Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians

Baseline Performance of Ultrasound-Based Strategies in Breast Cancer Screening Among Chinese Women

RATIONALE AND OBJECTIVE

There is a notable absence of robust evidence on the efficacy of ultrasound-based breast cancer screening strategies, particularly in populations with a high prevalence of dense breasts. Our study addresses this gap by evaluating the effectiveness of such strategies in Chinese women, thereby enriching the evidence base for identifying the most efficacious screening approaches for women with dense breast tissue.

METHODS

Conducted from October 2018 to August 2022 in Central China, this prospective cohort study enrolled 8996 women aged 35-64 years, divided into two age groups (35-44 and 45-64 years). Participants were screened for breast cancer using hand-held ultrasound (HHUS) and automated breast ultrasound system (ABUS), with the older age group also receiving full-field digital mammography (FFDM). The Breast Imaging Reporting and Data System (BI-RADS) was employed for image interpretation, with abnormal results indicated by BI-RADS 4/5, necessitating a biopsy; BI-RADS 3 required follow-up within 6-12 months by primary screening strategies; and BI-RADS 1/2 were classified as negative.

RESULTS

Among the screened women, 29 cases of breast cancer were identified, with 4 (1.3‰) in the 35-44 years age group and 25 (4.2‰) in the 45-64 years age group. In the younger age group, HHUS and ABUS performed equally well, with no significant difference in their AUC values (0.8678 vs. 0.8679, P > 0.05). For the older age group, ABUS as a standalone strategy (AUC 0.9935) and both supplemental screening methods (HHUS with FFDM, AUC 0.9920; ABUS with FFDM, AUC 0.9928) outperformed FFDM alone (AUC 0.8983, P < 0.05). However, there was no significant difference between HHUS alone and FFDM alone (AUC 0.9529 vs. 0.8983, P > 0.05).

CONCLUSION

The findings indicate that both HHUS and ABUS exhibit strong performance as independent breast cancer screening strategies, with ABUS demonstrating superior potential. However, the integration of FFDM with these ultrasound techniques did not confer a substantial improvement in the overall effectiveness of the screening process.

Geriatric Breast Cancer: Staging, Molecular Surrogates, and Treatment. A Review & Meta-analysis

Breast cancer (BC) is one of the most frequent cancers in females across the globe. Treatment recommendations for BC patients are primarily driven by patient age, staging and tumor molecular subtype. Thus, we updated the general overview of BC staging, molecular surrogates, and treatment choices for women >70 years based on a systematic study encompassing the years 2013-2023. A PRISMA guidelines and PICO framework were followed, and relevant research articles were searched using different data bases (Web of Sciences, PubMed, MEDLINE, and Scopus). Mixed Methods Appraisal Tool was used for studies quality assessment. The research articles that made it into the systematic review were compiled using qualitative criteria. In the meanwhile, heterogeneity was determined using meta-analysis with RevMan 5.4. We applied a random effects model with a 0.05 significance level. Overall, there were 4151 research articles, after screening only 17 articles with 39,906 patients were included. Conclusion: Elderly patients with breast cancer should be treated differently in an adapted way. The treatment should not be the same worldwide due to different health systems. Molecular surrogates are different in geriatric patients. Surgery is the best option for treatment in this subset of patients. We need to have therapeutic decision appointments for elderly patients with breast cancer. The guidelines and medical authority should be used in the best decision.

Effect of Messaging on Support for Breast Cancer Screening Cessation Among Older US Women: A Randomized Clinical Trial

Importance

Many older women are screened for breast cancer beyond guideline-recommended thresholds. Messaging holds promise to reduce overscreening.

Objective

To investigate the effect of a message on older women's support for and intentions of stopping breast cancer screening.

Design, Setting, and Participants

A 2-wave randomized clinical online survey trial using a nationally representative online panel was performed from May 12 to June 19, 2023. Women 65 years or older without breast cancer were eligible to participate.

Intervention

A pilot-tested breast cancer screening cessation message delivered to a hypothetical older woman with serious illnesses and functional impairment. The message was described as from 1 of 3 sources (clinician, news story, or family member). Participants were randomized into 4 groups: no message (group 1 [control]), a single message from a clinician at wave 1 and no message at wave 2 (group 2), a message from a news story (wave 1) and a clinician (wave 2) (group 3), and a message from a family member (wave 1) and a clinician (wave 2) (group 4).

Main Outcomes and Measures

Support for stopping screening in the hypothetical older woman (primary) and screening intentions for oneself (secondary) were assessed on 7-point scales, with higher values indicating stronger support for and intentions to stop screening. Means were compared using analysis of variance. The message effect on screening intentions among participants 75 years or older and those with life expectancy of less than 10 years were also explored.

Results

A total of 3051 women participated in wave 1 of the trial. The mean (SD) age was 72.8 (5.9) years; 272 (8.9%) were non-Hispanic Black and 2506 (82.1%) were non-Hispanic White. Of these women, 2796 (91.6%) completed wave 2. Group 2 had significantly higher support for screening cessation in the hypothetical patient at wave 2 (mean score, 3.14 [95% CI, 2.99-3.29]) compared with group 1 (mean score, 2.68 [95% CI, 2.54-2.82]; P < .001). The effect was even stronger in group 3 (mean score, 4.23 [95% CI, 4.09-4.38]) and group 4 (mean score, 4.12 [95% CI, 3.97-4.27]) compared with both groups 1 and 2 (all P < .001). Message effects on self-screening intentions followed a similar pattern, with larger effects among participants 75 years or older or with limited life expectancy.

Conclusions and Relevance

In this randomized clinical trial, a breast cancer screening cessation message significantly increased older women's support for and intentions of screening cessation. The strongest effects were observed when the message was delivered over time from multiple sources. Future work needs to engage potential message sources to examine the feasibility and acceptability of multilevel messaging strategies and their effect on screening behavior.

Trial Registration

ClinicalTrials.gov Identifier: NCT05821023.

Routine Clinical Breast Examination Is a Low-Yield Practice Among Women at High Risk of Breast Cancer

BACKGROUND

For women at increased risk of breast cancer, the National Comprehensive Cancer Network (NCCN) guidelines recommend clinical encounters every 6-12 months. While screening mammography has corresponded with a relative risk reduction in breast cancer mortality of approximately 20%, evidence validating clinical breast examination (CBE) as an efficacious screening modality is deficient. Our study aimed to assess the conventional merit of regular CBE for breast cancer detection among individuals at increased risk of breast cancer development.

METHODS

Women > 18 years with documented high-risk encounters at Corewell Health West from 1 January 2018 to 31 December 22 were retrospectively reviewed. High-risk criteria included genetic predisposition, 5-year (> 1.7%) or lifetime (> 20%) Tyrer-Cuzick and/or Gail Model risk estimations, thoracic radiotherapy before age 30 years, lobular carcinoma in-situ, or atypical hyperplasia. Patients with a history of breast cancer or bilateral prophylactic mastectomy prior to 2018 were excluded.

RESULTS

Of the 9171 cumulative high-risk encounters among 2493 women, only one breast cancer was detected by CBE. CBE resulted in 1 (0.04%) cancer diagnosis compared with 30 (1.2%) detected on screening imaging and 10 (0.4%) self-reported. Of the 30 image-detected cancers, 28 (93.3%) had no detectable clinical findings at the time of preoperative consultation. Self-reported and CBE-detected cancers were more likely to be of higher clinical stage compared with imaging-detected malignancies.

CONCLUSIONS

The role of routine CBE as a cancer detection modality in the high-risk patient population appears to be limited. Telemedicine can be offered to individuals who have completed screening imaging but are unable to commit and/or are inconvenienced by in-person high-risk breast cancer assessments.

Tumor Doubling Time and Screening Interval

The goal of screening is to detect breast cancers when still curable to decrease breast cancer-specific mortality. Breast cancer screening in the United States is routinely performed with digital mammography and digital breast tomosynthesis. This article reviews breast cancer doubling time by tumor subtype and examines the impact of doubling time on breast cancer screening intervals. By the article's end, the reader will be better equipped to have informed discussions with patients and medical professionals regarding the benefits and disadvantages of the currently recommended screening mammography intervals.

Advancing Breast Cancer Diagnosis: The Impact of Elastography Integration Into Breast Imaging Reporting and Data System (BIRADS) Categorization

OBJECTIVE

This study evaluates the impact of integrating elastography into the Breast Imaging Reporting and Data System (BIRADS) categorization on breast cancer diagnostics in an African population. It explores the association and agreement between traditional BIRADS and those modified by elastography, as well as between quantitative and qualitative elastography methods.

METHODS

A total of 200 participants who underwent breast imaging as part of their diagnostic evaluation for breast lesions were included in the study. Participant characteristics, including age distribution and indicators for breast cancer diagnoses, were analyzed. Brightness mode (B-mode) findings without elastography were assessed using the BIRADS classification. Elastography was integrated into the BIRADS categorization to evaluate its impact on breast cancer diagnostics. The association and agreement between BIRADS with and without elastography were analyzed.

RESULTS

Participants predominantly aged 40-49 showed significant staging differences with the integration of elastography. Traditional B-mode staging identified 29 (49%) of participants in BIRADS stage IV and 14 (23%) in stage V, whereas elastography adjusted these figures significantly, enhancing diagnostic refinement. There was a fair agreement between BIRADS with and without elastography (kappa = 0.322), while a substantial agreement was found between quantitative and qualitative elastography (kappa = 0.674).

CONCLUSION

The results of the study provide evidence that the integration of elastography into BIRADS categorization can significantly improve the accuracy of breast cancer diagnosis in African women. Elastography enhanced lesion characterization, supporting more personalized and precise clinical management. Continued research is needed to fully integrate elastography into routine diagnostic workflows and understand its broader clinical implications in Africa.

Personalized and continuous care intervention affects rehabilitation, living quality, and negative emotions of patients with breast cancer

BACKGROUND

Breast cancer is among the most common malignancies worldwide. With progress in treatment methods and levels, the overall survival period has been prolonged, and the demand for quality care has increased.

AIM

To investigate the effect of individualized and continuous care intervention in patients with breast cancer.

METHODS

Two hundred patients with breast cancer who received systemic therapy at The First Affiliated Hospital of Hebei North University (January 2021 to July 2023) were retrospectively selected as research participants. Among them, 134 received routine care intervention (routing group) and 66 received personalized and continuous care (intervention group). Self-rating anxiety scale (SAS), self-rating depression scale (SDS), and Functional Assessment of Cancer Therapy-Breast (FACT-B) scores, including limb shoulder joint activity, complication rate, and care satisfaction, were compared between both groups after care.

RESULTS

SAS and SDS scores were lower in the intervention group than in the routing group at one and three months after care. The total FACT-B scores and five dimensions in the intervention group were higher than those in the routing group at three months of care. The range of motion of shoulder anteflexion, posterior extension, abduction, internal rotation, and external rotation in the intervention group was higher than that in the routing group one month after care. The incidence of postoperative complications was 18.18% lower in the intervention group than in the routing group (34.33%; P <0.05). Satisfaction with care was 90.91% higher in the intervention group than in the routing group (78.36%; P <0.05).

CONCLUSION

Personalized and continuous care can alleviate negative emotions in patients with breast cancer, quicken rehabilitation of limb function, decrease the incidence of complications, and improve living quality and care satisfaction.

Relationship between age at menarche and breast cancer in individuals, as well as in first-degree kin and estrogen receptor status: a Mendelian randomization study

Target

We executed a Mendelian randomization (MR) investigation employing two distinct cohorts of genetic instrumental variables to elucidate the causal nexus between age at menarche (AAM) and the incidence of disparate breast cancer (BC) subtypes, in addition to the incidence of BC among first-degree kin.

Methods

We aggregated statistical data pertaining to AAM and BC from various consortia representing a homogenous population cohort. MR analysis was conducted employing inverse variance weighted (IVW) methodology as the principal approach, complemented by weighted median and MR-Egger regression techniques for an exhaustive evaluation. To evaluate the presence of pleiotropy, we applied the MR-Egger intercept test, MR-PRESSO, and leave-one-out sensitivity analysis.

Results

Upon exclusion of confounding SNP, an increment of one standard deviation in AAM was inversely correlated with the incidence of BC. (odds ratio [OR] 0.896, 95% confidence interval [CI] 0.831-0.968)/(OR 0.998, 95% CI 0.996-0.999) and estrogen receptor-positive (ER+) BC incidence (OR 0.895, 95% CI 0.814-0.983). It was also associated with reducing the risk of maternal BC incidence (OR 0.995, 95% CI 0.990-0.999) and sibling BC incidence (OR 0.997, 95% CI 0.994-0.999). No significant association was found between AAM and estrogen receptor-negative (ER-) BC incidence (OR 0.936, 95% CI 0.845-1.037).

Conclusion

Our study substantiated the causal relationship between a delayed AAM and a diminished risk of BC in probands, as well as in their maternal progenitors and siblings. Furthermore, the analysis suggests that AAM exerts a considerable potential causal influence on the risk of developing Luminal-a/b subtype of BC.

Canadian Association of Radiologists Breast Disease Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Breast Disease Expert Panel consists of breast imaging radiologists, a high-risk breast clinician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 69 recommendation statements across the 20 scenarios. This guideline presents the methods of development and the recommendations for referring asymptomatic individuals, symptomatic patients, and other scenarios requiring imaging of the breast.

Development and Evaluation of Messages for Reducing Overscreening of Breast Cancer in Older Women

BACKGROUND

Many older women are screened for breast cancer beyond guideline-recommended thresholds. One contributor is pro-screening messaging from health care professionals, media, and family/friends. In this project, we developed and evaluated messages for reducing overscreening in older women.

METHODS

We surveyed women ages 65+ who were members of a nationally representative online panel. We constructed 8 messages describing reasons to consider stopping mammograms, including guideline recommendations, false positives, overdiagnosis, and diminishing benefits from screening due to competing risks. Messages varied in their format; some presented statistical evidence, and some described short anecdotes. Each participant was randomized to read 4 of 8 messages. We also randomized participants to one of 3 message sources (clinician, family member, and news story). We assessed whether the message would make participants "want to find out more information" and "think carefully" about mammograms.

RESULTS

Participants (N=790) had a mean age of 73.5 years; 25.8% were non-White. Across all messages, 73.0% of the time, participants agreed that the messages would make them seek more information (range among different messages=64.2%-78.2%); 46.5% of the time participants agreed that the messages would make them think carefully about getting mammograms (range =36.7%-50.7%). Top-rated messages mentioned false-positive anecdotes and overdiagnosis evidence. Ratings were similar for messages from clinicians and news sources, but lower from the family member source.

CONCLUSIONS

Overall, participants positively evaluated messages designed to reduce breast cancer overscreening regarding perceived effects on information seeking and deliberation. Combining the top-rated messages into messaging interventions may be a novel approach to reduce overscreening.

Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review

BACKGROUND

This scoping review aimed to identify and present the evidence describing key motivations for breast cancer screening among women aged ≥ 75 years. Few of the internationally available guidelines recommend continued biennial screening for this age group. Some suggest ongoing screening is unnecessary or should be determined on individual health status and life expectancy. Recent research has shown that despite recommendations regarding screening, older women continue to hold positive attitudes to breast screening and participate when the opportunity is available.

METHODS

All original research articles that address motivation, intention and/or participation in screening for breast cancer among women aged ≥ 75 years were considered for inclusion. These included articles reporting on women who use public and private breast cancer screening services and those who do not use screening services (i.e., non-screeners). The Joanna Briggs Institute (JBI) methodology for scoping reviews was used to guide this review. A comprehensive search strategy was developed with the assistance of a specialist librarian to access selected databases including: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Web of Science and PsychInfo. The review was restricted to original research studies published since 2009, available in English and focusing on high-income countries (as defined by the World Bank). Title and abstract screening, followed by an assessment of full-text studies against the inclusion criteria was completed by at least two reviewers. Data relating to key motivations, screening intention and behaviour were extracted, and a thematic analysis of study findings undertaken.

RESULTS

A total of fourteen (14) studies were included in the review. Thematic analysis resulted in identification of three themes from included studies highlighting that decisions about screening were influenced by: knowledge of the benefits and harms of screening and their relationship to age; underlying attitudes to the importance of cancer screening in women's lives; and use of decision aids to improve knowledge and guide decision-making.

CONCLUSION

The results of this review provide a comprehensive overview of current knowledge regarding the motivations and screening behaviour of older women about breast cancer screening which may inform policy development.

Breast cancer screening and early diagnosis in China: a systematic review and meta-analysis on 10.72 million women

BACKGROUND

The incidence of breast cancer among Chinese women has gradually increased in recent years. This study aims to analyze the situation of breast cancer screening programs in China and compare the cancer detection rates (CDRs), early-stage cancer detection rates (ECDRs), and the proportions of early-stage cancer among different programs.

METHODS

We conducted a systematic review and meta-analysis of studies in multiple literature databases. Studies that were published between January 1, 2010 and June 30, 2023 were retrieved. A random effects model was employed to pool the single group rate, and subgroup analyses were carried out based on screening model, time, process, age, population, and follow-up method.

RESULTS

A total of 35 studies, including 47 databases, satisfied the inclusion criteria. Compared with opportunistic screening, the CDR (1.32‰, 95% CI: 1.10‰-1.56‰) and the ECDR (0.82‰, 95% CI: 0.66‰-0.99‰) were lower for population screening, but the proportion of early-stage breast cancer (80.17%, 95% CI: 71.40%-87.83%) was higher. In subgroup analysis, the CDR of population screening was higher in the urban group (2.28‰, 95% CI: 1.70‰-2.94‰), in the breast ultrasonography (BUS) in parallel with mammography (MAM) group (3.29‰, 95% CI: 2.48‰-4.21‰), and in the second screening follow-up group (2.47‰, 95% CI: 1.64‰-3.47‰), and the proportion of early-stage breast cancer was 85.70% (95% CI: 68.73%-97.29%), 88.18% (95% CI: 84.53%-91.46%), and 90.05% (95% CI: 84.07%-94.95%), respectively.

CONCLUSION

There were significant differences between opportunistic and population screening programs. The results of these population screening studies were influenced by the screening process, age, population, and follow-up method. In the future, China should carry out more high-quality and systematic population-based screening programs to improve screening coverage and service.

Screening mammographic performance by race and age in the National Mammography Database: 29,479,665 screening mammograms from 13,181,241 women

PURPOSE

There are insufficient large-scale studies comparing the performance of screening mammography in women of different races. This study aims to compare the screening performance metrics across racial and age groups in the National Mammography Database (NMD).

METHODS

All screening mammograms performed between January 1, 2008, and December 31, 2021, in women aged 30-100 years from 746 mammography facilities in 46 U.S. states in the NMD were included. Patients were stratified by 10-year age intervals and 5 racial groups (African American, American Indian, Asian, White, unknown). Incidence of risk factors (breast density, personal history, family history of breast cancer, age), and time since prior exams were compared. Five screening mammography metrics were calculated: recall rate (RR), cancer detection rate (CDR), positive predictive values for recalls (PPV1), biopsy recommended (PPV2) and biopsy performed (PPV3).

RESULTS

29,479,655 screening mammograms performed in 13,181,241 women between January 1, 2008, and December 31, 2021, from the NMD were analyzed. The overall mean performance metrics were RR 10.00% (95% CI 9.99-10.02), CDR 4.18/1000 (4.16-4.21), PPV1 4.18% (4.16-4.20), PPV2 25.84% (25.72-25.97), PPV3 25.78% (25.66-25.91). With advancing age, RR significantly decreases, while CDR, PPV1, PPV2, and PPV3 significantly increase. Incidence of personal/family history of breast cancer, breast density, age, prior mammogram availability, and time since prior mammogram were mostly similar across all races. Compared to White women, African American women had significantly higher RR, but lower CDR, PPV1, PPV2 and PPV3.

CONCLUSIONS

Benefits of screening mammography increase with age, including for women age > 70 and across all races. Screening mammography is effective; with lower RR and higher CDR, PPV2, and PPV3 with advancing age. African American women have poorer outcomes from screening mammography (higher RR and lower CDR), compared to White and all women in the NMD. Racial disparity can be partly explained by higher rate of African American women lost to follow up.

Harms and benefits of mammographic screening for breast cancer in Brazil

INTRODUCTION

In the absence of evidence on the effect of mammographic screening on overall mortality, comparing the number of deaths avoided with the number of deaths caused by screening would be ideal, but the only existing models of this type adopt a very narrow definition of harms. The objective of the present study was to estimate the number of deaths prevented and induced by various mammography screening protocols in Brazil.

METHODS

A simulation study of cohorts of Brazilian women screened, considering various age groups and screening interval protocols, was performed based on life tables. The number of deaths avoided and caused by screening was estimated, as was the absolute risk reduction, the number needed to invite for screening-NNS, the net benefit of screening, and the ratio of "lives saved" to "lives lost". Nine possible combinations of balances between benefits and harms were performed for each protocol, in addition to other sensitivity analyses.

RESULTS AND CONCLUSIONS

The most efficient protocol was biennial screening from 60 to 69 years of age, with almost three times more deaths avoided than biennial screening from 50 to 59 years of age, with a similar number of deaths avoided by biennial screening from 50 to 69 years of age and with the greatest net benefit. Compared with the best scenario of annual screening from 40 to 49 years of age, the NNS of the protocol with biennial screening from 60 to 69 years of age was three-fold lower. Even in its best scenario, the addition of annual screening from 40 to 49 years of age to biennial screening from 50 to 69 years of age results in a decreased net benefit. However, even in the 50-69 year age group, the estimated reduction in breast cancer mortality for Brazil was half that estimated for the United Kingdom.

Validating a model for predicting breast cancer and nonbreast cancer death in women aged 55 years and older

BACKGROUND

To support mammography screening decision making, we developed a competing-risk model to estimate 5-year breast cancer risk and 10-year nonbreast cancer death for women aged 55 years and older using Nurses' Health Study data and examined model performance in the Black Women's Health Study (BWHS). Here, we examine model performance in predicting 10-year outcomes in the BWHS, Women's Health Initiative-Extension Study (WHI-ES), and Multiethnic Cohort (MEC) and compare model performance to existing breast cancer prediction models.

METHODS

We used competing-risk regression and Royston and Altman methods for validating survival models to calculate our model's calibration and discrimination (C index) in BWHS (n = 17 380), WHI-ES (n = 106 894), and MEC (n = 49 668). The Nurses' Health Study development cohort (n = 48 102) regression coefficients were applied to the validation cohorts. We compared our model's performance with breast cancer risk assessment tool (Gail) and International Breast Cancer Intervention Study (IBIS) models by computing breast cancer risk estimates and C statistics.

RESULTS

When predicting 10-year breast cancer risk, our model's C index was 0.569 in BWHS, 0.572 in WHI-ES, and 0.576 in MEC. The Gail model's C statistic was 0.554 in BWHS, 0.564 in WHI-ES, and 0.551 in MEC; IBIS's C statistic was 0.547 in BWHS, 0.552 in WHI-ES, and 0.562 in MEC. The Gail model underpredicted breast cancer risk in WHI-ES; IBIS underpredicted breast cancer risk in WHI-ES and in MEC but overpredicted breast cancer risk in BWHS. Our model calibrated well. Our model's C index for predicting 10-year nonbreast cancer death was 0.760 in WHI-ES and 0.763 in MEC.

CONCLUSIONS

Our competing-risk model performs as well as existing breast cancer prediction models in diverse cohorts and predicts nonbreast cancer death. We are developing a website to disseminate our model.

Eradicating Atherosclerotic Events by Targeting Early Subclinical Disease: It Is Time to Retire the Therapeutic Paradigm of Too Much, Too Late

Recent decades have seen spectacular advances in understanding and managing atherosclerotic cardiovascular disease, but paradoxically, clinical progress has stalled. Residual risk of atherosclerotic cardiovascular disease events is particularly vexing, given recognized lifestyle interventions and powerful modern medications. Why? Atherosclerosis begins early in life, yet clinical trials and mechanistic studies often emphasize terminal, end-stage plaques, meaning on the verge of causing heart attacks and strokes. Thus, current clinical evidence drives us to emphasize aggressive treatments that are delayed until patients already have advanced arterial disease. I call this paradigm "too much, too late." This brief review covers exciting efforts that focus on preventing, or finding and treating, arterial disease before its end-stage. Also included are specific proposals to establish a new evidence base that could justify intensive short-term interventions (induction-phase therapy) to treat subclinical plaques that are early enough perhaps to heal. If we can establish that such plaques are actionable, then broad screening to find them in early midlife individuals would become imperative-and achievable. You have a lump in your coronaries! can motivate patients and clinicians. We must stop thinking of a heart attack as a disease. The real disease is atherosclerosis. In my opinion, an atherosclerotic heart attack is a medical failure. It is a manifestation of longstanding arterial disease that we had allowed to progress to its end-stage, despite knowing that atherosclerosis begins early in life and despite the availability of remarkably safe and highly effective therapies. The field needs a transformational advance to shift the paradigm out of end-stage management and into early interventions that hold the possibility of eradicating the clinical burden of atherosclerotic cardiovascular disease, currently the biggest killer in the world. We urgently need a new evidence base to redirect our main focus from terminal, end-stage atherosclerosis to earlier, and likely reversible, human arterial disease.

Evaluating clinical efficacy of hospital-based surveillance with mammography and ultrasonography for breast cancer

Periodic mammography and/or sonography examinations are conducted across numerous hospitals nationalwidely, especially for antedees with a positive mammography screening. Despite the regular practice, clinical efficacy of hospital-based breast cancer surveillance remains unclear. Specifically, the impact of surveillance interval upon survival and prognostic surrogates stratified by menopausal status, as well as malignant transition rate should be deciphered. We retrieved cancer registry to ascertain 841 breast cancers with surveillance history through administration data. Healthy controls underwent breast surveillance and were concurrently free of cancer. More benign diseases rather than cancers were identified from premenopausal women (age ≤50 years) with sonography alone within one year, as well as older women (age >50) with both mammography and sonography one to two years before a cancer or benign diagnosis. Among breast cancers, mammography alone during the antecedent one to two years had a protective effect for diagnosing carcinoma in situ rather than invasive cancer (age-adjusted odds ratio: 0.048, P = 0.016). Three-state time homogeneous Markov model showed that hospital-based breast surveillance within 2 years of disease onset reduced the malignant transition rate by 65.16% (59.79-76.74%). The clinical efficacy of breast cancer surveillance was evidenced.

Validation of a Proteomic-Based Prognostic Model for Breast Cancer and Immunological Analysis

Breast cancer (BC) has emerged as an extremely destructive malignancy, causing significant harm to female patients and society at large. Proteomic research holds great promise for early diagnosis and treatment of diseases, and the integration of proteomics with genomics can offer valuable assistance in the early diagnosis, treatment, and improved prognosis of BC patients. In this study, we downloaded breast cancer protein expression data from The Cancer Genome Atlas (TCGA) and combined proteomics with genomics to construct a proteomic-based prognostic model for BC. This model consists of nine proteins (HEREGULIN, IDO, PEA15, MERIT40_pS29, CIITA, AKT2, CD171 DVL3, and CABL9). The accuracy of the model in predicting the survival prognosis of BC patients was further validated through risk curve analysis, survival curve analysis, and independent prognostic analysis. We further confirmed the impact of differential expression of these nine key proteins on overall survival in BC patients, and the differential expression of the key proteins and their encoding genes was validated using immunohistochemical staining. Enrichment analysis revealed functional associations primarily related to PPAR signaling pathway, steroid hormone metabolism, chemokine signaling pathway, DNA conformation changes, immunoglobulin production, and immunoglobulin complex in the high- and low-risk groups. Immune infiltration analysis revealed differential expression of immune cells between the high- and low-risk groups, providing a theoretical basis for subsequent immunotherapy. The model constructed in this study can predict the survival of BC patients, and the identified key proteins may serve as biomarkers to aid in the early diagnosis of BC. Enrichment analysis and immune infiltration analysis provide a necessary theoretical basis for further exploration of the molecular mechanisms and subsequent immunotherapy.

U structured network with three encoding paths for breast tumor segmentation

Breast ultrasound segmentation remains challenging because of the blurred boundaries, irregular shapes, and the presence of shadowing and speckle noise. The majority of approaches stack convolutional layers to extract advanced semantic information, which makes it difficult to handle multiscale issues. To address those issues, we propose a three-path U-structure network (TPUNet) that consists of a three-path encoder and an attention-based feature fusion block (AFF Block). Specifically, instead of simply stacking convolutional layers, we design a three-path encoder to capture multiscale features through three independent encoding paths. Additionally, we design an attention-based feature fusion block to weight and fuse feature maps in spatial and channel dimensions. The AFF Block encourages different paths to compete with each other in order to synthesize more salient feature maps. We also investigate a hybrid loss function for reducing false negative regions and refining the boundary segmentation, as well as the deep supervision to guide different paths to capture the effective features under the corresponding receptive field sizes. According to experimental findings, our proposed TPUNet achieves more excellent results in terms of quantitative analysis and visual quality than other rival approaches.

Global, regional, and national lifetime probabilities of developing cancer in 2020

The lifetime risk of cancer is a measure of the cumulative risk of cancer over a specific age range and has a clear, intuitive appeal. However, comparative assessments of cancer-specific risk across populations are limited. We used the adjusted for multiple primaries method to estimate the lifetime risk of cancer from the obtained data from GLOBOCAN for 185 countries/regions for the year 2020, alongside all-cause mortality and population data from the United Nations. The estimated global lifetime risk of cancer from birth to death was 25.10% (95% confidence interval (CI): 25.08%-25.11%) in 2020; the risk was 26.27% (95% CI: 26.24%-26.30%) in men and 23.96% (95% CI: 23.93%-23.98%) in women. Significant differences were observed in the risks between countries/regions within world areas and by the human development level. The lifetime risk of cancer was 38.48%, 25.38%, 11.36%, and 10.34% in countries/regions with very high, high, medium, and low Human Development Index, respectively. Globally, prostate and breast cancers were associated with the greatest lifetime risks among men and women (4.65% and 5.90%, respectively). The lifetime risk of cancer decreased with age, with a remaining risk of 12.61% (95% CI: 12.60%-12.63%) from the age of 70 years. The lifetime risk from birth to death translates to approximately one in four persons developing cancer, with men and women having similar risk levels. The identified age-specific variations in cancer risk at the population level can provide crucial information to support targeted cancer prevention and health system planning.

Breast Cancer Screening and Prevention

Breast cancer is the most common cancer among U.S. women and its incidence increases with age. Endogenous estrogen exposure, proliferative benign breast disease, breast density, and family history may also indicate increased risk for breast cancer. Early detection with screening mammography reduces breast cancer mortality, but the net benefits vary by age. Assessing a patient's individual breast cancer risk can guide decisions regarding breast cancer screening. All women benefit from healthy behaviors which may reduce breast cancer risk. Some women at increased risk for breast cancer may benefit from risk-reducing medications. Use of screening measures remains suboptimal, especially for uninsured women.

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

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.

Use of calcium channel blockers and risk of breast cancer among women aged 55 years and older: a nationwide population-based cohort study

This retrospective cohort study was aimed to compare the incidence of breast cancer among women aged ≥55 who received calcium channel blockers and angiotensin converting enzyme inhibitors/angiotensin II receptor blockers. We used the 2002-2015 Health and Welfare Database in Taiwan. Women 55 years and older who initiated antihypertensive treatment were included. Breast cancer risk for patients receiving calcium channel blockers was compared to those receiving angiotensin converting enzyme inhibitors/angiotensin II receptor blockers. Cox proportional hazards models were used to generate adjusted hazard ratios for breast cancer. We found that the risk of breast cancer was similar between calcium channel blockers users and angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (adjusted hazard ratio [aHR] and 95% CI = 1.03 [0.80 to 1.34]). No significant risk increase was observed in the stratified analysis by dihydropyridine (aHR = 1.02 [0.78 to 1.33]) and non-dihydropyridine calcium channel blockers (aHR = 1.23 [0.48 to 3.20]). No difference in the risk of breast cancer associated with calcium channel blockers exposure was observed in patients who used hormone replacement therapy (aHR = 1.02 [0.29 to 3.58]). The risk for breast cancer was observed to be significantly lower in patients receiving calcium channel blockers than in those receiving angiotensin converting enzyme inhibitors/angiotensin II receptor blockers at a treatment duration of 5 or more years (aHR = 0.57 [0.33 to 0.98]). In conclusion, the risk for breast cancer is similar for calcium channel blockers and angiotensin converting enzyme inhibitors/angiotensin II receptor blocker users in an Asian population.

Prolonged screening interval due to the COVID-19 pandemic and its association with tumor characteristics and treatment; a register-based study from BreastScreen Norway

OBJECTIVE

During the COVID-19 pandemic Norway had to suspend its national breast cancer screening program. We aimed to investigate the effect of the pandemic-induced suspension on the screening interval, and its subsequent association with the tumor characteristics and treatment of screen-detected (SDC) and interval breast cancer (IC).

METHODS

Information about women aged 50-69, participating in BreastScreen Norway, and diagnosed with a SDC (N = 3799) or IC (N = 1806) between 2018 and 2021 was extracted from the Cancer Registry of Norway. Logistic regression was used to investigate the association between COVID-19 induced prolonged screening intervals and tumor characteristics and treatment.

RESULTS

Women with a SDC and their last screening exam before the pandemic had a median screening interval of 24.0 months (interquartile range: 23.8-24.5), compared to 27.0 months (interquartile range: 25.8-28.5) for those with their last screening during the pandemic. The tumor characteristics and treatment of women with a SDC, last screening during the pandemic, and a screening interval of 29-31 months, did not differ from those of women with a SDC, last screening before the pandemic, and a screening interval of 23-25 months. ICs detected 24-31 months after screening, were more likely to be histological grade 3 compared to ICs detected 0-23 months after screening (odds ratio: 1.40, 95% confidence interval: 1.06-1.84).

CONCLUSIONS

Pandemic-induced prolonged screening intervals were not associated with the tumor characteristics and treatment of SDCs, but did increase the risk of a histopathological grade 3 IC. This study provides insights into the possible effects of extending the screening interval.

Breast Cancer Screening and Diagnosis: Recent Advances in Imaging and Current Limitations

Breast cancer detection has a significant impact on population health. Although there are many breast imaging modalities, mammography is the predominant tool for breast cancer screening. The introduction of digital breast tomosynthesis to mammography has contributed to increased cancer detection rates and decreased recall rates. In average-risk women, starting annual screening mammography at age 40 years has demonstrated the highest mortality reduction. In intermediate- and high-risk women as well as in those with dense breasts, additional modalities, including MRI, ultrasound, and molecular breast imaging, can also be considered for adjunct screening to improve the detection of mammographically occult malignancy.

New Approaches and Recommendations for Risk-Adapted Breast Cancer Screening

Population-based breast cancer screening using mammography as the gold standard imaging modality has been in clinical practice for over 40 years. However, the limitations of mammography in terms of sensitivity and high false-positive rates, particularly in high-risk women, challenge the indiscriminate nature of population-based screening. Additionally, in light of expanding research on new breast cancer risk factors, there is a growing consensus that breast cancer screening should move toward a risk-adapted approach. Recent advancements in breast imaging technology, including contrast material-enhanced mammography (CEM), ultrasound (US) (automated-breast US, Doppler, elastography US), and especially magnetic resonance imaging (MRI) (abbreviated, ultrafast, and contrast-agent free), may provide new opportunities for risk-adapted personalized screening strategies. Moreover, the integration of artificial intelligence and radiomics techniques has the potential to enhance the performance of risk-adapted screening. This review article summarizes the current evidence and challenges in breast cancer screening and highlights potential future perspectives for various imaging techniques in a risk-adapted breast cancer screening approach. EVIDENCE LEVEL: 1. TECHNICAL EFFICACY: Stage 5.

The current role of nuclear medicine in breast cancer

Breast cancer is the most common cancer in females worldwide. Nuclear medicine plays an important role in patient management, not only in initial staging, but also during follow-up. Radiopharmaceuticals to study breast cancer have been used for over 50 years, and several of these are still used in clinical practice, according to the most recent guideline recommendations.In this critical review, an overview of nuclear medicine procedures used during the last decades is presented. Current clinical indications of each of the conventional nuclear medicine and PET/CT examinations are the focus of this review, and are objectively provided. Radionuclide therapies are also referred, mainly summarising the methods to palliate metastatic bone pain. Finally, recent developments and future perspectives in the field of nuclear medicine are discussed. In this context, the promising potential of new radiopharmaceuticals not only for diagnosis, but also for therapy, and the use of quantitative imaging features as potential biomarkers, are addressed.Despite the long way nuclear medicine has gone through, it looks like it will continue to benefit clinical practice, paving the way to improve healthcare provided to patients with breast cancer.

Estimating Breast Cancer Overdiagnosis After Screening Mammography Among Older Women in the United States

BACKGROUND

Overdiagnosis is increasingly recognized as a harm of breast cancer screening, particularly for older women.

OBJECTIVE

To estimate overdiagnosis associated with breast cancer screening among older women by age.

DESIGN

Retrospective cohort study comparing the cumulative incidence of breast cancer among older women who continued screening in the next interval with those who did not. Analyses used competing risk models, stratified by age.

SETTING

Fee-for-service Medicare claims, linked to the SEER (Surveillance, Epidemiology, and End Results) program.

PATIENTS

Women 70 years and older who had been recently screened.

MEASUREMENTS

Breast cancer diagnoses and breast cancer death for up to 15 years of follow-up.

RESULTS

This study included 54 635 women. Among women aged 70 to 74 years, the adjusted cumulative incidence of breast cancer was 6.1 cases (95% CI, 5.7 to 6.4) per 100 screened women versus 4.2 cases (CI, 3.5 to 5.0) per 100 unscreened women. An estimated 31% of breast cancer among screened women were potentially overdiagnosed. For women aged 75 to 84 years, cumulative incidence was 4.9 (CI, 4.6 to 5.2) per 100 screened women versus 2.6 (CI, 2.2 to 3.0) per 100 unscreened women, with 47% of cases potentially overdiagnosed. For women aged 85 and older, the cumulative incidence was 2.8 (CI, 2.3 to 3.4) among screened women versus 1.3 (CI, 0.9 to 1.9) among those not, with up to 54% overdiagnosis. We did not see statistically significant reductions in breast cancer-specific death associated with screening.

LIMITATIONS

This study was designed to estimate overdiagnosis, limiting our ability to draw conclusions on all benefits and harms of screening. Unmeasured differences in risk for breast cancer and differential competing mortality between screened and unscreened women may confound results. Results were sensitive to model specifications and definition of a screening mammogram.

CONCLUSION

Continued breast cancer screening was associated with greater incidence of breast cancer, suggesting overdiagnosis may be common among older women who are diagnosed with breast cancer after screening. Whether harms of overdiagnosis are balanced by benefits and for whom remains an important question.

PRIMARY FUNDING SOURCE

National Cancer Institute.

When should electronic medical records reminders for cancer screening stop?-Results from a national physician survey

BACKGROUND

Many older adults are screened for breast and colorectal cancers beyond guideline recommended thresholds. Electronic medical record (EMR) reminders are commonly used to prompt cancer screening. Behavioral economics theory suggests that changing the default settings for these reminders can be effective to reduce over-screening. We examined physician perspectives about acceptable thresholds for stopping EMR cancer screening reminders.

METHODS

In a national survey of 1200 primary care physicians (PCP) and 600 gynecologists randomly selected from the AMA Masterfile, we asked physicians to choose whether EMR reminders for cancer screening should stop based on a list of criteria that included age, life expectancy, specific serious illnesses, and functional limitations. Physicians could choose multiple responses. PCPs were randomized to questions about breast or colorectal cancer screening.

RESULTS

A total of 592 physicians participated (adjusted response rate 54.1%). 54.6% chose age and 71.8% chose life expectancy as criteria for stopping EMR reminders; only 30.6% chose functional limitations. Regarding age thresholds, 52.4% chose ages ≤75, 42.0% chose a threshold between 75 and 85, 5.6% would not stop reminders even at age 85. Regarding life expectancy thresholds, 32.0% chose ≥10 years, 53.1% chose a threshold between 5 and 9 years, 14.9% would not stop reminders even when life expectancy is <5 years.

CONCLUSIONS

We found that many physicians would continue EMR reminders for cancer screening even in light of older age, limited life expectancy, and functional limitations. This may reflect reluctance to stop cancer screening and/or reluctance to stop EMR reminders so that physicians can retain control to decide for individual patients, for example, to assess patient preference and ability to tolerate treatment. There was consensus for stopping EMR reminders at ages 85+ and <5-year life expectancy. Interventions that seek to reduce over-screening by suppressing EMR reminders may be important for these groups but may have limited physician buy-in outside these thresholds.

Impact of Patient Comorbidities on Presentation Stage of Breast and Colon Cancers

BACKGROUND

While patients with multiple comorbidities may have frequent contact with medical providers, it is unclear whether their healthcare visits translate into earlier detection of cancers, specifically breast and colon cancers.

METHODS

Patients diagnosed with stage I-IV breast ductal carcinoma and colon adenocarcinoma were identified from the National Cancer Database and stratified by comorbidity burden, dichotomized as a Charlson Comorbidity Index (CCI) Score of <2 or ≥2. Characteristics associated with comorbidities were analyzed by univariate and multivariate logistic regression. Propensity-score matching was performed to determine the impact of CCI on stage at cancer diagnosis, dichotomized as early (I-II) or late (III-IV).

RESULTS

A total of 672,032 patients with colon adenocarcinoma and 2,132,889 with breast ductal carcinoma were included. Patients with colon adenocarcinoma who had a CCI ≥ 2 (11%, n = 72,620) were more likely to be diagnosed with early-stage disease (53% vs. 47%; odds ratio [OR] 1.02, p = 0.017), and this finding persisted after propensity matching (CCI ≥ 2 55% vs. CCI < 2 53%, p < 0.001). Patients with breast ductal carcinoma who had a CCI ≥ 2 (4%, n = 85,069) were more likely to be diagnosed with late-stage disease (15% vs. 12%; OR 1.35, p < 0.001). This finding also persisted after propensity matching (CCI ≥ 2 14% vs. CCI < 2 10%, p < 0.001).

CONCLUSIONS

Patients with more comorbidities are more likely to present with early-stage colon cancers but late-stage breast cancers. This finding may reflect differences in practice patterns for routine screening in these patients. Providers should continue guideline directed screenings to detect cancers at an earlier stage and optimize outcomes.

A pictorial guide to artifacts on contrast mammography: How to avoid pitfalls and improve interpretation

Contrast-enhanced mammography (CEM) is an increasingly accepted emerging imaging modality that demonstrates a similar sensitivity to MRI but has the advantage of being less time consuming and inexpensive. The use of CEM continues to expand as it is recognized and utilized as a valuable tool for diagnostic and potentially screening examinations. As with any radiologic examination, artifacts occur and knowledge of these is important for adequate image interpretation. The purpose of this paper is to provide a pictorial review the common artifacts encountered on CEM examinations and identify causes and potential resolutions.

Predictors of nonadherence to breast cancer screening guidelines in a United States urban comprehensive cancer center

BACKGROUND

This study aimed to identify predictors of nonadherence to breast cancer screening guidelines in an urban screening clinic among high- and average-risk women in the United States.

METHODS

We reviewed records of 6090 women who received ≥2 screening mammograms over 2 years at the Karmanos Cancer Institute to examine how breast cancer risk and breast density were associated with guideline-concordant screening. Incongruent screening was defined as receiving supplemental imaging between screening mammograms for average-risk women, and as not receiving recommended supplemental imaging for high-risk women. We used t-tests and chi-square tests to examine bivariate associations with guideline-congruent screening, and probit regression to regress guideline-congruence unto breast cancer risk, breast density, and their interaction, controlling for age and race.

RESULTS

Incongruent screening was more likely among high- versus average-risk women (97.7% vs. 0.9%, p < 0.01). Among average-risk women, incongruent screening was more likely among those with dense versus nondense breasts (2.0% vs. 0.1%, p < 0.01). Among high-risk women, incongruent screening was more likely among those with nondense versus dense breasts (99.5% vs. 95.2%, p < 0.01). The significant main effects of density and high-risk on increased incongruent screening were qualified by a density by high-risk interaction, showing a weaker association between risk and incongruent screening among women with dense breasts (simple slope = 3.71, p < 0.01) versus nondense breasts (simple slope = 5.79, p < 0.01). Age and race were not associated with incongruent screening.

CONCLUSIONS

Lack of adherence to evidence-based screening guidelines has led to underutilization of supplementary imaging for high-risk women and potential overutilization for women with dense breasts without other risk factors.

Feasibility of Diffusion Tensor Imaging for Decreasing Biopsy Rates in Breast Imaging: Interim Analysis of a Prospective Study

Because of the limited specificity of diagnostic imaging, many breast lesions referred for biopsy turn out to be benign. The objective of this study was to evaluate whether diffusion tensor MRI (DTI) parametric maps can be used to safely avoid biopsy of breast lesions. Individuals referred for breast biopsy based on mammogram (MG), ultrasound (US), and/or contrast enhanced (CE)-MRI were recruited. Scans consisting of T2-weighted and DTI sequences were performed. Multiple DTI-derived parametric color maps were evaluated semi-quantitatively to characterize lesions as "definitely benign," "not definitely benign," or "suspicious." All patients subsequently underwent biopsy. In this moderately-sized prospective study, 21 out of 47 pathologically proven benign lesions were characterized by both readers as "definitely benign," which would have precluded the need for biopsy. Biopsy was recommended for 11 out of 13 cancers that were characterized as "suspicious." In the remaining two cancers and 26 of 47 benign lesions, the scans were characterized as "not definitely benign" and hence required biopsy. The main causes for "not definitely benign" scans were small lesion sizes and noise. The results suggest that in appropriately selected patients, DTI may be used to safely reduce the number of unnecessary breast biopsies.

Changes in Breast Cancer Presentation during COVID-19: Experience in an Urban Academic Center

The COVID-19 pandemic strained healthcare systems worldwide, delaying breast cancer screening and surgery. In 2019, approximately 80% of breast cancers in the U.S. were diagnosed on screening examinations, with 76.4% of eligible Medicare patients undergoing screening at least every two years. Since the start of the pandemic, many women have been reluctant to seek elective screening mammography, even with the lifting of pandemic-related restrictions in access to routine healthcare. We describe the effect of the COVID-19 pandemic on breast cancer presentation at a tertiary academic medical center greatly impacted by the pandemic.

Women 75 Years Old or Older: To Screen or Not to Screen?

Breast cancer is the most common cancer in women, with the incidence rising substantially with age. Older women are a vulnerable population at increased risk of developing and dying from breast cancer. However, women aged 75 years and older were excluded from all randomized controlled screening trials, so the best available data regarding screening benefits and risks in this age group are from observational studies and modeling predictions. Benefits of screening in older women are the same as those in younger women: early detection of smaller lower-stage cancers, resulting in less invasive treatment and lower morbidity and mortality. Mammography performs significantly better in older women with higher sensitivity, specificity, cancer detection rate, and positive predictive values, accompanied by lower recall rates and false positives. The overdiagnosis rate is low, with benefits outweighing risks until age 90 years. Although there are conflicting national and international guidelines about whether to continue screening mammography in women beyond age 74 years, clinicians can use shared decision making to help women make decisions about screening and fully engage them in the screening process. For women aged 75 years and older in good health, continuing annual screening mammography will save the most lives. An informed discussion of the benefits and risks of screening mammography in older women needs to include each woman's individual values, overall health status, and comorbidities. This article will review the benefits, risks, and controversies surrounding screening mammography in women 75 years old and older and compare the current recommendations for screening this population from national and international professional organizations. ^©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Different Types of Patient Health Information Associated With Physician Decision-making Regarding Cancer Screening Cessation for Older Adults

Importance

Although guidelines use limited life expectancy to guide physician decision-making regarding cessation of cancer screening, many physicians recommend screening for older adults with limited life expectancies. Different ways of presenting information may influence older adults' screening decision-making; whether the same is true for physicians is unknown.

Objective

To examine how different ways of presenting patient health information are associated with physician decision-making about cancer screening cessation for older adults.

Design, Setting, and Participants

A national survey was mailed from April 29 to November 8, 2021, to a random sample of 1800 primary care physicians and 600 gynecologists from the American Medical Association Physician Masterfile. Primary care physicians were surveyed about breast, colorectal, or prostate cancer screenings. Gynecologists were surveyed about breast cancer screening.

Main Outcomes and Measures

Using vignettes of 2 older patients with limited life expectancies, 4 pieces of information about each patient were presented: (1) description of health conditions and functional status, (2) life expectancy, (3) equivalent physiological age, and (4) risk of dying from the specific cancer in the patient's remaining lifetime. The primary outcome was which information was perceived to be the most influential in screening cessation.

Results

The final sample included 776 participants (adjusted response rate, 52.8%; mean age, 51.4 years [range, 27-91 years]; 402 of 775 participants were men [51.9%]; 508 of 746 participants were White [68.1%]). The 2 types of information that were most often chosen as the factors most influential in cancer screening cessation were description of the patient's health or functional status (36.7% of vignettes [569 of 1552]) and risk of death from cancer in the patient's remaining lifetime (34.9% of vignettes [542 of 1552]). Life expectancy was chosen as the most influential factor in 23.1% of vignettes (358 of 1552). Physiological age was the least often chosen (5.3% of vignettes [83 of 1552]) as the most influential factor. Description of patient's health or functional status was the most influential factor among primary care physicians (estimated probability, 40.2%; 95% CI, 36.2%-44.2%), whereas risk of death from cancer was the most influential factor among gynecologists (estimated probability, 43.1%; 95% CI, 34.0%-52.1%). Life expectancy was perceived as a more influential factor in the vignette with more limited life expectancy (estimated probability, 27.9%; 95% CI, 24.5%-31.3%) and for colorectal cancer (estimated probability, 33.9%; 95% CI, 27.3%-40.5%) or prostate cancer (28.0%; 95% CI, 21.7%-34.2%) screening than for breast cancer screening (estimated probability, 14.5%; 95% CI, 10.9%-18.0%).

Conclusions and Relevance

Findings from this national survey study of physicians suggest that, in addition to the patient's health and functional status, the cancer risk in the patient's remaining lifetime and life expectancy were the factors most associated with physician decision-making regarding cancer screening cessation; information on cancer risk in the patient's remaining lifetime and life expectancy is not readily available during clinical encounters. Decision support tools that present a patient's cancer risk and/or limited life expectancy may help reduce overscreening among older adults.

Closing the gap in osteoporosis management: the critical role of primary care in bone health

OBJECTIVE

The World Health Organization issued a call to action for primary care to lead efforts in managing noncommunicable diseases, including osteoporosis. Although common, osteoporosis remains underdiagnosed and undertreated. Primary care practitioners (PCPs) are critical in identifying individuals at risk for osteoporosis and osteoporotic fractures; however, recent advances in assessment, diagnosis, and treatment of osteoporosis have not been incorporated into clinical practice in primary care due to numerous reasons including time constraints and insufficient knowledge. To close this gap in clinical practice, we believe PCPs need a practical strategy to facilitate osteoporosis assessment and management that is easy to implement.

METHODS

In this article, we consolidate information from various global guidelines and highlight areas of agreement to create a streamlined osteoporosis management strategy for a global audience of PCPs.

RESULTS

We present a systematic approach to facilitate osteoporosis assessment and management that includes four steps: (1) identifying patients at risk through proactive screening strategies, (2) investigating and diagnosing patients, (3) intervening with personalized treatment plans, and (4) implementing patient-centered strategies for long-term management and monitoring of patients.

CONCLUSION

Primary care has a central role in ensuring the incorporation of key elements of holistic care as outlined by the World Health Organization in managing noncommunicable diseases including osteoporosis; namely, a people-centered approach, incorporation of specialist services, and multidisciplinary care. This approach is designed to strengthen the health system's response to the growing osteoporosis epidemic.

Multisystem Imaging Recommendations/Guidelines: In the Pursuit of Precision Oncology

With an increasing rate of cancers in almost all age groups and advanced screening techniques leading to an early diagnosis and longer longevity of patients with cancers, it is of utmost importance that radiologists assigned with cancer imaging should be prepared to deal with specific expected and unexpected circumstances that may arise during the lifetime of these patients. Tailored integration of preventive and curative interventions with current health plans and global escalation of efforts for timely diagnosis of cancers will pave the path for a cancer-free world. The commonly encountered circumstances in the current era, complicating cancer imaging, include coronavirus disease 2019 infection, pregnancy and lactation, immunocompromised states, bone marrow transplant, and screening of cancers in the relevant population. In this article, we discuss the imaging recommendations pertaining to cancer screening and diagnosis in the aforementioned clinical circumstances.

Screening Programs for Breast Cancer: Toward Individualized, Risk-Adapted Strategies of Early Detection

Early detection of breast cancer (BC) comprises two approaches: screening of asymptomatic women in a specified target population at risk (usually a target age range for women at average risk), and early diagnosis for women with BC signs and symptoms. Screening for BC is a key health intervention for early detection. While population-based screening programs have been implemented for age-selected women, the pivotal clinical trials have not addressed the global utility nor the improvement of screening performance by utilizing more refined parameters for patient eligibility, such as individualized risk stratification. In addition, with the exception of the subset of women known to carry germline pathogenetic mutations in (high- or moderately-penetrant) cancer predisposition genes, such as BRCA1 and BRCA2, there has been less success in outreach and service provision for the unaffected relatives of women found to carry a high-risk mutation (i.e., "cascade testing") as it is in these individuals for whom such actionable information can result in cancers (and/or cancer deaths) being averted. Moreover, even in the absence of clinical cancer genetics services, as is the case for the immediate and at least near-term in most countries globally, the capacity to stratify the risk of an individual to develop BC has existed for many years, is available for free online at various sites/platforms, and is increasingly being validated for non-Caucasian populations. Ultimately, a precision approach to BC screening is largely missing. In the present chapter, we aim to address the concept of risk-adapted screening of BC, in multiple facets, and understand if there is a value in the implementation of adapted screening strategies in selected women, outside the established screening prescriptions, in the terms of age-range, screening modality and schedules of imaging.

Breast cancer knowledge & information seeking among African American women below screening age

OBJECTIVES

African American women below screening age disproportionately face greater mortality from breast cancer relative to peers of other races and African American women of screening age. The current study examines breast cancer knowledge and health information seeking of African American women below screening age.

METHODS

We collected survey data from 99 African American women below screening age on their breast cancer knowledge and health information seeking behaviors. As secondary analysis, we harmonized data from a previous study to compare breast cancer knowledge between African American women below and of (N = 209) screening age.

RESULTS

The average woman below screening age correctly answered 2.84 (SD=1.08) of six breast cancer knowledge items, 2.67 (SD=1.01) of five mammogram items, 1.44 (SD=0.86) of three treatment items, and had lower knowledge (p < .001) in each area relative to screening age women. Women below screening age sought information primarily from medical providers and the internet.

CONCLUSIONS

A strategy for eliminating early-onset breast cancer disparities impacting African American women is addressing the limited breast cancer knowledge in this age group. Practice Implications In addition to age-appropriate information for this group, guidance for medical providers would be beneficial, as providers are this group's most common source of health information.

The Landmark Series-Addressing Disparities in Breast Cancer Screening: New Recommendations for Black Women

Randomized, clinical trials have established the efficacy of screening mammography in improving survival from breast cancer for women through detection of early, asymptomatic disease. However, disparities in survival rates between black women and women from other racial and ethnic groups following breast cancer diagnosis persist. Various professional groups have different, somewhat conflicting, guidelines with regards to recommended age for commencing screening as well as recommended frequency of screening exams, but the trials upon which these recommendations are based were not specifically designed to examine benefit among black women. Furthermore, these recommendations do not appear to incorporate the unique epidemiological circumstances of breast cancer among black women, including higher rates of diagnosis before age 40 years and greater likelihood of advanced stage at diagnosis, into their formulation. In this review, we examined the epidemiologic and socioeconomic factors that are associated with breast cancer among black women and assess the implications of these factors for screening in this population. Specifically, we recommend that by no later than age 25 years, all black women should undergo baseline assessment for future risk of breast cancer utilizing a model that incorporates race (e.g., Breast Cancer Risk Assessment Tool [BCRAT], formerly the Gail model) and that this assessment should be conducted by a breast specialist or a healthcare provider (e.g., primary care physician or gynecologist) who is trained to assess breast cancer risk and is aware of the increased risks of early (i.e., premenopausal) and biologically aggressive (e.g., late-stage, triple-negative) breast cancer among black women.

Studies of parenchymal texture added to mammographic breast density and risk of breast cancer: a systematic review of the methods used in the literature

This systematic review aimed to assess the methods used to classify mammographic breast parenchymal features in relation to the prediction of future breast cancer. 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 to extract published articles in English describing the relationship of parenchymal texture features with the risk of breast cancer. Twenty-eight articles published since 2016 were included in the final review. The identification of parenchymal texture features varied from using a predefined list to machine-driven identification. A reduction in the number of features chosen for subsequent analysis in relation to cancer incidence then varied across statistical approaches and machine learning methods. The variation in approach and number of features identified for inclusion in analysis precluded generating a quantitative summary or meta-analysis of the value of these features to improve predicting risk of future breast cancers. This updated overview of the state of the art revealed research gaps; based on these, we provide recommendations for future studies using parenchymal features for mammogram images to make use of accumulating image data, and external validation of prediction models that extend to 5 and 10 years to guide clinical risk management. Following these recommendations could enhance the applicability of models, helping improve risk classification and risk prediction for women to tailor screening and prevention strategies to the level of risk.

Evaluation of Harms Reporting in U.S. Cancer Screening Guidelines

BACKGROUND

Cancer screening should be recommended only when the balance between benefits and harms is favorable. This review evaluated how U.S. cancer screening guidelines reported harms, within and across organ-specific processes to screen for cancer.

OBJECTIVE

To describe current reporting practices and identify opportunities for improvement.

DESIGN

Review of guidelines.

SETTING

United States.

PATIENTS

Patients eligible for screening for breast, cervical, colorectal, lung, or prostate cancer according to U.S. guidelines.

MEASUREMENTS

Information was abstracted on reporting of patient-level harms associated with screening, diagnostic follow-up, and treatment. The authors classified harms reporting as not mentioned, conceptual, qualitative, or quantitative and noted whether literature was cited when harms were described. Frequency of harms reporting was summarized by organ type.

RESULTS

Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines. Conceptualization of harms and use of quantitative evidence also differed by organ type.

LIMITATIONS

This review considers only patient-level harms. The authors did not verify accuracy of harms information presented in the guidelines.

CONCLUSION

The review identified opportunities for improving conceptualization, assessment, and reporting of screening process-related harms in guidelines. Future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. Improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Misinformation and Facts about Breast Cancer Screening

Quality medical practice is based on science and evidence. For over a half-century, the efficacy of breast cancer screening has been challenged, particularly for women aged 40-49. As each false claim has been raised, it has been addressed and refuted based on science and evidence. Nevertheless, misinformation continues to be promoted, resulting in confusion for women and their physicians. Early detection has been proven to save lives for women aged 40-74 in randomized controlled trials of mammography screening. Observational studies, failure analyses, and incidence of death studies have provided evidence that there is a major benefit when screening is introduced to the general population. In large part due to screening, there has been an over 40% decline in deaths from breast cancer since 1990. Nevertheless, misinformation about screening continues to be promoted, adding to the confusion. Despite claims to the contrary, a careful reading of the guidelines issued by major groups such as the U.S. Preventive Services Task Force and the American College of Physicians shows that they all agree that most lives are saved by screening starting at the age of 40. There is no scientific support for using the age of 50 as a threshold for screening. All women should be provided with the facts and not false information about breast cancer screening so that they can make "informed decisions" for themselves about whether to participate.

Global guidelines for breast cancer screening: A systematic review

Objectives

Breast cancer screening guidelines could provide valuable tools for clinical decision making by reviewing the available evidence and providing recommendations. Little information is known about how many countries have issued breast cancer screening guidelines and the differences among existing guidelines. We systematically reviewed current guidelines and summarized corresponding recommendations, to provide references for good clinical practice in different countries.

Methods

Systematic searches of MEDLINE, EMBASE, Web of Science, and Scopus from inception to March 27th, 2021 were conducted and supplemented by reviewing the guideline development organizations. The quality of screening guidelines was assessed from six domains of the Appraisal of Guidelines for Research and Evaluation Ⅱ (AGREE Ⅱ) instrument by two appraisers. The basic information and recommendations of the issued guidelines were extracted and summarized.

Results

A total of 23 guidelines issued between 2010 and 2021 in 11 countries or regions were identified for further review. The content and quality varied across the guidelines. The average AGREE Ⅱ scores of the guidelines ranged from 33.3% to 87.5%. The highest domain score was "clarity of presentation" while the domain with the lowest score was "applicability". For average-risk women, most of the guidelines recommended mammographic screening for those aged 40–74 years, specifically, those aged 50–69 years were regarded as the optimal age group for screening. Nine of 23 guidelines recommended against an upper age limit for breast cancer screening. Mammography (MAM) was recommended as the primary screening modality for average-risk women by all included guidelines. Most guidelines suggested annual or biennial mammographic screening. Risk factors of breast cancer identified in the guidelines mainly fell within five categories which could be broadly summarized as the personal history of pre-cancerous lesions and/or breast cancer; the family history of breast cancer; the known genetic predisposition of breast cancer; the history of mantle or chest radiation therapy; and dense breasts. For women at higher risk, there was a consensus among most guidelines that annual MAM or annual magnetic resonance imaging (MRI) should be given, and the screening should begin earlier than the average-risk group.

Conclusions

The majority of 23 included international guidelines were issued by developed countries which contained roughly the same but not identical recommendations on breast cancer screening age, methods, and intervals. Most guidelines recommended annual or biennial mammographic screening between 40 and 74 years for average-risk populations and annual MAM or annual MRI starting from a younger age for high-risk populations. Current guidelines varied in quality and increased efforts are needed to improve the methodological quality of guidance documents. Due to lacking clinical practice guidelines tailored to different economic levels, low- and middle-income countries (LMICs) should apply and implement the evidence-based guidelines with higher AGREE Ⅱ scores considering local adaption.

•

This systematic review comprehensively maps the recommendations of the latest international breast screening guidelines, providing valuable tools for clinical decision making in different settings.

•

Most guidelines recommend annual or biennial mammographic screening between 40 and 74 years for the average-risk populations and annual MAM or annual MRI starting from a younger age for the high-risk populations. However, there are indeed discrepancies in screening age, methods, and intervals among countries.

•

High-quality evidence and rigorous methodology are the keys to guidance development, but current guidelines vary in methodological quality.

Patient, primary care provider, and stakeholder perspectives on mammography screening frequency: lessons learned from a qualitative study

BACKGROUND

U.S. professional organizations have provided conflicting recommendations on annual vs. biennial mammography screening. Potential harms of more frequent screening include increased anxiety and costs of false positive results, including unnecessary breast biopsies and overdiagnosis.

OBJECTIVE

To characterize current practices and beliefs surrounding mammography screening frequency and perspectives on using risk-based screening to inform screening intervals.

DESIGN

Semi-structured interviews informed by the Consolidated Framework for Implementation Research (CFIR).

PARTICIPANTS

Patients, primary care providers (PCPs), third-party stakeholders (breast radiologists, radiology administrators, patient advocates).

MAIN MEASURES

Qualitative data, with a codebook developed based upon prespecified implementation science constructs.

KEY RESULTS

We interviewed 25 patients, 11 PCPs, and eight key stakeholders, including three radiologists, two radiology administrators, and three patient advocates. Most patients reported having annual mammograms, however, half believed having mammograms every two years was acceptable. Some women were worried early breast cancer would be missed if undergoing biennial screening. PCPs were equally split between recommending annual and biennial mammograms. Although PCPs were interested in using breast cancer risk models to inform screening decisions, concerns raised include time burden and lack of familiarity with breast cancer risk assessment tools. All breast radiologists believed patients should receive annual mammograms, while patient advocates and radiology administrators were split between annual vs. biennial. Radiologists were worried about missing breast cancer diagnoses when mammograms are not performed yearly. Patient advocates and radiology administrators were more open to biennial mammograms and utilizing risk-based screening.

CONCLUSIONS

Uncertainty remains across stakeholder groups regarding appropriate mammogram screening intervals. Radiologists recommend annual mammography, whereas patients and PCPs were evenly split between annual vs. biennial screening, although both favored annual screening among higher-risk women. Breast cancer risk assessment tools may help facilitate decisions about screening intervals, but face barriers to widespread implementation in the primary care setting. These results will inform future implementation strategies to adopt risk-stratified breast cancer screening.

Health Economics Research in Cancer Screening: Research Opportunities, Challenges, and Future Directions

Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, "choosing wisely" screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.