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King TA, Mittendorf EA. Breast Articles From 2023: Informing Practice Across the Continuum of Care. Ann Surg Oncol 2024; 31:4470-4476. [PMID: 38734863 DOI: 10.1245/s10434-024-15387-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024]
Abstract
With new investigations and clinical trials in breast oncology reported every year, it is critical that surgeons be aware of advances and insights into the evolving care paradigms and treatments available to their patients. This article highlights five publications found to be particularly impactful this past year. These articles report on efforts to select the minimal effective dose of tamoxifen for prevention, to challenge the existing age-based screening guidelines as they relate to race and ethnicity, to refine axillary management treatment standards, to optimize systemic therapy in multidisciplinary care settings, and to reduce the burden of breast cancer-related lymphedema after treatment. Taken together, these efforts have an impact on all facets of the continuum of care from prevention and screening through treatment and survivorship.
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Affiliation(s)
- Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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2
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Cheung SM, Chan KS, Zhou W, Husain E, Gagliardi T, Masannat Y, He J. Spatial heterogeneity of peri-tumoural lipid composition in postmenopausal patients with oestrogen receptor positive breast cancer. Sci Rep 2024; 14:4699. [PMID: 38409583 PMCID: PMC10897464 DOI: 10.1038/s41598-024-55458-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: 09/23/2023] [Accepted: 02/23/2024] [Indexed: 02/28/2024] Open
Abstract
Deregulation of lipid composition in adipose tissue adjacent to breast tumour is observed in ex vivo and animal models. Novel non-invasive magnetic resonance imaging (MRI) allows rapid lipid mapping of the human whole breast. We set out to elucidate the spatial heterogeneity of peri-tumoural lipid composition in postmenopausal patients with oestrogen receptor positive (ER +) breast cancer. Thirteen participants (mean age, 62 ± [SD] 6 years) with ER + breast cancer and 13 age-matched postmenopausal healthy controls were scanned on MRI. The number of double bonds in triglycerides was computed from MRI images to derive lipid composition maps of monounsaturated, polyunsaturated, and saturated fatty acids (MUFA, PUFA, SFA). The spatial heterogeneity measures (mean, median, skewness, entropy and kurtosis) of lipid composition in the peri-tumoural region and the whole breast of participants and in the whole breast of controls were computed. The Ki-67 proliferative activity marker and CD163 antibody on tumour-associated macrophages were assessed histologically. Mann Whitney U or Wilcoxon tests and Spearman's coefficients were used to assess group differences and correlations, respectively. For comparison against the whole breast in participants, peri-tumoural MUFA had a lower mean (median (IQR), 0.40 (0.02), p < .001), lower median (0.42 (0.02), p < .001), a negative skewness with lower magnitude (- 1.65 (0.77), p = .001), higher entropy (4.35 (0.64), p = .007) and lower kurtosis (5.13 (3.99), p = .001). Peri-tumoural PUFA had a lower mean (p < .001), lower median (p < .001), a positive skewness with higher magnitude (p = .005) and lower entropy (p = .002). Peri-tumoural SFA had a higher mean (p < .001), higher median (p < .001), a positive skewness with lower magnitude (p < .001) and lower entropy (p = .012). For comparison against the whole breast in controls, peri-tumoural MUFA had a negative skewness with lower magnitude (p = .01) and lower kurtosis (p = .009), however there was no difference in PUFA or SFA. CD163 moderately correlated with peri-tumoural MUFA skewness (rs = - .64), PUFA entropy (rs = .63) and SFA skewness (rs = .59). There was a lower MUFA and PUFA while a higher SFA, and a higher heterogeneity of MUFA while a lower heterogeneity of PUFA and SFA, in the peri-tumoural region in comparison with the whole breast tissue. The degree of lipid deregulation was associated with inflammation as indicated by CD163 antibody on macrophages, serving as potential marker for early diagnosis and response to therapy.
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Affiliation(s)
- Sai Man Cheung
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.
| | - Kwok-Shing Chan
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Wenshu Zhou
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Ehab Husain
- Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Tanja Gagliardi
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Department of Radiology, Royal Marsden Hospital, London, UK
| | - Yazan Masannat
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Broomfield Breast Unit, Broomfield Hospital, Mid and South Essex NHS Trust, Chelmsford, UK
- London Breast Institute, Princess Grace Hospital, London, UK
| | - Jiabao He
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.
- Faculty of Medical Sciences, Newcastle Magnetic Resonance Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
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Serrano D, Gandini S, Thomas P, Crew KD, Kumar NB, Vornik LA, Lee JJ, Veronesi P, Viale G, Guerrieri-Gonzaga A, Lazzeroni M, Johansson H, D’Amico M, Guasone F, Spinaci S, Bertelsen BE, Mellgren G, Bedrosian I, Weber D, Castile T, Dimond E, Heckman-Stoddard BM, Szabo E, Brown PH, DeCensi A, Bonanni B. Efficacy of Alternative Dose Regimens of Exemestane in Postmenopausal Women With Stage 0 to II Estrogen Receptor-Positive Breast Cancer: A Randomized Clinical Trial. JAMA Oncol 2023; 9:664-672. [PMID: 36951827 PMCID: PMC10037202 DOI: 10.1001/jamaoncol.2023.0089] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/06/2022] [Indexed: 03/24/2023]
Abstract
Importance Successful therapeutic cancer prevention requires definition of the minimal effective dose. Aromatase inhibitors decrease breast cancer incidence in high-risk women, but use in prevention and compliance in adjuvant settings are hampered by adverse events. Objective To compare the noninferiority percentage change of estradiol in postmenopausal women with estrogen receptor-positive breast cancer given exemestane, 25 mg, 3 times weekly or once weekly vs a standard daily dose with a noninferiority margin of -6%. Design, Setting, and Participants This multicenter, presurgical, double-blind phase 2b randomized clinical trial evaluated 2 alternative dosing schedules of exemestane. Postmenopausal women with estrogen receptor-positive breast cancer who were candidates for breast surgery were screened from February 1, 2017, to August 31, 2019. Blood samples were collected at baseline and final visit; tissue biomarker changes were assessed from diagnostic biopsy and surgical specimen. Biomarkers were measured in different laboratories between April 2020 and December 2021. Interventions Exemestane, 25 mg, once daily, 3 times weekly, or once weekly for 4 to 6 weeks before surgery. Main Outcomes and Measures Serum estradiol concentrations were measured by solid-phase extraction followed by liquid chromatography-tandem mass spectrometry detection. Toxic effects were evaluated using the National Cancer Institute terminology criteria, and Ki-67 was assessed by immunohistochemistry. Results A total of 180 women were randomized into 1 of the 3 arms; median (IQR) age was 66 (60-71) years, 63 (60-69) years, and 65 (61-70) years in the once-daily, 3-times-weekly, and once-weekly arms, respectively. In the intention-to-treat population (n = 171), the least square mean percentage change of serum estradiol was -89%, -85%, and -60% for exemestane once daily (n = 55), 3 times weekly (n = 56), and once weekly (n = 60), respectively. The difference in estradiol percentage change between the once-daily and 3-times-weekly arms was -3.6% (P for noninferiority = .37), whereas in compliant participants (n = 153), it was 2.0% (97.5% lower confidence limit, -5.6%; P for noninferiority = .02). Among secondary end points, Ki-67 and progesterone receptor were reduced in all arms, with median absolute percentage changes of -7.5%, -5.0%, and -4.0% for Ki-67 in the once-daily, 3-times-weekly, and once-weekly arms, respectively (once daily vs 3 times weekly, P = .31; once daily vs once weekly, P = .06), and -17.0%, -9.0%, and -7.0% for progesterone receptor, respectively. Sex hormone-binding globulin and high-density lipoprotein cholesterol had a better profile among participants in the 3-times-weekly arm compared with once-daily arm. Adverse events were similar in all arms. Conclusions and Relevance In this randomized clinical trial, exemestane, 25 mg, given 3 times weekly in compliant patients was noninferior to the once-daily dosage in decreasing serum estradiol. This new schedule should be further studied in prevention studies and in women who do not tolerate the daily dose in the adjuvant setting. Trial Registration ClinicalTrials.gov Identifier: NCT02598557; EudraCT: 2015-005063-16.
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Affiliation(s)
| | - Sara Gandini
- European Institute of Oncology IRCCS, Milan, Italy
| | | | | | - Nagi B. Kumar
- Moffitt Cancer Center, University of South Florida, Tampa
| | - Lana A. Vornik
- The University of Texas MD Anderson Cancer Center, Houston
| | - J. Jack Lee
- The University of Texas MD Anderson Cancer Center, Houston
| | | | | | | | | | | | | | | | | | - Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Diane Weber
- The University of Texas MD Anderson Cancer Center, Houston
| | - Tawana Castile
- The University of Texas MD Anderson Cancer Center, Houston
| | - Eileen Dimond
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | | | - Eva Szabo
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Powel H. Brown
- The University of Texas MD Anderson Cancer Center, Houston
| | - Andrea DeCensi
- Ospedali Galliera, Genoa, Italy
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, United Kingdom
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Jayasekera J, Zhao A, Schechter C, Lowry K, Yeh JM, Schwartz MD, O'Neill S, Wernli KJ, Stout N, Mandelblatt J, Kurian AW, Isaacs C. Reassessing the Benefits and Harms of Risk-Reducing Medication Considering the Persistent Risk of Breast Cancer Mortality in Estrogen Receptor-Positive Breast Cancer. J Clin Oncol 2023; 41:859-870. [PMID: 36455167 PMCID: PMC9901948 DOI: 10.1200/jco.22.01342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/26/2022] [Accepted: 10/19/2022] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Recent studies, including a meta-analysis of 88 trials, have shown higher than expected rates of recurrence and death in hormone receptor-positive breast cancer. These new findings suggest a need to re-evaluate the use of risk-reducing medication to avoid invasive breast cancer and breast cancer death in high-risk women. METHODS We adapted an established Cancer Intervention and Surveillance Modeling Network model to evaluate the lifetime benefits and harms of risk-reducing medication in women with a ≥ 3% 5-year risk of developing breast cancer according to the Breast Cancer Surveillance Consortium risk calculator. Model input parameters were derived from meta-analyses, clinical trials, and large observational data. We evaluated the effects of 5 years of risk-reducing medication (tamoxifen/aromatase inhibitors) with annual screening mammography ± magnetic resonance imaging (MRI) compared with no screening, MRI, or risk-reducing medication. The modeled outcomes included invasive breast cancer, breast cancer death, side effects, false positives, and overdiagnosis. We conducted subgroup analyses for individual risk factors such as age, family history, and prior biopsy. RESULTS Risk-reducing tamoxifen with annual screening (± MRI) decreased the risk of invasive breast cancer by 40% and breast cancer death by 57%, compared with no tamoxifen or screening. This is equivalent to an absolute reduction of 95 invasive breast cancers, and 42 breast cancer deaths per 1,000 high-risk women. However, these drugs are associated with side effects. For example, tamoxifen could increase the number of endometrial cancers up to 11 per 1,000 high-risk women. Benefits and harms varied by individual characteristics. CONCLUSION The addition of risk-reducing medication to screening could further decrease the risk of breast cancer death. Clinical guidelines for high-risk women should consider integrating shared decision making for risk-reducing medication and screening on the basis of individual risk factors.
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Affiliation(s)
- Jinani Jayasekera
- Population and Community Health Sciences Branch, Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD
| | - Amy Zhao
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
| | - Clyde Schechter
- Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Kathryn Lowry
- Department of Radiology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA
| | - Jennifer M. Yeh
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA
| | - Marc D. Schwartz
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
| | - Suzanne O'Neill
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
| | - Karen J. Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Natasha Stout
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Healthcare Institute, Boston, MA
| | - Jeanne Mandelblatt
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
| | - Allison W. Kurian
- Departments of Medicine and of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Claudine Isaacs
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC
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Lunt L, Coogan A, Perez CB. Lobular Neoplasia. Surg Clin North Am 2022; 102:947-963. [DOI: 10.1016/j.suc.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Buttiron Webber T, Marra D, Puntoni M, Giuliano S, Briata IM, Cevasco I, Clavarezza M, D'Amico M, Defferrari C, Gozza A, Provinciali N, Lazzeroni M, Bonanni B, DeCensi A. Patient- versus physician-reported outcomes in a low-dose tamoxifen trial in noninvasive breast cancer. Breast J 2021; 27:817-823. [PMID: 34626060 DOI: 10.1111/tbj.14296] [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: 04/19/2021] [Revised: 09/28/2021] [Accepted: 09/28/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND We recently conducted a de-escalation trial of low-dose tamoxifen 5 mg/day ("babytam", BT) or placebo given for 3 years in 500 women with noninvasive breast cancer. Women on babytam had a 52% reduction of recurrence (invasive breast cancer or DCIS) after 5 years. Since menopausal symptoms are major reasons for treatment withdrawal during tamoxifen preventive therapy, we compared and analyzed the patient-reported outcomes (PROs) with the physician-reported adverse events and studied their association with recurrence. METHODS Menopausal symptoms recorded by physicians using the Common Terminology Criteria (CTCAEs) were compared with a patient self-reported validated questionnaire reviewed by a research nurse at baseline and every 6 months up to 36 months. Hot flashes (HF), the main outcome measure, were detected through a self-report 7-day diary for frequency and intensity. Treatment adherence and efficacy were assessed by the Kaplan-Meier curves and the Cox model. RESULTS The number of HF events at 12, 24, and 36 months for PROs versus CTCAEs was 246 versus 12, 238 versus 8, and 210 versus 4, respectively. The majority of events were grade 1. There was no difference in PROs between babytam and placebo except for HF daily frequency, which increased by 1.5 events (95% CI, 1.1-1.8) on placebo to 2.1 on babytam (95% CI, 1.7-2.5, p = 0.05). The presence of HF at baseline was a favorable prognostic factor for recurrence and a predictive factor for response to babytam. Adherence was similar between babytam and placebo. CONCLUSIONS The use of PROs is effective for identifying frequent mild grade menopausal symptoms which are underestimated by physicians but important prognostic and predictive factors. Research nurse can use these results as a tool to reassure patients about symptoms, improve adherence to treatment, and limit dropouts.
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Affiliation(s)
| | | | - Matteo Puntoni
- Clinical & Epidemiological Research Unit, University Hospital of Parma, Parma, Italy
| | - Silvia Giuliano
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | | | - Isabella Cevasco
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | | | - Mauro D'Amico
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | | | - Alberto Gozza
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | | | | | | | - Andrea DeCensi
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy.,Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
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Dunne EC, Quinn EM, Stokes M, Barry JM, Kell M, Flanagan F, Kennedy MM, Walsh SM. Upgrade rates and outcomes of screen-detected atypical intraductal epithelial proliferation (AIDEP) diagnosed on core needle biopsy. Breast Dis 2021; 40:155-160. [PMID: 33749633 DOI: 10.3233/bd-201031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Atypical intraductal epithelial proliferation (AIDEP) is a breast lesion categorised as "indeterminate" if identified on core needle biopsy (CNB). The rate at which these lesions are upgraded following diagnostic excision varies in the literature. Women diagnosed with AIDEP are thought to be at increased risk of breast cancer. Our aim was to identify the rate of upgrade to invasive or in situ carcinoma in a group of patients diagnosed with AIDEP on screening mammography and to quantify their risk of subsequent breast cancer. METHODS We conducted a retrospective review of a prospectively maintained database containing all patients diagnosed with AIDEP on CNB between 2005 and 2012 in an Irish breast screening centre. Basic demographic data was collected along with details of the original CNB result, rate of upgrade to carcinoma and details of any subsequent cancer diagnoses. RESULTS In total 113 patients were diagnosed with AIDEP on CNB during the study period. The upgrade rate on diagnostic excision was 28.3% (n = 32). 6.2% (n = 7) were upgraded to invasive cancer and 22.1% (n = 25) to DCIS. 81 patients were not upgraded on diagnostic excision and were offered 5 years of annual mammographic surveillance. 9.88% (8/81) of these patients went on to receive a subsequent diagnosis of malignancy. The mean time to diagnosis of these subsequent cancers was 65.41 months (range 20.18-145.21). CONCLUSION Our data showing an upgrade rate of 28% to carcinoma reflects recently published data and we believe it supports the continued practice of excising AIDEP to exclude co-existing carcinoma.
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Affiliation(s)
- Emma C Dunne
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Edel M Quinn
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Maurice Stokes
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John M Barry
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Malcolm Kell
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fidelma Flanagan
- Department of Breast Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Margaret M Kennedy
- Department of Cellular Pathology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Siun M Walsh
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Padamsee TJ, Hils M, Muraveva A. Understanding low chemoprevention uptake by women at high risk of breast cancer: findings from a qualitative inductive study of women's risk-reduction experiences. BMC Womens Health 2021; 21:157. [PMID: 33863327 PMCID: PMC8052843 DOI: 10.1186/s12905-021-01279-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/22/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Chemoprevention is one of several methods that have been developed to help high-risk women reduce their risk of breast cancer. Reasons for the low uptake of chemoprevention are poorly understood. This paper seeks a deeper understanding of this phenomenon by drawing on women's own narratives about their awareness of chemoprevention and their risk-related experiences. METHODS This research is based on a parent project that included fifty in-depth, semi-structured interviews with a purposive sample of African American and White women at elevated risk of breast cancer. This specific study draws on the forty-seven interviews conducted with women at high or severe risk of breast cancer, all of whom are eligible to use chemoprevention for breast cancer risk-reduction. Interviews were analyzed using grounded theory methods. RESULTS Forty-five percent of participants, and only 21% of African American participants, were aware of chemoprevention options. Women who had seen specialists were more likely to be aware, particularly if they had ongoing specialist access. Aware and unaware women relied on different types of sources for prevention-related information. Those whose main source of information was a healthcare provider were more likely to know about chemoprevention. Aware women used more nuanced information gathering strategies and worried more about cancer. Women simultaneously considered all risk-reduction options they knew about. Those who knew about chemoprevention but were reluctant to use it felt this way for multiple reasons, having to do with potential side effects, perceived extreme-ness of the intervention, similarity to chemotherapy, unknown information about chemoprevention, and reluctance to take medications in general. CONCLUSIONS Lack of chemoprevention awareness is a critical gap in women's ability to make health-protective choices. Future research in this field must consider complexities in both women's perspectives on chemoprevention and the reasons they are reluctant to use it.
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Affiliation(s)
- Tasleem J. Padamsee
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210 USA
| | - Megan Hils
- Lutheran Social Services of Central Ohio, Worthington, OH USA
| | - Anna Muraveva
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH USA
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9
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DeCensi A, Puntoni M, Johansson H, Guerrieri-Gonzaga A, Caviglia S, Avino F, Cortesi L, Ponti A, Pacquola MG, Falcini F, Gulisano M, Digennaro M, Cariello A, Cagossi K, Pinotti G, Lazzeroni M, Serrano D, Briata IM, Buttiron Webber T, Boni L, Bonanni B. Effect Modifiers of Low-Dose Tamoxifen in a Randomized Trial in Breast Noninvasive Disease. Clin Cancer Res 2021; 27:3576-3583. [PMID: 33608319 DOI: 10.1158/1078-0432.ccr-20-4213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/21/2020] [Accepted: 02/17/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Low-dose tamoxifen halved recurrence after surgery in a phase III trial in breast noninvasive disease without increasing adverse events. We explored the effect of low-dose tamoxifen in clinically relevant subgroups, including menopausal status, estradiol levels, smoking, body mass index, and proliferation of baseline lesion. PATIENTS AND METHODS Incidence of invasive breast cancer or ductal carcinoma in situ was the primary endpoint. HRs and interaction terms were estimated using Cox models. RESULTS A favorable HR and 95% confidence interval (CI) could be demonstrated for postmenopausal status (HR = 0.30; 95% CI, 0.11-0.82 vs. HR = 0.73; 95% CI, 0.30-1.76 in premenopausal women; P interaction = 0.13), women with estradiol less than 15.8 pg/mL, presence of menopausal symptoms at baseline, and never smoking (P interaction = 0.07), although the interaction P value was >0.05 for all characteristics. Efficacy was similar in all body mass index categories. Tumors with Ki-67 above the median level of 10% had a greater benefit (HR = 0.27; 95% CI, 0.09-0.81) than those with Ki-67 ≤10% (HR = 1.58; 95% CI, 0.45-5.60; P interaction = 0.04). CONCLUSIONS The efficacy of low-dose tamoxifen seems to be greater in postmenopausal women and in women with lower estradiol levels. Benefits appear to be larger also in women with menopausal symptoms, never smokers, and tumors with Ki-67 >10%. Our results by menopausal status provide important insight into low-dose tamoxifen personalized treatment, although caution is necessary given their exploratory nature. Observation of an improved response in tumors with Ki-67 >10% is consistent but the use of the marker in this setting is investigational.See related commentary by Fabian, p. 3510.
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Affiliation(s)
- Andrea DeCensi
- E.O. Ospedali Galliera, Genoa, Italy. .,Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | | | | | | | | | - Franca Avino
- Istituto Nazionale Tumori "Fondazione Pascale," Naples, Italy
| | - Laura Cortesi
- A. O. Universitaria Policlinico di Modena, Modena, Italy
| | - Antonio Ponti
- CPO Piemonte, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Fabio Falcini
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (I.R.S.T.), Meldola, Italy
| | | | | | | | | | | | | | | | | | | | - Luca Boni
- IRCCS Ospedale San Martino, Genova, Italy
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Macdonald C, Saunders CM, Keogh LA, Hunter M, Mazza D, McLachlan SA, Jones SC, Nesci S, Friedlander ML, Hopper JL, Emery JD, Hickey M, Milne RL, Phillips KA. Breast Cancer Chemoprevention: Use and Views of Australian Women and Their Clinicians. Cancer Prev Res (Phila) 2020; 14:131-144. [PMID: 33115784 DOI: 10.1158/1940-6207.capr-20-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/27/2020] [Accepted: 10/15/2020] [Indexed: 11/16/2022]
Abstract
Guidelines endorse the use of chemoprevention for breast cancer risk reduction. This study examined the barriers and facilitators to chemoprevention use for Australian women at increased risk of breast cancer, and their clinicians. Surveys, based on the Theoretical Domains Framework, were mailed to 1,113 women at ≥16% lifetime risk of breast cancer who were enrolled in the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer cohort study (kConFab), and their 524 treating clinicians. Seven hundred twenty-five women (65%) and 221 (42%) clinicians responded. Only 10 (1.4%) kConFab women had ever taken chemoprevention. Three hundred seventy-eight (52%) kConFab women, two (3%) breast surgeons, and 51 (35%) family physicians were not aware of chemoprevention. For women, the strongest barriers to chemoprevention were side effects (31%) and inadequate information (23%), which operate in the Theoretical Domains Framework domains of "beliefs about consequences" and "knowledge," respectively. Strongest facilitators related to tamoxifen's long-term efficacy (35%, "knowledge," "beliefs about consequences," and "goals" domains), staying healthy for family (13%, "social role" and "goals" domains), and abnormal breast biopsy (13%, "environmental context" domain). The strongest barrier for family physicians was insufficient knowledge (45%, "knowledge" domain) and for breast surgeons was medication side effects (40%, "beliefs about consequences" domain). The strongest facilitators for both clinician groups related to clear guidelines, strong family history, and better tools to select patients ("environmental context and resources" domain). Clinician knowledge and resources, and beliefs about the side-effect consequences of chemoprevention, are key domains that could be targeted to potentially enhance uptake. PREVENTION RELEVANCE: Despite its efficacy in reducing breast cancer incidence, chemoprevention is underutilised. This survey study of Australian women and their clinicians used behavioural change theory to identify modifiable barriers to chemoprevention uptake, and to suggest interventions such as policy change, educational resources and public campaigns, that may increase awareness and use.See related Spotlight by Vogel, p. 1.
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Affiliation(s)
- Courtney Macdonald
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | | | - Louise A Keogh
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Morgan Hunter
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Melbourne, Australia
| | - Sue-Anne McLachlan
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia.,Department of Medical Oncology, St Vincent's Hospital, Fitzroy, Melbourne, Australia
| | - Sandra C Jones
- ACU Engagement, Australian Catholic University, Melbourne, Australia
| | - Stephanie Nesci
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael L Friedlander
- Prince of Wales Clinical School University of New South Wales, Sydney, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Jon D Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Australia.,School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Martha Hickey
- Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women's Hospital, Melbourne, Australia
| | - Roger L Milne
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia.,Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Melbourne, Australia
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11
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Specialist recommendation for chemoprevention medications in patients at familial risk of breast cancer: a cross-sectional survey in England. J Community Genet 2020; 12:111-120. [PMID: 33118147 PMCID: PMC7846641 DOI: 10.1007/s12687-020-00490-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022] Open
Abstract
In England, the National Institute for Health and Care Excellence guideline for familial breast cancer recommends chemoprevention for women at high and moderate familial risk of breast cancer. However, prescribing of chemoprevention has not improved since the introduction of the guideline in 2013. The study aims to identify the current practice, in England, of familial cancer specialists offering chemoprevention and recommending prescribing in primary care. This was an anonymized national cross-sectional survey of familial breast cancer risk services in England. Lead clinicians were sent an online survey link. The survey questions included whether chemoprevention was offered/considered for high- and moderate-risk women, when chemoprevention prescribing and recommendation to primary care started, medications prescribed, age groups considered for chemoprevention, and existence of a shared prescribing protocol with primary care. The survey was sent to 115 hospital services; responses from 50 services (43%) were included in the analysis. Of the 40 services offering chemoprevention for high-risk women, 15 (38%) did not prescribe but 31 (78%) recommended prescribing to primary care. Of the 31 services considering chemoprevention for moderate risk, eight (26%) did not prescribe with 26 (84%) recommended prescribing to primary care. Only three services reported having a shared protocol with primary care. Within 3 years of the guidelines, many services recognized the role of chemoprevention for both high and moderate risk with a key role for primary care to initiate prescribing. However, there is still room for improvement.
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12
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Abstract
Despite decades of laboratory, epidemiological and clinical research, breast cancer incidence continues to rise. Breast cancer remains the leading cancer-related cause of disease burden for women, affecting one in 20 globally and as many as one in eight in high-income countries. Reducing breast cancer incidence will likely require both a population-based approach of reducing exposure to modifiable risk factors and a precision-prevention approach of identifying women at increased risk and targeting them for specific interventions, such as risk-reducing medication. We already have the capacity to estimate an individual woman's breast cancer risk using validated risk assessment models, and the accuracy of these models is likely to continue to improve over time, particularly with inclusion of newer risk factors, such as polygenic risk and mammographic density. Evidence-based risk-reducing medications are cheap, widely available and recommended by professional health bodies; however, widespread implementation of these has proven challenging. The barriers to uptake of, and adherence to, current medications will need to be considered as we deepen our understanding of breast cancer initiation and begin developing and testing novel preventives.
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Affiliation(s)
- Kara L Britt
- Breast Cancer Risk and Prevention Laboratory, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia.
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Kelly-Anne Phillips
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
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13
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Lazzeroni M, Puntoni M, Provinciali N, Webber TB, Briata IM, D'Amico M, Giuliano S, Siri G, Cagnacci S, DeCensi A. Estimating the magnitude of clinical benefit of systemic therapy in patients with DCIS or pre-invasive disease of the breast. Breast 2020; 48 Suppl 1:S39-S43. [PMID: 31839158 DOI: 10.1016/s0960-9776(19)31121-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The challenge of effective management of ductal carcinoma in situ (DCIS) and other pre-malignant disorders of the breast is to select patients who will not progress to invasive carcinoma from those at the highest risk who require radiotherapy and/or endocrine therapy to minimize the risk of a subsequent invasive recurrence. Although IBIS-II and NSABP-B35 DCIS phase III trials proved that tamoxifen 20 mg/day and anastrozole reduce the risk of ipsilateral and contralateral events, the toxicities of both drugs have hampered the drug uptake by high-risk women. We recently reported results of a 3-year placebo-controlled trial of low-dose (5 mg/d) tamoxifen in 500 women with intraepithelial neoplasia (70% DCIS). At a median follow-up of 5 years, women randomly assigned to low-dose tamoxifen had half the number of subsequent diagnoses of DCIS or invasive cancer compared with those randomly assigned to placebo but no increase in thromboembolic events or endometrial cancers. The 5-year number needed to treat was 22 (95% CI, 20-27). Our attention is now focused on prognostic and predictive markers to identify patients who can derive the greatest benefits from low dose tamoxifen, such as for instance the expression of 23 genes involved in cell cycle progression (CCP). In conclusion, we endorse an active treatment of DCIS as the standard of care.
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Affiliation(s)
- Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Matteo Puntoni
- Clinical Trial Office, E.O. Ospedali Galliera, Genoa, Italy
| | | | | | | | - Mauro D'Amico
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | - Silvia Giuliano
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | - Giacomo Siri
- Clinical Trial Office, E.O. Ospedali Galliera, Genoa, Italy
| | - Sara Cagnacci
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Andrea DeCensi
- Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy; Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom.
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14
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Phillips KA, Liao Y, Milne RL, MacInnis RJ, Collins IM, Buchsbaum R, Weideman PC, Bickerstaffe A, Nesci S, Chung WK, Southey MC, Knight JA, Whittemore AS, Dite GS, Goldgar D, Giles GG, Glendon G, Cuzick J, Antoniou AC, Andrulis IL, John EM, Daly MB, Buys SS, Hopper JL, Terry MB. Accuracy of Risk Estimates from the iPrevent Breast Cancer Risk Assessment and Management Tool. JNCI Cancer Spectr 2019; 3:pkz066. [PMID: 31853515 PMCID: PMC6901082 DOI: 10.1093/jncics/pkz066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/14/2019] [Accepted: 08/20/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND iPrevent is an online breast cancer (BC) risk management decision support tool. It uses an internal switching algorithm, based on a woman's risk factor data, to estimate her absolute BC risk using either the International Breast Cancer Intervention Study (IBIS) version 7.02, or Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm version 3 models, and then provides tailored risk management information. This study assessed the accuracy of the 10-year risk estimates using prospective data. METHODS iPrevent-assigned 10-year invasive BC risk was calculated for 15 732 women aged 20-70 years and without BC at recruitment to the Prospective Family Study Cohort. Calibration, the ratio of the expected (E) number of BCs to the observed (O) number and discriminatory accuracy were assessed. RESULTS During the 10 years of follow-up, 619 women (3.9%) developed BC compared with 702 expected (E/O = 1.13; 95% confidence interval [CI] =1.05 to 1.23). For women younger than 50 years, 50 years and older, and BRCA1/2-mutation carriers and noncarriers, E/O was 1.04 (95% CI = 0.93 to 1.16), 1.24 (95% CI = 1.11 to 1.39), 1.13 (95% CI = 0.96 to 1.34), and 1.13 (95% CI = 1.04 to 1.24), respectively. The C-statistic was 0.70 (95% CI = 0.68 to 0.73) overall and 0.74 (95% CI = 0.71 to 0.77), 0.63 (95% CI = 0.59 to 0.66), 0.59 (95% CI = 0.53 to 0.64), and 0.65 (95% CI = 0.63 to 0.68), respectively, for the subgroups above. Applying the newer IBIS version 8.0b in the iPrevent switching algorithm improved calibration overall (E/O = 1.06, 95% CI = 0.98 to 1.15) and in all subgroups, without changing discriminatory accuracy. CONCLUSIONS For 10-year BC risk, iPrevent had good discriminatory accuracy overall and was well calibrated for women aged younger than 50 years. Calibration may be improved in the future by incorporating IBIS version 8.0b.
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Affiliation(s)
- Kelly-Anne Phillips
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Yuyan Liao
- Department of Epidemiology, Columbia University Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Roger L Milne
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Precision Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Robert J MacInnis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Ian M Collins
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Richard Buchsbaum
- Department of Biostatistics, Columbia University Medical Center, New York, NY
| | - Prue C Weideman
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Adrian Bickerstaffe
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Stephanie Nesci
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Wendy K Chung
- Mailman School of Public Health, and Departments of Pediatrics and Medicine, Columbia University Medical Center, New York, NY
| | - Melissa C Southey
- Genetic Epidemiology Laboratory, Department of Clinical Pathology, University of Melbourne, Parkville, Victoria, Australia
- Precision Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Julia A Knight
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Alice S Whittemore
- Departments of Health Research and Policy and of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA
| | - Gillian S Dite
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - David Goldgar
- Department of Dermatology and Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT
| | - Graham G Giles
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Gord Glendon
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Irene L Andrulis
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Departments of Molecular Genetics and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Esther M John
- Department of Medicine and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Mary B Daly
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA
| | - Saundra S Buys
- Department of Medicine and Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Mary Beth Terry
- Department of Epidemiology, Columbia University Medical Center, New York, NY
| | - for the kConFab Investigators
- Research Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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15
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Orsaria P, Grasso A, Carino R, Caredda E, Sammarra M, Altomare C, Rabitti C, Gullotta G, Perrone G, Pantano F, Buonomo OC, Altomare V. Heterogeneous risk profiles among B3 breast lesions of uncertain malignant potential. TUMORI JOURNAL 2019; 106:115-125. [DOI: 10.1177/0300891619868301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Most cases of breast lesions of uncertain malignant potential (B3) undergo surgical intervention. We aimed to analyze the outcome of B3 lesion subtypes in a large series of screen-detected cases. Methods: We screened 2,986 core needle biopsies to classify B3 lesions. Positive predictive values (PPVs) for malignancy were calculated for a comprehensive risk characterization according to clinicopathologic and morphologic variables. Results: B3 lesions comprised 35% atypical ductal hyperplasia (PPV = 20%), 16.7% flat epithelial atypia (PPV = 12%), 22.7% lobular neoplasia (PPV = 16.2%), 9% papillary lesion (PPV = 18.5%), 8.6% phyllodes tumor (PPV = 3.8%), and 8% radial scars (PPV = 4.1%) based on histopathologic diagnosis. Upgrade rates were 15.9% for calcifications, 13.7% for mass lesions, and 16.7% for architectural deformities, with 8.3% of malignant lesions classified as ductal carcinoma in situ and 6.7% as invasive cancers (PPV = 15%). Conclusion: B3 lesions entail a heterogeneous risk of malignancy, and careful radiologic–pathologic correlation is required for optimal treatment.
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Affiliation(s)
- Paolo Orsaria
- Department of Breast Surgery, University Campus Bio-Medico, Rome, Italy
| | - Antonella Grasso
- Department of Breast Surgery, University Campus Bio-Medico, Rome, Italy
| | - Rita Carino
- Department of Breast Surgery, University Campus Bio-Medico, Rome, Italy
| | - Emanuele Caredda
- Department of Biomedicine and Prevention, Tor Vergata University Hospital, Rome, Italy
| | - Matteo Sammarra
- Department of Radiology, University Campus Bio-Medico, Rome, Italy
| | - Carlo Altomare
- Department of Radiology, University Campus Bio-Medico, Rome, Italy
| | - Carla Rabitti
- Department of Human Pathology, University Campus Bio-Medico, Rome, Italy
| | - Gabriella Gullotta
- Department of Human Pathology, University Campus Bio-Medico, Rome, Italy
| | - Giuseppe Perrone
- Department of Human Pathology, University Campus Bio-Medico, Rome, Italy
| | - Francesco Pantano
- Department of Medical Oncology, University Campus Bio-Medico, Rome, Italy
| | | | - Vittorio Altomare
- Department of Breast Surgery, University Campus Bio-Medico, Rome, Italy
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16
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Fabian CJ. Will a Low-Dose Option Improve Uptake of Tamoxifen for Breast Cancer Risk Reduction? J Clin Oncol 2019; 37:1595-1597. [DOI: 10.1200/jco.19.00656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Kehm RD, Hopper JL, John EM, Phillips KA, MacInnis RJ, Dite GS, Milne RL, Liao Y, Zeinomar N, Knight JA, Southey MC, Vahdat L, Kornhauser N, Cigler T, Chung WK, Giles GG, McLachlan SA, Friedlander ML, Weideman PC, Glendon G, Nesci S, Andrulis IL, Buys SS, Daly MB, Terry MB. Regular use of aspirin and other non-steroidal anti-inflammatory drugs and breast cancer risk for women at familial or genetic risk: a cohort study. Breast Cancer Res 2019; 21:52. [PMID: 30999962 PMCID: PMC6471793 DOI: 10.1186/s13058-019-1135-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/05/2019] [Indexed: 01/23/2023] Open
Abstract
Background The use of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with reduced breast cancer risk, but it is not known if this association extends to women at familial or genetic risk. We examined the association between regular NSAID use and breast cancer risk using a large cohort of women selected for breast cancer family history, including 1054 BRCA1 or BRCA2 mutation carriers. Methods We analyzed a prospective cohort (N = 5606) and a larger combined, retrospective and prospective, cohort (N = 8233) of women who were aged 18 to 79 years, enrolled before June 30, 2011, with follow-up questionnaire data on medication history. The prospective cohort was further restricted to women without breast cancer when medication history was asked by questionnaire. Women were recruited from seven study centers in the United States, Canada, and Australia. Associations were estimated using multivariable Cox proportional hazards regression models adjusted for demographics, lifestyle factors, family history, and other medication use. Women were classified as regular or non-regular users of aspirin, COX-2 inhibitors, ibuprofen and other NSAIDs, and acetaminophen (control) based on self-report at follow-up of ever using the medication for at least twice a week for ≥1 month prior to breast cancer diagnosis. The main outcome was incident invasive breast cancer, based on self- or relative-report (81% confirmed pathologically). Results From fully adjusted analyses, regular aspirin use was associated with a 39% and 37% reduced risk of breast cancer in the prospective (HR = 0.61; 95% CI = 0.33–1.14) and combined cohorts (HR = 0.63; 95% CI = 0.57–0.71), respectively. Regular use of COX-2 inhibitors was associated with a 61% and 71% reduced risk of breast cancer (prospective HR = 0.39; 95% CI = 0.15–0.97; combined HR = 0.29; 95% CI = 0.23–0.38). Other NSAIDs and acetaminophen were not associated with breast cancer risk in either cohort. Associations were not modified by familial risk, and consistent patterns were found by BRCA1 and BRCA2 carrier status, estrogen receptor status, and attained age. Conclusion Regular use of aspirin and COX-2 inhibitors might reduce breast cancer risk for women at familial or genetic risk. Electronic supplementary material The online version of this article (10.1186/s13058-019-1135-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca D Kehm
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Esther M John
- Department of Medicine and Stanford Cancer Institute, Stanford University School of Medicine, 780 Welch Road, Stanford, CA, 94304, USA
| | - Kelly-Anne Phillips
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Robert J MacInnis
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia.,Cancer Epidemiology, Cancer Council Victoria, 615 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Gillian S Dite
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Roger L Milne
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia.,Cancer Epidemiology, Cancer Council Victoria, 615 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, 3168, Australia
| | - Yuyan Liao
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA
| | - Nur Zeinomar
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA
| | - Julia A Knight
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, Ontario, M5T3M7, Canada
| | - Melissa C Southey
- Genetic Epidemiology Laboratory, Department of Pathology, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Linda Vahdat
- Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.,C Anthony and Jean Whittingham Cancer Center, 34 Maple Street, Norwalk, CT, 06856, USA
| | - Naomi Kornhauser
- Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA
| | - Tessa Cigler
- Weill Cornell Medicine Breast Center, 428 E 72nd St, New York, NY, 10021, USA
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, 1150 St Nicholas Ave, New York, NY, 10032, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA
| | - Graham G Giles
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia.,Cancer Epidemiology, Cancer Council Victoria, 615 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Sue-Anne McLachlan
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Medical Oncology, St Vincent's Hospital, 41 Victoria St, Fitzroy, VIC, 3065, Australia
| | - Michael L Friedlander
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, 2052, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Barker St, Randwick, NSW, 2031, Australia
| | - Prue C Weideman
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Gord Glendon
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada
| | - Stephanie Nesci
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | | | - Irene L Andrulis
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada.,Departments of Molecular Genetics and Laboratory Medicine and Pathobiology, University of Toronto, 164 College Street, Toronto, ON, M5S 3G9, Canada
| | - Saundra S Buys
- Department of Medicine and Huntsman Cancer Institute, University of Utah Health, 2000 Cir of Hope Dr, Salt Lake City, UT, 84103, USA
| | - Mary B Daly
- Department of Clinical Genetics, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA. .,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA.
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18
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DeCensi A, Puntoni M, Guerrieri-Gonzaga A, Caviglia S, Avino F, Cortesi L, Taverniti C, Pacquola MG, Falcini F, Gulisano M, Digennaro M, Cariello A, Cagossi K, Pinotti G, Lazzeroni M, Serrano D, Branchi D, Campora S, Petrera M, Buttiron Webber T, Boni L, Bonanni B. Randomized Placebo Controlled Trial of Low-Dose Tamoxifen to Prevent Local and Contralateral Recurrence in Breast Intraepithelial Neoplasia. J Clin Oncol 2019; 37:1629-1637. [PMID: 30973790 PMCID: PMC6601429 DOI: 10.1200/jco.18.01779] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Tamoxifen administered for 5 years at 20 mg/d is effective in breast cancer treatment and prevention, but toxicity has limited its broad use. Biomarker trials showed that 5 mg/d is not inferior to 20 mg/d in decreasing breast cancer proliferation. We hypothesized that a lower dose given for a shorter period could be as effective in preventing recurrence from breast intraepithelial neoplasia but have a lower toxicity than the standard dose. PATIENTS AND METHODS We conducted a multicenter randomized trial of tamoxifen, 5 mg/d or placebo administered for 3 years after surgery in women with hormone-sensitive or unknown breast intraepithelial neoplasia, including atypical ductal hyperplasia and lobular or ductal carcinoma in situ. The primary end point was the incidence of invasive breast cancer or ductal carcinoma in situ. RESULTS Five hundred women 75 years of age or younger were included. After a median follow-up of 5.1 years (interquartile range, 3.9-6.3 years), there were 14 neoplastic events with tamoxifen and 28 with placebo (11.6 v 23.9 per 1,000 person-years; hazard ratio, 0.48; 95% CI, 0.26 to 0.92; P = .02), which resulted in a 5-year number needed to treat of 22 (95% CI, 20 to 27). Tamoxifen decreased contralateral breast events by 75% (three v 12 events; hazard ratio, 0.25; 95% CI, 0.07 to 0.88; P = .02). Patient-reported outcomes were not different between arms except for a slight increase in frequency of daily hot flashes with tamoxifen (P = .02). There were 12 serious adverse events with tamoxifen and 16 with placebo, including one deep vein thrombosis and one stage I endometrial cancer with tamoxifen and one pulmonary embolism with placebo. CONCLUSION Tamoxifen at 5 mg/d for 3 years can halve the recurrence of breast intraepithelial neoplasia with a limited toxicity, which provides a new treatment option in these disorders.
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Affiliation(s)
- Andrea DeCensi
- 1 Ente Ospedaliero Ospedali Galliera, Genoa, Italy.,2 Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | | | | | - Franca Avino
- 4 Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
| | - Laura Cortesi
- 5 Azienda Ospedaliera-Universitaria Policlinico di Modena, Modena, Italy
| | - Cristiana Taverniti
- 6 Azienda Ospedaliera-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Fabio Falcini
- 8 Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
| | | | | | - Anna Cariello
- 11 Azienda Unità Sanitaria Locale della Romagna, Ravenna, Italy
| | | | | | | | | | | | - Sara Campora
- 1 Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | | | | | - Luca Boni
- 14 Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
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Serrano D, Gandini S, Guerrieri-Gonzaga A, Feroce I, Johansson H, Macis D, Aristarco V, Bonanni B, DeCensi A. Quality of Life in a Randomized Breast Cancer Prevention Trial of Low-Dose Tamoxifen and Fenretinide in Premenopausal Women. Cancer Prev Res (Phila) 2018; 11:811-818. [PMID: 30352838 DOI: 10.1158/1940-6207.capr-18-0073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/18/2018] [Accepted: 10/11/2018] [Indexed: 11/16/2022]
Abstract
Menopausal symptoms are the main reason for withdrawal in tamoxifen prevention trials. Here, we present Menopause Quality of Life (MenQoL) assessment within a randomized 2 × 2 phase II clinical trial of low-dose tamoxifen and the synthetic retinoid fenretinide. A total of 235 premenopausal women at higher risk for breast cancer were randomized to either tamoxifen 5 mg daily, fenretinide 200 mg daily, their combination, or placebo. Climacteric symptoms were investigated using the MenQoL questionnaire which was self-administered at each visit for 2 years of treatment and for 1 year of follow-up. CYP2D6 was genotyped in subjects taking tamoxifen to study the association with menopausal symptoms. The MenQoL effect size analysis showed no statistically significant difference among the four treatment arms for all four domains (vasomotor, physical, psychosocial, and sexual). Vasomotor symptoms only slightly increased under tamoxifen, with a score at year two of 1.45, 1.21, 0.58, and 1.17 in the combined, tamoxifen, fenretinide, and placebo arms, respectively. Compared with the slow metabolizers, a higher percentage of subjects with CYP2D6 extensive metabolizer genotype complained of a ≥3 score in the vasomotor, psychosocial, and sexual domain in the tamoxifen arms (P value = 0.01, 0.007, and 0.007, respectively). QoL in premenopausal or perimenopausal women was not significantly worsened by low-dose tamoxifen or fenretinide. Our findings suggest that a low dose of tamoxifen may increase its acceptability for breast cancer prevention.
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Affiliation(s)
- Davide Serrano
- Division of Cancer Prevention and Genetics, European Institute of Oncology IRCCS, Milan, Italy.
| | - Sara Gandini
- Molecular and Pharmacoepidemiology Unit, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Irene Feroce
- Division of Cancer Prevention and Genetics, European Institute of Oncology IRCCS, Milan, Italy
| | - Harriet Johansson
- Division of Cancer Prevention and Genetics, European Institute of Oncology IRCCS, Milan, Italy
| | - Debora Macis
- Division of Cancer Prevention and Genetics, European Institute of Oncology IRCCS, Milan, Italy
| | - Valentina Aristarco
- Division of Cancer Prevention and Genetics, European Institute of Oncology IRCCS, Milan, Italy
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology IRCCS, Milan, Italy
| | - Andrea DeCensi
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom.,Division of Medical Oncology, Galliera Hospital, Genoa, Italy
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Spaeth E, Starlard-Davenport A, Allman R. Bridging the Data Gap in Breast Cancer Risk Assessment to Enable Widespread Clinical Implementation across the Multiethnic Landscape of the US. ACTA ACUST UNITED AC 2018; 2:1-6. [PMID: 30662981 PMCID: PMC6334765 DOI: 10.29245/2578-2967/2018/4.1137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Breast cancer remains the second leading cause of cancer death among women and is the most commonly diagnosed cancer in women. Breast cancer risk assessment has been clinically available for nearly 30 years yet is under-utilized in practice for multiple reasons. Incorporation of polygenic risk as well as breast density measurements, promise to increase the accuracy of risk assessment. With that comes the hope that both prevention and screening become more personalized and thus more effective. Incidence rates have been static over the past 15 years and have even increased slightly in African American and Asian/Pacific Islander populations despite the robust data on breast cancer risk reduction measures that exist. Current challenges in reducing breast cancer incidence begin with robust data curation that allows for appropriate risk stratification across our multiethnic population and conclude with the implementation of prevention strategies within our fractured healthcare system.
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Affiliation(s)
| | - Athena Starlard-Davenport
- Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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