Breast imaging and intervention in the overweight and obese patient

Tips and Tricks for Image-Guided Breast Biopsies: Technical Factors for Success

Image-guided biopsy is an integral step in the diagnosis and management of suspicious image-detected breast or axillary lesions, allowing for accurate diagnosis and, if indicated, treatment planning. Tissue sampling can be performed under guidance of a full spectrum of breast imaging modalities, including stereotactic, tomosynthesis, sonographic, and MRI, each with its own set of advantages and limitations. Procedural planning, which includes consideration of technical, patient, and lesion factors, is vital for diagnostic accuracy and limitation of complications. The purpose of this paper is to review and provide guidance for breast imaging radiologists in selecting the best procedural approach for the individual patient to ensure accurate diagnosis and optimal patient outcomes. Common patient and lesion factors that may affect successful sampling and contribute to postbiopsy complications are reviewed and include obesity, limited patient mobility, patient motion, patients prone to vasovagal reactions, history of anticoagulation, and lesion location, such as proximity to vital structures or breast implant.

Co-design of an intervention to optimize mammographic screening participation in women with obesity and/or physical disabilities

BACKGROUND

Mammographic breast screening/rescreening rates are suboptimal for women with obesity and/or physical disabilities. This study describes development of an intervention framework targeting obesity- and disability-related barriers to improve participation.

METHODS

Mixed methods combined a systematic review with first-person perspectives to optimise screening engagement among women with obesity and/or physical disabilities. Phase 1 (systematic review) was conducted following the PRISMA framework. Phase 2 involved in-depth interviews with n = 8 women with lived experience of obesity and/or physical disabilities. An inductive coding approach was applied to the data which was then combined with Phase 1 results to develop the intervention framework.

RESULTS

Six studies were included in the systematic review. Tailored education based on individual risk increased willingness to undergo mammographic screening. Recommendations to improve the screening experience included partnerships with consumers, targeted messaging, and enhanced professional development for breast screening staff. Participants also identified strategies to improve the uptake of screening and the experience itself.

CONCLUSION

Development and evaluation of interventions informed by frameworks like the one developed in this study are needed to improve engagement in screening to promote regular participation among women with physical disabilities and/or obesity.

IMPLICATIONS FOR PRACTICE

Successful implementation of practice interventions co-designed by women with obesity and/or physical disabilities are likely to improve their breast screening participation. Enhanced training of radiographers aimed at upskilling in empathetic communication around required manoeuvring and potentially longer screening times for clients with obesity and/or physical disabilities may encourage more positive client practitioner interactions. Client information aimed at women with obesity should include information on how to prepare for the appointment and explain there may be equipment limitations compromising imaging which may not be completed at an initial appointment.

Obesity and breast cancer

The paper presents an analysis of the latest literature data on the problem of obesity and breast cancer (BC). This review presents modern approaches to the diagnosis of BC in obese patients, new molecular methods of breast imaging,  analyzes the features of the course of BC with obesity depending on menstrual status, molecular biological subtypes of the tumor, the mechanisms of the development of BC against the background of obesity.

A review of mammographic image quality in Papua New Guinea

INTRODUCTION

To report for the first time the image quality of mammograms performed in Papua New Guinea (PNG) using the Perfect, Good, Moderate, Inadequate (PGMI) image evaluation system (IES); and to benchmark the image quality against BreastScreen Australia (BSA) National Accreditation Standards (NAS).

METHODS

A retrospective image quality analysis of the de-identified mammograms of 102 women imaged at the Port Moresby General Hospital (PMGH) was undertaken using the PGMI IES. Each craniocaudal (CC) and mediolateral oblique (MLO) image was assigned a grade and the reasons for the grade recorded. Age was recorded in years. Simple frequency analysis was undertaken and comparison with BSA NAS 2.4 was made.

RESULTS

Women were aged between 25 and 74 years. There were 111 CC views and 109 MLO views. The most frequent individual grade for the CC view was G (83.8%) and for the MLO view M (72.48%); and for a routine series (four images), P and G combined (14.8%). Non-visualisation of the IMA (28%), nipple not in profile (26%) and short length of pectoral muscle (12%) were the most cited reasons for assigning an M grade.

CONCLUSION

The reported image quality is not commensurate with that required by BSA (P and G > 50%) and while common positioning errors can be rectified through education and training, it is also important to recognise the complex challenges faced by PNG radiographers in obtaining mammographic images that extend beyond education and training and reflect the emerging nature of the modality as well as wider health, economic and other issues. This work raises the need for national standards, dedicated equipment, and radiographer education to best serve the women of PNG.

Visualization of the Nipple in Profile: Does It Really Affect Selected Outcomes in Organized Mammographic Screening?

OBJECTIVE

To investigate whether having the nipple imaged in profile was associated with breast characteristics or compression parameters, and whether it affected selected outcomes in screening with standard digital mammography or digital breast tomosynthesis.

METHODS

In this IRB-approved retrospective study, results from 87 450 examinations (174 900 breasts) performed as part of BreastScreen Norway, 2016-2019, were compared by nipple in profile status and screening technique using descriptive statistics and generalized estimating equations. Unadjusted and adjusted odds ratios with 95% confidence intervals (95% CIs) were estimated for outcomes of interest, including age, breast volume, volumetric breast density, and compression force as covariates.

RESULTS

Achieving the nipple in profile versus not in profile was associated with lower breast volume (845.1 cm3 versus 1059.9 cm3, P < 0.01) and higher mammographic density (5.6% versus 4.4%, P < 0.01). Lower compression force and higher compression pressure were applied to breasts with the nipple in profile (106.6 N and 11.5 kPa) compared to the nipple not in profile (110.8 N and 10.5 kPa, P < 0.01 for both). The adjusted odds ratio was 0.95 (95% CI: 0.88-1.02; P = 0.15) for recall and 0.92 (95% CI: 0.77-1.10; P = 0.36) for screen-detected cancer for nipple in profile versus not in profile.

CONCLUSION

Breast characteristics and compression parameters might hamper imaging of the nipple in profile. However, whether the nipple was in profile or not on the screening mammograms did not influence the odds of recall or screen-detected cancer, regardless of screening technique.

Relationship between body mass index and malignancy rates of MRI-guided breast biopsies: impact of clinicodemographic factors

PURPOSE

To determine the positive predictive value (PPV) of magnetic resonance imaging (MRI)-guided breast biopsy stratified by body mass index (BMI). Secondary endpoints include evaluation of indications for breast MRI and identification of factors associated with malignant biopsy.

METHODS

We retrospectively analyzed results of MRI-guided breast biopsies in a consecutive cohort of women at a single institution between 2014 and 2019. The PPV was compared between BMI subgroups and the overall group by the one-sample z-test. Factors associated with malignant biopsy were analyzed using multivariate regression analysis.

RESULTS

Among 427 MRI-guided breast biopsies, the PPV was significantly higher in patients with a BMI ≥ 35 compared to BMI < 35 (38.6% versus 24.5%, p = 0.043). This remained true in the 180 biopsies from high-risk screening studies, but there was no difference in PPV by BMI in the 205 biopsies performed to evaluate extent of known disease. Among this cohort who underwent MRI-guided breast biopsy, the underlying indication for MRI was less likely to be high-risk screening in those with a higher BMI or Black or Hispanic race (p = 0.015 and p < 0.001, respectively). For high-risk screening studies, only BMI ≥ 35 was associated with malignant biopsies (OR 37.5, p = 0.003). For evaluation of extent of disease studies, only increased lesion size was a significant predictor of malignant result (OR 1.01, p = 0.04).

CONCLUSIONS

Among women who underwent MRI-guided breast biopsy, elevated BMI was associated with increased PPV and malignant biopsies. Patients with a higher BMI or Black or Hispanic race who had MRI-guided biopsy were less likely to be undergoing high-risk screening and more likely to have breast MRI to evaluate extent of known disease.

Diabetes, Obesity, and Inflammation: Impact on Clinical and Radiographic Features of Breast Cancer

Obesity, diabetes, and inflammation increase the risk of breast cancer, the most common malignancy in women. One of the mainstays of breast cancer treatment and improving outcomes is early detection through imaging-based screening. There may be a role for individualized imaging strategies for patients with certain co-morbidities. Herein, we review the literature regarding the accuracy of conventional imaging modalities in obese and diabetic women, the potential role of anti-inflammatory agents to improve detection, and the novel molecular imaging techniques that may have a role for breast cancer screening in these patients. We demonstrate that with conventional imaging modalities, increased sensitivity often comes with a loss of specificity, resulting in unnecessary biopsies and overtreatment. Obese women have body size limitations that impair image quality, and diabetes increases the risk for dense breast tis-sue. Increased density is known to obscure the diagnosis of cancer on routine screening mammography. Novel molecu-lar imaging agents with targets such as estrogen receptor, human epidermal growth factor receptor 2 (HER2), pyrimi-dine analogues, and ligand-targeted receptor probes, among others, have potential to reduce false positive results. They can also improve detection rates with increased resolution and inform therapeutic decision making. These emerg-ing imaging techniques promise to improve breast cancer diagnosis in obese patients with diabetes who have dense breasts, but more work is needed to validate their clinical application.

Full-field digital mammography: the '30% rule' and influences on visualisation of the pectoralis major muscle on the craniocaudal view of the breast

INTRODUCTION

To investigate compliance to the '30% rule' and key factors which may influence visualisation of the pectoralis major muscle (PMM) on the craniocaudal (CC) view of the breast.

METHODS

A retrospective review of 2688 paired full-field digital mammography (FFDM) CC view mammograms of women attending BreastScreen NSW between August and October 2015 was undertaken. PMM visualisation and measurements of PMM width and length, compressed breast thickness, the posterior nipple line (PNL) and age were recorded. Statistical analysis was performed using descriptive and inferential statistics to investigate associations between key breast measurements, age and PMM visualisation.

RESULTS

PMM visualisation was reported in 10.4% of images unilaterally (one breast, left or right only), 14.1% bilaterally (both left and right breasts) and 24.5% overall (unilateral and bilateral combined). There was little or no correlations between PMM length or width and age, breast compressed thickness or PNL. Multiple logistic regression analysis found that up to 15% of the variance in visualisation of the PMM was accounted for by the predictors overall. While some predictors provided a statistically significant contribution to the model, the contribution was small and the odds ratio for all predictors approximated 1.

CONCLUSION

This research could not replicate the '30% rule', and visualisation of the PMM was determined not to be influenced by the variables investigated. The significance of the 'rule' itself must be challenged where the vast majority of images (70-85%) do not comply, and there is no requirement for repeat imaging if the 'rule' is not met. Further research should be undertaken to validate this study including analysis of diagnostic images for comparison.

Obesity and breast cancer screening: Cross-sectional survey results from the behavioral risk factor surveillance system

BACKGROUND

Postmenopausal obese women demonstrate an elevated breast cancer risk and experience increased breast cancer morbidity and mortality compared with women with a normal body mass index (BMI). However, to the authors' knowledge, prior studies have yielded inconclusive results regarding the effects of obesity on mammography screening adherence. Using national cross-sectional survey data, the objective of the current study was to assess the current association between increasing BMI and use of mammography screening.

METHODS

Cross-sectional survey data from the 2016 Behavioral Risk Factor Surveillance System, a state-based national telephone survey of noninstitutionalized adults in the United States, was used to identify the association between mammography screening use and increasing incremental BMI categories, including normal (18.5-24.9 kg/m2 ), overweight (25-29.9 kg/m2 ), obese class I (30-34.9 kg/m2 ), obese class II (35-39.9 kg/m2 ), and obese class III (>40 kg/m2 ), with adjustments for potential confounders. A multivariable logistic regression model was used to evaluate the effect of each BMI category on self-reported mammography use, using unadjusted and adjusted odds ratios. Effect modification by race/ethnicity was determined by testing interaction terms using Wald tests.

RESULTS

Of 116,343 survey respondents, 33.5% (38,984 respondents) had a normal BMI, 32.6% (37,969 respondents) were overweight, 19.3% (22,416 respondents) were classified as obese class I, 8.4% (9791 respondents) were classified as obese class II, and 6.2% (7183 respondents) were classified as obese class III. There was no statistically significant difference (P < .05) observed with regard to mammography use between women with a normal BMI and obese women from each obese class (classes I-III) when compared individually. There also was no evidence of effect modification by race (P = .53).

CONCLUSIONS

In contrast to prior reports, the results of the current study demonstrated no association between obesity and adherence to screening mammography. These findings may relate to the increasing social acceptance of obesity among women from all racial/ethnic groups and the removal of weight-related facility-level barriers over time.

Optimizing Projectional Radiographic Imaging of the Abdomen of Obese Patients: An e-Delphi Study

PURPOSE

Obesity is increasing in prevalence globally, with increased demands placed on radiology departments to image obese patients to assist with diagnosis and management. The aim of this study was to determine perceived best practice techniques currently used in clinical practice for projectional radiography of the abdomen for obese patients with the aim to help elucidate areas for future research and education needs in this field.

EXPERIMENTAL DESIGN

A two round e-Delphi study was undertaken to establish a consensus within a reference group of expert Australian clinical educator diagnostic radiographers (CEDRs). Initially, a conceptual map of issues regarding imaging obese patients was undertaken by analysing interview transcripts of 12 CEDRs. This informed an online questionnaire design used in Delphi rounds 1 and 2. A consensus threshold was set <75% "agreement/disagreement", with 15 and 14 CEDRs participating in rounds 1 and 2, respectively.

RESULTS

Seven of the 11 statements reach consensus after round 2. Consensus on using a combination of higher peak kilovoltage (kVp) and milliampere-seconds (mAs) to increase radiation exposure increased source-to-image distance and tighter collimation was achieved. There was no consensus regarding patient positioning practices or patient communication strategies. The expert group reported the importance of personal confidence and treating patients as individuals when applying techniques.

CONCLUSION

Diversity of experts' opinions and current practice may be due to the variations in obese patients' size and presentation. Therefore, there is a need for extensive empirical evidence to underpin practice and education resources for radiographers when imaging obese patients.

Stigma in Practice: Barriers to Health for Fat Women

In this paper, we explore barriers to health for fat people. By shifting the focus from what fat people do or do not do, neoliberal principles are replaced by a focus instead on structural and institutional policies, attitudes, and practices. This includes the impact of stigma on the health treatment and health-seeking behavior of fat people. For example, we consider the role that provider anti-fat attitudes and confirmation bias play in the failure to provide evidenced-based healthcare to fat patients. This is an autoethnographic paper, which provides the opportunity to read research from the perspective of fat scholars, framed by questions such as: can fat people have health? Is health itself a state of being, a set of behaviors, a commodity, a performance; perhaps the new social contract? As a co-written autoethnographic paper, one aspect of the evidence provided is the recorded experiences of the two fat authors. This includes writing from notes, journals, compiled and repeated experiences with medical professionals, family, and the community. Framed by feminist standpoint and supported by literature drawn from Fat Studies, Public Health, Obesity Research, and other interdisciplinary fields, this is a valuable opportunity to present an extended account of fat discrimination and the impact of the stigma fat people face through the medical profession and other sectors of the community, written by fat individuals. The paper concludes by considering the health pathways available to fat people. Special attention is paid to whether Bacon and Aphramor's Health at Every Size paradigm provides a path to health for fat individuals.

Technologists' Characteristics and Quality of Positioning in Daily Practice in a Canadian Breast Cancer Screening Program

RATIONALE AND OBJECTIVES

This study evaluates to what extent technologists' experience, training, or practice in mammography are associated with screening mammography positioning quality.

MATERIALS AND METHODS

Positioning quality of a random sample of 1278 mammograms drawn from the 394,190 screening examinations performed in 2004-2005 in the Breast Cancer Screening Program of Quebec (Canada) was evaluated by an expert radiologist. Information on technologists' experience, training, and practice was obtained by mailed questionnaire. Multivariable Poisson regression models with robust estimation of variance were used to assess the association of technologists' characteristics with higher positioning quality.

RESULTS

Of 254 randomly selected technologists, 220 (86.6%) completed the questionnaire. Participating technologists did 89.2% of available sampled mammograms (1088 of 1220), of which 45.9% were of higher positioning quality. Technologists who, in addition to mandatory training, followed at least 15 hours of hands-on training in positioning performed higher positioning quality (adjusted ratio = 1.3, 95%CI = 1.1-1.5) than technologists with no such additional training. Technologists providing at least 15 hours of continued medical education also performed higher positioning quality (adjusted ratio = 1.3, 95%CI = 1.1-1.5) than those who provided less than 15 hours of continued medical education. Being involved in film development and proportion of mammograms performed that are screening compared to diagnostic were also associated with positioning quality, although the latter association was less clear.

CONCLUSIONS

Extra hands-on training in positioning could further improve screening mammography positioning quality in the screening program because many technologists did not have such additional training.

Clinic exam room design: present and future

OBJECTIVE

This article aims to deconstruct various design qualities and strategies of clinic exam rooms, and discuss how they influence users' interaction and behavior in the space. Relevant literature supports the advantages and disadvantages of different design strategies. Annotated exam room prototypes illustrate the design qualities and strategies discussed.

BACKGROUND

Advancements in technology and medicine, along with new legislative policies, are influencing the way care providers deliver care and ultimately clinic exam room designs. The patient-centered medical home model has encouraged primary care providers to make patients more active leaders of their health plan which will influence the overall functionality and configuration of clinic exam rooms. Specific design qualities discussed include overall size, location of doors and privacy curtains, positioning of exam tables, influence of technology in the consultation area, types of seating, and placement of sink and hand sanitizing dispensers. In addition, future trends of exam room prototypes are presented.

CONCLUSIONS

There is a general lack of published evidence to support design professionals' design solutions for outpatient exam rooms. Future research should investigate such topics as the location of exam tables and privacy curtains as they relate to patient privacy; typical size and location of consultation table as it relates to patient connection and communication; and placement of sinks and sanitization dispensers as they relate to frequency and patterns of usage.

KEYWORDS

Literature review, outpatient, technology, visual privacy.

Obese patients and radiography literature: what do we know about a big issue?

Obesity is a global health issue with obese patients requiring specialised diagnosis, treatment and care through the health service. The practical and social difficulties associated with medical imaging of obese patients are an increasingly common problem and it is currently unknown how student and qualified radiographers perceive and respond to these challenges. By better understanding challenges presented in providing quality imaging and care of imaging obese patients, education for both qualified and student radiographers can be enhanced. Radiographers are heavily reliant on visual and tactile senses to locate the position of anatomical structures for diagnostic imaging and determine radiation exposure through a delicate consideration of dose, image quality and anatomical attenuation. However, obese patients require modifications to routine radiographic practice in terms of movement/assisted positioning, equipment capabilities to take increased weight or coverage. These patients may also be subject to compromised radiological diagnosis through poor visualisation of structures. In this paper, the professional and educational literature was narratively reviewed to assess gaps in the evidence base related to the skill and care knowledge for obese patients. Literature was sourced relating to discrete radiographic considerations such as the technical factors of imaging obese patients, exposure and the impact of obesity on imaging departments’ service provisions. The recent literature (post-2000 to coincide with the sharp increase in global obesity) on the perceptions of health professionals and student health practitioners has also been explored because there are no specific radiographer studies to report. By understanding the research in similar fields, we may identify what common attitudes qualified and student radiographer's hold and what challenges, technical and care related, can be prepared for.

The impact of overweight and obesity on breast cancer: data from Switzerland, so far a country little affected by the current global obesity epidemic

This review presents results from the project "The Impact of Overweight/Obesity on Breast Cancer: data from Switzerland". Swiss data is interesting because the general female population is distinctive in two areas when compared to that of most other industrialized countries: Switzerland has comparatively low rates of overweight (22-23%) and obesity (7-8%) and has rather stable rates of overweight and obesity. The entire project comprised three major issues: (I) etiology of breast cancer (BC). There is a consistently shown association between obesity and postmenopausal BC risk in countries with high obesity prevalence rates in the literature. In our Swiss study group, however, we did not find higher rates of overweight and obesity in postmenopausal BC cases than in the general population. A possible explanation for this observation may be a curvilinear dose-response relationship between BMI and postmenopausal BC risk, so that an increased risk may only be observed in populations with a high prevalence of obese/very obese women; (II) tumor characteristics. BMI was significantly associated with tumor size; this applied not only to the cases where the tumor was found by self-detection, but also to lesions detected by radiological breast examinations. In addition, a higher BMI was positively correlated with advanced TNM stage, unfavorable grading and a higher St. Gallen risk score. No associations were observed between BMI and histological subtype, estrogen receptor status, HER2 status and triple negative BC; (III) patient compliance and persistence towards adjuvant BC therapy. Many studies found that the prognosis of overweight/obese BC patients was significantly lower than that of normal weight patients. However, failure of compliance and persistence towards therapy on the part of the patient is not a contributing factor for this observed unfavorable prognosis. In most therapy modes, patients with increasing BMI demonstrated greater motivation and perseverance towards the recommended treatment.

Clinical image quality in daily practice of breast cancer mammography screening

OBJECTIVE

To assess the quality of screening mammograms performed in daily practice in the Quebec Breast Cancer Screening Program.

SUBJECTS AND METHODS

Clinical image quality of a random subsample of 197 screening mammograms performed in 2004-2005 was independently evaluated by 2 radiologists based on the criteria by Canadian Association of Radiologists (CAR). When disagreement occurred for overall judgement or positioning score, the mammograms were reviewed by a third radiologist. Cohen's kappas for interrater agreement were computed. Multivariable robust Poisson regression models were used to study associations of overall quality and positioning with body mass index (BMI) and breast density.

RESULTS

The CAR criteria were not satisfied for 49.7% of the mammograms. Positioning was the quality attribute most often deficient, with 37.2% of mammograms failing positioning. Interrater agreement ranged from slight (kappa = 0.02 for compression and sharpness) to fair (kappa = 0.30 for exposure). For overall quality, women with a BMI ≥ 30 kg/m(2) had a failure proportion of 67.5% compared with 34.9% for women with a BMI<25 kg/m(2) (risk ratio 2.1 [95% confidence interval, 1.5-3.0]). For positioning, women with a BMI ≥ 30 kg/m(2) had a failure proportion of 53.8% compared with 27.9% for women with a BMI < 25 kg/m(2) (risk ratio 1.9 [95% confidence interval, 1.2-3.1]). Effects of breast density on image quality differed among radiologists.

CONCLUSION

Despite measures to ensure high-quality imaging, including CAR accreditation, approximately half of this random sample of screening mammograms failed the CAR quality standards. It would be important to define quality targets for screening mammograms carried out in daily practice to interpret such observations.

Impact of body mass index on prognostically relevant breast cancer tumor characteristics

BACKGROUND

This study analyzes the association of body mass index (BMI) and prognostically relevant breast cancer (BC) characteristics in a country that has been rather spared of the global obesity epidemic.

PATIENTS AND METHODS

Based on 20-year data (1999-2009, n = 1,414) of the prospective relational BC database of the University Hospital Basel, Switzerland, the associations between BMI, tumor size and stage, histological subtype, grading, hormonal receptor status, HER2 status and 'triple-negative' status were evaluated. Multivariate analysis considered BMI and patient's age.

RESULTS

The association between increasing BMI and the above-mentioned variables were as follows (results described in each case: Beta-coefficient or odds ratio, 95% confidence interval, p value): tumor size, (1) entire cohort: 0.03 (0.01-0.05), p < 0.001, (2) tumor found by self-palpation: 0.05 (0.03-0.07), p < 0.001, (3) tumor found by radiological examination: 0.03 (0-0.07), p = 0.044; advanced TNM stage: 1.16 (1.02-1.31), p = 0.022; histological subtype: 1.04 (0.89-1.22), p = 0.602; unfavorable grading: 1.11 (1.00-1.25), p = 0.057; positive estrogen receptor status: 0.95 (0.83-1.09), p = 0.459; positive HER2 status: 0.92 (0.74-1.15), p = 0.467; presence of a 'triple-negative' carcinoma: 1.19 (0.93-1.52), p = 0.165. Consideration of only postmenopausal BC patients (n = 1,063) did attenuate the results, but did not change the direction of the associations with BMI.

CONCLUSION

BMI was positively associated with TNM stage, grading and tumor size for tumors that were found by self-detection, as well as for those lesions detected by radiological breast examinations.

Impact of mammography screening interval on breast cancer diagnosis by menopausal status and BMI

BACKGROUND

Controversy remains regarding the frequency of screening mammography. Women with different risks for developing breast cancer because of body mass index (BMI) may benefit from tailored recommendations.

OBJECTIVE

To determine the impact of mammography screening interval for women who are normal weight (BMI < 25), overweight (BMI 25-29.9), or obese (BMI ≥ 30), stratified by menopausal status.

DESIGN

Two cohorts selected from the Breast Cancer Surveillance Consortium. Patient and mammography data were linked to pathology databases and tumor registries.

PARTICIPANTS

The cohort included 4,432 women aged 40-74 with breast cancer; the false-positive analysis included a cohort of 553,343 women aged 40-74 without breast cancer.

MAIN MEASURES

Stage, tumor size and lymph node status by BMI and screening interval (biennial vs. annual). Cumulative probability of false-positive recall or biopsy by BMI and screening interval. Analyses were stratified by menopausal status.

KEY RESULTS

Premenopausal obese women undergoing biennial screening had a non-significantly increased odds of a tumor size > 20 mm relative to annual screeners (odds ratio [OR] = 2.07; 95 % confidence interval [CI] 0.997 to 4.30). Across all BMI categories from normal to obese, postmenopausal women with breast cancer did not present with higher stage, larger tumor size or node positive tumors if they received biennial rather than annual screening. False-positive recall and biopsy recommendations were more common among annually screened women.

CONCLUSION

The only negative outcome identified for biennial vs. annual screening was a larger tumor size (> 20 mm) among obese premenopausal women. Since annual mammography does not improve stage at diagnosis compared to biennial screening and false-positive recall/biopsy rates are higher with annual screening, women and their primary care providers should weigh the harms and benefits when deciding on annual versus biennial screening.

The impact of obesity on follow-up after an abnormal screening mammogram

BACKGROUND

Effective breast cancer screening and early detection are crucial for obese women, who experience a higher incidence of the disease and present at later stages.

METHODS

We examined the association between body mass index (BMI) and timeliness of follow-up after 241,222 abnormal screening mammograms carried out on 201,470 women in the Breast Cancer Surveillance Consortium. Each mammogram had one of three recommendations for follow-up: short-interval follow-up, immediate additional diagnostic imaging, and biopsy/surgical consultation. We used logistic regression to estimate the adjusted effect of BMI on any recorded follow-up within 270 days of the recommendation; linear regression was used to model the mean follow-up time among those with recorded follow-up.

RESULTS

As compared with normal-weight women, higher BMI was associated with slightly increased odds of follow-up among women who received a recommendation for short-interval follow-up (ORs: 1.03-1.10; P = 0.04) or immediate additional imaging (ORs: 1.03-1.09; P = 0.01). No association was found for biopsy/surgical consultation recommendations (P = 0.90). Among those with recorded follow-up, higher BMI was associated with longer mean time to follow-up for both short-interval (3-10 days; P < 0.001) and additional imaging recommendations (2-3 days; P < 0.001) but not biopsy/surgical consultation (P = 0.06). Regardless of statistical significance, actual differences in days to follow-up across BMI groups were small and unlikely to be clinically significant.

CONCLUSIONS

Once obese women access screening mammography, their follow-up after abnormal results is similar to that of normal-weight women.

IMPACT

Efforts to improve early detection of breast cancer in obese women should focus elsewhere, such as improving participation in screening mammography.

Impact of body mass index on compliance and persistence to adjuvant breast cancer therapy

Several authors found that the prognosis of overweight and obese breast cancer (BC) patients was lower than that of normal weight patients. We present the first study which evaluates the impact of body mass index (BMI) on compliance (i.e. to start a recommended therapy) and persistence to adjuvant BC therapy. An unselected cohort of 766 patients (≤75 years) diagnosed from 1997 to 2009 was analyzed in relevance to the four adjuvant therapy modalities: (A) radiation, (B) chemotherapy, (C) therapy with trastuzumab, and (D) endocrine therapy. With respect to compliance, multivariate analyses calculated Odds ratios (ORs) >1 for increased BMI in all four therapy modalities, i.e. increased BMI had a positive influence on compliance. The results were significant for radiotherapy (OR,2.37;95%CI,1.45-3.88;p < 0.001) and endocrine therapy (OR,1.92;95%CI,1.21-3.04;p = 0.002) and showed a trend in chemotherapy (OR,1.42;95%CI,0.97-2.08;p = 0.063). Analyzing persistence, increasing BMI had ORs <1 for chemotherapy and therapy with trastuzumab, both not reaching statistical significance. For endocrine therapy, increasing BMI was a significant predictor for persistence (OR,1.35;95%CI,1.08-1.80;p = 0.042). Failure of compliance and persistence to adjuvant therapy does not pose a contributing factor for the observed unfavorable prognosis in overweight/obese BC patients. In most therapy modes, patients with increasing BMI demonstrated a higher motivation and perseverance to the recommended treatment.

Advancements in the use of blood tests for cancer screening in women at high risk for endometrial and breast cancer

Several years ago, it was argued that the identification of serum biomarkers is one of the most promising approaches for the detection of early-stage malignant or even premalignant lesions. In this review, the need to establish better monitoring protocols is described for obese women who are at higher risk for the development of malignancies commonly associated with excess weight; specifically endometrial and postmenopausal breast cancer. These cancers have been chosen for this review article as our aim was to focus on female cancers that have been linked with obesity. Cancer screening is essential in detecting disease in its earliest stage in order to reduce morbidity and mortality; however, effective screening is not available for many cancer types. Even for cancers that have effective screening protocols available, there are barriers to screening in obese individuals, such as reduced mobility and embarrassment. These barriers often delay screening in these vulnerable population groups, leading to detection of the disease at a more advanced stage and ultimately leading to a poorer prognosis. As of today, biomarkers do not replace but augment imaging and other existing screening approaches. Future development of blood- or urine-based biomarkers as a way to screen individuals at high risk for certain cancers may prove to be an excellent method for overcoming the barriers that individuals at high risk are facing today. The overall purpose of this manuscript is to provide an overview of screening techniques and to identified barriers and alternate biomarker-based approaches for improvement of endometrial and breast cancer screening in obese women.