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Kim E, Lewin AA. Breast Density: Where Are We Now? Radiol Clin North Am 2024; 62:593-605. [PMID: 38777536 DOI: 10.1016/j.rcl.2023.12.007] [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] [Indexed: 05/25/2024]
Abstract
Breast density refers to the amount of fibroglandular tissue relative to fat on mammography and is determined either qualitatively through visual assessment or quantitatively. It is a heritable and dynamic trait associated with age, race/ethnicity, body mass index, and hormonal factors. Increased breast density has important clinical implications including the potential to mask malignancy and as an independent risk factor for the development of breast cancer. Breast density has been incorporated into breast cancer risk models. Given the impact of dense breasts on the interpretation of mammography, supplemental screening may be indicated.
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Affiliation(s)
- Eric Kim
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Alana A Lewin
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA; New York University Grossman School of Medicine, New York University Langone Health, Laura and Isaac Perlmutter Cancer Center, 160 East 34th Street 3rd Floor, New York, NY 10016, USA.
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2
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Skinner MK. Epigenetic biomarkers for disease susceptibility and preventative medicine. Cell Metab 2024; 36:263-277. [PMID: 38176413 DOI: 10.1016/j.cmet.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/11/2023] [Accepted: 11/28/2023] [Indexed: 01/06/2024]
Abstract
The development of molecular biomarkers for disease makes it possible for preventative medicine approaches to be considered. Therefore, therapeutics, treatments, or clinical management can be used to delay or prevent disease development. The problem with genetic mutations as biomarkers is the low frequency with genome-wide association studies (GWASs), generally at best a 1% association of the patients with the disease. In contrast, epigenetic alterations have a high-frequency association of greater than 90%-95% of individuals with pathology in epigenome-wide association studies (EWASs). A wide variety of human diseases have been shown to have epigenetic biomarkers that are disease specific and that detect pathology susceptibility. This review is focused on the epigenetic biomarkers for disease susceptibility, and it distinct from the large literature on epigenetics of disease etiology or progression. The development of efficient epigenetic biomarkers for disease susceptibility will facilitate a paradigm shift from reactionary medicine to preventative medicine.
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Affiliation(s)
- Michael K Skinner
- Center for Reproductive Biology, School of Biological Sciences, Washington State University, Pullman, WA 99164-4236, USA.
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3
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Nickel B, Ormiston‐Smith N, Hammerton L, Cvejic E, Vardon P, Mcinally Z, Legerton P, Baker K, Isautier J, Larsen E, Giles M, Brennan ME, McCaffery KJ, Houssami N. Psychosocial outcomes and health service use after notifying women participating in population breast screening when they have dense breasts: a BreastScreen Queensland randomised controlled trial. Med J Aust 2023; 219:423-428. [PMID: 37751916 PMCID: PMC10952548 DOI: 10.5694/mja2.52117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Robust evidence regarding the benefits and harms of notifying Australian women when routine breast screening identifies that they have dense breasts is needed for informing future mammography population screening practice and policy. OBJECTIVES To assess the psychosocial and health services use effects of notifying women participating in population-based breast cancer screening that they have dense breasts; to examine whether the mode of communicating this information about its implications (print, online formats) influences these effects. METHODS AND ANALYSIS The study population comprises women aged 40 years or older who attend BreastScreen Queensland Sunshine Coast services for mammographic screening and are found to have dense breasts (BI-RADS density C or D). The randomised controlled trial includes three arms (952 women each): standard BreastScreen care (no notification of breast density; control arm); notification of dense breasts in screening results letter and print health literacy-sensitive information (intervention arm 1) or a link or QR code to online video-based health literacy-sensitive information (intervention arm 2). Baseline demographic data will be obtained from BreastScreen Queensland. Outcomes data will be collected in questionnaires at baseline and eight weeks, twelve months, and 27 months after breast screening. Primary outcomes will be psychological outcomes and health service use; secondary outcomes will be supplemental screening outcomes, cancer worry, perceived breast cancer risk, knowledge about breast density, future mammographic screening intentions, and acceptability of notification about dense breasts. ETHICS APPROVAL Gold Coast Hospital and Health Service Ethics Committee (HREC/2023/QGC/89770); Sunshine Coast Hospital and Health Service Research Governance and Development (SSA/2023/QSC/89770). DISSEMINATION OF FINDINGS Findings will be reported in peer-reviewed journals and at national and international conferences. They will also be reported to BreastScreen Queensland, BreastScreen Australia, Cancer Australia, and other bodies involved in cancer care and screening, including patient and support organisations. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12623000001695p (prospective: 9 January 2023).
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Affiliation(s)
- Brooke Nickel
- School of Public Healththe University of SydneySydneyNSW
| | | | - Lisa Hammerton
- Sunshine Coast Service, BreastScreen QueenslandNambourQLD
| | - Erin Cvejic
- School of Public Healththe University of SydneySydneyNSW
| | - Paul Vardon
- Cancer Screening Unit, Queensland Department of HealthBrisbaneQLD
| | - Zoe Mcinally
- Cancer Screening Unit, Queensland Department of HealthBrisbaneQLD
| | - Paula Legerton
- Cancer Screening Unit, Queensland Department of HealthBrisbaneQLD
| | - Karen Baker
- Cancer Screening Unit, Queensland Department of HealthBrisbaneQLD
| | | | - Emma Larsen
- Sunshine Coast Service, BreastScreen QueenslandNambourQLD
| | | | - Meagan E Brennan
- School of Public Healththe University of SydneySydneyNSW
- The University of Notre Dame AustraliaSydneyNSW
| | | | - Nehmat Houssami
- School of Public Healththe University of SydneySydneyNSW
- The Daffodil Centre, the University of Sydney and Cancer Council NSWSydneyNSW
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Anandarajah A, Chen Y, Stoll C, Hardi A, Jiang S, Colditz GA. Repeated measures of mammographic density and texture to evaluate prediction and risk of breast cancer: a systematic review of the methods used in the literature. Cancer Causes Control 2023; 34:939-948. [PMID: 37340148 PMCID: PMC10533570 DOI: 10.1007/s10552-023-01739-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 06/14/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE It may be important for women to have mammograms at different points in time to track changes in breast density, as fluctuations in breast density can affect breast cancer risk. This systematic review aimed to assess methods used to relate repeated mammographic images to breast cancer risk. METHODS The databases including Medline (Ovid) 1946-, Embase.com 1947-, CINAHL Plus 1937-, Scopus 1823-, Cochrane Library (including CENTRAL), and Clinicaltrials.gov were searched through October 2021. Eligibility criteria included published articles in English describing the relationship of change in mammographic features with risk of breast cancer. Risk of bias was assessed using the Quality in Prognostic Studies tool. RESULTS Twenty articles were included. The Breast Imaging Reporting and Data System and Cumulus were most commonly used for classifying mammographic density and automated assessment was used on more recent digital mammograms. Time between mammograms varied from 1 year to a median of 4.1, and only nine of the studies used more than two mammograms. Several studies showed that adding change of density or mammographic features improved model performance. Variation in risk of bias of studies was highest in prognostic factor measurement and study confounding. CONCLUSION This review provided an updated overview and revealed research gaps in assessment of the use of texture features, risk prediction, and AUC. We provide recommendations for future studies using repeated measure methods for mammogram images to improve risk classification and risk prediction for women to tailor screening and prevention strategies to level of risk.
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Affiliation(s)
- Akila Anandarajah
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave MSC 8100-0094-2200, Saint Louis, MO, 63110, USA
| | - Yongzhen Chen
- Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Carolyn Stoll
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave MSC 8100-0094-2200, Saint Louis, MO, 63110, USA
| | - Angela Hardi
- Bernard Becker Medical Library, Washington University School of Medicine, MSC 8132-12-01, 660 S Euclid Ave, Saint Louis, MO, 63110, USA
| | - Shu Jiang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave MSC 8100-0094-2200, Saint Louis, MO, 63110, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave MSC 8100-0094-2200, Saint Louis, MO, 63110, USA.
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5
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Mariapun S, Ho WK, Eriksson M, Tai MC, Mohd Taib NA, Yip CH, Rahmat K, Li J, Hartman M, Hall P, Easton DF, Lindstrom S, Teo SH. Evaluation of SNPs associated with mammographic density in European women with mammographic density in Asian women from South-East Asia. Breast Cancer Res Treat 2023; 201:237-245. [PMID: 37338730 PMCID: PMC10865780 DOI: 10.1007/s10549-023-06984-2] [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: 11/19/2022] [Accepted: 05/24/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Mammographic density (MD), after accounting for age and body mass index (BMI), is a strong heritable risk factor for breast cancer. Genome-wide association studies (GWAS) have identified 64 SNPs in 55 independent loci associated with MD in women of European ancestry. Their associations with MD in Asian women, however, are largely unknown. METHOD Using linear regression adjusting for age, BMI, and ancestry-informative principal components, we evaluated the associations of previously reported MD-associated SNPs with MD in a multi-ethnic cohort of Asian ancestry. Area and volumetric mammographic densities were determined using STRATUS (N = 2450) and Volpara™ (N = 2257). We also assessed the associations of these SNPs with breast cancer risk in an Asian population of 14,570 cases and 80,870 controls. RESULTS Of the 61 SNPs available in our data, 21 were associated with MD at a nominal threshold of P value < 0.05, all in consistent directions with those reported in European ancestry populations. Of the remaining 40 variants with a P-value of association > 0.05, 29 variants showed consistent directions of association as those previously reported. We found that nine of the 21 MD-associated SNPs in this study were also associated with breast cancer risk in Asian women (P < 0.05), seven of which showed a direction of associations that was consistent with that reported for MD. CONCLUSION Our study confirms the associations of 21 SNPs (19/55 or 34.5% out of all known MD loci identified in women of European ancestry) with area and/or volumetric densities in Asian women, and further supports the evidence of a shared genetic basis through common genetic variants for MD and breast cancer risk.
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Affiliation(s)
- Shivaani Mariapun
- Cancer Research Malaysia, Subang Jaya, Selangor, Malaysia
- School of Mathematical Sciences, Faculty of Science and Engineering, University of Nottingham Malaysia, Semenyih, Selangor, Malaysia
| | - Weang Kee Ho
- Cancer Research Malaysia, Subang Jaya, Selangor, Malaysia
- School of Mathematical Sciences, Faculty of Science and Engineering, University of Nottingham Malaysia, Semenyih, Selangor, Malaysia
| | - Mikael Eriksson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mei Chee Tai
- Cancer Research Malaysia, Subang Jaya, Selangor, Malaysia
| | - Nur Aishah Mohd Taib
- Faculty of Medicine, University Malaya Cancer Research Institute, University Malaya, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cheng Har Yip
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Subang Jaya Medical Centre, Subang Jaya, Malaysia
| | - Kartini Rahmat
- Faculty of Medicine, University Malaya Cancer Research Institute, University Malaya, Kuala Lumpur, Malaysia
- Biomedical Imaging Department, Faculty of Medicine, Universiti Malaya Research Imaging Centre, University of Malaya, Kuala Lumpur, Malaysia
| | - Jingmei Li
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
- Human Genetics, Genome Institute of Singapore, Singapore, Singapore
| | - Mikael Hartman
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Department of Surgery, National University Hospital and National University Health System, Singapore, Singapore
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | - Douglas F Easton
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Sara Lindstrom
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Soo-Hwang Teo
- Cancer Research Malaysia, Subang Jaya, Selangor, Malaysia.
- Faculty of Medicine, University Malaya Cancer Research Institute, University Malaya, Kuala Lumpur, Malaysia.
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Law R, Krupa K, Rusby J. Preventative therapy for breast cancer: a clinical experience. Breast Cancer Res Treat 2023:10.1007/s10549-023-06985-1. [PMID: 37336835 PMCID: PMC10361902 DOI: 10.1007/s10549-023-06985-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/24/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Breast Cancer incidence in the UK is estimated to rise to 71,000 per year by 2035. Preventative strategies could significantly reduce this. Preventative therapy reduces women's risk of oestrogen receptor positive breast cancer, but uptake remains low. Having established a preventative therapy clinic as part of a wider breast cancer prevention project, we explored qualitative data to inform future preventative efforts. METHOD Women aged 30 to 60 who had benign diagnoses at a symptomatic breast clinic or were under mammographic surveillance in the moderate risk family history clinic were invited to participate in the study. Those who expressed an interest and completed an initial questionnaire had their breast cancer risk calculated using the IBIS risk calculator. Those at increased risk were invited to a consultation about preventative therapy. RESULTS 182 women were identified as increased risk (≥ 17% lifetime or ≥ 3% 10-year risk NICE guidelines: Familial breast cancer: classification, care and managing breast cancer and related risks in people with a family history of breast cancer, 20131) of whom 91 women (50%) would not have been identified by family history criteria alone. 96% attended a risk/prevention consultation and all eligible women accepted screening mammography but only 14 (8%) women requested a preventative therapy prescription during the duration of the study. Reluctance to take medication and inconvenient time of life were common reasons for declining preventative therapy. Despite this, the majority were grateful for breast cancer risk and prevention information. CONCLUSIONS Women at increased risk of breast cancer accept additional screening but are reluctant to take preventative therapy. This suggests that stratified screening methods using risk calculations would have high uptake. Raising awareness of preventative therapy is important and the breast cancer community has yet to find the optimum timing and formula for discussing it and must accept women's informed preferences above artificial targets. REGISTRATION NUMBERS The PIONEER study was granted Health Research Authority (HRA) ethical approval by the Westminster Ethics Committee. IRAS project ID 265619, ClinicalTrials.gov Identifier: NCT04574063. Recruitment began in September 2020 and was completed in October 2021.
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Affiliation(s)
- Rebekah Law
- The Royal Marsden Hospital, London, UK.
- Institute of Cancer Research, London, UK.
| | | | - Jennifer Rusby
- The Royal Marsden Hospital, London, UK
- Institute of Cancer Research, London, UK
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7
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Howell A, Howell SJ. Tamoxifen evolution. Br J Cancer 2023; 128:421-425. [PMID: 36765172 PMCID: PMC9938251 DOI: 10.1038/s41416-023-02158-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 02/12/2023] Open
Affiliation(s)
- A. Howell
- grid.5379.80000000121662407Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK ,grid.417286.e0000 0004 0422 2524Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Wythenshawe, Manchester, UK ,grid.412917.80000 0004 0430 9259Manchester Breast Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
| | - S. J. Howell
- grid.5379.80000000121662407Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK ,grid.417286.e0000 0004 0422 2524Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Wythenshawe, Manchester, UK ,grid.412917.80000 0004 0430 9259Manchester Breast Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
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8
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Edmonds CE, O'Brien SR, Conant EF. Mammographic Breast Density: Current Assessment Methods, Clinical Implications, and Future Directions. Semin Ultrasound CT MR 2023; 44:35-45. [PMID: 36792272 DOI: 10.1053/j.sult.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mammographic breast density is widely accepted as an independent risk factor for the development of breast cancer. In addition, because dense breast tissue may mask breast malignancies, breast density is inversely related to the sensitivity of screening mammography. Given the risks associated with breast density, as well as ongoing efforts to stratify individual risk and personalize breast cancer screening and prevention, numerous studies have sought to better understand the factors that impact breast density, and to develop and implement reproducible, quantitative methods to assess mammographic density. Breast density assessments have been incorporated into risk assessment models to improve risk stratification. Recently, novel techniques for analyzing mammographic parenchymal complexity, or texture, have been explored as potential means of refining mammographic tissue-based risk assessment beyond breast density.
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Affiliation(s)
- Christine E Edmonds
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Sophia R O'Brien
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Emily F Conant
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
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9
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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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10
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Assessing breast density using the chemical-shift encoding-based proton density fat fraction in 3-T MRI. Eur Radiol 2022; 33:3810-3818. [PMID: 36538074 PMCID: PMC10182116 DOI: 10.1007/s00330-022-09341-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Abstract
Objectives
There is a clinical need for a non-ionizing, quantitative assessment of breast density, as one of the strongest independent risk factors for breast cancer. This study aims to establish proton density fat fraction (PDFF) as a quantitative biomarker for fat tissue concentration in breast MRI and correlate mean breast PDFF to mammography.
Methods
In this retrospective study, 193 women were routinely subjected to 3-T MRI using a six-echo chemical shift encoding-based water-fat sequence. Water-fat separation was based on a signal model accounting for a single T2* decay and a pre-calibrated 7-peak fat spectrum resulting in volumetric fat-only, water-only images, PDFF- and T2*-values. After semi-automated breast segmentation, PDFF and T2* values were determined for the entire breast and fibroglandular tissue. The mammographic and MRI-based breast density was classified by visual estimation using the American College of Radiology Breast Imaging Reporting and Data System categories (ACR A-D).
Results
The PDFF negatively correlated with mammographic and MRI breast density measurements (Spearman rho: −0.74, p < .001) and revealed a significant distinction between all four ACR categories. Mean T2* of the fibroglandular tissue correlated with increasing ACR categories (Spearman rho: 0.34, p < .001). The PDFF of the fibroglandular tissue showed a correlation with age (Pearson rho: 0.56, p = .03).
Conclusion
The proposed breast PDFF as an automated tissue fat concentration measurement is comparable with mammographic breast density estimations. Therefore, it is a promising approach to an accurate, user-independent, and non-ionizing breast density assessment that could be easily incorporated into clinical routine breast MRI exams.
Key Points
• The proposed PDFF strongly negatively correlates with visually determined mammographic and MRI-based breast density estimations and therefore allows for an accurate, non-ionizing, and user-independent breast density measurement.
• In combination with T2*, the PDFF can be used to track structural alterations in the composition of breast tissue for an individualized risk assessment for breast cancer.
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11
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Assessing the knowledge, attitudes and barriers regarding health promotion of breast cancer among community pharmacists. Future Sci OA 2022; 8:FSO826. [PMID: 36874370 PMCID: PMC9979115 DOI: 10.2144/fsoa-2022-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/10/2023] [Indexed: 02/05/2023] Open
Abstract
Aim This study aimed to identify the perspective knowledge, attitudes, and barriers of community pharmacists in promoting breast cancer health. Methods An internet-based self-administrated questionnaire was distributed using social media groups to the community pharmacists in Jordan. Results A 76.7% of the pharmacists had insufficient knowledge score of breast cancer and 92.7% had positive attitude. Access to breast cancer educational materials was the major barrier to pharmacists. A significant association was found between pharmacists' knowledge and breast cancer educational materials being given to patients (p < 0.001). Conclusion Despite the low breast cancer knowledge score and stated barriers that could prevent actualizing community pharmacists' role, they had positive attitude toward educating patients about breast cancer health.
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12
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Dolan H, McCaffery K, Houssami N, Cvejic E, Brennan M, Hersch J, Dorrington M, Verde A, Vaccaro L, Nickel B. Australian Women's Intentions and Psychological Outcomes Related to Breast Density Notification and Information: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2216784. [PMID: 35708691 PMCID: PMC9204548 DOI: 10.1001/jamanetworkopen.2022.16784] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Whether the benefits of notifying women about breast density outweigh the potential harms to inform current and future mammogram screening practice remains unknown. OBJECTIVE To assess the effect of mammographic breast density notification and information provision on women's intention to seek supplemental screening and psychological outcomes. DESIGN, SETTING, AND PARTICIPANTS A 3-arm online randomized clinical trial was conducted from August 10 to 31, 2021. Data analysis was conducted from September 1 to October 20, 2021. Participants included Australian residents identifying as female, aged between 40 and 74 years, with no history of breast cancer who were residing in jurisdictions without existing breast density notification with screening mammograms. INTERVENTIONS Women were randomized to receive 1 of the following hypothetical breast screening test result letters: screening mammogram result letter without breast density messaging (control), screening mammogram result letter with breast density messaging and an existing density information letter taken from a screening service in Australia (intervention 1), and screening mammogram result letter with breast density messaging and a health literacy-sensitive version of the letter adapted for people with lower health literacy (intervention 2). MAIN OUTCOMES AND MEASURES Primary outcomes were intention to seek supplemental screening; feeling anxious (uneasy, worried, or nervous), informed, or confused; and having breast cancer worry. RESULTS A total of 1420 Australian women were randomized and included in the final analysis. The largest group consisted of 603 women aged 60 to 74 years (42.5%). Compared with the control cohort (n = 480), women who received density notification via intervention 1 (n = 470) and intervention 2 (n = 470) reported a significantly higher intention to seek supplemental screening (0.8% vs 15.6% and 14.2%; P < .001) and feeling anxious (14.2% vs 49.4% and 48.5%; P < .001), confusion (7.8% vs 24.0% and 23.6%; P < .001), and worry about breast cancer (quite/very worried: 6.9% vs 17.2% and 15.5%; P < .001). There were no statistically significant differences in these outcomes between the 2 intervention groups. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, breast density notification and information integrated with screening mammogram results increased women's intention to seek supplemental screening and made women feel anxious, confused, or worried about breast cancer. These findings have relevance and implications for mammogram screening services and policy makers considering whether and, if so, how best to implement widespread notification of breast density as part of mammography screening. TRIAL REGISTRATION ACTRN12621000253808.
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Affiliation(s)
- Hankiz Dolan
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Nehmat Houssami
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
| | - Erin Cvejic
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Meagan Brennan
- University of Notre Dame Australia, School of Medicine Sydney, Sydney, Australia
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, Sydney, Australia
| | - Jolyn Hersch
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | - Angela Verde
- Breast Cancer Network Australia, Melbourne, Australia
| | - Lisa Vaccaro
- Health Consumers New South Wales, Sydney, Australia
- Discipline of Behavioural and Social Sciences in Health, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Rapid Reductions in Breast Density following Tamoxifen Therapy as Evaluated by Whole-Breast Ultrasound Tomography. J Clin Med 2022; 11:jcm11030792. [PMID: 35160244 PMCID: PMC8836554 DOI: 10.3390/jcm11030792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 02/05/2023] Open
Abstract
Purpose: Women whose mammographic breast density declines within 12–18 months of initiating tamoxifen for chemoprevention or adjuvant treatment show improved therapeutic responses compared with those whose density is unchanged. We tested whether measuring changes in sound speed (a surrogate of breast density) using ultrasound tomography (UST) could enable rapid identification of favorable responses to tamoxifen. Methods: We evaluated serial density measures at baseline and at 1 to 3, 4 to 6, and 12+ months among 74 women (aged 30–70 years) following initiation of tamoxifen for clinical indications, including an elevated risk of breast cancer (20%) and diagnoses of in situ (39%) or invasive (40%) breast carcinoma, enrolled at Karmanos Cancer Institute and Henry Ford Health System (Detroit, MI, USA). For comparison, we evaluated an untreated group with screen negative mammography and frequency-matched on age, race, and menopausal status (n = 150), at baseline and 12 months. Paired t-tests were used to assess differences in UST sound speed over time and between tamoxifen-treated and untreated patients. Results: Sound speed declined steadily over the 12 month period among patients receiving tamoxifen (mean (SD): −3.0 (8.2) m/s; p = 0.001), whereas density remained unchanged in the untreated group (mean (SD): 0.4 (7.1) m/s; p = 0.75 (relative change between groups: p = 0.0009)). In the tamoxifen group, we observed significant sound speed reductions as early as 4–6 months after tamoxifen initiation (mean (SD): −2.1 (6.8) m/s; p = 0.008). Sound speed reductions were greatest among premenopausal patients (P-interaction = 0.0002) and those in the middle and upper tertiles of baseline sound speed (P-interaction = 0.002). Conclusions: UST can image rapid declines in sound speed following initiation of tamoxifen. Given that sound speed and mammographic density are correlated, we propose that UST breast imaging may capture early responses to tamoxifen, which in turn may have utility in predicting therapeutic efficacy.
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Yaghjyan L, Smotherman C, Heine J, Colditz GA, Rosner B, Tamimi RM. Associations of Oral Contraceptives with Mammographic Breast Density in Premenopausal Women. Cancer Epidemiol Biomarkers Prev 2021; 31:436-442. [PMID: 34862209 DOI: 10.1158/1055-9965.epi-21-0853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/15/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We investigated the associations of oral contraceptives (OC) with percent breast density (PD), absolute dense area (DA), nondense area (NDA), and a novel image intensity variation (V) measure in premenopausal women. METHODS This study included 1,233 controls from a nested case-control study within Nurses' Health Study II cohort. Information on OCs was collected in 1989 and updated biennially. OC use was defined from the questionnaire closest to the mammogram date. PD, DA, and NDA were measured from digitized film mammograms using a computer-assisted thresholding technique; the V measure was obtained with a previously developed algorithm measuring the SD of pixel values in the eroded breast region. Generalized linear regression was used to assess associations between OCs and density measures (square root-transformed PD, DA, and NDA, and -untransformed V). RESULTS OC use was not associated with PD [current vs. never: β = -0.06; 95% confidence interval (CI), -0.37-0.24; past vs. never: β = 0.10; 95% CI, -0.09-0.29], DA (current vs. never: β = -0.20; 95% CI -0.59-0.18; past vs. never: β = 0.13; 95% CI, -0.12-0.39), and NDA (current vs. never: β = -0.19; 95% CI, -0.56-0.18; past vs. never: β = -0.01; 95% CI, -0.28-0.25). Women with younger age at initiation had significantly greater V-measure (<20 years vs. never: β = 26.88; 95% CI, 3.18-50.58; 20-24 years vs. never: β = 20.23; 95% CI, -4.24-44.71; 25-29 years vs. never: β = 2.61; 95% CI -29.00-34.23; ≥30 years vs. never: β = 0.28; 95% CI, -34.16-34.72, P trend = 0.03). CONCLUSIONS Our findings suggest that an earlier age at first OC use was associated with significantly greater V. IMPACT These findings could guide decisions about the age for OC initiation.
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Affiliation(s)
- Lusine Yaghjyan
- Department of Epidemiology, University of Florida, College of Public Health and Health Professions and College of Medicine, Gainesville, Florida.
| | - Carmen Smotherman
- Department of Epidemiology, University of Florida, College of Public Health and Health Professions and College of Medicine, Gainesville, Florida
| | - John Heine
- Cancer Epidemiology Department, Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Graham A Colditz
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.,Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
| | - Bernard Rosner
- Channing Division of Network Medicine, Department of Medicine Research, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rulla M Tamimi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
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Tapia E, Villa-Guillen DE, Chalasani P, Centuori S, Roe DJ, Guillen-Rodriguez J, Huang C, Galons JP, Thomson CA, Altbach M, Trujillo J, Pinto L, Martinez JA, Algotar AM, Chow HHS. A randomized controlled trial of metformin in women with components of metabolic syndrome: intervention feasibility and effects on adiposity and breast density. Breast Cancer Res Treat 2021; 190:69-78. [PMID: 34383179 PMCID: PMC8560579 DOI: 10.1007/s10549-021-06355-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/06/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Obesity is a known risk factor for post-menopausal breast cancer and may increase risk for triple negative breast cancer in premenopausal women. Intervention strategies are clearly needed to reduce obesity-associated breast cancer risk. METHODS We conducted a Phase II double-blind, randomized, placebo-controlled trial of metformin in overweight/obese premenopausal women with components of metabolic syndrome to assess the potential of metformin for primary breast cancer prevention. Eligible participants were randomized to receive metformin (850 mg BID, n = 76) or placebo (n = 75) for 12 months. Outcomes included breast density, assessed by fat/water MRI with change in percent breast density as the primary endpoint, anthropometric measures, and intervention feasibility. RESULTS Seventy-six percent in the metformin arm and 83% in the placebo arm (p = 0.182) completed the 12-month intervention. Adherence to study agent was high with more than 80% of participants taking ≥ 80% assigned pills. The most common adverse events reported in the metformin arm were gastrointestinal in nature and subsided over time. Compared to placebo, metformin intervention led to a significant reduction in waist circumference (p < 0.001) and waist-to-hip ratio (p = 0.019). Compared to placebo, metformin did not change percent breast density and dense breast volume but led to a numerical but not significant decrease in non-dense breast volume (p = 0.070). CONCLUSION We conclude that metformin intervention resulted in favorable changes in anthropometric measures of adiposity and a borderline decrease in non-dense breast volume in women with metabolic dysregulation. More research is needed to understand the impact of metformin on breast cancer risk reduction. TRIAL REGISTRATION ClinicalTrials.gov NCT02028221. Registered January 7, 2014, https://clinicaltrials.gov/ct2/show/NCT02028221.
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Affiliation(s)
- Edgar Tapia
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
| | | | - Pavani Chalasani
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Sara Centuori
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Denise J Roe
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ, USA
| | - Jose Guillen-Rodriguez
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
| | - Chuan Huang
- Department of Radiology, Stony Brook University, Stony Brook, NY, USA
| | - Jean-Phillippe Galons
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
- Department of Medical Imaging, University of Arizona, Tucson, AZ, USA
| | - Cynthia A Thomson
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
- Department of Health Promotion Sciences, University of Arizona, Tucson, AZ, USA
| | - Maria Altbach
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
- Department of Medical Imaging, University of Arizona, Tucson, AZ, USA
| | - Jesse Trujillo
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
| | - Liane Pinto
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
| | - Jessica A Martinez
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ, USA
| | - Amit M Algotar
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA
- Department of Family and Community Medicine, University of Arizona, Tucson, AZ, USA
| | - H-H Sherry Chow
- University of Arizona Cancer Center, University of Arizona, 1515 N Campbell Ave, Tucson, AZ, 85724, USA.
- Department of Medicine, University of Arizona, Tucson, AZ, USA.
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Quantitative Breast Density in Contrast-Enhanced Mammography. J Clin Med 2021; 10:jcm10153309. [PMID: 34362092 PMCID: PMC8348046 DOI: 10.3390/jcm10153309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 11/16/2022] Open
Abstract
Contrast-enhanced mammography (CEM) demonstrates a potential role in personalized screening models, in particular for women at increased risk and women with dense breasts. In this study, volumetric breast density (VBD) measured in CEM images was compared with VBD obtained from digital mammography (DM) or tomosynthesis (DBT) images. A total of 150 women who underwent CEM between March 2019 and December 2020, having at least a DM/DBT study performed before/after CEM, were included. Low-energy CEM (LE-CEM) and DM/DBT images were processed with automatic software to obtain the VBD. VBDs from the paired datasets were compared by Wilcoxon tests. A multivariate regression model was applied to analyze the relationship between VBD differences and multiple independent variables certainly or potentially affecting VBD. Median VBD was comparable for LE-CEM and DM/DBT (12.73% vs. 12.39%), not evidencing any statistically significant difference (p = 0.5855). VBD differences between LE-CEM and DM were associated with significant differences of glandular volume, breast thickness, compression force and pressure, contact area, and nipple-to-posterior-edge distance, i.e., variables reflecting differences in breast positioning (coefficient of determination 0.6023; multiple correlation coefficient 0.7761). Volumetric breast density was obtained from low-energy contrast-enhanced spectral mammography and was not significantly different from volumetric breast density measured from standard mammograms.
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Shawahna R, Awawdeh H. Pharmacists' knowledge, attitudes, beliefs, and barriers toward breast cancer health promotion: a cross-sectional study in the Palestinian territories. BMC Health Serv Res 2021; 21:429. [PMID: 33952277 PMCID: PMC8101222 DOI: 10.1186/s12913-021-06458-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/28/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Among all cancers, breast cancer is the most prevalent cancer and the leading cause of mortality among women in developing countries including Palestine. Community pharmacists are trusted and easily accessible healthcare providers who could be engaged in breast cancer health promotion. This study was conducted with the aim of exploring knowledge, attitudes, beliefs, and barriers toward breast cancer health promotion among community pharmacists in the Palestinian territories. METHODS This study was conducted in a cross-sectional design using a questionnaire among community pharmacists. Knowledge of community pharmacists of breast cancer was tested using a 26-item knowledge test. Attitudes and beliefs of the community pharmacists with regard to breast cancer promotion were explored using 14 items. Barrier to breast cancer health promotion were explored using 9 items. RESULTS Data were collected from 200 community pharmacists. The median knowledge score was 69.2 % with and IQR of 15.2 %. Of the community pharmacists, 67.5 % scored 50 % and above in the knowledge test. Multivariate logistic regression showed that community pharmacists who were female in gender were more likely to score 50 % and above in the knowledge test compared to the community pharmacists who were male in gender (OR = 4.73, 95 % CI of 2.26-9.89). The community pharmacists had positive attitudes toward breast cancer health promotion. There was a significant moderate positive correlation between knowledge and attitudes scores (Spearman's rho = 0.37, p-value < 0.001). Lack of reimbursement, lack of enough personnel, lack of time, and fear of offending the patients were the main barriers to breast cancer health promotion (percentage of agreement > 60.0 %). CONCLUSIONS This study shed light on the role of community pharmacists in breast cancer health promotion. Pharmacists had good knowledge of breast cancer and positive attitudes toward promoting the health of patients with breast cancer. Further studies are still needed to determine how to integrate community pharmacists in the team of healthcare providers caring for patients with breast cancer.
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Affiliation(s)
- Ramzi Shawahna
- Department of Physiology, Pharmacology and Toxicology, Faculty of Medicine and Health Sciences, An- Najah National University, P.O. Box 7, New Campus, Building: 19, Office: 1340, Nablus, Palestine.
- An-Najah BioSciences Unit, Centre for Poisons Control, Chemical and Biological Analyses, An-Najah National University, Nablus, Palestine.
| | - Hiba Awawdeh
- Faculty of Graduate Studies, An-Najah National University, Nablus, Palestine
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