Collaborative Modeling to Compare Different Breast Cancer Screening Strategies: A Decision Analysis for the US Preventive Services Task Force

Importance

The effects of breast cancer incidence changes and advances in screening and treatment on outcomes of different screening strategies are not well known.

Objective

To estimate outcomes of various mammography screening strategies.

Design, Setting, and Population

Comparison of outcomes using 6 Cancer Intervention and Surveillance Modeling Network (CISNET) models and national data on breast cancer incidence, mammography performance, treatment effects, and other-cause mortality in US women without previous cancer diagnoses.

Exposures

Thirty-six screening strategies with varying start ages (40, 45, 50 years) and stop ages (74, 79 years) with digital mammography or digital breast tomosynthesis (DBT) annually, biennially, or a combination of intervals. Strategies were evaluated for all women and for Black women, assuming 100% screening adherence and "real-world" treatment.

Main Outcomes and Measures

Estimated lifetime benefits (breast cancer deaths averted, percent reduction in breast cancer mortality, life-years gained), harms (false-positive recalls, benign biopsies, overdiagnosis), and number of mammograms per 1000 women.

Results

Biennial screening with DBT starting at age 40, 45, or 50 years until age 74 years averted a median of 8.2, 7.5, or 6.7 breast cancer deaths per 1000 women screened, respectively, vs no screening. Biennial DBT screening at age 40 to 74 years (vs no screening) was associated with a 30.0% breast cancer mortality reduction, 1376 false-positive recalls, and 14 overdiagnosed cases per 1000 women screened. Digital mammography screening benefits were similar to those for DBT but had more false-positive recalls. Annual screening increased benefits but resulted in more false-positive recalls and overdiagnosed cases. Benefit-to-harm ratios of continuing screening until age 79 years were similar or superior to stopping at age 74. In all strategies, women with higher-than-average breast cancer risk, higher breast density, and lower comorbidity level experienced greater screening benefits than other groups. Annual screening of Black women from age 40 to 49 years with biennial screening thereafter reduced breast cancer mortality disparities while maintaining similar benefit-to-harm trade-offs as for all women.

Conclusions

This modeling analysis suggests that biennial mammography screening starting at age 40 years reduces breast cancer mortality and increases life-years gained per mammogram. More intensive screening for women with greater risk of breast cancer diagnosis or death can maintain similar benefit-to-harm trade-offs and reduce mortality disparities.

Benefits and Harms of Mammography Screening in 75 + Women to Inform Shared Decision-making: a Simulation Modeling Study

BACKGROUND

Guidelines recommend shared decision-making (SDM) around mammography screening for women ≥ 75 years old.

OBJECTIVE

To use microsimulation modeling to estimate the lifetime benefits and harms of screening women aged 75, 80, and 85 years based on their individual risk factors (family history, breast density, prior biopsy) and comorbidity level to support SDM in clinical practice.

DESIGN, SETTING, AND PARTICIPANTS

We adapted two established Cancer Intervention and Surveillance Modeling Network (CISNET) models to evaluate the remaining lifetime benefits and harms of screening U.S. women born in 1940, at decision ages 75, 80, and 85 years considering their individual risk factors and comorbidity levels. Results were summarized for average- and higher-risk women (defined as having breast cancer family history, heterogeneously dense breasts, and no prior biopsy, 5% of the population).

MAIN OUTCOMES AND MEASURES

Remaining lifetime breast cancers detected, deaths (breast cancer/other causes), false positives, and overdiagnoses for average- and higher-risk women by age and comorbidity level for screening (one or five screens) vs. no screening per 1000 women.

RESULTS

Compared to stopping, one additional screen at 75 years old resulted in six and eight more breast cancers detected (10% overdiagnoses), one and two fewer breast cancer deaths, and 52 and 59 false positives per 1000 average- and higher-risk women without comorbidities, respectively. Five additional screens over 10 years led to 23 and 31 additional breast cancer cases (29-31% overdiagnoses), four and 15 breast cancer deaths avoided, and 238 and 268 false positives per 1000 average- and higher-risk screened women without comorbidities, respectively. Screening women at older ages (80 and 85 years old) and high comorbidity levels led to fewer breast cancer deaths and a higher percentage of overdiagnoses.

CONCLUSIONS

Simulation models show that continuing screening in women ≥ 75 years old results in fewer breast cancer deaths but more false positive tests and overdiagnoses. Together, clinicians and 75 + women may use model output to weigh the benefits and harms of continued screening.

Estimation of Breast Cancer Overdiagnosis in a U.S. Breast Screening Cohort

BACKGROUND

Mammography screening can lead to overdiagnosis-that is, screen-detected breast cancer that would not have caused symptoms or signs in the remaining lifetime. There is no consensus about the frequency of breast cancer overdiagnosis.

OBJECTIVE

To estimate the rate of breast cancer overdiagnosis in contemporary mammography practice accounting for the detection of nonprogressive cancer.

DESIGN

Bayesian inference of the natural history of breast cancer using individual screening and diagnosis records, allowing for nonprogressive preclinical cancer. Combination of fitted natural history model with life-table data to predict the rate of overdiagnosis among screen-detected cancer under biennial screening.

SETTING

Breast Cancer Surveillance Consortium (BCSC) facilities.

PARTICIPANTS

Women aged 50 to 74 years at first mammography screen between 2000 and 2018.

MEASUREMENTS

Screening mammograms and screen-detected or interval breast cancer.

RESULTS

The cohort included 35 986 women, 82 677 mammograms, and 718 breast cancer diagnoses. Among all preclinical cancer cases, 4.5% (95% uncertainty interval [UI], 0.1% to 14.8%) were estimated to be nonprogressive. In a program of biennial screening from age 50 to 74 years, 15.4% (UI, 9.4% to 26.5%) of screen-detected cancer cases were estimated to be overdiagnosed, with 6.1% (UI, 0.2% to 20.1%) due to detecting indolent preclinical cancer and 9.3% (UI, 5.5% to 13.5%) due to detecting progressive preclinical cancer in women who would have died of an unrelated cause before clinical diagnosis.

LIMITATIONS

Exclusion of women with first mammography screen outside BCSC.

CONCLUSION

On the basis of an authoritative U.S. population data set, the analysis projected that among biennially screened women aged 50 to 74 years, about 1 in 7 cases of screen-detected cancer is overdiagnosed. This information clarifies the risk for breast cancer overdiagnosis in contemporary screening practice and should facilitate shared and informed decision making about mammography screening.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Abstract GS4-06: Estimation of breast cancer overdiagnosis in a US breast screening cohort

Background. Breast cancer screening is subject to overdiagnosis, that is the mammographic detection of cancers that would not become symptomatic or otherwise cause harm in the absence of screening. The risk of overdiagnosis associated with screening mammography is a concern but there is no consensus about its magnitude. Estimates based on excess incidence are prone to bias, and estimates based on models have been criticized for not explicitly accommodating indolent tumors. Methods. We obtained individual mammography screening and breast cancer diagnosis records from the Breast Cancer Surveillance Consortium (BCSC), an authoritative data source in the US. Women aged 50-74 years who had their first mammogram in the BCSC between 2000-2018 were included. We fit a mathematical model that accounts for the transition from healthy to preclinical and clinical disease while allowing for a fraction of indolent preclinical tumors. We performed Bayesian inference using the Hamiltonian Monte Carlo sampler Stan to estimate model parameters and predict overdiagnosis rates under biennial and annual screening between ages 50 and 74. We defined the breast cancer overdiagnosis rate as the fraction of screen-detected cancers that would not have been symptomatically detected in the woman’s remaining lifetime. Overdiagnosis arises from two possible scenarios: the screen-detection of indolent cancers, and the screen-detection of progressive cancers that do not progress to clinical disease before the woman dies from causes unrelated to breast cancer. To calculate the second contribution, we determined the risk of other-cause death using age-cohort-adjusted annual mortality risks. Results. The analytic cohort included 35,986 women, 82,677 screens and 718 breast cancer diagnoses. The mean fraction of indolent cancers among all preclinical cases (detected and undetected) was 3.6% (95% credible interval [CI]: 0.2% to 13.8%), the mean preclinical sojourn time was 6.5 years (CI: 4.9 to 8.6) and the mean test sensitivity was 81.7% (CI: 72.6% to 89.0%). For a program of biennial screening from age 50 to 74, the predicted overdiagnosis rate among screen-detected cases was 15.3% (95% prediction interval [PI]: 9.7% to 25.2%), where 6.0% (PI: 0.2% to 19.0%) was due to the detection of indolent cancers and 9.3% (PI: 5.8%-13.6%) was due to competing mortality. For a program of annual screening from age 50 to 74, the overall predicted overdiagnosis rate was 14.6% (PI: 9.4% to 23.9%). Discussion. Our results indicate that overdiagnosis among screen-detected cancers is less frequent than estimated by excess-incidence studies and more frequent than estimated by previous modeling studies that did not account for indolent tumors.

Citation Format: Marc D Ryser, Jane Lange, Lurdes Inoue, Ellen S O'Meara, Charlotte Gard, Diana L Miglioretti, Jean-Luc Bulliard, Andrew F Brouwer, E. Shelley Hwang, Ruth B Etzioni. Estimation of breast cancer overdiagnosis in a US breast screening cohort [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr GS4-06.

Mammography adherence in relation to function-related indicators in older women

Prior studies of screening mammography patterns by functional status in older women show inconsistent results. We used Breast Cancer Surveillance Consortium-Medicare linked data (1999-2014) to investigate the association of functional limitations with adherence to screening mammography in 145,478 women aged 66-74 years. Functional limitation was represented by a claims-based function-related indicator (FRI) score which incorporated 16 items reflecting functional status. Baseline adherence was defined as mammography utilization 9-30 months after the index screening mammography. Longitudinal adherence was examined among women adherent at baseline and defined as time from the index mammography to end of the first 30-month gap in mammography. Multivariable logistic regression and Cox proportional hazards models were used to investigate baseline and longitudinal adherence, respectively. Subgroup analyses were conducted by age (66-70 vs. 71-74 years). Overall, 69.6% of participants had no substantial functional limitation (FRI score 0), 23.5% had some substantial limitations (FRI score 1), and 6.8% had serious limitations (FRI score ≥ 2). Mean age at baseline was 68.5 years (SD = 2.6), 85.3% of participants were white, and 77.1% were adherent to screening mammography at baseline. Women with a higher FRI score were more likely to be non-adherent at baseline (FRI ≥ 2 vs. 0: aOR = 1.13, 95% CI = 1.06, 1.20, p-trend < 0.01). Similarly, a higher FRI score was associated with longitudinal non-adherence (FRI ≥ 2 vs. 0: aHR = 1.16, 95% CI = 1.11, 1.22, p-trend < 0.01). Effect measures of FRI did not differ substantially by age categories. Older women with a higher burden of functional limitations are less likely to be adherent to screening mammography recommendations.

Cost-Effectiveness of Screening Mammography Beyond Age 75 Years : A Cost-Effectiveness Analysis

BACKGROUND

The cost-effectiveness of screening mammography beyond age 75 years remains unclear.

OBJECTIVE

To estimate benefits, harms, and cost-effectiveness of extending mammography to age 80, 85, or 90 years according to comorbidity burden.

DESIGN

Markov microsimulation model.

DATA SOURCES

SEER (Surveillance, Epidemiology, and End Results) program and Breast Cancer Surveillance Consortium.

TARGET POPULATION

U.S. women aged 65 to 90 years in groups defined by Charlson comorbidity score (CCS).

TIME HORIZON

Lifetime.

PERSPECTIVE

National health payer.

INTERVENTION

Screening mammography to age 75, 80, 85, or 90 years.

OUTCOME MEASURES

Breast cancer death, survival, and costs.

RESULTS OF BASE-CASE ANALYSIS

Extending biennial mammography from age 75 to 80 years averted 1.7, 1.4, and 1.0 breast cancer deaths and increased days of life gained by 5.8, 4.2, and 2.7 days per 1000 women for comorbidity scores of 0, 1, and 2, respectively. Annual mammography beyond age 75 years was not cost-effective, but extending biennial mammography to age 80 years was ($54 000, $65 000, and $85 000 per quality-adjusted life-year [QALY] gained for women with CCSs of 0, 1, and ≥2, respectively). Overdiagnosis cases were double the number of deaths averted from breast cancer.

RESULTS OF SENSITIVITY ANALYSIS

Costs per QALY gained were sensitive to changes in invasive cancer incidence and shift of breast cancer stage with screening mammography.

LIMITATION

No randomized controlled trials of screening mammography beyond age 75 years are available to provide model parameter inputs.

CONCLUSION

Although annual mammography is not cost-effective, biennial screening mammography to age 80 years is; however, the absolute number of deaths averted is small, especially for women with comorbidities. Women considering screening beyond age 75 years should weigh the potential harms of overdiagnosis versus the potential benefit of averting death from breast cancer.

PRIMARY FUNDING SOURCE

National Cancer Institute and National Institutes of Health.

Prioritizing breast imaging services during the COVID pandemic: A survey of breast imaging facilities within the Breast Cancer Surveillance Consortium

The COVID-19 pandemic disrupted breast cancer screening and diagnostic imaging in the United States. We sought to evaluate how medical facilities prioritized breast imaging services during periods of reduced capacity or upon re-opening after closures. In fall 2020, we surveyed 77 breast imaging facilities within the Breast Cancer Surveillance Consortium in the United States. The survey ascertained the pandemic's impact on clinical practices during March-September 2020. Nearly all facilities (97%) reported closing or operating at reduced capacity at some point during this period. All facilities were open by August 2020, though 14% were still operating at reduced capacity in September 2020. During periods of re-opening or reduced capacity, 93% of facilities reported prioritizing diagnostic breast imaging over breast cancer screening. For diagnostic imaging, facilities prioritized based on rescheduling canceled appointments (89%), specific indication for diagnostic imaging (89%), patient demand (84%), individual characteristics and risk factors (77%), and time since last imaging examination (72%). For screening mammography, facilities prioritized based on rescheduled cancelations (96%), patient demand (83%), individual characteristics and risk factors (73%), and time since last mammogram (71%). For biopsy services, more than 90% of facilities reported prioritization based on rescheduling of canceled exams, patient demand, patient characteristics and risk factors and level of suspicion on imaging. The observed patterns from this large and geographically diverse sample of facilities in the United States indicate that multiple factors were commonly used to prioritize breast imaging services during periods of reduced capacity.

Abstract 2531: Function-related indicator and outcomes of screening mammography in older women from the BCSC-Medicare Cohort

Background: Although there is evidence pointing to the role of comorbidity and age in screening mammography outcomes among older women, the impact of functional decline on mortality in this population is unknown.

Methods: We used data from 238,849 women in the Breast Cancer Surveillance Consortium-Medicare (BCSC) linked database from 1999-2015 who had at least one screening mammogram at ages 66-94 years. We estimated the 10-year cumulative incidence of breast cancer, breast cancer death, and non-breast cancer death by function-related indicator (FRI) which incorporated 16 claims-based items reflecting functional or health status in older people. In the analysis, FRI score was categorized as an ordinal variable (0, 1, and 2+) and a higher score indicated a higher burden of functional limitations. Fine and Gray proportional sub-distribution hazards models were applied with incident breast cancer and death treated as competing events. Risk estimates by FRI scores (0, 1, and 2+) were adjusted by age and NCI comorbidity index separately and stratified by these factors.

Results: During a median follow-up of 101 months, 9,252 women were diagnosed with breast cancer. During follow-up, 406 women died of breast cancer and 41,640 died from non-breast cancer causes. The 10-year age-adjusted cumulative incidence of invasive breast cancer slightly decreased with increasing FRI score (FRI=0: 4.0%, 95% CI=3.8%-4.1%; FRI=1: 3.9%, 95% CI=3.7%-4.2%; FRI=2+: 3.5%, 95% CI=3.1%-3.9%). Risk of death from non-breast cancer causes increased with FRI score (FRI=0: 18.8%, 95% CI=18.5%-19.1%; FRI=1: 24.4%, 95% CI=23.9%-25.0%; FRI=2+: 39.8%, 95% CI=38.8%-40.9%). Risk of breast cancer death was low with minimal risk differences across FRI scores (FRI=0: 0.24%, 95%CI=0.20%-0.28%; FRI=1: 0.20%, 95%CI=0.14%-0.26%; FRI=2+: 0.30%, 95% CI=0.18%-0.42%). Risk estimates in NCI comorbidity index-adjusted models were largely similar to outcomes in age-adjusted models. Stratified analyses suggested similar patterns of risk estimates by FRI.

Conclusion: Cumulative risk of death from non-breast cancer causes substantially increases with FRI score, suggesting that the potential of screening mammography to benefit older women is low among those with a high burden of functional limitation.

Citation Format: Dongyu Zhang, Linn Abraham, Joshua Demb, Diana L. Miglioretti, Shailesh Advani, Brian L. Sprague, Louise M. Henderson, Tracy Onega, Karen Wernli, Louise C. Walter, Karla Kerlikowske, John T. Schousboe, Ellen S. O'Meara, Dejana Braithwaite. Function-related indicator and outcomes of screening mammography in older women from the BCSC-Medicare Cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2531.

Function-related Indicators and Outcomes of Screening Mammography in Older Women: Evidence from the Breast Cancer Surveillance Consortium Cohort

BACKGROUND

Previous reports suggested risk of death and breast cancer varied by comorbidity and age in older women undergoing mammography. However, impacts of functional limitations remain unclear.

METHODS

We used data from 238,849 women in the Breast Cancer Surveillance Consortium-Medicare linked database (1999-2015) who had screening mammogram at ages 66-94 years. We estimated risk of breast cancer, breast cancer death, and non-breast cancer death by function-related indicator (FRI) which incorporated 16 claims-based items and was categorized as an ordinal variable (0, 1, and 2+). Fine and Gray proportional sub-distribution hazards models were applied with breast cancer and death treated as competing events. Risk estimates by FRI scores were adjusted by age and NCI comorbidity index separately and stratified by these factors.

RESULTS

Overall, 9,252 women were diagnosed with breast cancer, 406 died of breast cancer, and 41,640 died from non-breast cancer causes. The 10-year age-adjusted invasive breast cancer risk slightly decreased with FRI score [FRI = 0: 4.0%, 95% confidence interval (CI) = 3.8-4.1; FRI = 1: 3.9%, 95% CI = 3.7-4.2; FRI ≥ 2: 3.5%, 95% CI = 3.1-3.9). Risk of non-breast cancer death increased with FRI score (FRI = 0: 18.8%, 95% CI = 18.5-19.1; FRI = 1: 24.4%, 95% CI = 23.9-25.0; FRI ≥ 2: 39.8%, 95% CI = 38.8-40.9]. Risk of breast cancer death was low with minimal differences across FRI scores. NCI comorbidity index-adjusted models and stratified analyses yielded similar patterns.

CONCLUSIONS

Risk of non-breast cancer death substantially increases with FRI score, whereas risk of breast cancer death is low regardless of functional status.

IMPACT

Older women with functional limitations should be informed that they may not benefit from screening mammography.

Barriers to Implementing Cardiovascular Risk Calculation in Primary Care: Alignment With the Consolidated Framework for Implementation Research

INTRODUCTION

Cardiovascular disease risk calculators can inform and guide preventive strategies and treatment decisions by clinicians and patients. However, their uptake in primary care has been slow despite the recommendation in national cardiovascular disease prevention guidelines. Identifying the barriers to the implementation of cardiovascular disease risk calculators is essential for promoting their adoption.

METHODS

The authors qualitatively analyzed structured physician educator notes written during an outreach education intervention with 44 small- and medium-sized primary care clinics that participated in the Agency for Healthcare Research and Quality‒funded EvidenceNOW Healthy Hearts Northwest trial. The authors coded barriers to the implementation of cardiovascular disease risk calculation and aligned them to the Consolidated Framework for Implementation Research.

RESULTS

The authors identified 13 barriers from the physician educators' notes. The majority (n=8, 62%) mapped to the framework's Inner Setting domain. The 5 most commonly noted barriers were (1) time constraints to use a calculator (N=23 clinics), (2) limitations to accessing a calculator or the necessary information to use a calculator (N=22 clinics), (3) no or minimal buy-in from clinicians or staff to use a calculator (N=19 clinics), (4) reported patient fear of side effects from statin medications or patient dislike of taking medications per the guidelines (N=17 clinics), and (5) lack of documented clinic workflow for using a calculator (N=16 clinics).

CONCLUSIONS

To improve the uptake of cardiovascular disease risk calculation in primary care, future cardiovascular disease prevention and implementation research should consider tailoring interventions to the common barriers to implementing cardiovascular disease risk calculation.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02839382.

Screening Mammography Outcomes: Risk of Breast Cancer and Mortality by Comorbidity Score and Age

BACKGROUND

Potential benefits of screening mammography among women ages 75 years and older remain unclear.

METHODS

We evaluated 10-year cumulative incidence of breast cancer and death from breast cancer and other causes by Charlson Comorbidity Index (CCI) and age in the Medicare-linked Breast Cancer Surveillance Consortium (1999-2010) cohort of 222 088 women with no less than 1 screening mammogram between ages 66 and 94 years.

RESULTS

During median follow-up of 107 months, 7583 were diagnosed with invasive breast cancer and 1742 with ductal carcinoma in situ; 471 died from breast cancer and 42 229 from other causes. The 10-year cumulative incidence of invasive breast cancer did not change with increasing CCI but decreased slightly with age: ages 66-74 years (CCI0 = 4.0% [95% CI = 3.9% to 4.2%] vs CCI  ≥ 2 = 3.9% [95% CI = 3.5% to 4.3%]); ages 75-84 years (CCI0 = 3.7% [95% CI = 3.5% to 3.9%] vs CCI  ≥ 2 = 3.4% [95% CI = 2.9% to 3.9%]); and ages 85-94 years (CCI0 = 2.7% [95% CI = 2.3% to 3.1%] vs CCI  ≥ 2 = 2.1% [95% CI = 1.3% to 3.0%]). The 10-year cumulative incidence of other-cause death increased with increasing CCI and age: ages 66-74 years (CCI0 = 10.4% [95% CI = 10.3 to 10.7%] vs CCI ≥ 2 = 43.4% [95% CI = 42.2% to 44.4%]), ages 75-84 years (CCI0 = 29.8% [95% CI = 29.3% to 30.2%] vs CCI ≥ 2 = 61.7% [95% CI = 60.2% to 63.3%]), and ages 85 to 94 years (CCI0 = 60.3% [95% CI = 59.1% to 61.5%] vs CCI  ≥ 2 = 84.8% [95% CI = 82.5% to 86.9%]). The 10-year cumulative incidence of breast cancer death was small and did not vary by age: ages 66-74 years = 0.2% (95% CI = 0.2% to 0.3%), ages 75-84 years = 0.29% (95% CI = 0.25% to 0.34%), and ages 85 to 94 years = 0.3% (95% CI = 0.2% to 0.4%).

CONCLUSIONS

Cumulative incidence of other-cause death was many times higher than breast cancer incidence and death, depending on comorbidity and age. Hence, older women with increased comorbidity may experience diminished benefit from continued screening.

The Role of Social Determinants of Health in Self-Reported Access to Health Care Among Women Undergoing Screening Mammography

Background: Social determinants of health (SDOH) contribute to health care disparities, with social and economic barriers often leading to difficulties in obtaining necessary care. We evaluated barriers to receiving health care, focusing on caretaker responsibilities, health insurance and cost, and transportation. Materials and Methods: We included women ages ≥40 years receiving screening mammography across three Breast Cancer Surveillance Consortium registries from 2012 to 2017. Women self-reported social and financial barriers to receiving health care in the 12 months before their screening mammogram. We evaluated woman- and census-based community-level factors associated with reporting a barrier using multivariate logistic regression. We assessed interaction with urban versus nonurban residence using Wald tests. Results: Among 393,430 women, 3.6% reported a barrier with a higher proportion in urban versus nonurban settings (3.9% [n = 11,977] vs. 2.2% [n = 1,655], respectively; p < 0.001). Among women reporting a barrier, health care cost and/or no insurance was the most common (49.3%), and no transportation was the least common (7.8%). Compared with white women, odds of reporting barriers were higher among black (adjusted odds ratio [aOR] = 1.30, 95% confidence interval [CI]: 1.16-1.44), Hispanic (aOR = 1.66, 95% CI: 1.53-1.80), and other race (aOR = 1.84, 95% CI: 1.65-2.04) women. Barriers were less likely in women with higher median household income (aOR = 0.69, 95% CI: 0.61-0.79) or higher average health insurance costs (aOR = 0.85, 95% CI: 0.74-0.98), but were more likely in high diversity index areas (aOR = 1.28, 95% CI: 1.11-1.48). Conclusions: Social and financial barriers exist based on race/ethnicity and SDOH related to income, insurance costs, and place of residence among women undergoing screening mammography. Breast imaging facilities could utilize information on these barriers to improve biennial screening adherence or ensure that women with abnormal findings obtain appropriate follow-up care through targeted interventions.

Strategies to Identify Women at High Risk of Advanced Breast Cancer During Routine Screening for Discussion of Supplemental Imaging

IMPORTANCE

Federal legislation proposes requiring that screening mammography reports to practitioners and women incorporate breast density information and that women with dense breasts discuss supplemental imaging with their practitioner given their increased risk of interval breast cancer. Instead of discussing supplemental imaging with all women with dense breasts, it may be more efficient to identify women at high risk of advanced breast cancer who may benefit most from supplemental imaging.

OBJECTIVE

To identify women at high risk of advanced breast cancer to target woman-practitioner discussions about the need for supplemental imaging.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study assessed 638 856 women aged 40 to 74 years who had 1 693 163 screening digital mammograms taken at Breast Cancer Surveillance Consortium (BCSC) imaging facilities from January 3, 2005, to December 31, 2014. Data analysis was performed from October 10, 2018, to March 20, 2019.

EXPOSURES

Breast Imaging Reporting and Data System (BI-RADS) breast density and BCSC 5-year breast cancer risk.

MAIN OUTCOMES AND MEASURES

Advanced breast cancer (stage IIB or higher) within 12 months of screening mammography; high advanced cancer rates (≥0.61 cases per 1000 mammograms) defined as the top 25th percentile of advanced cancer rates, and discussions per potential advanced cancer prevented.

RESULTS

A total of 638 856 women (mean [SD] age, 56.5 [8.9] years) were included in the study. Women with dense breasts (heterogeneously or extremely dense) accounted for 47.0% of screened women and 60.0% of advanced cancers. Low advanced cancer rates (<0.61 per 1000 mammograms) occurred in 34.5% of screened women with dense breasts. High advanced breast cancer rates occurred in women with heterogeneously dense breasts and a 5-year risk of 2.5% or higher (6.0% of screened women) and those with extremely dense breasts and a 5-year risk of 1.0% or higher (6.5% of screened women). Density-risk subgroups at high advanced cancer risk comprised 12.5% of screened women and 27.1% of advanced cancers. Density-risk subgroups had the fewest supplemental imaging discussions per potential advanced cancer prevented compared with a strategy based on dense breasts (1097 vs 1866 discussions). Women with heterogeneously dense breasts and a 5-year risk less than 1.67% (21.7% of screened women) had high rates of false-positive short-interval follow-up recommendation without undergoing supplemental imaging.

CONCLUSIONS AND RELEVANCE

The findings suggest that breast density notification should be combined with breast cancer risk so women at highest risk for advanced cancer are targeted for supplemental imaging discussions and women at low risk are not. BI-RADS breast density combined with BCSC 5-year risk may offer a more efficient strategy for supplemental imaging discussions than targeting all women with dense breasts.

A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care

PURPOSE

We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance.

METHODS

Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach.

RESULTS

Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76).

CONCLUSIONS

Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.

Airborne metals and polycyclic aromatic hydrocarbons in relation to mammographic breast density

Background

Breast density is strongly related to breast cancer. Identifying associations between environmental exposures and density may elucidate relationships with breast cancer. Metals and polycyclic aromatic hydrocarbons (PAHs) may influence breast density via oxidative stress or endocrine disruption.

Methods

Study participants (n = 222,581) underwent a screening mammogram in 2011 at a radiology facility in the Breast Cancer Surveillance Consortium. Zip code residential levels of airborne PAHs and metals (arsenic, cadmium, chromium, cobalt, lead, manganese, mercury, nickel, and selenium) were assessed using the 2011 EPA National Air Toxics Assessment. Breast density was measured using the Breast Imaging–Reporting and Data System (BI-RADS) lexicon. Logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CI) for the individual air toxics and dense breasts (BI-RADS 3 or 4). Weighted quantile sum (WQS) regression was used to model the association between the air toxic mixture and density.

Results

Higher residential levels of arsenic, cobalt, lead, manganese, nickel, or PAHs were individually associated with breast density. Comparing the highest to the lowest quartile, higher odds of having dense breasts were observed for cobalt (OR = 1.60, 95% CI 1.56–1.64) and lead (OR = 1.56, 95% CI 1.52–1.64). Associations were stronger for premenopausal women. The WQS index was associated with density overall (OR = 1.22, 95% CI 1.20–1.24); the most heavily weighted air toxics were lead and cobalt.

Conclusions

In this first study to evaluate the association between air toxics and breast density, women living in areas with higher concentrations of lead and cobalt were more likely to have dense breasts.

Electronic supplementary material

The online version of this article (10.1186/s13058-019-1110-7) contains supplementary material, which is available to authorized users.

Breast Biopsy Intensity and Findings Following Breast Cancer Screening in Women With and Without a Personal History of Breast Cancer

IMPORTANCE

There is little evidence on population-based harms and benefits of screening breast magnetic resonance imaging (MRI) in women with and without a personal history of breast cancer (PHBC).

OBJECTIVE

To evaluate biopsy rates and yield in the 90 days following screening (mammography vs magnetic resonance imaging with or without mammography) among women with and without a PHBC.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of 6 Breast Cancer Surveillance Consortium (BCSC) registries. Population-based sample of 812 164 women undergoing screening, 2003 through 2013.

EXPOSURES

A total of 2 048 994 digital mammography and/or breast MRI screening episodes (mammogram alone vs MRI with or without screening mammogram within 30 days).

MAIN OUTCOMES AND MEASURES

Biopsy intensity (surgical greater than core greater than fine-needle aspiration) and yield (invasive cancer greater than ductal carcinoma in situ greater than high-risk benign greater than benign) within 90 days of a screening episode. We computed age-adjusted rates of biopsy intensity (per 1000 screening episodes) and biopsy yield (per 1000 screening episodes with biopsies). Outcomes were stratified by PHBC and by BCSC 5-year breast cancer risk among women without PHBC.

RESULTS

We included 101 103 and 1 939 455 mammogram screening episodes in women with and without PHBC, respectively; MRI screening episodes included 3763 with PHBC and 4673 without PHBC. Age-adjusted core and surgical biopsy rates (per 1000 episodes) doubled (57.1; 95% CI, 50.3-65.1) following MRI compared with mammography (23.6; 95% CI, 22.4-24.8) in women with PHBC. Differences (per 1000 episodes) were even larger in women without PHBC: 84.7 (95% CI, 75.9-94.9) following MRI and 14.9 (95% CI, 14.7-15.0) following mammography episodes. Ductal carcinoma in situ and invasive biopsy yield (per 1000 episodes) was significantly higher following mammography compared with MRI episodes in women with PHBC (mammography, 404.6; 95% CI, 381.2-428.8; MRI, 267.6; 95% CI, 208.0-337.8) and nonsignificantly higher, but in the same direction, in women without PHBC (mammography, 279.3; 95% CI, 274.2-284.4; MRI, 214.6; 95% CI, 158.7-280.8). High-risk benign lesions were more commonly identified following MRI regardless of PHBC. Higher biopsy rates and lower cancer yield following MRI were not explained by increasing age or higher 5-year breast cancer risk.

CONCLUSIONS AND RELEVANCE

Women with and without PHBC who undergo screening MRI experience higher biopsy rates coupled with significantly lower cancer yield findings following biopsy compared with screening mammography alone. Further work is needed to identify women who will benefit from screening MRI to ensure an acceptable benefit-to-harm ratio.

Cumulative Incidence of Non-breast Cancer Mortality and Breast Cancer Risk by Comorbidity and Age among Older Women Undergoing Screening Mammography: The Medicare-linked Breast Cancer Surveillance Consortium Cohort Study

Due to an increasing comorbidity burden with aging, the margin of benefit from screening mammography in women ages ≥65 is highly variable. This study examined 10-year cumulative risk of non-breast cancer mortality and breast cancer by comorbidity and age in a screening population. Methods: We used prospective cohort data from the Breast Cancer Surveillance Consortium (BCSC), which included 198,362 women ages ≥65 years who have undergone at least one screening mammogram. We calculated cumulative incidence of non-breast cancer mortality and risk of breast cancer 10 years following the screening mammogram for women ages 65–74, 75–84 and ≥85 years stratified by the Charlson Comorbidity Index (CCI scores 0, 1 and ≥2). Results: During a median follow-up time of 8.1 years (interquartile range, 4.6 to 10 years), 34,768 died from non-breast cancer causes and 6,327 women were diagnosed with invasive breast cancer of whom 359 died from breast cancer and 942 from non-breast cancer causes. The 10-year cumulative risk of invasive breast cancer following a screening mammogram did not significantly decrease with elevating CCI score and age for women ages 65–74 [CCI 0 = 4.0% (95% CI, 3.9%–4.1%) vs. CCI ≥2 = 3.8% (95% CI, 3.3%–4.3%)], ages 75–84 [CCI 0 = 3.7% (95% CI, 3.5%–3.9%) vs. CCI ≥ 2 = 3.4% (95% CI, 2.8%–4.0%)], and ages ≥85 [CCI 0 = 2.7%, (95% CI, 2.3%–3.2%) vs. CCI ≥ 2 = 2.5% (95% CI, 1.4%–3.6%)]. Cumulative risk of non-breast cancer mortality significantly increased with increasing CCI and age for women ages 65–74 [CCI 0 = 11% (95% CI, 10%–11%] vs. CCI ≥ 2 = 45% (95% CI, [43%–46%)], ages 75–84 [CCI 0 = 29% (95% CI, 29%–30%) vs. CCI ≥2 = 62% (95% CI, 60%–63%)], and ages ≥85 [CCI 0 = 59%, (95% CI, 57%–60%) vs. CCI ≥2 = 84% (95% CI, 81%–86%)]. Conclusion: Risk of non-breast cancer mortality was high and significantly increased with rising comorbidity burden and age whereas breast cancer risk was low and non-significantly decreased with both. These results suggest that women with a CCI score of ≥2 or ages ≥75 years may experience minimal benefit from continuing routine screening mammography. Future research is needed to delineate the specific benefits and harms of screening mammography in subsets of older women defined by age and comorbidity burden.

Underutilization of Supplemental Magnetic Resonance Imaging Screening Among Patients at High Breast Cancer Risk

BACKGROUND

Women at high lifetime breast cancer risk may benefit from supplemental breast magnetic resonance imaging (MRI) screening, in addition to routine mammography screening for earlier cancer detection.

MATERIALS AND METHODS

We performed a cross-sectional study of 422,406 women undergoing routine mammography screening across 86 Breast Cancer Surveillance Consortium (BCSC) facilities during calendar year 2012. We determined availability and use of on-site screening breast MRI services based on woman-level characteristics, including >20% lifetime absolute risk using the National Cancer Institute risk assessment tool. Multivariate analyses were performed to determine sociodemographic characteristics associated with on-site screening MRI use.

RESULTS

Overall, 43.9% (2403/5468) of women at high lifetime risk attended a facility with on-site breast MRI screening availability. However, only 6.6% (158/2403) of high-risk women obtained breast MRI screening within a 2-year window of their screening mammogram. Patient factors associated with on-site MRI screening use included younger (<40 years) age (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.34-4.21), family history (OR = 1.72, 95% CI: 1.13-2.63), prior breast biopsy (OR = 2.09, 95% CI: 1.22-3.58), and postsecondary education (OR = 2.22, 95% CI: 1.04-4.74).

CONCLUSIONS

While nearly half of women at high lifetime breast cancer risk undergo routine screening mammography at a facility with on-site breast MRI availability, supplemental breast MRI remains widely underutilized among those who may benefit from earlier cancer detection. Future studies should evaluate whether other enabling factors such as formal risk assessment and patient awareness of high lifetime breast cancer risk can mitigate the underutilization of supplemental screening breast MRI.

Multilevel factors associated with long-term adherence to screening mammography in older women in the U.S

In the U.S., guidelines recommend that women continue mammography screening until at least age 74, but recent evidence suggests declining screening rates in older women. We estimated adherence to screening mammography and multilevel factors associated with adherence in a longitudinal cohort of older women. Women aged 66-75years receiving screening mammography within the Breast Cancer Surveillance Consortium were linked to Medicare claims (2005-2010). Claims data identified baseline adherence, defined as receiving subsequent mammography within approximately 2years, and length of time adherent to guidelines. Characteristics associated with adherence were investigated using logistic and Cox proportional hazards regression models. Analyses were stratified by age to investigate variation in relationships between patient factors and adherence. Among 49,775 women, 89% were adherent at baseline. Among women 66-70years, those with less than a high school education were more likely to be non-adherent at baseline (odds ratio [OR] 1.96; 95% confidence interval [CI] 1.65-2.33) and remain adherent for less time (hazard ratio [HR] 1.41; 95% CI 1.11-1.80) compared to women with a college degree. Women with ≥1 versus no Charlson co-morbidities were more likely to be non-adherent at baseline (OR 1.46; 95% CI 1.31-1.62) and remain adherent for less time (HR 1.44; 95% CI 1.24-1.66). Women aged 71-75 had lower adherence overall, but factors associated with non-adherence were similar. In summary, adherence to guidelines is high among Medicare-enrolled women in the U.S. receiving screening mammography. Efforts are needed to ensure that vulnerable populations attain these same high levels of adherence.

Body size measures, hemostatic and inflammatory markers and risk of venous thrombosis: The Longitudinal Investigation of Thromboembolism Etiology

OBJECTIVE

Obesity is an important venous thrombosis (VT) risk factor but the reasons for this are unclear.

MATERIALS AND METHODS

In a cohort of 20,914 individuals aged 45 and older without prior VT, we calculated the relative risk (RR) of VT over 12.6years follow-up according to baseline body size measures, and studied whether associations were mediated by biomarkers of hemostasis and inflammation that are related to adiposity.

RESULTS

Greater levels of all body size measures (weight, height, waist, hip circumference, calf circumference, body-mass index, waist-hip ratio, fat mass and fat-free mass) were associated with increased risk of VT, with 4th versus 1st quartile RRs of 1.5-3.0. There were no multiplicative interactions of biomarkers with obesity status. Adjustment for biomarkers associated with VT risk and body size (factors VII and VIII, von Willebrand factor, partial thromboplastin time, D-dimer, C-reactive protein and factor XI) only marginally lowered, or did not impact, the RRs associated with body size measures.

CONCLUSIONS

Greater body size, by multiple measures, is a risk factor for VT. Associations were not mediated by circulating levels of studied biomarkers suggesting that body size relates to VT because of physical factors associated with blood flow, not the hypercoagulability or inflammation associated with adiposity.

Factors Associated With Rates of False-Positive and False-Negative Results From Digital Mammography Screening: An Analysis of Registry Data

BACKGROUND

Women screened with digital mammography may receive false-positive and false-negative results and subsequent imaging and biopsies. How these outcomes vary by age, time since the last screening, and individual risk factors is unclear.

OBJECTIVE

To determine factors associated with false-positive and false-negative digital mammography results, additional imaging, and biopsies among a general population of women screened for breast cancer.

DESIGN

Analysis of registry data.

SETTING

Participating facilities at 5 U.S. Breast Cancer Surveillance Consortium breast imaging registries with linkages to pathology databases and tumor registries.

PATIENTS

405,191 women aged 40 to 89 years screened with digital mammography between 2003 and 2011. A total of 2963 were diagnosed with invasive cancer or ductal carcinoma in situ within 12 months of screening.

MEASUREMENTS

Rates of false-positive and false-negative results and recommendations for additional imaging and biopsies from a single screening round; comparisons by age, time since the last screening, and risk factors.

RESULTS

Rates of false-positive results (121.2 per 1000 women [95% CI, 105.6 to 138.7]) and recommendations for additional imaging (124.9 per 1000 women [CI, 109.3 to 142.3]) were highest among women aged 40 to 49 years and decreased with increasing age. Rates of false-negative results (1.0 to 1.5 per 1000 women) and recommendations for biopsy (15.6 to 17.5 per 1000 women) did not differ greatly by age. Results did not differ by time since the last screening. False-positive rates were higher for women with risk factors, particularly family history of breast cancer; previous benign breast biopsy result; high breast density; and, for younger women, low body mass index.

LIMITATIONS

Confounding by variation in patient-level characteristics and outcomes across registries and regions may have been present. Some factors, such as numbers of first- and second-degree relatives with breast cancer and diagnoses associated with previous benign biopsy results, were not examined.

CONCLUSION

False-positive mammography results and additional imaging are common, particularly for younger women and those with risk factors, whereas biopsies occur less often. Rates of false-negative results are low.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and National Cancer Institute.

Comparing sensitivity and specificity of screening mammography in the United States and Denmark

Delivery of screening mammography differs substantially between the United States (US) and Denmark. We evaluated whether there are differences in screening sensitivity and specificity. We included screens from women screened at age 50-69 years during 1996-2008/2009 in the US Breast Cancer Surveillance Consortium (BCSC) (n = 2,872,791), and from two population-based mammography screening programs in Denmark (Copenhagen, n = 148,156 and Funen, n = 275,553). Women were followed-up for 1 year. For initial screens, recall rate was significantly higher in BCSC (17.6%) than in Copenhagen (4.3%) and Funen (3.1%). Sensitivity was fairly similar in BCSC (91.8%) and Copenhagen (90.5%) and Funen (92.5%). At subsequent screens, recall rates were 8.8%, 1.8% and 1.4% in BCSC, Copenhagen and Funen, respectively. The BCSC sensitivity (82.3%) was lower compared with that in Copenhagen (88.9%) and Funen (86.9%), but when stratified by time since last screen, the sensitivity was similar. For both initial and subsequent screenings, the specificity of screening in BCSC (83.2% and 91.6%) was significantly lower than that in Copenhagen (96.6% and 98.8%) and Funen (97.9% and 99.2%). By taking time since last screen into account, it was found that American and Danish women had the same probability of having their asymptomatic cancers detected at screening. However, the majority of women free of asymptomatic cancers experienced more harms in terms of false-positive findings in the US than in Denmark.

Performance of digital screening mammography among older women in the United States

BACKGROUND

Although healthy women aged 65 years have a life expectancy of 20 years, there is a paucity of data on the performance of digital screening mammography among these women. The authors examined the performance and outcomes of digital screening mammography among a national group of women aged ≥65 years.

METHODS

From Breast Cancer Surveillance Consortium data for the years 2005 to 2011, the authors included 296,496 full-field digital screening mammograms among 133,042 women ages ≥65 years without a history of breast cancer. Sensitivity, specificity, positive predictive value (PPV1 ), recall rates, and 95% confidence intervals (95% CIs) were calculated across the spectrum of age and breast density. Multivariate logistic regression was used to compare mammography accuracy, cancer-detection rates (CDRs), and tumor characteristics by age and breast density.

RESULTS

Multivariate analyses revealed a significant decrease in the recall rate with age (P for linear trend [Ptrend ] < .001) and significant increases in specificity, PPV1 , and CDR with age (Ptrend  < .001, Ptrend  < .001, and Ptrend  = .01, respectively). Sensitivity did not vary significantly with age. Among women with cancer, the proportion with invasive disease increased with age from 76% at ages 65 to 74 years to 81% at ages ≥80 years. There was a higher proportion of late stage cancers and positive lymph nodes among women ages 65 to 74 years compared with women in the older age groups.

CONCLUSIONS

The specificity, PPV1 , recall rate, and CDR of digital screening mammography improved with increased age. In addition, as age increased, the proportion of women with invasive versus ductal carcinoma in situ rose, whereas the proportion of women with positive lymph nodes decreased.

Breast cancer detection with short-interval follow-up compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy results

PURPOSE

To compare the cancer detection rate and stage after benign stereotactic or ultrasonography (US)-guided core breast biopsy between patients with short-interval follow-up (SIFU) and those who return to annual screening.

MATERIALS AND METHODS

The Breast Cancer Surveillance Consortium (BCSC) registry and the BCSC Statistical Coordinating Center received institutional review board approval for active and passive consent processes and a waiver of consent. All procedures were HIPAA compliant. BCSC data for 1994-2010 were used to compare ipsilateral breast cancer detection rates and tumor characteristics for diagnoses within 3 months after SIFU (3-8 months) versus return to annual screening (RTAS) mammography (9-18 months) after receiving a benign pathology result from image-guided breast biopsy.

RESULTS

In total, 17 631 biopsies with benign findings were identified with SIFU or RTAS imaging. In the SIFU group, 27 ipsilateral breast cancers were diagnosed in 10 715 mammographic examinations (2.5 cancers per 1000 examinations) compared with 16 cancers in 6916 mammographic examinations in the RTAS group (2.3 cancers per 1000 examinations) (P = .88). Sixteen cancers after SIFU (59%; 95% confidence interval [CI]: 39%, 78%) were invasive versus 12 after RTAS (75%; 95% CI: 48%, 93%). The invasive cancer rate was 1.5 per 1000 examinations after SIFU (95% CI: 0.9, 2.4) and 1.7 per 1000 examinations (95% CI: 0.9, 3.0) after RTAS (P = .70). Among invasive cancers, 25% were late stage (stage 2B, 3, or 4) in the SIFU group (95% CI: 7%, 52%) versus 27% in the RTAS group (95% CI: 6%, 61%). Positive lymph nodes were found in seven (44%; 95% CI: 20%, 70%) invasive cancers after SIFU and in three (25%; 95% CI: 5%, 57%) invasive cancers after RTAS.

CONCLUSION

Similar rates of cancer detection were found between SIFU and RTAS after benign breast biopsy with no significant differences in stage, tumor size, or nodal status, although the present study was limited by sample size. These findings suggest that patients with benign radiologic-pathologic-concordant percutaneous breast biopsy results could return to annual screening.

Investigation of mammographic breast density as a risk factor for ovarian cancer

BACKGROUND

Endogenous hormones and growth factors that increase mammographic breast density could increase ovarian cancer risk. We examined whether high breast density is associated with ovarian cancer risk.

METHODS

We conducted a cohort study of 724,603 women aged 40 to 79 years with 2,506,732 mammograms participating in the Breast Cancer Surveillance Consortium from 1995 to 2009. Incident epithelial ovarian cancer was diagnosed in 1373 women. We used partly conditional Cox regression to estimate the association between breast density and 5-year risk of incident epithelial ovarian cancer overall and stratified by 10-year age group. All statistical tests were two-sided.

RESULTS

Compared with women with scattered fibroglandular densities, women with heterogeneously dense and extremely dense breast tissue had 20% and 18% increased 5-year risk of incident epithelial ovarian cancer (hazard ratio [HR] = 1.20, 95% confidence interval [CI] = 1.06 to 1.36; HR = 1.18, 95% CI = 0.93 to 1.50, respectively; P(trend) = .01). Among women aged 50 to 59 years, we observed a trend in elevated risk associated with increased breast density (P(trend) = .02); women with heterogeneously and extremely dense breast tissue had 30% (HR = 1.30; 95% CI = 1.03 to 1.64) and 65% (HR = 1.65; 95% CI = 1.12 to 2.44) increased risk, respectively, compared with women with scattered fibroglandular densities. The pattern was similar but not statistically significant at age 40 to 49 years. There were no consistent patterns of breast density and ovarian cancer risk at age 60 to 79 years.

CONCLUSIONS

Dense breast tissue was associated with a modest increase in 5-year ovarian cancer risk in women aged 50 to 59 years but was not associated with ovarian cancer at ages 40 to 49 or 60 to 79 years.

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.

Mammographic screening interval in relation to tumor characteristics and false-positive risk by race/ethnicity and age

BACKGROUND

Biennial screening mammography retains most of the benefits of annual breast cancer screening with reduced harms. Whether screening guidelines based on race/ethnicity and age would be more effective than age-based guidelines is unknown.

METHODS

Mammography data from the Breast Cancer Surveillance Consortium were linked to pathology and tumor databases. The authors identified women aged 40 to 74 years who underwent annual, biennial, or triennial screening mammography between 1994 and 2008. Logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (95% CI) of adverse tumor characteristics among 14,396 incident breast cancer cases and 10-year cumulative risks of false-positive recall and biopsy recommendation among 1,276,312 noncases.

RESULTS

No increased risk of adverse tumor characteristics associated with biennial versus annual screening were noted in white women, black women, Hispanic women aged 40 to 49 years, or Asian women aged 50 to 74 years. Hispanic women aged 50 to 74 years who screened biennially versus annually were found to have an increased risk of late-stage disease (OR, 1.6; 95% CI, 1.0-2.5) and large tumors (OR, 1.6; 95% CI, 1.1-2.4). Asian women aged 40 to 49 years who underwent biennial screening had an elevated risk of positive lymph nodes (OR, 3.1; 95% CI, 1.3-7.1). No elevated risks were associated with triennial versus biennial screening. Cumulative false-positive risks decreased markedly with a longer screening interval.

CONCLUSIONS

The authors found limited evidence of elevated risks of adverse tumor characteristics with biennial versus annual screening, whereas cumulative false-positive risks were lower. However, elevated risks of late-stage disease in Hispanic women and lymph node-positive disease in younger Asian women who screened less often than annually warrant consideration and replication.

Benign breast disease, mammographic breast density, and the risk of breast cancer

BACKGROUND

Benign breast disease and high breast density are prevalent, strong risk factors for breast cancer. Women with both risk factors may be at very high risk.

METHODS

We included 42818 women participating in the Breast Cancer Surveillance Consortium who had no prior diagnosis of breast cancer and had undergone at least one benign breast biopsy and mammogram; 1359 women developed incident breast cancer in 6.1 years of follow-up (78.1% invasive, 21.9% ductal carcinoma in situ). We calculated hazard ratios (HRs) using Cox regression analysis. The referent group was women with nonproliferative changes and average density. All P values are two-sided.

RESULTS

Benign breast disease and breast density were independently associated with breast cancer. The combination of atypical hyperplasia and very high density was uncommon (0.6% of biopsies) but was associated with the highest risk for breast cancer (HR = 5.34; 95% confidence interval [CI] = 3.52 to 8.09, P < .001). Proliferative disease without atypia (25.6% of biopsies) was associated with elevated risk that varied little across levels of density: average (HR = 1.37; 95% CI = 1.11 to 1.69, P = .003), high (HR = 2.02; 95% CI = 1.68 to 2.44, P < .001), or very high (HR = 2.05; 95% CI = 1.54 to 2.72, P < .001). Low breast density (4.5% of biopsies) was associated with low risk (HRs <1) for all benign pathology diagnoses.

CONCLUSIONS

Women with high breast density and proliferative benign breast disease are at very high risk for future breast cancer. Women with low breast density are at low risk, regardless of their benign pathologic diagnosis.

Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy

IMPORTANCE

Controversy exists about the frequency women should undergo screening mammography and whether screening interval should vary according to risk factors beyond age.

OBJECTIVE

To compare the benefits and harms of screening mammography frequencies according to age, breast density, and postmenopausal hormone therapy (HT) use.

DESIGN

Prospective cohort.

SETTING

Data collected January 1994 to December 2008 from mammography facilities in community practice that participate in the Breast Cancer Surveillance Consortium (BCSC) mammography registries.

PARTICIPANTS

Data were collected prospectively on 11,474 women with breast cancer and 922,624 without breast cancer who underwent mammography at facilities that participate in the BCSC.

MAIN OUTCOMES AND MEASURES

We used logistic regression to calculate the odds of advanced stage (IIb, III, or IV) and large tumors (>20 mm in diameter) and 10-year cumulative probability of a false-positive mammography result by screening frequency, age, breast density, and HT use. The main predictor was screening mammography interval.

RESULTS

Mammography biennially vs annually for women aged 50 to 74 years does not increase risk of tumors with advanced stage or large size regardless of women's breast density or HT use. Among women aged 40 to 49 years with extremely dense breasts, biennial mammography vs annual is associated with increased risk of advanced-stage cancer (odds ratio [OR], 1.89; 95% CI, 1.06-3.39) and large tumors (OR, 2.39; 95% CI, 1.37-4.18). Cumulative probability of a false-positive mammography result was high among women undergoing annual mammography with extremely dense breasts who were either aged 40 to 49 years (65.5%) or used estrogen plus progestogen (65.8%) and was lower among women aged 50 to 74 years who underwent biennial or triennial mammography with scattered fibroglandular densities (30.7% and 21.9%, respectively) or fatty breasts (17.4% and 12.1%, respectively).

CONCLUSIONS AND RELEVANCE

Women aged 50 to 74 years, even those with high breast density or HT use, who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. When deciding whether to undergo mammography, women aged 40 to 49 years who have extremely dense breasts should be informed that annual mammography may minimize their risk of advanced-stage disease but the cumulative risk of false-positive results is high.

Screening outcomes in older US women undergoing multiple mammograms in community practice: does interval, age, or comorbidity score affect tumor characteristics or false positive rates?

Background Uncertainty exists about the appropriate use of screening mammography among older women because comorbid illnesses may diminish the benefit of screening. We examined the risk of adverse tumor characteristics and false positive rates according to screening interval, age, and comorbidity. Methods From January 1999 to December 2006, data were collected prospectively on 2993 older women with breast cancer and 137 949 older women without breast cancer who underwent mammography at facilities that participated in a data linkage between the Breast Cancer Surveillance Consortium and Medicare claims. Women were aged 66 to 89 years at study entry to allow for measurement of 1 year of preexisting illnesses. We used logistic regression analyses to calculate the odds of advanced (IIb, III, IV) stage, large (>20 millimeters) tumors, and 10-year cumulative probability of false-positive mammography by screening frequency (1 vs 2 years), age, and comorbidity score. The comorbidity score was derived using the Klabunde approximation of the Charlson score. All statistical tests were two-sided. Results Adverse tumor characteristics did not differ statistically significantly by comorbidity, age, or interval. Cumulative probability of a false-positive mammography result was higher among annual screeners than biennial screeners irrespective of comorbidity: 48.0% (95% confidence interval [CI] = 46.1% to 49.9%) of annual screeners aged 66 to 74 years had a false-positive result compared with 29.0% (95% CI = 28.1% to 29.9%) of biennial screeners. Conclusion Women aged 66 to 89 years who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of a false-positive recommendation than annual screeners, regardless of comorbidity.

Gender differences in tea, coffee, and cognitive decline in the elderly: the Cardiovascular Health Study

Although caffeine can enhance cognitive function acutely, long-term effects of consumption of caffeine-containing beverages such as tea and coffee are uncertain. Data on 4,809 participants aged 65 and older from the Cardiovascular Health Study (CHS) were used to examine the relationship of consumption of tea and coffee, assessed by food frequency questionnaire, on change in cognitive function by gender. Cognitive performance was assessed using serial Modified Mini-Mental State (3MS) examinations, which were administered annually up to 9 times. Linear mixed models were used to estimate rates of change in standard 3MS scores and scores modeled using item response theory (IRT). Models were adjusted for age, education, smoking status, clinic site, diabetes, hypertension, stroke, coronary heart disease, depression score, and APOE genotype. Over the median 7.9 years of follow-up, participants who did not consume tea or coffee declined annually an average of 1.30 points (women) and 1.11 points (men) on standard 3MS scores. In fully adjusted models using either standard or IRT 3MS scores, we found modestly reduced rates of cognitive decline for some, but not all, levels of coffee and tea consumption for women, with no consistent effect for men. Caffeine consumption was also associated with attenuation in cognitive decline in women. Dose-response relationships were not linear. These longitudinal analyses suggest a somewhat attenuated rate of cognitive decline among tea and coffee consumers compared to non-consumers in women but not in men. Whether this association is causal or due to unmeasured confounding requires further study.

Risk factors for breast cancer for women aged 40 to 49 years: a systematic review and meta-analysis

BACKGROUND

Identifying risk factors for breast cancer specific to women in their 40s could inform screening decisions.

PURPOSE

To determine what factors increase risk for breast cancer in women aged 40 to 49 years and the magnitude of risk for each factor.

DATA SOURCES

MEDLINE (January 1996 to the second week of November 2011), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (fourth quarter of 2011), Scopus, reference lists of published studies, and the Breast Cancer Surveillance Consortium.

STUDY SELECTION

English-language studies and systematic reviews of risk factors for breast cancer in women aged 40 to 49 years. Additional inclusion criteria were applied for each risk factor.

DATA EXTRACTION

Data on participants, study design, analysis, follow-up, and outcomes were abstracted. Study quality was rated by using established criteria, and only studies rated as good or fair were included. Results were summarized by using meta-analysis when sufficient studies were available or from the best evidence based on study quality, size, and applicability when meta-analysis was not possible. Data from the Breast Cancer Surveillance Consortium were analyzed with proportional hazards models by using partly conditional Cox regression. Reference groups for comparisons were set at U.S. population means.

DATA SYNTHESIS

Sixty-six studies provided data for estimates. Extremely dense breasts on mammography or first-degree relatives with breast cancer were associated with at least a 2-fold increase in risk for breast cancer. Prior breast biopsy, second-degree relatives with breast cancer, or heterogeneously dense breasts were associated with a 1.5- to 2.0-fold increased risk; current use of oral contraceptives, nulliparity, and age 30 years or older at first birth were associated with a 1.0- to 1.5-fold increased risk.

LIMITATIONS

Studies varied by measures, reference groups, and adjustment for confounders, which could bias combined estimates. Effects of multiple risk factors were not considered.

CONCLUSION

Extremely dense breasts and first-degree relatives with breast cancer were each associated with at least a 2-fold increase in risk for breast cancer in women aged 40 to 49 years. Identification of these risk factors may be useful for personalized mammography screening.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Breast density, body mass index, and risk of tumor marker-defined subtypes of breast cancer

PURPOSE

Breast density and body mass index (BMI) are correlated attributes and are both potentially modifiable risk factors for breast cancer. However, relationships between these factors and risk of molecularly-defined subtypes of breast cancer have not been established.

METHODS

We used breast density and BMI data collected by the Breast Cancer Surveillance Consortium from 1,054,466 women ages 40 to 84 years receiving mammography, including 13,797 women subsequently diagnosed with breast cancer. Cases were classified into three groups on the basis of expression of the estrogen receptor (ER), progesterone receptor (PR), and HER2:1) ER-positive (ER+, n = 10,026), 2) HER2-expressing (ER-negative/PR-negative/HER2-positive, n = 308), or triple-negative (ER-negative/PR-negative/HER2-negative, n = 705). Using Cox regression, we evaluated subtype-specific associations with breast density and BMI.

RESULTS

Breast density was similarly positively associated with risk of all subtypes, especially among women ages 40 to 64 years. BMI was positively associated with risks of ER+ and triple-negative breast cancer in women ages 50 to 84 who were not users of hormone therapy.

CONCLUSIONS

Breast density is positively associated with breast cancer risk, regardless of disease subtype. Associations with BMI appear to vary more by breast cancer subtype. Additional studies are needed to confirm and further characterize risk factors for HER2-expressing and triple-negative breast cancer.

Hospitalization for infection and risk of acute ischemic stroke: the Cardiovascular Health Study

BACKGROUND AND PURPOSE

Little is known about the acute precipitants of ischemic stroke, although evidence suggests infections contribute to risk. We hypothesized that acute hospitalization for infection is associated with the short-term risk of stroke.

METHODS

The case-crossover design was used to compare hospitalization for infection during case periods (90, 30, or 14 days before an incident ischemic stroke) and control periods (equivalent time periods exactly 1 or 2 years before stroke) in the Cardiovascular Health Study, a population-based cohort of 5888 elderly participants from 4 US sites. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated by conditional logistic regression. Confirmatory analyses assessed hazard ratios of stroke from Cox regression models, with hospitalization for infection as a time-varying exposure.

RESULTS

During a median follow-up of 12.2 years, 669 incident ischemic strokes were observed in participants without a baseline history of stroke. Hospitalization for infection was more likely during case than control time periods; for 90 days before stroke, OR=3.4 (95% CI, 1.8 to 6.5). The point estimates of risks were higher when we examined shorter intervals: for 30 days, OR=7.3 (95% CI, 1.9 to 40.9), and for 14 days, OR=8.0 (95% CI, 1.7 to 77.3). In survival analyses, risk of stroke was associated with hospitalization for infection in the preceding 90 days, adjusted hazard ratio=2.4 (95% CI, 1.6 to 3.4).

CONCLUSIONS

Hospitalization for infection is associated with a short-term increased risk of stroke, with higher risks observed for shorter intervals preceding stroke.

The contribution of a 9p21.3 variant, a KIF6 variant, and C-reactive protein to predicting risk of myocardial infarction in a prospective study

Background

Genetic risk factors might improve prediction of coronary events. Several variants at chromosome 9p21.3 have been widely reported to be associated with coronary heart disease (CHD) in prospective and case-control studies. A variant of KIF6 (719Arg) has also been reported to be associated with increased risk of CHD in large prospective studies, but not in case-control studies. We asked whether the addition of genetic information (the 9p21.3 or KIF6 variants) or a well-established non-genetic risk factor (C-reactive protein [CRP]) can improve risk prediction by the Framingham Risk Score (FRS) in the Cardiovascular Health Study (CHS)--a prospective observational study of risk factors for cardiovascular disease among > 5,000 participants aged 65 or older.

Methods

Improvement of risk prediction was assessed by change in the area under the receiver-operator characteristic curve (AUC) and by net reclassification improvement (NRI).

Results

Among white participants the FRS was improved by addition of KIF6 719Arg carrier status among men as assessed by the AUC (from 0.581 to 0.596, P = 0.03) but not by NRI (NRI = 0.027, P = 0.32). Adding both CRP and 719Arg carrier status to the FRS improved risk prediction by the AUC (0.608, P = 0.02) and NRI (0.093, P = 0.008) in men, but not women (P ≥ 0.24).

Conclusions

While none of these risk markers individually or in combination improved risk prediction among women, a combination of KIF6 719Arg carrier status and CRP levels modestly improved risk prediction among white men; although this improvement is not significant after multiple-testing correction. These observations should be investigated in other prospective studies.

Association of coagulation-related and inflammation-related genes and factor VIIc levels with stroke: the Cardiovascular Health Study

BACKGROUND

Thrombosis and inflammation are critical in stroke etiology, but associations of coagulation and inflammation gene variants with stroke, and particularly factor VII levels, are inconclusive.

OBJECTIVES

To test the associations between 736 single-nucleotide polymorphisms (SNPs) between tagging haplotype patterns of 130 coagulation and inflammation genes, and stroke events, in the 5888 participants aged ≥ 65 years of the observational Cardiovascular Health Study cohort.

PATIENTS/METHODS

With 16 years of follow-up, age-adjusted and sex-adjusted Cox models were used to estimate associations of SNPs and FVIIc levels with future stroke.

RESULTS

Eight hundred and fifteen strokes occurred in 5255 genotyped participants without baseline stroke (748 ischemic strokes; 586 among whites). Among whites, six SNPs were associated with stroke, with a nominal P-value of < 0.01: rs6046 and rs3093261 (F7); rs4918851 and rs3781387 (HABP2); and rs3138055 (NFKB1A) and rs4648004 (NFKB1). Two of these SNPs were associated with FVIIc levels (units of percentage activity): rs6046 (β = -18.5, P = 2.38 × 10(-83)) and rs3093261 (β = 2.99, P = 3.93 × 10(-6)). After adjustment for age, sex, race, and cardiovascular risk factors, the association of FVIIc quintiles (Q) with stroke were as follows (hazard ratio; 95% confidence interval): Q1, reference; Q2, 1.4, 1.1-1.9); Q3, 1.1, 0.8-1.5); Q4, 1.5, 1.1-2.0); and Q5, 1.6, 1.2-2.2). Associations between SNPs and stroke were independent of FVIIc levels.

CONCLUSIONS

Variations in FVII-related genes and FVIIc levels were associated with risk of incident ischemic stroke in this elderly cohort, suggesting a potential causal role for FVII in stroke etiology.

Albuminuria and the risk of incident stroke and stroke types in older adults

BACKGROUND

The kidney biomarker that best reflects risk of stroke is unknown. We sought to evaluate the association of stroke with 3 kidney biomarkers: albuminuria, cystatin C, and glomerular filtration rate.

METHODS

These 3 biomarkers were determined in 3,287 participants without history of stroke from the Cardiovascular Health Study, a longitudinal cohort study of men and women age 65 years and older from 4 US communities. The biomarkers were albuminuria ascertained using urinary albumin-to-creatinine ratio (UACR) from morning spot urine, creatinine-based estimated glomerular filtration rate (eGFR), and cystatin C. Outcomes were incident stroke (any, ischemic, or hemorrhagic) during follow-up between 1996 and 2006.

RESULTS

A total of 390 participants had an incident stroke: 81% ischemic, 12% hemorrhagic, and 7% unclassified. In adjusted Cox regression models, UACR was more strongly related to any stroke, ischemic stroke, and hemorrhagic stroke than eGFR and cystatin C. The hazard ratio (HR) of any stroke comparing the top to bottom quintile of UACR was 2.10 (95% confidence interval [CI] 1.47-3.00), while HR for eGFR was 1.29 (95% CI 0.91-1.84) and for cystatin C was 1.22 (95% CI 0.85-1.74). When considering clinically relevant categories, elevated UACR was associated with increased hazard of any stroke and ischemic stroke regardless of eGFR or cystatin C categories.

CONCLUSIONS

UACR was the kidney biomarker most strongly associated with risk of incident stroke. Results in this elderly cohort may not be applicable to younger populations. These findings suggest that measures of glomerular filtration and permeability have differential effects on stroke risk.

Trajectories of neighborhood poverty and associations with subclinical atherosclerosis and associated risk factors: the multi-ethnic study of atherosclerosis

The authors used data from the Multi-Ethnic Study of Atherosclerosis and latent trajectory class modeling to determine patterns of neighborhood poverty over 20 years (1980-2000 residential history questionnaires were geocoded and linked to US Census data). Using these patterns, the authors examined 1) whether trajectories of neighborhood poverty were associated with differences in the amount of subclinical atherosclerosis (common carotid intimal-media thickness) and 2) associated risk factors (body mass index, hypertension, diabetes, current smoking) at baseline (January 2000-August 2002). The authors found evidence of 5 stable trajectory groups with differing levels of neighborhood poverty ( approximately 6%, 12%, 20%, 30%, and 45%) and 1 group with 29% poverty in 1980 and approximately 11% in 2000. Mostly for women, higher cumulative neighborhood poverty was generally significantly associated with worse cardiovascular outcomes. Trends generally persisted after adjustment for adulthood socioeconomic position and race/ethnicity, although they were no longer statistically significant. Among women who had moved during the 20 years, the long-term measure had stronger associations with outcomes (except smoking) than a single, contemporaneous measure. Results indicate that cumulative 20-year exposure to neighborhood poverty is associated with greater cardiovascular risk for women. In residentially mobile populations, single-point-in-time measures underestimate long-term effects.

Ginkgo biloba for preventing cognitive decline in older adults: a randomized trial

CONTEXT

The herbal product Ginkgo biloba is taken frequently with the intention of improving cognitive health in aging. However, evidence from adequately powered clinical trials is lacking regarding its effect on long-term cognitive functioning.

OBJECTIVE

To determine whether G. biloba slows the rates of global or domain-specific cognitive decline in older adults.

DESIGN, SETTING, AND PARTICIPANTS

The Ginkgo Evaluation of Memory (GEM) study, a randomized, double-blind, placebo-controlled clinical trial of 3069 community-dwelling participants aged 72 to 96 years, conducted in 6 academic medical centers in the United States between 2000 and 2008, with a median follow-up of 6.1 years.

INTERVENTION

Twice-daily dose of 120-mg extract of G. biloba (n = 1545) or identical-appearing placebo (n = 1524).

MAIN OUTCOME MEASURES

Rates of change over time in the Modified Mini-Mental State Examination (3MSE), in the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-Cog), and in neuropsychological domains of memory, attention, visual-spatial construction, language, and executive functions, based on sums of z scores of individual tests.

RESULTS

Annual rates of decline in z scores did not differ between G. biloba and placebo groups in any domains, including memory (0.043; 95% confidence interval [CI], 0.034-0.051 vs 0.041; 95% CI, 0.032-0.050), attention (0.043; 95% CI, 0.037-0.050 vs 0.048; 95% CI, 0.041-0.054), visuospatial abilities (0.107; 95% CI, 0.097-0.117 vs 0.118; 95% CI, 0.108-0.128), language (0.045; 95% CI, 0.037-0.054 vs 0.041; 95% CI, 0.033-0.048), and executive functions (0.092; 95% CI, 0.086-0.099 vs 0.089; 95% CI, 0.082-0.096). For the 3MSE and ADAS-Cog, rates of change varied by baseline cognitive status (mild cognitive impairment), but there were no differences in rates of change between treatment groups (for 3MSE, P = .71; for ADAS-Cog, P = .97). There was no significant effect modification of treatment on rate of decline by age, sex, race, education, APOE*E4 allele, or baseline mild cognitive impairment (P > .05).

CONCLUSION

Compared with placebo, the use of G. biloba, 120 mg twice daily, did not result in less cognitive decline in older adults with normal cognition or with mild cognitive impairment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00010803.

CRP gene variation and risk of community-acquired pneumonia

BACKGROUND AND OBJECTIVE

CRP has several potentially antibacterial effects, and variation in the CRP gene is known to influence CRP levels. Whether this variation influences risk of infection, and hence whether CRP has anti-infective activity in humans, is uncertain.

METHODS

We evaluated a series of haplotype-tagging single nucleotide polymorphisms among 5374 individuals in the Cardiovascular Health Study, a cohort of older adults from four communities, who were followed for community-acquired pneumonia for 12-13 years. Secondarily, we evaluated whether these polymorphisms varied among men in the Health Professionals Follow-up Study who self-reported pneumonia on biennial questionnaires.

RESULTS

There were 581 (507 white and 74 black) Cardiovascular Health Study participants with incident hospitalizations for pneumonia. No single nucleotide polymorphism or haplotypes were associated with risk among white Cardiovascular Health Study participants. Among black participants, the haplotype tagged by A790T was associated with lower risk of incident pneumonia (hazard ratio 0.5; 95% confidence interval: 0.3-0.9) and with higher CRP levels. In Health Professionals Follow-up Study, a separate haplotype was associated with less frequent self-reported pneumonia but not with circulating CRP levels.

CONCLUSIONS

Some genetic variants in CRP may be associated with risk of pneumonia, but haplotypes associated with risk are variably associated with baseline CRP levels. If CRP is a relevant component of innate immunity in humans, the inducibility or tissue-specificity of expression may be at least as important as chronic circulating levels.

Trajectories of dehydroepiandrosterone sulfate predict mortality in older adults: the cardiovascular health study

BACKGROUND

Dehydroepiandrosterone sulfate (DHEAS) has been proposed as an antiaging hormone, but its importance is unclear. Assessment of an individual's ability to maintain a DHEAS set point, through examination of multiple DHEAS levels over time, may provide insight into biologic aging.

METHODS

Using Cox proportional hazard models, we examined the relationship between DHEAS trajectory patterns and all-cause death in 950 individuals aged >or=65 years who were enrolled in the Cardiovascular Health Study and had DHEAS levels measured at three to six time points.

RESULTS

Overall, there was a slight decline in DHEAS levels over time (-0.013 microg/mL/y). Three trajectory components were examined: slope, variability, and baseline DHEAS. When examined individually, a steep decline or extreme variability in DHEAS levels was associated with higher mortality (p < .001 for each), whereas baseline DHEAS level was not. In adjusted models including all three components, steep decline (hazard ratio [HR] 1.75, confidence interval [CI] 1.32-2.33) and extreme variability (HR 1.89, CI 1.47-2.43) remained significant predictors of mortality, whereas baseline DHEAS level remained unpredictive of mortality (HR 0.97 per standard deviation, CI 0.88-1.07). The effect of trajectory pattern was more pronounced in men than in women. Individuals with both a steep decline and extreme variability in DHEAS levels had a significantly higher death rate than those with neither pattern (141 vs 48 deaths per 1,000 person-years, p < .001).

CONCLUSIONS

Our data show significant heterogeneity in the individual trajectories of DHEAS levels and suggest that these trajectories provide important biologic information about the rate of aging, whereas the DHEAS level itself does not.

Midlife and late-life obesity and the risk of dementia: cardiovascular health study

BACKGROUND

While high adiposity in middle age appears to be related to greater dementia risk, studies exploring this association in the elderly are conflicting.

OBJECTIVE

To evaluate associations between midlife and late-life obesity and risk of dementia.

DESIGN

Prospective study with mean follow-up of 5.4 years (1992-1994 through 1999).

SETTING

Community-dwelling sample in 4 US sites recruited from Medicare eligibility files.

PARTICIPANTS

A total of 2798 adults without dementia (mean age, 74.7 years; 59.1% women) participating in the Cardiovascular Health Study who underwent magnetic resonance imaging were measured for height and weight at baseline at age 65 years or older (late life), and self-reported weight at age 50 years (midlife). Body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) was calculated at both times.

MAIN OUTCOME MEASURES

Dementia, Alzheimer disease, and vascular dementia classified by a multidisciplinary committee using standardized criteria.

RESULTS

Classification resulted in 480 persons with incident dementia, 245 with Alzheimer disease (no vascular dementia), and 213 with vascular dementia (with or without Alzheimer disease). In evaluations of midlife obesity, an increased risk of dementia was found for obese (BMI >30) vs normal-weight (BMI 20-25) persons, adjusted for demographics (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.03-1.87) and for cardiovascular risk factors (1.36; 0.94-1.95). The risk estimates were reversed in assessments of late-life BMI. Underweight persons (BMI <20) had an increased risk of dementia (1.62; 1.02-2.64), whereas being overweight (BMI >25-30) was not associated (0.92; 0.72-1.18) and being obese reduced the risk of dementia (0.63; 0.44-0.91) compared with those with normal BMI.

CONCLUSION

These results help explain the "obesity paradox" as differences in dementia risk across time are consistent with physical changes in the trajectory toward disability.

Cross-sectional and longitudinal associations of neighborhood cohesion and stressors with depressive symptoms in the multiethnic study of atherosclerosis

PURPOSE

This study examined associations of neighborhood social cohesion, violence, and aesthetic quality with depressive symptoms among 2,619 healthy adults aged 45-84 years enrolled in the Multiethnic Study of Atherosclerosis.

METHODS

Neighborhood characteristics were estimated by surveying a separate sample of area residents. Measures of aesthetic environment, social cohesion, and violence were combined into a summary score with increasing scores indicating more favorable environments. Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression (CES-D) scale. Marginal maximum likelihood estimation was used to assess associations of neighborhood characteristics with CES-D score at baseline and with the odds of developing incident depression (CES-D score >/=16 or use of antidepressants) over a 4-5 year follow-up among persons with CES-D less than 16 at baseline. Models were adjusted for age, income, education, and race/ethnicity.

RESULTS

Lower levels of social cohesion and aesthetic quality and higher levels of violence were associated with higher mean CES-D scores in men and women (P for trend <0.01, adjusted mean difference in CES-D per 1 SD increase in summary score -1.01 [95% confidence interval = -1.85, -0.17] and -1.08 [95% confidence interval = -1.88, -0.28] in men and women, respectively). Associations of neighborhood characteristics with incident depression were in the expected direction for women but confidence intervals were wide (odds ratio of incident depression = 0.89 [0.63, 1.26]). No association was seen for men (odds ratio = 0.96 [0.74, 1.25]).

CONCLUSION

Neighborhood social cohesion, aesthetic quality, and violence are associated with the presence of depressive symptoms in residents.

Gene variants associated with ischemic stroke: the cardiovascular health study

BACKGROUND AND PURPOSE

The purpose of this study was to determine whether 74 single nucleotide polymorphisms (SNPs), which had been associated with coronary heart disease, are associated with incident ischemic stroke.

METHODS

Based on antecedent studies of coronary heart disease, we prespecified the risk allele for each of the 74 SNPs. We used Cox proportional hazards models that adjusted for traditional risk factors to estimate the associations of these SNPs with incident ischemic stroke during 14 years of follow-up in a population-based study of older adults: the Cardiovascular Health Study (CHS).

RESULTS

In white CHS participants, the prespecified risk alleles of 7 of the 74 SNPs (in HPS1, ITGAE, ABCG2, MYH15, FSTL4, CALM1, and BAT2) were nominally associated with increased risk of stroke (one-sided P<0.05, false discovery rate=0.42). In black participants, the prespecified risk alleles of 5 SNPs (in KRT4, LY6G5B, EDG1, DMXL2, and ABCG2) were nominally associated with stroke (one-sided P<0.05, false discovery rate=0.55). The Val12Met SNP in ABCG2 was associated with stroke in both white (hazard ratio, 1.46; 90% CI, 1.05 to 2.03) and black (hazard ratio, 3.59; 90% CI, 1.11 to 11.6) participants of CHS. Kaplan-Meier estimates of the 10-year cumulative incidence of stroke were greater among Val allele homozygotes than among Met allele carriers in both white (10% versus 6%) and black (12% versus 3%) participants of CHS.

CONCLUSIONS

The Val12Met SNP in ABCG2 (encoding a transporter of sterols and xenobiotics) was associated with incident ischemic stroke in white and black participants of CHS.

Lipoprotein-associated phospholipase A2 and risk of venous thrombosis in older adults

Lipoprotein-associated phospholipase A2 (Lp-PLA2) is an enzyme involved in inflammation and platelet function. Inherited deficiency and elevated levels are associated with atherosclerosis. Given potential common etiologies of atherosclerosis and venous thrombosis (VT), we hypothesized that low and high Lp-PLA2 would be associated with VT risk. Lp-PLA(2) mass and activity were measured in baseline samples of Cardiovascular Health Study participants (5,888 men and women age > or =65), excluding 354 reporting pre-baseline VT. The study endpoint was VT unrelated to cancer after 11.6 years follow-up. Hazard ratios were estimated using Cox proportional hazard models, adjusting for age, race, sex, and body-mass index. With 129 cases of VT, there was no association of Lp-PLA2 activity with risk. Adjusted hazard ratios were 1.19 (CI 0.62, 2.29) and 0.87 (CI 0.43, 1.76) for the lowest and highest decile, respectively, compared to the 10-25th percentile. Corresponding hazard ratios for Lp-PLA2 mass were 1.63 (CI 0.79, 3.34) and 1.33 (CI 0.61, 2.87). Results were robust to several definitions of low or high Lp-PLA2. While the association of Lp-PLA(2) levels with arterial disease events implies a role for this enzyme in atherogenesis, our findings suggest that it is not prothrombotic.

Biomarkers of Inflammation and MRI-Defined Small Vessel Disease of the Brain: The Cardiovascular Health Study

BACKGROUND AND PURPOSE

To clarify the role of inflammation in the pathogenesis of small vessel disease of the brain, we investigated the association between common variation in the C-reactive protein (CRP) and interleukin (IL)-6 genes, plasma CRP and IL6 levels, and presence of MRI-defined white matter lesions (WML) and brain infarcts (BI) in elderly participants of the Cardiovascular Health Study.

METHODS

Tag single nucleotide polymorphisms (SNPs) in the CRP and IL6 genes were selected from the SeattleSNPs database. In cross-sectional analyses, logistic regression models adjusting for known cardiovascular disease risk factors were constructed to assess the associations of plasma CRP and IL6 levels and common CRP and IL6 gene haplotypes with presence of WML or BI in Blacks (n=532) and Whites (n=2905).

RESULTS

Plasma IL6 and CRP levels were associated with presence of WML and BI in both races. In Whites, common haplotypes of the IL6 gene were significantly associated with WML and BI. The common haplotype tagged by the -174G/C promoter polymorphism was associated with an increased risk of WML (OR=1.14; 95% CI: [1.02; 1.28]). The common haplotype tagged by the -572G/C promoter polymorphism was associated with an increased risk of BI (OR=1.57; 95% CI: [1.15; 2.14]). Significant associations were lacking for WML or BI with IL6 gene variation in Blacks, or with CRP gene variation in either race.

CONCLUSIONS

This study provides evidence of a genetic basis underlying the relationship between plasma biomarkers of inflammation and small vessel disease of the brain. Further studies to elucidate the specific role of IL6 in disease pathogenesis are warranted.

Weight, mortality, years of healthy life, and active life expectancy in older adults

OBJECTIVES

To determine whether weight categories predict subsequent mortality and morbidity in older adults.

DESIGN

Multistate life tables, using data from the Cardiovascular Health Study, a longitudinal population-based cohort of older adults.

SETTING

Data were provided by community-dwelling seniors in four U.S. counties: Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Allegheny County, Pennsylvania.

PARTICIPANTS

Five thousand eight hundred eighty-eight adults aged 65 and older at baseline.

MEASUREMENTS

The age- and sex-specific probabilities of transition from one health state to another and from one weight category to another were estimated. From these probabilities, future life expectancy, years of healthy life, active life expectancy, and the number of years spent in each weight and health category after age 65 were estimated.

RESULTS

Women who are healthy and of normal weight at age 65 have a life expectancy of 22.1 years. Of that, they spend, on average, 9.6 years as overweight or obese and 5.3 years in fair or poor health. For both men and women, being underweight at age 65 was associated with worse outcomes than being normal weight, whereas being overweight or obese was rarely associated with worse outcomes than being normal weight and was sometimes associated with significantly better outcomes.

CONCLUSION

Similar to middle-aged populations, older adults are likely to be or to become overweight or obese, but higher weight is not associated with worse health in this age group. Thus, the number of older adults at a "healthy" weight may be much higher than currently believed.

Association of gene variants with incident myocardial infarction in the Cardiovascular Health Study

OBJECTIVE

We asked whether single nucleotide polymorphisms (SNPs) that had been nominally associated with cardiovascular disease in antecedent studies were also associated with cardiovascular disease in a population-based prospective study of 4522 individuals aged 65 or older.

METHODS AND RESULTS

Based on antecedent studies, we prespecified a risk allele and an inheritance model for each of 74 SNPs. We then tested the association of these SNPs with myocardial infarction (MI) in the Cardiovascular Health Study (CHS). The prespecified risk alleles of 8 SNPs were nominally associated (1-sided P<0.05) with increased risk of MI in White CHS participants. The false discovery rate for these 8 was 0.43, suggesting that about 4 of these 8 are likely to be true positives. The 4 of these 8 SNPs that had the strongest evidence for association with cardiovascular disease before testing in CHS (association in 3 antecedent studies) were in KIF6 (CHS HR=1.29; 90%CI 1.1 to 1.52), VAMP8 (HR=1.2; 90%CI 1.02 to 1.41), TAS2R50 (HR=1.13; 90%CI 1 to 1.27), and LPA (HR=1.62; 90%CI 1.09 to 2.42).

CONCLUSIONS

Although most of the SNPs investigated were not associated with MI in CHS, evidence from this investigation combined with previous studies suggests that 4 of these SNPs are likely associated with MI.