Understanding low chemoprevention uptake by women at high risk of breast cancer: findings from a qualitative inductive study of women's risk-reduction experiences

Use of web-based decision support to improve informed choice for chemoprevention: a qualitative analysis of pre-implementation interviews (SWOG S1904)

BACKGROUND

Women with high-risk breast lesions, such as atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS), have a 4- to tenfold increased risk of breast cancer compared to women with non-proliferative breast disease. Despite high-quality data supporting chemoprevention, uptake remains low. Interventions are needed to break down barriers.

METHODS

The parent trial, MiCHOICE, is a cluster randomized controlled trial evaluating the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. For this pre-implementation analysis, 25 providers participated in semi-structured interviews prior to accessing decision support tools. Interviews sought to understand attitudes/beliefs and barriers/facilitators to chemoprevention.

RESULTS

Interviews with 25 providers (18 physicians and 7 advanced practice providers) were included. Providers were predominantly female (84%), white (72%), and non-Hispanic (88%). Nearly all providers (96%) had prescribed chemoprevention for eligible patients. Three themes emerged in qualitative analysis. The first theme describes providers' confidence in chemoprevention and the utility of decision support tools. The second theme elucidates barriers to chemoprevention, including time constraints, risk communication and perceptions of patients' fear of side effects and anxiety. The third theme is the need for early implementation of decision support tools.

CONCLUSIONS

This qualitative study suggests that providers were interested in the early inclusion of decision aids (DA) in their chemoprevention discussion workflow. The DAs may help overcome certain barriers which were elucidated in these interviews, including patient level concerns about side effects, clinic time constraints and difficulty communicating risk. A multi-faceted intervention with a DA as one active component may be needed.

TRIAL REGISTRATION

This trial was registered with the NIH clinical trial registry, clinicaltrials.gov, NCT04496739.

Breast Cancer Risk Assessment Tool (BCRAT) and long-term breast cancer mortality in the Women's Health Initiative

BACKGROUND

While the Breast Cancer Risk Assessment Tool (BCRAT) predicts breast cancer incidence, the model's performance, re-purposed to predict breast cancer mortality, is uncertain. Therefore, we examined whether the BCRAT model predicts breast cancer mortality in postmenopausal women in the Women's Health Initiative (WHI).

METHODS

BCRAT 5-year breast cancer incidence risk estimates were calculated for 145,408 women (aged 50-79 years) enrolled in the WHI at 40 US clinical centers to examine associations of BCRAT risk groups (< 1%, 1-< 3%, ≥ 3%) with breast cancer mortality using Cox proportional regression modeling in all participants and in those with incident breast cancer.

RESULTS

Women with BCRAT ≥ 3% risk, compared to women with BCRAT < 1% risk, were older (age 70-79 years: 38.3% versus 5.3%), less commonly Black (1.1% versus 40.2%), and had stronger breast cancer family history. With 20-years follow-up, considering all participants, with 8,849 breast cancers and 1,076 breast cancer deaths, breast cancer mortality in BCRAT group ≥ 3% was not higher versus BCRAT group < 1% (Hazard Ratio [HR] 1.06 95% Confidence Interval [CI] 0.80-1.40): percent without 20-year breast cancer mortality; 99.4% [group < 1%] and 98.8% [group ≥ 3%]. Considering women with incident breast cancer, breast cancer mortality was also not higher in BCRAT group ≥ 3% versus BCRAT group < 1% (HR 1.07 95% CI 0.79-1.45).

CONCLUSIONS

The BCRAT model, at ≥ 3% 5-year incidence risk (US guideline threshold for chemoprevention), does not identify women with higher breast cancer mortality risk, with implications for breast cancer prevention strategies.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Body composition changes during breast cancer preventive treatment with anastrozole: Findings from the IBIS-II trial

Background

Uptake to anastrozole for breast cancer prevention is low, partly due to women's concerns about side effects including gains in weight and specifically gains in body fat. Previous evidence does not link anastrozole with gains in weight, but there is a lack of data on any effects on body composition i.e. changes in fat and fat free mass. Here we assess association of anastrozole with body composition changes in a prospective sub-study from the second international breast intervention trial (IBIS-II).

Methods

Participants had DXA scans at baseline and for five years of anastrozole/placebo and beyond (between March 2004 and September 2017. Primary outcomes were changes in body weight, body fat and fat free mass at 9-18 months. A linear model was used to estimate the size of a differential effect in these outcomes by randomised treatment allocation adjusted for baseline value and time since last scan, age, 10-year breast cancer risk, smoking and HRT status.

Results

203 postmenopausal women were recruited (n = 95 anastrozole, n = 108 placebo), mean age 58 years (SD = 5.4), BMI 28.0 kg/m2 (SD = 5.5). There was no evidence of a strong association between anastrozole or placebo and endpoints at 9-18 months; effect size (95 %CI) for anastrozole minus placebo for body weight (per/kg) -0.11 (-1.29-1.08); body fat 0.11 (-0.75-0.96) and fat free mass -0.30 (-0.79-0.19).

Conclusions

There is unlikely to be a clinically significant change to body composition with anastrozole for breast cancer prevention.

Risk-management decision-making data from a community-based sample of racially diverse women at high risk of breast cancer: rationale, methods, and sample characteristics of the Daughter Sister Mother Project survey

BACKGROUND

To understand the dynamics that limit use of risk-management options by women at high risk of breast cancer, there is a critical need for research that focuses on patient perspectives. Prior research has left important gaps: exclusion of high-risk women not in risk-related clinical care, exclusion of non-white populations, and lack of attention to the decision-making processes that underlie risk-management choices. Our objective was to create a more inclusive dataset to facilitate research to address disparities related to decision making for breast cancer risk management.

METHODS

The Daughter Sister Mother Project survey collects comprehensive information about the experiences of women at high risk of breast cancer. We collected novel measures of feelings about and reactions to cancer screenings; knowledge, barriers, and facilitators of risk-management options; beliefs related to cancer risk and risk management; and involvement with loved ones who had cancer. Eligible individuals were non-Hispanic white and non-Hispanic Black adult women who self-identified as having high risk of breast cancer and had no personal history of cancer. Between October 2018 and August 2019, 1053 respondents completed the online survey. Of these, 717 were confirmed through risk prediction modeling to have a lifetime breast cancer risk of ≥ 20%. Sociodemographic characteristics of this sample were compared to those of nationally representative samples of the US population: the 2019 Health Information National Trends Survey and the Pew Research Center report: Jewish Americans in 2020.

RESULTS

The sample of 717 women at objectively high risk of breast cancer was largely (95%) recruited from non-clinical sources. Of these respondents, only 31% had seen a genetic counselor, 34% had had genetic testing specific to breast cancer risk, and 35% had seen at least one breast or cancer care specialist. The sample includes 35% Black respondents and 8% with Ashkenazi Jewish ancestry. Although encompassing a substantial range of ages, incomes, and education levels, respondents are overall somewhat younger, higher-income, and more educated than the US population as a whole.

CONCLUSIONS

The DSM dataset offers comprehensive data from a community-based, diverse sample of women at high risk of breast cancer. The dataset includes substantial proportions of Black and Ashkenazi Jewish women and women who are not already in clinical care related to their breast cancer risk. This sample will facilitate future studies of risk-management behaviors among women who are and are not receiving high-risk care, and of variations in risk-management experiences across race and ethnicity.

Impact of Affordable Care Act provisions on the racial makeup of patients enrolled at a Deep South, high-risk breast cancer clinic

Purpose

Black women are less likely to receive screening mammograms and are at a higher lifetime risk for developing breast cancer compared to their White counterparts. Affordable Care Act (ACA) provisions decreased cost sharing for women's preventive screening, potentially mitigating screening disparities. We examined enrollment of a high-risk screening program before and after ACA implementation stratified by race.

Methods

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

Results

2,767 patients enrolled in the clinic. On average, patients were 46 years old (SD, ± 12), 82% were commercially insured, and 8% lived in a highly disadvantaged neighborhood. In ITS models accounting for trends over time, Prior to ACA implementation, White patient enrollment was stable (IRR 1.01, 95% CI 1.00-1.02) while Black patient enrollment increased at 13% per year (IRR 1.13, 95% CI 1.05-1.22). Compared to the pre-ACA enrollment period, the post-ACA enrollment rate remained unchanged for White patients (IRR 0.99, 95% CI 0.97-1.01) but decreased by 17% for Black patients (IRR 0.83, 95% CI 0.74-0.92).

Conclusion

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

Contributions of nanotechnology to the intraductal drug delivery for local treatment and prevention of breast cancer

Breast cancer is a major public health problem, affecting millions of people. It is a very heterogeneous disease, with localized and invasive forms, and treatment generally consists of a combination of surgery and radiotherapy followed by administration of estrogen receptor modulators or aromatase inhibitors. Given its heterogeneity, management strategies that take into consideration the type of disease and biological markers and can provide more personalized and local treatment are required. More recently, the intraductal administration (i.e., into the breast ducts) of drugs has attracted significant attention due to its ability of providing drug distribution through the ductal tree in a minimally invasive manner. Although promising, intraductal administration is not trivial, and difficulties in duct identification and cannulation are important challenges to the further development of this route. New drug delivery strategies such as nanostructured systems can help to achieve the full benefits of the route due to the possibility of prolonging tissue retention, improving targeting and selectivity, increasing cytotoxicity and reducing the frequency of administration. This review aims at discussing the potential benefits and challenges of intraductal administration, focusing on the design and use of nanocarriers as innovative and feasible strategies for local breast cancer therapy and prevention.

Predicting breast cancer risk in a racially diverse, community-based sample of potentially high-risk women

BACKGROUND

Identifying women with high risk of breast cancer is necessary to study high-risk experiences and deliver risk-management care. Risk prediction models estimate individuals' lifetime risk but have rarely been applied in community-based settings among women not yet receiving specialized care. Therefore, we aimed: (1) to apply three breast cancer risk prediction models (i.e., Gail, Claus, and IBIS) to a racially diverse, community-based sample of women, and (2) to assess risk prediction estimates using survey data.

METHODS

An online survey was administered to women who were determined by a screening instrument to have potentially high risk for breast cancer. Risk prediction models were applied using their self-reported family and medical history information. Inclusion in the high-risk subsample required ≥20% lifetime risk per ≥1 model. Descriptive statistics were used to compare the proportions of women identified as high risk by each model.

RESULTS

N = 1053 women were initially eligible and completed the survey. All women, except one, self-reported the information necessary to run at least one model; 90% had sufficient information for >1 model. The high-risk subsample included 717 women, of which 75% were identified by one model only; 96% were identified by IBIS, 3% by Claus, <1% by Gail. In the high-risk subsample, 20% were identified by two models and 3% by all three models.

CONCLUSIONS

Assessing breast cancer risk using self-reported data in a community-based sample was feasible. Different models identify substantially different groups of women who may be at high risk for breast cancer; use of multiple models may be beneficial for research and clinical care.

A Lipid-Based In Situ-Forming Hexagonal Phase for Prolonged Retention and Drug Release in the Breast Tissue

In this study, the addition of monoolein to phosphatidylcholine (PC), tricaprylin, and propylene glycol (PG) mixtures was studied to produce fluid precursor formulations (FIPs) that could transform into hexagonal phase (resistant to aqueous dilution) in vitro and in vivo. The overall goal was to obtain FIPs that could incorporate chemopreventive drugs for subcutaneous administration in the mammary tissue to inhibit the development and/or recurrence of breast cancer. Increasing PG content reduced FIP viscosity up to ~ 2.5-fold, while increases in PC (over monoolein) increased the formation of emulsified systems. The hexagonal phase was observed at 20% of water and higher, with the minimum amount of water necessary for this formation increasing with PG content. The selected FIP formed a depot in vivo after ~ 24 h of administration; its structure was compatible with the hexagonal phase and it remained in the mammary tissue for at least 30 days, prolonging the permanence of a fluorescent probe. In vitro, the release of the synthetic retinoid fenretinide was slow, with ~ 9% of the drug released in 72 h. Consistent with this slow release, fenretinide IC₅₀ in breast cancer cells was ~ 100-fold higher in the selected FIP compared to its solution. The FIP reduced cell migration and presented higher cytotoxicity towards tumor compared to non-tumor cells. Given the limited number of options for pharmacological prevention of breast cancer development and recurrences, this formulation could potentially find applicability to reduce the frequency of administration and improve local concentrations of chemopreventive drugs.

Qualitative analysis of shared decision-making for chemoprevention in the primary care setting: provider-related barriers

Background

Chemoprevention with anti-estrogens, such as tamoxifen, raloxifene or aromatase inhibitors, have been shown to reduce breast cancer risk in randomized controlled trials; however, uptake among women at high-risk for developing breast cancer remains low. The aim of this study is to identify provider-related barriers to shared decision-making (SDM) for chemoprevention in the primary care setting.

Methods

Primary care providers (PCPs) and high-risk women eligible for chemoprevention were enrolled in a pilot study and a randomized clinical trial of web-based decision support tools to increase chemoprevention uptake. PCPs included internists, family practitioners, and gynecologists, whereas patients were high-risk women, age 35–75 years, who had a 5-year invasive breast cancer risk ≥ 1.67%, according to the Gail model. Seven clinical encounters of high-risk women and their PCPs who were given access to these decision support tools were included in this study. Audio-recordings of the clinical encounters were transcribed verbatim and analyzed using grounded theory methodology.

Results

Six primary care providers, of which four were males (mean age 36 [SD 6.5]) and two were females (mean age 39, [SD 11.5]) and seven racially/ethnically diverse high-risk female patients participated in this study. Qualitative analysis revealed three themes: (1) Competing demands during clinical encounters; (2) lack of knowledge among providers about chemoprevention; and (3) limited risk communication during clinical encounters.

Conclusions

Critical barriers to SDM about chemoprevention were identified among PCPs. Providers need education and resources through decision support tools to engage in risk communication and SDM with their high-risk patients, and to gain confidence in prescribing chemoprevention in the primary care setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01954-y.

Risk management recommendations and patient acceptance vary with high-risk breast lesions

INTRODUCTION

Lobular carcinoma in situ (LCIS), atypical ductal and lobular hyperplasia (AH) increase breast cancer risk. We examined risk management recommendations (RMR) and acceptance in AH/LCIS.

METHODS

All patients with AH/LCIS on core needle biopsy from 2013 to 2016 at our institution were identified; cancer patients were excluded. Univariate and multivariate analysis examined factors associated with management.

RESULTS

98 % of patients were evaluated by breast surgeons and 53 % underwent risk model calculation (RC). 77 % had new RMR. RMR of MRI screening (MRI), genetic counselling (GC) and medical oncology (MO) referral were 41 %, 18 %, 77 %, respectively. MRI screening was more likely recommended in those with strong family history (p = 0.01), and high RC (p < 0.001). Uptake of at least one RMR did not occur in 84 % of patients. Use of RC correlated with MO acceptance (p = 0.049).

CONCLUSIONS

Diagnosis of atypia has the potential to change risk management for most, however only 16 % of patients accepted all RMR.