicine, Manchester Academic Health Sciences Centre, University of Manchester and Central Manchester Foundation Trust, Manchester M13 9WL, UK
- The Christie NHS Foundation Trust, Withington, Manchester M20 4BX, UK
| | - Louise S Donnelly
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Elaine F Harkness
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Centre for Imaging Sciences, Institute for Population Health, University of Manchester, Oxford Road, Manchester M13 9PT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Susan M Astley
- Centre for Imaging Sciences, Institute for Population Health, University of Manchester, Oxford Road, Manchester M13 9PT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Paula Stavrinos
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Sarah Dawe
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Donna Watterson
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Lynne Fox
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Jamie C Sergeant
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester M13 9PT, UK
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
| | - Sarah Ingham
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Vaughan House, Portsmouth Street, Manchester M13 9GB, UK
| | - Michelle N Harvie
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Mary Wilson
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Ursula Beetles
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Iain Buchan
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Vaughan House, Portsmouth Street, Manchester M13 9GB, UK
| | - Adam R Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - David P French
- School of Psychological Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - Anthony Howell
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- The Christie NHS Foundation Trust, Withington, Manchester M20 4BX, UK
- Centre for Imaging Sciences, Institute for Population Health, University of Manchester, Oxford Road, Manchester M13 9PT, UK
| |
Collapse
|
31
|
Brentnall AR, Harkness EF, Astley SM, Donnelly LS, Stavrinos P, Sampson S, Fox L, Sergeant JC, Harvie MN, Wilson M, Beetles U, Gadde S, Lim Y, Jain A, Bundred S, Barr N, Reece V, Howell A, Cuzick J, Evans DGR. Mammographic density adds accuracy to both the Tyrer-Cuzick and Gail breast cancer risk models in a prospective UK screening cohort. Breast Cancer Res 2015; 17:147. [PMID: 26627479 PMCID: PMC4665886 DOI: 10.1186/s13058-015-0653-5] [Citation(s) in RCA: 161] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/06/2015] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION The Predicting Risk of Cancer at Screening study in Manchester, UK, is a prospective study of breast cancer risk estimation. It was designed to assess whether mammographic density may help in refinement of breast cancer risk estimation using either the Gail model (Breast Cancer Risk Assessment Tool) or the Tyrer-Cuzick model (International Breast Intervention Study model). METHODS Mammographic density was measured at entry as a percentage visual assessment, adjusted for age and body mass index. Tyrer-Cuzick and Gail 10-year risks were based on a questionnaire completed contemporaneously. Breast cancers were identified at the entry screen or shortly thereafter. The contribution of density to risk models was assessed using odds ratios (ORs) with profile likelihood confidence intervals (CIs) and area under the receiver operating characteristic curve (AUC). The calibration of predicted ORs was estimated as a percentage [(observed vs expected (O/E)] from logistic regression. RESULTS The analysis included 50,628 women aged 47-73 years who were recruited between October 2009 and September 2013. Of these, 697 had breast cancer diagnosed after enrolment. Median follow-up was 3.2 years. Breast density [interquartile range odds ratio (IQR-OR) 1.48, 95 % CI 1.34-1.63, AUC 0.59] was a slightly stronger univariate risk factor than the Tyrer-Cuzick model [IQR-OR 1.36 (95 % CI 1.25-1.48), O/E 60 % (95 % CI 44-74), AUC 0.57] or the Gail model [IQR-OR 1.22 (95 % CI 1.12-1.33), O/E 46 % (95 % CI 26-65 %), AUC 0.55]. It continued to add information after allowing for Tyrer-Cuzick [IQR-OR 1.47 (95 % CI 1.33-1.62), combined AUC 0.61] or Gail [IQR-OR 1.45 (95 % CI 1.32-1.60), combined AUC 0.59]. CONCLUSIONS Breast density may be usefully combined with the Tyrer-Cuzick model or the Gail model.
Collapse
Affiliation(s)
- Adam R Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Charterhouse Square, Barts and The London, Queen Mary University of London, London, EC1M 6BQ, UK.
| | - Elaine F Harkness
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
- Centre for Imaging Sciences, Institute for Population Health, University of Manchester, Manchester, UK.
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Susan M Astley
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
- Centre for Imaging Sciences, Institute for Population Health, University of Manchester, Manchester, UK.
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Louise S Donnelly
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Paula Stavrinos
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Sarah Sampson
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Lynne Fox
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Jamie C Sergeant
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UK.
- National Institute for Health Research (NIHR) Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
| | - Michelle N Harvie
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Mary Wilson
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Ursula Beetles
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Soujanya Gadde
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Yit Lim
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Anil Jain
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
- Institute of Cancer Sciences, University of Manchester, Manchester, UK.
| | - Sara Bundred
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Nicola Barr
- Education and Research Centre, University Hospital of South Manchester, Manchester, UK.
| | - Valerie Reece
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
| | - Anthony Howell
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
- The Christie NHS Foundation Trust, Manchester, UK.
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Charterhouse Square, Barts and The London, Queen Mary University of London, London, EC1M 6BQ, UK.
| | - D Gareth R Evans
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.
- The Christie NHS Foundation Trust, Manchester, UK.
- Institute of Human development, Genomic Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
| |
Collapse
|
32
|
Evans DG, Howell A. Can the breast screening appointment be used to provide risk assessment and prevention advice? Breast Cancer Res 2015; 17:84. [PMID: 26155950 PMCID: PMC4496847 DOI: 10.1186/s13058-015-0595-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Breast cancer risk is continuing to increase across all societies with rates in countries with traditionally lower risks catching up with the higher rates in the Western world. Although cure rates from breast cancer have continued to improve such that absolute numbers of breast cancer deaths have dropped in many countries despite rising incidence, only some of this can be ascribed to screening with mammography, and debates over the true value of population-based screening continue. As such, enthusiasm for risk-stratified screening is gaining momentum. Guidelines in a number of countries already suggest more frequent screening in certain higher-risk (particularly, familial) groups, but this could be extended to assessing risks across the population. A number of studies have assessed breast cancer risk by using risk algorithms such as the Gail model, Tyrer-Cuzick, and BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm), but the real questions are when and where such an assessment should take place. Emerging evidence from the PROCAS (Predicting Risk Of Cancer At Screening) study is showing not only that it is feasible to undertake risk assessment at the population screening appointment but that this assessment could allow reduction of screening in lower-risk groups in many countries to 3-yearly screening by using mammographic density-adjusted breast cancer risk.
Collapse
Affiliation(s)
- D Gareth Evans
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK. .,Genomic Medicine, Manchester Academic Health Science Centre, University of Manchester, Central Manchester Foundation Trust, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK. .,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Christie Hospital, Wilmslow Road, Withington, Manchester, M20 4BX, UK.
| | - Anthony Howell
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Christie Hospital, Wilmslow Road, Withington, Manchester, M20 4BX, UK
| |
Collapse
|
33
|
Belkić K, Cohen M, Wilczek B, Andersson S, Berman AH, Márquez M, Vukojević V, Mints M. Imaging surveillance programs for women at high breast cancer risk in Europe: Are women from ethnic minority groups adequately included? (Review). Int J Oncol 2015; 47:817-39. [PMID: 26134040 DOI: 10.3892/ijo.2015.3063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/02/2015] [Indexed: 11/06/2022] Open
Abstract
Women from ethnic minority groups, including immigrants and refugees are reported to have low breast cancer (BC) screening rates. Active, culturally-sensitive outreach is vital for increasing participation of these women in BC screening programs. Women at high BC risk and who belong to an ethnic minority group are of special concern. Such women could benefit from ongoing trials aimed at optimizing screening strategies for early BC detection among those at increased BC risk. Considering the marked disparities in BC survival in Europe and its enormous and dynamic ethnic diversity, these issues are extremely timely for Europe. We systematically reviewed the literature concerning European surveillance studies that had imaging in the protocol and that targeted women at high BC risk. The aim of the present review was thereby to assess the likelihood that women at high BC risk from minority ethnic groups were adequately included in these surveillance programs. Twenty-seven research groups in Europe reported on their imaging surveillance programs for women at increased BC risk. The benefit of strategies such as inclusion of magnetic resonance imaging and/or more intensive screening was clearly documented for the participating women at increased BC risk. However, none of the reports indicated that sufficient outreach was performed to ensure that women at increased BC risk from minority ethnic groups were adequately included in these surveillance programs. On the basis of this systematic review, we conclude that the specific screening needs of ethnic minority women at increased BC risk have not yet been met in Europe. Active, culturally-sensitive outreach is needed to identify minority women at increased BC risk and to facilitate their inclusion in on-going surveillance programs. It is anticipated that these efforts would be most effective if coordinated with the development of European-wide, population-based approaches to BC screening.
Collapse
Affiliation(s)
- Karen Belkić
- The Karolinska Institute and Hospital, Departments of Oncology-Pathology, Women's and Children's Health and of Clinical Neuroscience, Stockholm, Sweden
| | - Miri Cohen
- University of Haifa, Faculty of Social Welfare and Health Sciences, Haifa, Israel
| | - Brigitte Wilczek
- Sankt Görans Hospital, Unilabs Department of Mammography, Stockholm, Sweden
| | - Sonia Andersson
- The Karolinska Institute and Hospital, Departments of Oncology-Pathology, Women's and Children's Health and of Clinical Neuroscience, Stockholm, Sweden
| | - Anne H Berman
- The Karolinska Institute and Hospital, Departments of Oncology-Pathology, Women's and Children's Health and of Clinical Neuroscience, Stockholm, Sweden
| | - Marcela Márquez
- The Karolinska Institute and Hospital, Departments of Oncology-Pathology, Women's and Children's Health and of Clinical Neuroscience, Stockholm, Sweden
| | - Vladana Vukojević
- The Karolinska Institute and Hospital, Departments of Oncology-Pathology, Women's and Children's Health and of Clinical Neuroscience, Stockholm, Sweden
| | - Miriam Mints
- The Karolinska Institute and Hospital, Departments of Oncology-Pathology, Women's and Children's Health and of Clinical Neuroscience, Stockholm, Sweden
| |
Collapse
|