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Ergun MA, Hajjar A, Alagoz O, Rampurwala M. Optimal breast cancer risk reduction policies tailored to personal risk level. Health Care Manag Sci 2022; 25:363-388. [PMID: 35687269 PMCID: PMC10445480 DOI: 10.1007/s10729-022-09596-2] [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: 02/14/2021] [Accepted: 03/17/2022] [Indexed: 11/04/2022]
Abstract
Depending on personal and hereditary factors, each woman has a different risk of developing breast cancer, one of the leading causes of death for women. For women with a high-risk of breast cancer, their risk can be reduced by two main therapeutic approaches: 1) preventive treatments such as hormonal therapies (i.e., tamoxifen, raloxifene, exemestane); or 2) a risk reduction surgery (i.e., mastectomy). Existing national clinical guidelines either fail to incorporate or have limited use of the personal risk of developing breast cancer in their proposed risk reduction strategies. As a result, they do not provide enough resolution on the benefit-risk trade-off of an intervention policy as personal risk changes. In addressing this problem, we develop a discrete-time, finite-horizon Markov decision process (MDP) model with the objective of maximizing the patient's total expected quality-adjusted life years. We find several useful insights some of which contradict the existing national breast cancer risk reduction recommendations. For example, we find that mastectomy is the optimal choice for the border-line high-risk women who are between ages 22 and 38. Additionally, in contrast to the National Comprehensive Cancer Network recommendations, we find that exemestane is a plausible, in fact, the best, option for high-risk postmenopausal women.
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Affiliation(s)
- Mehmet A Ergun
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3242 Mechanical Engineering Building, 1513 University Avenue, Madison, WI, 53706, USA
- Department of Industrial Engineering, Istanbul Technical University, Istanbul, Turkey
| | - Ali Hajjar
- Harvard Medical School, Boston, Massachusetts, Boston, USA
- Massachusetts General Hospital Institute for Technology Assessment, Boston, USA
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3242 Mechanical Engineering Building, 1513 University Avenue, Madison, WI, 53706, USA.
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Park YHA, Keller A, Hsu TCM, Bidassie B, Venne V, Hawley D, Hoffman-Högg L, Heron B, Colonna S, Aggarwal A. Screening High-Risk Women Veterans for Breast Cancer. Fed Pract 2021; 38:S35-S41. [PMID: 34177240 PMCID: PMC8223736 DOI: 10.12788/fp.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Within the US Department of Veterans Affairs (VA), breast cancer prevalence has more than tripled from 1995 to 2012. Women veterans may be at an increased breast cancer risk based on service-related exposures and posttraumatic stress disorder (PTSD). METHODS Women veterans aged ≥ 35 years with no personal history of breast cancer were enrolled at 2 urban VA medical centers. We surveyed women veterans for 5-year and lifetime risks of invasive breast cancer using the Gail Breast Cancer Risk Assessment Tool (BCRAT). Data regarding demographics, PTSD status, eligibility for chemoprevention, and genetic counseling were also collected. Descriptive statistics were used to determine results. RESULTS A total of 99 women veterans participated, of which 60% were Black. In total, 35% were high risk with a 5-year BCRAT > 1.66%. Breast biopsies had been performed in 22% of our entire population; 57% had a family history positive for breast cancer. Comparatively, in our high-risk Black population, 33% had breast biopsies and 94% had a family history. High-risk patients were referred for chemoprevention; 5 accepted and 13 were referred for genetic counseling. PTSD was present in 31% of the high-risk subgroup. CONCLUSIONS A high percentage of Black patients participated in this pilot study, which also showed an above average rate of PTSD among women veterans who are at high risk for developing breast cancer. Historically, breast cancer rates among Black women are lower than those found in the general population. High participation among Black women veterans in this pilot study uncovered the potential for further study of this population, which is otherwise underrepresented in research. Limitations included a small sample size, exclusively urban population, and self-selection for screening. Future directions include the evaluation of genetic and molecular mutations in high risk Black women veterans, possibly even a role for PTSD epigenetic changes.
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Affiliation(s)
- Yeun-Hee Anna Park
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Alison Keller
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Ta-Chueh Melody Hsu
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Balmatee Bidassie
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Vickie Venne
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Douglas Hawley
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Lori Hoffman-Högg
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Bernadette Heron
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Sarah Colonna
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
| | - Anita Aggarwal
- is Chief of Hematology/Oncology; is a Research Coordinator; and is a Research Nurse Practitioner, all at James J. Peters Veterans Affairs Medical Center, Bronx, New York. is an Industrial Engineer VA Center for Applied Systems Engineering (VA-CASE), VISN11 - Veterans Engineering Resource Center (VERC) at Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana. was a Senior Genetic Counselor for the US Department of Veterans Affairs (VA) Genomic Medicine Services, and is a Hematologist/Oncologist; both at George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah. is a Hematologist/Oncologist at Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. is a ONS Clinical Nurse Advisor for the Oncology Field Advisory Committee and VHA National Program Manager for Prevention Policy at Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention, Durham, North Carolina and VHA Office of Nursing Services, Washington, DC. is a Program Manager at Veterans Health Administration, Pharmacy Benefits Management Services in Hines, Illinois. is a Hematologist/Oncologist Washington Veterans Affairs Medical Center, Washington, DC
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Anderson C, Nichols HB, House M, Sandler DP. Risk versus Benefit of Chemoprevention among Raloxifene and Tamoxifen Users with a Family History of Breast Cancer. Cancer Prev Res (Phila) 2019; 12:801-808. [PMID: 31431499 DOI: 10.1158/1940-6207.capr-19-0021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/04/2019] [Accepted: 08/14/2019] [Indexed: 11/16/2022]
Abstract
Tamoxifen and raloxifene have been approved for the primary prevention of breast cancer in high-risk women, but are associated with an increased risk of serious side effects. Few studies have characterized risk-benefit profiles for chemoprevention among women who initiate tamoxifen or raloxifene outside of a clinical trial setting. Use of raloxifene and tamoxifen for chemoprevention was self-reported in 2014 to 2016 by participants in The Sister Study, a prospective cohort of women with a sister who had been diagnosed with breast cancer. After exclusions, 432 current raloxifene users and 96 current tamoxifen users were matched to 4,307 and 953 nonusers, respectively, on age and year of cohort enrollment. Conditional logistic regression was used to evaluate characteristics associated with chemoprevention use. Risk-benefit profiles were examined using published indices that assess the level of evidence (none, moderate, strong) that the benefits of chemoprevention outweigh the risk of serious side effects. Among current chemoprevention users, 44% of tamoxifen users and 5% of raloxifene users had no evidence of a net benefit. In analyses of factors associated with chemoprevention use, having strong evidence of benefit was a significant predictor of raloxifene use, but not of tamoxifen use. In our sample of women with a first-degree family history of breast cancer, raloxifene was more commonly used for breast cancer prevention than tamoxifen. Most raloxifene users, but <60% of tamoxifen users, were likely to benefit. Use of risk-benefit tables can help women and their healthcare providers make an informed decision about breast cancer chemoprevention.
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Affiliation(s)
- Chelsea Anderson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hazel B Nichols
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | | | - Dale P Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina
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