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Kelly K, Parente DJ. Critical gaps in knowledge and implementation of recommendations by the US Preventive Services Task Force. Prev Med Rep 2023; 32:102120. [PMID: 36816763 PMCID: PMC9929441 DOI: 10.1016/j.pmedr.2023.102120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 01/29/2023] Open
Abstract
Introduction The United States Preventive Services Task Force (USPSTF) has issued 31 recommendations applicable to non-pregnant adults. We hypothesized variability in knowledge and implementation of these recommendations among US family medicine resident physicians. Methods We performed two electronic surveys: a local survey, and then a nationally-representative, multicenter, survey. We evaluated self-reported knowledge and implementation of USPSTF recommendations related to non-pregnant adults. Results 84 family medicine residents from 40 residency programs across 25 states participated. Knowledge and implementation of recommendations varied widely. Most residents lacked knowledge relating to breast cancer chemoprophylaxis (9.9 % "known in detail" or "mostly know"), BRCA-related genetic counseling (BRCA-GC) referral (30 %), tuberculosis (TB) screening (41 %), and sexually transmitted infection (STI) counseling (45 %). There is virtually no implementation of recommendations for breast cancer chemoprophylaxis (90 % never/rarely implement). Many residents never/rarely implement recommendations for BRCA-GC referral (75 %), TB screening (62 %), and HIV pre-exposure prophylaxis (61 %). This remained true even for residents in their final year of training. Relative to their male counterparts, female physicians more frequently implemented recommendations for BRCA-GC referral (11 % vs 0 % always/often implement, p = 0.019), cervical cancer screening (100 % vs 83 %, p = 0.019), and folic acid supplementation (60 % vs 29 %, p = 0.007). Knowledge and implementation of recommendations were strongly related (β = 0.75, 95 % CI 0.50-1.00, p < 0.001, Spearman R2 = 0.56). Conclusion Critical gaps exist in resident knowledge and implementation of USPSTF recommendations. We discuss urgent implications for cancer prevention, public health, and health equity.
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Affiliation(s)
| | - Daniel J. Parente
- Corresponding author at: 3901 Rainbow Blvd., MS 4010, Kansas City, KS 66160, USA.
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2
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Zhang J, McGuinness JE, He X, Jones T, Silverman T, Guzman A, May BL, Kukafka R, Crew KD. Breast Cancer Risk and Screening Mammography Frequency Among Multiethnic Women. Am J Prev Med 2023; 64:51-60. [PMID: 36137818 DOI: 10.1016/j.amepre.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/19/2022] [Accepted: 08/02/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION In 2009, the U.S. Preventive Services Task Force updated recommended mammography screening frequency from annual to biennial for average-risk women aged 50-74 years. The association between estimated breast cancer risk and mammography screening frequency was evaluated. METHODS A single-center retrospective cohort study was conducted among racially/ethnically diverse women, aged 50-74 years, who underwent screening mammography from 2014 to 2018. Data on age, race/ethnicity, first-degree family history of breast cancer, previous benign breast biopsies, and mammographic density were extracted from the electronic health record to calculate Breast Cancer Surveillance Consortium 5-year risk of invasive breast cancer, with a 5-year risk ≥1.67% defined as high risk. Multivariable analyses were conducted to determine the association between breast cancer risk factors and mammography screening frequency (annual versus biennial). Data were analyzed from 2020 to 2022. RESULTS Among 12,929 women with a mean age of 61±6.9 years, 82.7% underwent annual screening mammography, and 30.7% met high-risk criteria for breast cancer. Hispanic women were more likely to screen annually than non-Hispanic Whites (85.0% vs 79.8%, respectively), despite fewer meeting high-risk criteria. In multivariable analyses adjusting for breast cancer risk factors, high- versus low/average-risk women (OR=1.17; 95% CI=1.04, 1.32) and Hispanic versus non-Hispanic White women (OR=1.46; 95% CI=1.29, 1.65) were more likely to undergo annual mammography. CONCLUSIONS A majority of women continue to undergo annual screening mammography despite only a minority meeting high-risk criteria, and Hispanic women were more likely to screen annually despite lower overall breast cancer risk. Future studies should focus on the implementation of risk-stratified breast cancer screening strategies.
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Affiliation(s)
- Jingwen Zhang
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Julia E McGuinness
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York.
| | - Xin He
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Tarsha Jones
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
| | - Thomas Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ashlee Guzman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Benjamin L May
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York; Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Katherine D Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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3
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McGuinness JE, Bhatkhande G, Amenta J, Silverman T, Mata J, Guzman A, He T, Dimond J, Jones T, Kukafka R, Crew KD. Strategies to Identify and Recruit Women at High Risk for Breast Cancer to a Randomized Controlled Trial of Web-based Decision Support Tools. Cancer Prev Res (Phila) 2022; 15:399-406. [PMID: 35412592 DOI: 10.1158/1940-6207.capr-21-0593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/03/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022]
Abstract
We evaluated strategies to identify and recruit a racially/ethnically diverse cohort of women at high-risk for breast cancer to a randomized controlled trial (RCT). We enrolled 300 high-risk women and 50 healthcare providers to a RCT of standard educational materials alone or in combination with web-based decision support tools. We implemented five strategies to identify high-risk women: (i) recruitment among patients previously enrolled in a study evaluating breast cancer risk; (ii) automated breast cancer risk calculation using information extracted from the electronic health record (EHR); (iii) identification of women with atypical hyperplasia or lobular carcinoma in situ (LCIS) using International Classification of Diseases (ICD)-9/10 diagnostic codes; (iv) clinical encounters with enrolled healthcare providers; (v) recruitment flyers/online resources. Breast cancer risk was calculated using either the Gail or Breast Cancer Surveillance Consortium (BCSC) models. We identified 6,229 high-risk women and contacted 3,459 (56%), of whom 17.2% were identified from prior study cohort, 37.5% through EHR risk information, 14.8% with atypical hyperplasia/LCIS, 29.0% by clinical encounters, and 1.5% through recruitment flyers. Women from the different recruitment sources varied by age and 5-year invasive breast cancer risk. Of 300 enrolled high-risk women, 44.7% came from clinical encounters and 27.3% from prior study cohort. Comparing enrolled with not-enrolled participants, there were significant differences in mean age (57.2 vs. 59.1 years), proportion of non-Whites (41.5% vs. 54.8%), and mean 5-year breast cancer risk (3.0% vs. 2.3%). We identified and successfully recruited diverse high-risk women from multiple sources. These strategies may be implemented in future breast cancer chemoprevention trials. PREVENTION RELEVANCE We describe five strategies to identify and successfully recruit a large cohort of racially/ethnically diverse high-risk women from multiple sources to a randomized controlled trial evaluating interventions to increase chemoprevention uptake. Findings could inform recruitment efforts for future breast cancer prevention trials to increase recruitment yield of high-risk women.
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Affiliation(s)
- Julia E McGuinness
- Division of Hematology and Oncology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Gauri Bhatkhande
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Jacquelyn Amenta
- Division of Hematology and Oncology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Thomas Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Jennie Mata
- Division of Hematology and Oncology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Ashlee Guzman
- Division of Hematology and Oncology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Ting He
- Department of Biomedical Informatics and Data Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jill Dimond
- Sassafras Tech Collective, Ann Arbor, Michigan
| | - Tarsha Jones
- Christine E Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York.,Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Katherine D Crew
- Division of Hematology and Oncology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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4
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Bellhouse S, Hawkes RE, Howell SJ, Gorman L, French DP. Breast Cancer Risk Assessment and Primary Prevention Advice in Primary Care: A Systematic Review of Provider Attitudes and Routine Behaviours. Cancers (Basel) 2021; 13:4150. [PMID: 34439302 PMCID: PMC8394615 DOI: 10.3390/cancers13164150] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/20/2022] Open
Abstract
Implementing risk-stratified breast cancer screening is being considered internationally. It has been suggested that primary care will need to take a role in delivering this service, including risk assessment and provision of primary prevention advice. This systematic review aimed to assess the acceptability of these tasks to primary care providers. Five databases were searched up to July-August 2020, yielding 29 eligible studies, of which 27 were narratively synthesised. The review was pre-registered (PROSPERO: CRD42020197676). Primary care providers report frequently collecting breast cancer family history information, but rarely using quantitative tools integrating additional risk factors. Primary care providers reported high levels of discomfort and low confidence with respect to risk-reducing medications although very few reported doubts about the evidence base underpinning their use. Insufficient education/training and perceived discomfort conducting both tasks were notable barriers. Primary care providers are more likely to accept an increased role in breast cancer risk assessment than advising on risk-reducing medications. To realise the benefits of risk-based screening and prevention at a population level, primary care will need to proactively assess breast cancer risk and advise on risk-reducing medications. To facilitate this, adaptations to infrastructure such as integrated tools are necessary in addition to provision of education.
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Affiliation(s)
- Sarah Bellhouse
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (R.E.H.); (D.P.F.)
| | - Rhiannon E. Hawkes
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (R.E.H.); (D.P.F.)
| | - Sacha J. Howell
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK;
| | - Louise Gorman
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK;
| | - David P. French
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (R.E.H.); (D.P.F.)
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5
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Charaka H, Khalis M, Elfakir S, Huybrechts I, Khazraji YC, Lyoussi B, Soliman AS, Nejjari C. Knowledge, Perceptions, and Satisfaction of Moroccan Women Towards a New Breast Cancer Screening Program in Morocco. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2021; 36:657-663. [PMID: 31873856 DOI: 10.1007/s13187-019-01680-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The purpose of this study was to evaluate the knowledge, perceptions, and satisfaction of Moroccan women who resided the Meknes-Tafilalt region regarding a newly implemented breast cancer screening program in the region. The study was conducted in 24 randomly selected health centers from Meknes-Tafilalt region, Morocco. We targeted all women who resided in the region of the program and who met the inclusion criteria to participate in the screening program. Data was collected through a face-to-face questionnaire. In this study, 318 women were included. Results revealed moderate knowledge of breast cancer and the screening program. Most of the participants (90.5%) had heard of the breast cancer screening program. Only 33.6% of women declared that they are well informed about the program. Fear emotions related to breast cancer were reported by 93.1% of participants. About 82% of women accept to repeat a screening test every 2 years. Recommending the breast cancer screening test to their family and friends was stated by nearly 90% of women. The majority of women (94.9%) expressed their satisfaction about the screening test activities provided by health centers. Our results showed a moderate level of knowledge about breast cancer, a very positive attitude, and high overall satisfaction towards the breast cancer screening program in the Meknes-Tafilalt region. These results can guide development of appropriate breast cancer prevention strategies and sensibilisation campaigns in Morocco.
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Affiliation(s)
- Hafida Charaka
- Department of Research and Development, Hassan II University Hospital of Fez, Fez, Morocco
| | - Mohamed Khalis
- School of Public Health, Mohammed VI University of Health Sciences, Casablanca, Morocco.
| | - Samira Elfakir
- Department of Epidemiology and Public Health, Faculty of Medicine and Pharmacy, B.P. 1893, Km 2.2 Route Sidi Harazem, 30 000, Fez, Morocco
| | - Inge Huybrechts
- Nutrition and Metabolism Section, International Agency for Research on Cancer, Lyon, France
| | | | - Badiaa Lyoussi
- Laboratory of Physiology, Pharmacology and Environmental Health, Faculty of Science, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - Amr S Soliman
- Department of Community Health and Social Medicine, City University of New York, School of Medicine, New York, USA
| | - Chakib Nejjari
- International School of Public health, Mohammed VI University of Health Sciences, Casablanca, Morocco
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6
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Jahan N, Jones C, Rahman RL. Endocrine prevention of breast cancer. Mol Cell Endocrinol 2021; 530:111284. [PMID: 33882282 DOI: 10.1016/j.mce.2021.111284] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
Breast cancer (BC) is the most common non-cutaneous malignancy among women worldwide and is a significant cause of morbidity, mortality, and national health care expenditure. Unfortunately, with few exceptions like alcohol consumption, obesity, and physical activity, most BC risk factors are unmodifiable. Antiestrogen endocrine therapy, commonly known as BC chemoprevention, is an effective method of BC prevention. In multiple randomized trials, two selective estrogen receptor modulators - tamoxifen and raloxifene, and two aromatase inhibitors - exemestane and anastrozole have reduced BC incidence by 50%-65% in high-risk women. An estimated 15% of the US women between 35 and 79 years of age may qualify as high risk for BC, yet a small percentage of these women will ever have a formal BC risk assessment or a discussion of endocrine prevention options. The etiology of underutilization of endocrine prevention of BC is multifactorial - infrequent use of BC risk assessment tools in the primary care settings, insufficient knowledge of BC risk assessment tools and antiestrogen agents among primary care providers, concerns of side effects, inadequate time for counseling during primary care visit, and lack of predictive biomarkers may play significant roles. Many small studies incorporating risk assessment tools and decision-making aids showed minimal success in enhancing endocrine prevention. One critical factor for underutilization of endocrine prevention is low uptake of endocrine prevention by high-risk women even when appropriately recommended. Furthermore, adherence to BC endocrine prevention is unsatisfactorily low. Despite the current infrequent usage, endocrine prevention has the potential to reduce the public health burden of BC significantly. Innovative approaches like finding new agents, alternative dosing and schedule of currently available agents, transdermal medication delivery, increased public and professional awareness, and policymakers' commitments may bring the desired changes.
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Affiliation(s)
- Nusrat Jahan
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA.
| | - Catherine Jones
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
| | - Rakhshanda Layeequr Rahman
- Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
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7
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Jones S, Hogan B, Patel K, Ooi S, Turton P, Achuthan R, Kim B. Identification of factors that influence the decision to take chemoprevention in patients with a significant family history of breast cancer: results from a patient questionnaire survey. Breast Cancer Res Treat 2021; 187:207-213. [PMID: 33389407 DOI: 10.1007/s10549-020-06046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/02/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Chemoprevention reduces the risk of developing breast cancer in women with increased family history (FH) risk of breast cancer. However, chemoprevention uptake remains low and the reasons for this remain unclear. METHODS Patients with moderate- or high-risk FH of breast cancer were counselled about chemoprevention (n = 1620; September 2015 to July 2018) in breast clinics. A postal questionnaire survey was subsequently sent to these patients in order to explore the potential factors influencing their decision on chemoprevention uptake. RESULTS 518 patients (32%) completed the questionnaire survey; 75% were pre-menopausal and the majority had moderate as opposed to high-risk FH (87.5% vs. 12.5%). Breast cancer chemoprevention uptake rate was 10.8% (56/518). The identified incentives were more commonly stated for patients who took chemoprevention when compared to those who refused chemoprevention. The commonest incentives were breast cancer prevention (89.3% vs. 61.7%; p = 0.001), belief in the effectiveness of chemoprevention (76.8% vs. 63.4%; p = 0.048), and personal perception of breast cancer risk (67.9% vs. 45.5%; p = 0.002). Similarly, the identified barriers were more commonly stated for patients who refused chemoprevention when compared to those who took chemoprevention. The commonest barriers were side effects (79.4% vs. 55.4%; p = 0.001) and lack of information (53% vs. 28.6%; p = 0.001). CONCLUSION Despite its proven efficacy, chemoprevention uptake in patients with a significant FH of breast cancer remains low. We have identified important factors which influence the patient's decision making. Future clinic consultations should focus on exploring these factors to aid patient decision making.
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Affiliation(s)
- Stacey Jones
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
| | - Brian Hogan
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Kirtida Patel
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Shiwei Ooi
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Philip Turton
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Rajgopal Achuthan
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Baek Kim
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
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8
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Kaplan CP, Karliner L, Lee A, Livaudais-Toman J, Tice JA, Ozanne E. Acceptability of an mHealth breast cancer risk-reduction intervention promoting risk assessment, education, and discussion of risk in the primary care setting. Mhealth 2021; 7:54. [PMID: 34805385 PMCID: PMC8572750 DOI: 10.21037/mhealth-20-82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Breast cancer risk assessment tools and risk reduction strategies have advanced significantly over the past few decades but are underutilized in practice, due in part to limited acceptability by patients and physicians. We implemented a tablet-based Breast Cancer Risk Education Intervention (BreastCARE) tailored towards increasing patients' knowledge about their individual risk of developing breast cancer, increasing patient-physician discussion of breast cancer risk reduction practices, and increasing participation in recommended screening. METHODS We surveyed patients and physicians who received the BreastCARE intervention and analyzed their satisfaction and acceptability of the intervention. We compared patient satisfaction measures by race/ethnicity and used multivariable logistic regression models to examine the effect of race/ethnicity on measures of patient satisfaction with the tablet-based risk assessment and with the breast cancer risk report. We also compared measures of physician satisfaction by resident vs. attending/NP status. Finally, we identified patients' and physicians' suggestions for implementation. RESULTS Overall, both patients and physicians were highly satisfied with BreastCARE, with some variation by patient race/ethnicity and breast cancer risk status. The risk assessment tool and accompanying risk report helped transmit complex information in an efficient way. CONCLUSIONS Patient self-administered risk assessment with a health education component at the point of care is acceptable for both patients and physicians, and represents a novel approach to facilitating health promotion. This risk assessment tool should be made routine in primary care accompanied by results that are easy for the patient to understand and actionable for the clinician.
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Affiliation(s)
- Celia P. Kaplan
- Division of General Internal Medicine, University of California, San Francisco, CA, USA
- Multiethnic Health Equity Research Center, University of California, San Francisco, CA, USA
| | - Leah Karliner
- Division of General Internal Medicine, University of California, San Francisco, CA, USA
- Multiethnic Health Equity Research Center, University of California, San Francisco, CA, USA
| | - Andrew Lee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | | | - Jeffrey A. Tice
- Division of General Internal Medicine, University of California, San Francisco, CA, USA
| | - Elissa Ozanne
- Population Health Science, University of Utah School of Medicine, Salt Lake City, UT, USA
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9
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An Update on Screening and Prevention for Breast and Gynecological Cancers in Average and High Risk Individuals. Am J Med Sci 2020; 360:489-510. [DOI: 10.1016/j.amjms.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/22/2020] [Accepted: 06/03/2020] [Indexed: 11/21/2022]
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10
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Forrest LE, Forbes Shepherd R, Young MA, Keogh LA, James PA. Finding the five-year window: A qualitative study examining young women's decision-making and experience of using tamoxifen to reduce BRCA1/2 breast cancer risk. Psychooncology 2020; 30:159-166. [PMID: 33006205 DOI: 10.1002/pon.5556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Tamoxifen has been demonstrated to reduce breast cancer risk in high-risk, premenopausal women. Yet, very few young women with hereditary breast and ovarian cancer syndrome in Australia use tamoxifen, despite this being a less-invasive option compared to risk-reducing mastectomy. This study aims to examine young women's decision-making about and experience of taking tamoxifen to reduce their breast cancer risk. METHODS Young women with a BRCA1/2 mutation participated in semi-structured qualitative interviews, recruited mainly from a metropolitan clinical genetics service. Data were analysed using an inductive, team-based approach to thematic analysis. RESULTS Forty interviews with women aged 20-40 years with a BRCA1/2 mutation were conducted. Eleven women could not recall discussing tamoxifen with their healthcare provider or were too young to commence cancer risk management. Twenty-three women chose not to use tamoxifen because it is contraindicated for pregnancy or because it did not offer immediate and great enough risk reduction compared to bilateral risk-reducing mastectomy. Six women who were definite about not wanting to have children during the following 5-year period chose to use tamoxifen, and most experienced none or transient side effects. CONCLUSIONS Decision-making about tamoxifen was nuanced and informed by considerations characteristic of young adulthood, especially childbearing. Therefore, clinical discussions about tamoxifen with young women with a BRCA1/2 mutation must include consideration of their reproductive plans.
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Affiliation(s)
- Laura E Forrest
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Rowan Forbes Shepherd
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Mary-Anne Young
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Louise A Keogh
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Paul A James
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
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11
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Kandagatla P, Rizk NN, Dokic D, Kochkodan J, Estevez S, Yanik M, Goranta S, Huber‐Keener K, Jeruss JS. Patient and provider factors associated with the noninitiation of tamoxifen for young women at high‐risk for the development of breast cancer. Breast J 2020; 26:464-468. [PMID: 31538708 PMCID: PMC10167625 DOI: 10.1111/tbj.13528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 01/31/2023]
Abstract
We sought to identify factors associated with disparities in tamoxifen utilization among young patients at high-risk for developing breast cancer. We identified 67 premenopausal, high-risk women age 35-45, without surgical prophylaxis, who did not initiate tamoxifen. Factors associated with noninitiation were examined. About 37% of patients had no documented provider-based discussion regarding initiation. Type of high-risk diagnosis was the only factor associated with a provider-based discussion (P = .03). For patients offered tamoxifen, primary reasons for noninitiation were perceived minimal benefit (66.7%), fertility concerns (16.7%), and concerns about side effects (7.1%). Implementation of comprehensive educational strategies regarding the benefits of tamoxifen should be facilitated to improve initiation among young high-risk patients.
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Affiliation(s)
- Pridvi Kandagatla
- Surgery University of Michigan Ann Arbor Michigan
- Surgery Henry Ford Hospital Detroit Michigan
| | | | | | | | | | - Megan Yanik
- University of Michigan School of Medicine Ann Arbor Michigan
| | - Sowmya Goranta
- Internal Medicine Michigan State University Flint Michigan
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Ball S, Arevalo M, Juarez E, Payne JD, Jones C. Breast cancer chemoprevention: An update on current practice and opportunities for primary care physicians. Prev Med 2019; 129:105834. [PMID: 31494144 DOI: 10.1016/j.ypmed.2019.105834] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022]
Abstract
Several risk assessment models have been validated for the estimation of risk of breast cancer in women. Chemoprevention through hormonal therapy is an effective way to reduce the incidence of breast cancer in women with high risk. Selective estrogen receptor modulators, tamoxifen and raloxifene, are approved for this indication by the United States Food and Drug Administration, and aromatase inhibitors have also shown promise in recent studies. These medications are generally well tolerated, except for reported increased rates of fractures and venous thromboembolic events. Despite strong recommendations from several regulatory bodies, advocacy for chemoprevention has been inadequate in practice, more so among the primary care physicians. Studies have identified several barriers in physicians, patients, and the system, contributing to this problem. Lack of knowledge about risk assessment models and chemoprevention options preclude physicians from prescribing these medications with confidence. Fear of potential adverse events, confusion regarding the purpose of the therapy, and need for continued adherence for five years are among the principal reasons for reduced chemoprevention uptake and early discontinuation among patients. Multifaceted interventions directed at education and training of health care professionals, proper counseling of women at high risk, and promotion of the development of improved medications might help ensure better chemoprevention uptake in the target population.
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Affiliation(s)
- Somedeb Ball
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Meily Arevalo
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Edna Juarez
- Department of Internal Medicine, Memorial Medical Center, Las Cruces, NM, USA
| | - J Drew Payne
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Catherine Jones
- Division of Hematology and Medical Oncology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Crew KD, Silverman TB, Vanegas A, Trivedi MS, Dimond J, Mata J, Sin M, Jones T, Terry MB, Tsai WY, Kukafka R. Study protocol: Randomized controlled trial of web-based decision support tools for high-risk women and healthcare providers to increase breast cancer chemoprevention. Contemp Clin Trials Commun 2019; 16:100433. [PMID: 31497674 PMCID: PMC6722284 DOI: 10.1016/j.conctc.2019.100433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/11/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chemoprevention using selective estrogen receptor modulators and aromatase inhibitors has been shown to reduce invasive breast cancer incidence in high-risk women. Despite this evidence, few high-risk women who are eligible for chemoprevention utilize it as a risk-reducing strategy. Reasons for low uptake include inadequate knowledge about chemoprevention among patients and healthcare providers, concerns about side effects, time constraints during the clinical encounter, and competing comorbidities. METHODS/DESIGN We describe the study design of a randomized controlled trial examining the effect of two web-based decision support tools on chemoprevention decision antecedents and quality, referral for specialized counseling, and chemoprevention uptake among women at an increased risk for breast cancer. The trial is being conducted at a large, urban medical center. A total of 300 patients and 50 healthcare providers will be recruited and randomized to standard educational materials alone or in combination with the decision support tools. Patient reported outcomes will be assessed at baseline, one and six months after randomization, and after their clinic visit with their healthcare provider. DISCUSSION We are conducting this trial to provide evidence on how best to support personalized breast cancer risk assessment and informed and shared decision-making for chemoprevention. We propose to integrate the decision support tools into clinical workflow, which can potentially expand quality decision-making and chemoprevention uptake. TRIAL REGISTRATION NCT03069742.
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Affiliation(s)
- Katherine D. Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Thomas B. Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Alejandro Vanegas
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Meghna S. Trivedi
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Jill Dimond
- Sassafras Tech Collective, Ann Arbor, MI, USA
| | - Jennie Mata
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Margaret Sin
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Tarsha Jones
- Christine E Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Wei-Yann Tsai
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
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Ozanne E, Karliner LS, Tice JA, Haas JS, Livaudais-Toman J, Pasick RJ, Kaplan CP. An Intervention Tool to Increase Patient-Physician Discussion of Lifestyle Risk Factors for Breast Cancer. J Womens Health (Larchmt) 2019; 28:1468-1475. [PMID: 30222505 PMCID: PMC7207052 DOI: 10.1089/jwh.2018.7026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Risk assessment and discussion of lifestyle in primary care are crucial elements of breast cancer prevention and risk reduction. Our objective was to evaluate the impact of a breast cancer risk assessment and education tool on patient-physician discussion of behaviors and breast cancer risk. Materials and Methods: We conducted a randomized controlled trial with an ethnically and linguistically diverse sample of women, ages 40-74, from two primary care practices. Intervention participants completed a tablet computer-based Breast Cancer Risk Assessment and Education (BreastCARE) intervention in the waiting room before a scheduled visit. Both patients and physicians received an individualized risk report to discuss during the visit. Control patients underwent usual care. Telephone surveys assessed patient-physician discussion of weight, exercise, and alcohol use 1 week following the visit. Results: Among the 1235 participants, 27.7% (161/580) intervention and 22.3% (146/655) usual-care patients were high risk for breast cancer. Adjusting for clustering by physician, the intervention increased discussions of regular exercise (odds ratios [OR] = 1.94, 1.50-2.51) and weight (OR = 1.56, 1.23-1.96). There was no effect of the intervention on discussion of alcohol. Women with some college education were more likely to discuss their weight than those with high school education or less (OR = 1.75, 1.03-2.96). Similarly, non-English speakers were more likely to discuss their weight compared with English speakers (OR = 2.33, 1.04-5.22). Conclusions: BreastCARE is a feasible risk assessment tool that can successfully promote discussions about modifiable breast cancer risk factors between patients and primary care physicians.
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Affiliation(s)
- Elissa Ozanne
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Leah S. Karliner
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
- Multi-Ethnic Health Equity Research Center, University of California San Francisco, San Francisco, California
| | - Jeffrey A. Tice
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jennifer S. Haas
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jennifer Livaudais-Toman
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Rena J. Pasick
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Celia P. Kaplan
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
- Multi-Ethnic Health Equity Research Center, University of California San Francisco, San Francisco, California
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15
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Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Doubeni CA, Epling JW, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Tseng CW, Wong JB. Medication Use to Reduce Risk of Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2019; 322:857-867. [PMID: 31479144 DOI: 10.1001/jama.2019.11885] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Breast cancer is the most common nonskin cancer among women in the United States and the second leading cause of cancer death. The median age at diagnosis is 62 years, and an estimated 1 in 8 women will develop breast cancer at some point in their lifetime. African American women are more likely to die of breast cancer compared with women of other races. OBJECTIVE To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on medications for risk reduction of primary breast cancer. EVIDENCE REVIEW The USPSTF reviewed evidence on the accuracy of risk assessment methods to identify women who could benefit from risk-reducing medications for breast cancer, as well as evidence on the effectiveness, adverse effects, and subgroup variations of these medications. The USPSTF reviewed evidence from randomized trials, observational studies, and diagnostic accuracy studies of risk stratification models in women without preexisting breast cancer or ductal carcinoma in situ. FINDINGS The USPSTF found convincing evidence that risk assessment tools can predict the number of cases of breast cancer expected to develop in a population. However, these risk assessment tools perform modestly at best in discriminating between individual women who will or will not develop breast cancer. The USPSTF found convincing evidence that risk-reducing medications (tamoxifen, raloxifene, or aromatase inhibitors) provide at least a moderate benefit in reducing risk for invasive estrogen receptor-positive breast cancer in postmenopausal women at increased risk for breast cancer. The USPSTF found that the benefits of taking tamoxifen, raloxifene, and aromatase inhibitors to reduce risk for breast cancer are no greater than small in women not at increased risk for the disease. The USPSTF found convincing evidence that tamoxifen and raloxifene and adequate evidence that aromatase inhibitors are associated with small to moderate harms. Overall, the USPSTF determined that the net benefit of taking medications to reduce risk of breast cancer is larger in women who have a greater risk for developing breast cancer. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects. (B recommendation) The USPSTF recommends against the routine use of risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, in women who are not at increased risk for breast cancer. (D recommendation) This recommendation applies to asymptomatic women 35 years and older, including women with previous benign breast lesions on biopsy (such as atypical ductal or lobular hyperplasia and lobular carcinoma in situ). This recommendation does not apply to women who have a current or previous diagnosis of breast cancer or ductal carcinoma in situ.
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Affiliation(s)
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | - Karina W Davidson
- Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York
| | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | | | | | | | | | | | | | | | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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16
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Nelson HD, Fu R, Zakher B, Pappas M, McDonagh M. Medication Use for the Risk Reduction of Primary Breast Cancer in Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 322:868-886. [PMID: 31479143 DOI: 10.1001/jama.2019.5780] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Medications to reduce risk of breast cancer are effective for women at increased risk but also cause adverse effects. OBJECTIVE To update the 2013 US Preventive Services Task Force systematic review on medications to reduce risk of primary (first diagnosis) invasive breast cancer in women. DATA SOURCES Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, EMBASE, and MEDLINE (January 1, 2013, to February 1, 2019); manual review of reference lists. STUDY SELECTION Discriminatory accuracy studies of breast cancer risk assessment methods; randomized clinical trials of tamoxifen, raloxifene, and aromatase inhibitors for primary breast cancer prevention; studies of medication adverse effects. DATA EXTRACTION AND SYNTHESIS Investigators abstracted data on methods, participant characteristics, eligibility criteria, outcome ascertainment, and follow-up. Results of individual trials were combined by using a profile likelihood random-effects model. MAIN OUTCOMES AND MEASURES Probability of breast cancer in individuals (area under the receiver operating characteristic curve [AUC]); incidence of breast cancer, fractures, thromboembolic events, coronary heart disease events, stroke, endometrial cancer, and cataracts; and mortality. RESULTS A total of 46 studies (82 articles [>5 million participants]) were included. Eighteen risk assessment methods in 25 studies reported low accuracy in predicting the probability of breast cancer in individuals (AUC, 0.55-0.65). In placebo-controlled trials, tamoxifen (risk ratio [RR], 0.69 [95% CI, 0.59-0.84]; 4 trials [n = 28 421]), raloxifene (RR, 0.44 [95% CI, 0.24-0.80]; 2 trials [n = 17 806]), and the aromatase inhibitors exemestane and anastrozole (RR, 0.45 [95% CI, 0.26-0.70]; 2 trials [n = 8424]) were associated with a lower incidence of invasive breast cancer. Risk for invasive breast cancer was higher for raloxifene than tamoxifen in 1 trial after long-term follow-up (RR, 1.24 [95% CI, 1.05-1.47]; n = 19 747). Raloxifene was associated with lower risk for vertebral fractures (RR, 0.61 [95% CI, 0.53-0.73]; 2 trials [n = 16 929]) and tamoxifen was associated with lower risk for nonvertebral fractures (RR, 0.66 [95% CI, 0.45-0.98]; 1 trial [n = 13 388]) compared with placebo. Tamoxifen and raloxifene were associated with increased thromboembolic events compared with placebo; tamoxifen was associated with more events than raloxifene. Tamoxifen was associated with higher risk of endometrial cancer and cataracts compared with placebo. Symptomatic effects (eg, vasomotor, musculoskeletal) varied by medication. CONCLUSIONS AND RELEVANCE Tamoxifen, raloxifene, and aromatase inhibitors were associated with lower risk of primary invasive breast cancer in women but also were associated with adverse effects that differed between medications. Risk stratification methods to identify patients with increased breast cancer risk demonstrated low accuracy.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Bernadette Zakher
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Marian McDonagh
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
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17
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Xie Z, Wenger N, Stanton AL, Sepucha K, Kaplan C, Madlensky L, Elashoff D, Trent J, Petruse A, Johansen L, Layton T, Naeim A. Risk estimation, anxiety, and breast cancer worry in women at risk for breast cancer: A single-arm trial of personalized risk communication. Psychooncology 2019; 28:2226-2232. [PMID: 31461546 DOI: 10.1002/pon.5211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/17/2019] [Accepted: 08/21/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Elevated anxiety and breast cancer worry can impede mammographic screening and early breast cancer detection. Genetic advances and risk models make personalized breast cancer risk assessment and communication feasible, but it is unknown whether such communication of risk affects anxiety and disease-specific worry. We studied the effect of a personalized breast cancer screening intervention on risk perception, anxiety, and breast cancer worry. METHODS Women with a normal mammogram but elevated risk for breast cancer (N = 122) enrolled in the Athena Breast Health risk communication program were surveyed before and after receiving a letter conveying their breast cancer risk and a breast health genetic counselor consultation. We compared breast cancer risk estimation, anxiety, and breast cancer worry before and after risk communication and evaluated the relationship of anxiety and breast cancer worry to risk estimation accuracy. RESULTS Women substantially overestimated their lifetime breast cancer risk, and risk communication somewhat mitigated this overestimation (49% pre-intervention, 42% post-intervention, 13% Gail model risk estimate, P < .001). Both general anxiety and breast cancer worry declined significantly after risk communication in women with high baseline anxiety. Baseline anxiety and breast cancer worry were essentially unrelated to risk estimation accuracy, but risk communication increased alignment of worry with accuracy of risk assessment. CONCLUSIONS Personalized communication about breast cancer risk was associated with modestly improved risk estimation accuracy in women with relatively low anxiety and less anxiety and breast cancer worry in women with higher anxiety. We detected no negative consequences of informing women about elevated breast cancer risk.
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Affiliation(s)
- Zhuoer Xie
- Department of Hematology and Oncology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Neil Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Annette L Stanton
- Department of Psychology, University of California, Los Angeles, Los Angeles, California
| | - Karen Sepucha
- Health Decision Sciences Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Celia Kaplan
- General Internal Medicine, University of California, San Francisco, San Francisco, California
| | - Lisa Madlensky
- Division of Medical Genetics, University of California, San Diego, San Diego, California
| | - David Elashoff
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Jacqueline Trent
- Department of Hematology and Oncology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Antonia Petruse
- Department of Hematology and Oncology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Liliana Johansen
- Department of Hematology and Oncology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Tracy Layton
- Department of Biomedical Informatics, University of California, San Diego, San Diego, California
| | - Arash Naeim
- UCLA Center for SMART Health, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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18
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Implementing a Population-Based Breast Cancer Risk Assessment Program. Clin Breast Cancer 2019; 19:246-253.e2. [PMID: 31072694 DOI: 10.1016/j.clbc.2019.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 02/03/2019] [Accepted: 02/24/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Personalized breast cancer risk assessment is important in identifying and managing women at increased risk for breast cancer. However, there has been little evaluation of the practical aspects of implementing a population-based program that identifies and refers high-risk patients for further evaluation. PATIENTS AND METHODS We implemented a semiautomated approach to collect personal and family history to identify women at high risk of breast cancer. On the basis of the survey, women identified as elevated risk received letters inviting them to telephone consultations with licensed breast health genetic counselors (BHGCs). High-risk women's history was verified and counseling and referrals provided, as appropriate. RESULTS Among 20,558 women screened, 2000 (9.7%) women were identified as high risk on the basis of patient initial report. However, most (1,580) were excluded from receiving risk communication after BHGC review of risk information with the woman or because of previous attention to breast cancer risk or an abnormal mammogram. Among 420 subjects who received risk letters, 225 received a BHGC consultation. Of these 225 women, 63 were reclassified as average risk, 158 were referred to high-risk clinics, and 5 consultations were incomplete after determining that further information was needed. Of the 158 women referred to high-risk breast clinics, 51 attended an appointment. CONCLUSION This study highlights the complex nature of a population-based breast cancer screening program in a clinical setting and shows the substantial effort needed to identify newly discovered women at high risk for breast cancer and refer them to appropriate services.
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19
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Samimi G, Heckman-Stoddard BM, Kay SS, Bloodgood B, Coa KI, Robinson JL, Tennant B, Ford LG, Szabo E, Minasian L. Acceptability of Localized Cancer Risk Reduction Interventions Among Individuals at Average or High Risk for Cancer. Cancer Prev Res (Phila) 2019; 12:271-282. [PMID: 30824471 DOI: 10.1158/1940-6207.capr-18-0435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/28/2019] [Accepted: 02/22/2019] [Indexed: 12/30/2022]
Abstract
Individuals at high risk for cancer, including those already diagnosed with premalignant lesions, can potentially benefit from chemopreventive interventions to reduce cancer risk. However, uptake and acceptability have been hindered due to the risk of systemic toxicity and other adverse effects. Locally delivered chemopreventive agents, where direct action on the primary organ may limit systemic toxicity, are emerging as an option for high-risk individuals. While a number of clinical trials support the development of chemopreventive agents, it is crucial to understand the factors and barriers that influence their acceptability and use. We conducted 36 focus groups with 198 individuals at average and high risk of breast/ovarian, gynecologic, and head/neck/oral and lung cancers to examine the perceptions and acceptability of chemopreventive agents. Participants' willingness to use chemopreventive agents was influenced by several factors, including perceived risk of cancer, skepticism around prevention, previous knowledge of chemopreventive agents, support from trusted sources of health information, participation in other cancer-related risk-reduction activities, previous experience with similar modalities, cost, regimen, side effects, and perceived effectiveness of the preventive intervention. Our findings indicate that individuals may be more receptive to locally delivered chemopreventive agents if they perceive themselves to be at high risk for cancer and are given the necessary information regarding regimen and side effects to make an informed decision. Clinical trials that collect additional patient-centered data including side effects and how these interventions fit into an individual's lifestyle are imperative to improve uptake of chemopreventive agents.
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Affiliation(s)
- Goli Samimi
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland.
| | | | | | | | | | | | | | - Leslie G Ford
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Eva Szabo
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Lori Minasian
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
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Sutherland S, Meiser B, Kaur R, Mitchell G, Kirk J, Peate M, Tim Wong WK, Goodwin A. Assessing the medical workforces perceived barriers to the prescription of risk-reducing medication for women at high-risk of breast cancer. Breast J 2018; 25:34-40. [PMID: 30525267 DOI: 10.1111/tbj.13157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 11/27/2022]
Abstract
This study aims to determine the attitudes and barriers of Australian oncology health professionals towards using tamoxifen as a breast cancer risk-reducing medication (RRM). Our target group was health professionals involved in breast cancer risk assessment or treatment. Members of relevant medical organizations in Australia and New Zealand were invited to participate in a web-based survey assessing: their attitudes towards tamoxifen as a RRM; which health professionals they felt were responsible for initiating and monitoring women on RRM and their views on workforce issues related to RRM prescription. There were 100 respondents, including 33 genetic health professionals, 32 medical oncologists and 20 surgeons. Respondents perceived tamoxifen to be effective as a RRM (99%). However, only 41% of prescribing health professionals (n = 64) had ever prescribed tamoxifen as a RRM. Overall, survey respondents felt that the initiation of RRM was the role of specialists. Assessing a patient's risk of breast cancer was reported to be the role of cancer geneticists/familial cancer clinicians (74%) and medical oncologists (66%). Discussion about the use of RRM was reported to be the role of these same groups (84% and 85% respectively). Medical oncologists (83%) and breast physicians (70%) were most frequently considered to be responsible for initiating the prescription and monitoring women once commenced on RRM (72% and 71% respectively). Oncology health professionals express confidence in the effectiveness of tamoxifen as a RRM despite reporting low prescription rates. Findings demonstrate that these oncology health professionals felt that initiation of RRM was the role of cancer specialists, despite preventative medicine being seen as a primary care activity. If uptake among at-risk women increases, this will put a significant burden on cancer services and GPs will need to take on a greater role in the delivery of RRM.
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Affiliation(s)
- Sarah Sutherland
- Department of Medical Oncology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Bettina Meiser
- Psychosocial Research Group, Prince of Wales Clinical School, UNSW, Sydney, NSW, Australia
| | - Rajneesh Kaur
- Psychosocial Research Group, Prince of Wales Clinical School, UNSW, Sydney, NSW, Australia
| | - Gillian Mitchell
- Familial Cancer Centre, Peter MacCallum Cancer Centre, VIC, Australia.,The Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Judy Kirk
- Familial Cancer Service, Crown Princess Mary Cancer Centre, Wentworthville, NSW, Australia
| | - Michelle Peate
- Psychosocial Research Group, Prince of Wales Clinical School, UNSW, Sydney, NSW, Australia.,Department of Obstetrics & Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - W K Tim Wong
- School of Social Sciences, UNSW, Sydney, NSW, Australia
| | - Annabel Goodwin
- Department of Medical Oncology, Concord Repatriation General Hospital, Concord, NSW, Australia
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21
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Rainey L, van der Waal D, Donnelly LS, Evans DG, Wengström Y, Broeders M. Women's decision-making regarding risk-stratified breast cancer screening and prevention from the perspective of international healthcare professionals. PLoS One 2018; 13:e0197772. [PMID: 29856760 PMCID: PMC5983562 DOI: 10.1371/journal.pone.0197772] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/08/2018] [Indexed: 01/02/2023] Open
Abstract
Introduction Increased knowledge of breast cancer risk factors may enable a paradigm shift from one-size-fits-all breast cancer screening to screening and subsequent prevention guided by a woman’s individual risk of breast cancer. Professionals will play a key role in informing women about this new personalised screening and prevention programme. Therefore, it is essential to explore professionals’ views of the acceptability of this new programme, since this may affect shared decision-making. Methods Professionals from three European countries (the Netherlands, United Kingdom, and Sweden) participated in digital concept mapping, a systematic mixed methods approach used to explore complex multidimensional constructs. Results Across the three countries, professionals prioritised the following five themes which may impact decision-making from the perspective of eligible women: (1) Anxiety/worry; (2) Proactive approach; (3) Reassurance; (4) Lack of knowledge; and (5) Organisation of risk assessment and feedback. Furthermore, Dutch and British professionals expressed concerns regarding the acceptability of a heterogeneous screening policy, suggesting women will question their risk feedback and assigned pathway of care. Swedish professionals emphasised the potential impact of the programme on family relations. Conclusions The perspectives of Dutch, British, and Swedish professionals of women’s decision-making regarding personalised breast cancer screening and prevention generally appear in line with women’s own views of acceptability as previously reported. This will facilitate shared decision-making. However, concerns regarding potential consequences of this new programme for screening outcomes and organisation need to be addressed, since this may affect how professionals communicate the programme to eligible women.
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Affiliation(s)
- Linda Rainey
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail:
| | - Daniëlle van der Waal
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Louise S. Donnelly
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom
| | - D. Gareth Evans
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom
- Genomic Medicine, Division of Evolution and Genomic Sciences, Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- The Christie NHS Foundation Trust, Withington, Manchester, United Kingdom
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet & Theme Cancer, Karolinska University Hospital, Huddinge, Sweden
| | - Mireille Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Dutch Expert Centre for Screening, Nijmegen, The Netherlands
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22
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Roche CA, Tang R, Coopey SB, Hughes KS. Chemoprevention acceptance and adherence in women with high-risk breast lesions. Breast J 2018; 25:190-195. [DOI: 10.1111/tbj.13064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Constance A Roche
- Division of Surgical Oncology; Massachusetts General Hospital; Boston MA USA
| | - Rong Tang
- Division of Surgical Oncology; Massachusetts General Hospital; Boston MA USA
| | - Suzanne B Coopey
- Division of Surgical Oncology; Massachusetts General Hospital; Boston MA USA
| | - Kevin S Hughes
- Division of Surgical Oncology; Massachusetts General Hospital; Boston MA USA
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23
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Brewster AM, Thomas P, Brown P, Coyne R, Yan Y, Checka C, Middleton L, Do KA, Bevers T. A System-Level Approach to Improve the Uptake of Antiestrogen Preventive Therapy among Women with Atypical Hyperplasia and Lobular Cancer In Situ. Cancer Prev Res (Phila) 2018; 11:295-302. [DOI: 10.1158/1940-6207.capr-17-0314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/20/2017] [Accepted: 02/21/2018] [Indexed: 11/16/2022]
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24
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Rainey L, van der Waal D, Jervaeus A, Wengström Y, Evans DG, Donnelly LS, Broeders MJM. Are we ready for the challenge of implementing risk-based breast cancer screening and primary prevention? Breast 2018. [PMID: 29529454 DOI: 10.1016/j.breast.2018.02.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Increased knowledge of breast cancer risk factors provides opportunities to shift from a one-size-fits-all screening programme to a personalised approach, where screening and prevention is based on a woman's risk of developing breast cancer. However, potential implementation of this new paradigm could present considerable challenges which the present review aims to explore. METHODS Bibliographic databases were searched to identify studies evaluating potential implications of the implementation of personalised risk-based screening and primary prevention for breast cancer. Identified themes were evaluated using thematic analysis. RESULTS The search strategy identified 5699 unique publications, of which 59 were selected for inclusion. Significant changes in policy and practice are warranted. The organisation of breast cancer screening spans several healthcare delivery systems and clinical settings. Feasibility of implementation depends on how healthcare is funded and arranged, and potentially varies between countries. Piloting risk assessment and prevention counselling in primary care settings has highlighted implications relating to the need for extensive additional training on risk (communication) and prevention, impact on workflow, and professionals' personal discomfort breaching the topic with women. Additionally, gaps in risk estimation, psychological, ethical and legal consequences will need to be addressed. CONCLUSION The present review identified considerable unresolved issues and challenges. Potential implementation will require a more complex framework, in which a country's healthcare regulations, resources, and preferences related to screening and prevention services are taken into account. However, with the insights gained from the present overview, countries expecting to implement risk-based screening and prevention can start to inventory and address the issues that were identified.
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Affiliation(s)
- Linda Rainey
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Daniëlle van der Waal
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Anna Jervaeus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet & Theme Cancer, Karolinska University Hospital, Alfred Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet & Theme Cancer, Karolinska University Hospital, Alfred Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - D Gareth Evans
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, United Kingdom; Genomic Medicine, Division of Evolution and Genomic Sciences, Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom; The Christie NHS Foundation Trust, Withington, Manchester M20 4BX, United Kingdom
| | - Louise S Donnelly
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, United Kingdom
| | - Mireille J M Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands; Dutch Expert Center for Screening, PO Box 6873, 6503 GJ Nijmegen, The Netherlands
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25
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Maximov PY, Abderrahman B, Curpan RF, Hawsawi YM, Fan P, Jordan VC. A unifying biology of sex steroid-induced apoptosis in prostate and breast cancers. Endocr Relat Cancer 2018; 25:R83-R113. [PMID: 29162647 PMCID: PMC5771961 DOI: 10.1530/erc-17-0416] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/21/2017] [Indexed: 12/13/2022]
Abstract
Prostate and breast cancer are the two cancers with the highest incidence in men and women, respectively. Here, we focus on the known biology of acquired resistance to antihormone therapy of prostate and breast cancer and compare laboratory and clinical similarities in the evolution of the disease. Laboratory studies and clinical observations in prostate and breast cancer demonstrate that cell selection pathways occur during acquired resistance to antihormonal therapy. Following sex steroid deprivation, both prostate and breast cancer models show an initial increased acquired sensitivity to the growth potential of sex steroids. Subsequently, prostate and breast cancer cells either become dependent upon the antihormone treatment or grow spontaneously in the absence of hormones. Paradoxically, the physiologic sex steroids now kill a proportion of selected, but vulnerable, resistant tumor cells. The sex steroid receptor complex triggers apoptosis. We draw parallels between acquired resistance in prostate and breast cancer to sex steroid deprivation. Clinical observations and patient trials confirm the veracity of the laboratory studies. We consider therapeutic strategies to increase response rates in clinical trials of metastatic disease that can subsequently be applied as a preemptive salvage adjuvant therapy. The goal of future advances is to enhance response rates and deploy a safe strategy earlier in the treatment plan to save lives. The introduction of a simple evidence-based enhanced adjuvant therapy as a global healthcare strategy has the potential to control recurrence, reduce hospitalization, reduce healthcare costs and maintain a healthier population that contributes to society.
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Affiliation(s)
- Philipp Y Maximov
- Department of Breast Medical OncologyMD Anderson Cancer Centre, Houston, Texas, USA
| | - Balkees Abderrahman
- Department of Breast Medical OncologyMD Anderson Cancer Centre, Houston, Texas, USA
| | | | - Yousef M Hawsawi
- Department of GeneticsKing Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ping Fan
- Department of Breast Medical OncologyMD Anderson Cancer Centre, Houston, Texas, USA
| | - V Craig Jordan
- Department of Breast Medical OncologyMD Anderson Cancer Centre, Houston, Texas, USA
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26
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Radhakrishnan A, Nowak SA, Parker AM, Visvanathan K, Pollack CE. Linking physician attitudes to their breast cancer screening practices: A survey of US primary care providers and gynecologists. Prev Med 2018; 107:90-102. [PMID: 29155227 PMCID: PMC5846094 DOI: 10.1016/j.ypmed.2017.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 11/02/2017] [Accepted: 11/09/2017] [Indexed: 01/28/2023]
Abstract
Despite changes to breast cancer screening guidelines intended to decrease screening in younger and older women, mammography rates remain high. We investigated physician attitudes towards screening younger and older women. Surveys were mailed to US primary care providers and gynecologists between May and September 2016 (871/1665, 52.3% adjusted response rate). We assessed physician (1) attitudes towards screening younger (45-49years) and older (75+ years) women and (2) recommendations for routine mammography. We used exploratory factor analysis to identify underlying themes among physician attitudes and created measures standardized to a 5-point scale. Using multivariable logistic regression models, we examined associations between physician attitudes and screening recommendations. Attitudes identified with factor analysis included: potential regret, expectations, and discordant guidelines (referred to as potential regret), patient-related hazards due to screening, physician limitations and uncertainty, and concerns about rationing care. Gynecologists had higher levels of potential regret compared to internists. In adjusted analyses, physicians with increasing potential regret (1-point increment on 5-point scale) had higher odds of recommending mammography to younger (OR 8.68; 95% CI 5.25-14.36) and older women (OR 4.62; 95% CI 3.50-6.11). Increasing concern for patient-related hazards was associated with decreased odds of recommending screening to older women (OR 0.68; 95% CI 0.56-0.83). Physicians were more motivated by potential regret in recommending screening for younger and older women than by concerns for patient-related hazards in screening. Addressing physicians' most salient concerns, such as fear of missing cancer diagnoses and malpractice, may present an important opportunity to improving delivery of guideline-concordant cancer screening.
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Affiliation(s)
| | | | | | - Kala Visvanathan
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD, United States; Department of Epidemiology and Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Craig E Pollack
- Department of Epidemiology and Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD, United States
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27
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Noonan S, Pasa A, Fontana V, Caviglia S, Bonanni B, Costa A, Smith SG, Peccatori F, DeCensi A. A Survey among Breast Cancer Specialists on the Low Uptake of Therapeutic Prevention with Tamoxifen or Raloxifene. Cancer Prev Res (Phila) 2018; 11:38-43. [PMID: 29061559 DOI: 10.1158/1940-6207.capr-17-0162] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/03/2017] [Accepted: 10/12/2017] [Indexed: 11/16/2022]
Abstract
With this survey, we aimed to address the reasons why physicians are reluctant to prescribe breast cancer-preventive therapy with the selective estrogen receptor modulators (SERM) tamoxifen or raloxifene despite a strong evidence of efficacy. A self-administered 5-point Likert questionnaire was given during breast cancer meetings in Europe or sent via email to rank the importance of 10 predefined reasons for low uptake of SERMs for breast cancer therapeutic prevention. Analyses tested the associations between the stated reasons and physician characteristics such as gender, age, country of work, and specialty. Of 246 delivered questionnaires, 27 were incomplete and were excluded from analysis. Overall, there was a small variability in response scores, with a tendency for physicians to give moderate importance (score = 3) to all 10 statements. However, the top five reasons were: the expected greater preventive effectiveness of aromatase inhibitors (70.3% with score >3), difficulty applying current risk models in clinical practice (69.9%), the lack of clarity on the most appropriate physician for prevention advice (68.4%), the lack of reliable short-term biomarkers of effectiveness (67.5%), and the lack of commercial interest in therapeutic prevention (66.0%). The lack of reliable short-term biomarkers showed a tendency to discriminate between medical oncologists and other breast specialists (OR = 2.42; 95% CI, 0.93-6.25). This survey highlights the complexity of prescribing decisions among physicians in this context. Coupled with the known barriers among eligible women, these data may help to identify strategies to increase uptake of breast cancer therapeutic prevention. Cancer Prev Res; 11(1); 38-43. ©2017 AACR.
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Affiliation(s)
- Silvia Noonan
- Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | - Ambra Pasa
- Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy
| | - Vincenzo Fontana
- Clinical Epidemiology Unit, IRCCS AOU San Martino IST, Genoa, Italy
| | | | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | | | - Samuel G Smith
- Leeds Institute of Health Sciences, University of Leeds, United Kingdom
| | - Fedro Peccatori
- European School of Oncology Milan, Italy
- Gynecologic Oncology Division, European Institute of Oncology, Milan, Italy
| | - Andrea DeCensi
- Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy.
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
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28
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Siembida EJ, Radhakrishnan A, Nowak SA, Parker AM, Pollack CE. Linking Reminders and Physician Breast Cancer Screening Recommendations: Results From a National Survey. JCO Clin Cancer Inform 2017; 1:1-10. [PMID: 30657396 DOI: 10.1200/cci.17.00090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Physician reminders have successfully increased rates of mammography. However, considering recent changes to breast cancer screening guidelines that disagree on the optimal age to start and stop mammography screening, we sought to examine the extent to which reminders have been deployed for breast cancer screening targeting younger and older patients. METHODS A mailed survey was sent to a national sample of 2,000 primary care physicians between May and September 2016. Physicians were asked whether they received reminders to screen women in various age groups (40 to 44, 45 to 49, and ≥ 75 years), the organizational screening guidelines they trusted most, and whether they recommended routine breast cancer screening to average-risk women in the different age groups. Using regression models, we assessed the association between reminders and physician screening recommendations, controlling for physician and practice characteristics, and evaluated whether the association varied by the guidelines they trusted. RESULTS A total of 871 physicians responded (adjusted response rate, 52.3%). Overall, 28.9% of physicians reported receiving reminders for patient ages 40 to 44 years, 32.5% for patient ages 45 to 49 years, and 16.5% for patient ages ≥ 75 years. Receiving reminders significantly increased the likelihood of physicians recommending mammography screening. In adjusted analyses, 84% (95% CI, 77% to 90%) of physicians who received reminders recommended screening for women ages ≥ 75 versus 65% (95% CI, 62% to 69%) of those who did not receive reminders. The associations between reminders and screening recommendations remained consistent regardless of which guidelines physicians reported trusting. CONCLUSION Reminders were significantly associated with increases in physician screening recommendations for mammography, underscoring the need for careful implementation in scenarios where guidelines are discordant.
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Affiliation(s)
- Elizabeth J Siembida
- Elizabeth J. Siembida, National Cancer Institute, Rockville; Craig Evan Pollack, Johns Hopkins University, Baltimore, MD; Archana Radhakrishnan, University of Michigan, Ann Arbor, MI; Sarah A. Nowak, RAND Corporation, Santa Monica, CA; and Andrew M. Parker, RAND Corporation, Pittsburgh, PA
| | - Archana Radhakrishnan
- Elizabeth J. Siembida, National Cancer Institute, Rockville; Craig Evan Pollack, Johns Hopkins University, Baltimore, MD; Archana Radhakrishnan, University of Michigan, Ann Arbor, MI; Sarah A. Nowak, RAND Corporation, Santa Monica, CA; and Andrew M. Parker, RAND Corporation, Pittsburgh, PA
| | - Sarah A Nowak
- Elizabeth J. Siembida, National Cancer Institute, Rockville; Craig Evan Pollack, Johns Hopkins University, Baltimore, MD; Archana Radhakrishnan, University of Michigan, Ann Arbor, MI; Sarah A. Nowak, RAND Corporation, Santa Monica, CA; and Andrew M. Parker, RAND Corporation, Pittsburgh, PA
| | - Andrew M Parker
- Elizabeth J. Siembida, National Cancer Institute, Rockville; Craig Evan Pollack, Johns Hopkins University, Baltimore, MD; Archana Radhakrishnan, University of Michigan, Ann Arbor, MI; Sarah A. Nowak, RAND Corporation, Santa Monica, CA; and Andrew M. Parker, RAND Corporation, Pittsburgh, PA
| | - Craig Evan Pollack
- Elizabeth J. Siembida, National Cancer Institute, Rockville; Craig Evan Pollack, Johns Hopkins University, Baltimore, MD; Archana Radhakrishnan, University of Michigan, Ann Arbor, MI; Sarah A. Nowak, RAND Corporation, Santa Monica, CA; and Andrew M. Parker, RAND Corporation, Pittsburgh, PA
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29
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Crew KD. What Factors Influence Decision-Making about Breast Cancer Chemoprevention among High-Risk Women? Cancer Prev Res (Phila) 2017; 10:609-611. [PMID: 28978567 DOI: 10.1158/1940-6207.capr-17-0281] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 11/16/2022]
Abstract
Estrogen exposure is one of the strongest risk factors for breast cancer development. Chemoprevention with selective estrogen receptor modulators (SERM), such as tamoxifen and raloxifene, has been shown in randomized controlled trials to reduce breast cancer incidence by up to 50% among high-risk women. Despite the strength of this evidence, there is significant underutilization of chemoprevention. Given the relatively few modifiable breast cancer risk factors, SERM use provides an important strategy for the primary prevention of this disease. Understanding factors which influence chemoprevention decision-making will inform efforts to implement breast cancer risk assessment and increase chemoprevention uptake in clinical practice. Cancer Prev Res; 10(11); 609-11. ©2017 AACRSee related article by Holmberg et al., p. 625.
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Affiliation(s)
- Katherine D Crew
- Columbia University, College of Physicians and Surgeons, New York, New York. .,Columbia University, Mailman School of Public Health, New York, New York.,Herbert Irving Comprehensive Cancer Center, New York, New York
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30
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Adherence Patterns to National Comprehensive Cancer Network Guidelines for Referral of Women With Breast Cancer to Genetics Professionals. Am J Clin Oncol 2017; 39:363-7. [PMID: 24710121 DOI: 10.1097/coc.0000000000000073] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Genetic predisposition is responsible for 5% to 10% of breast cancer. The National Comprehensive Cancer Network (NCCN) established guidelines delineating appropriate candidates for genetic counseling. This study aims to determine referral patterns for genetic counseling in women who met such guidelines. MATERIALS AND METHODS Utilizing an institutional tumor registry, patients from an academic oncology program who met a subset of NCCN guidelines for genetic referrals between 2004 and 2010 were identified (breast cancer diagnosis ≤50 y without a known BRCA mutation). A retrospective chart review was conducted. Statistics were analyzed using SAS version 9.2. RESULTS A total of 314 patients were identified and 107 (34.1%) were referred for genetic counseling. Median age at diagnosis was younger for those referred versus not referred (43 and 46 y; P<0.0001). Women were more likely referred with a family history suspicious for an inherited cancer syndrome (67.3% vs. 36.2%; P<0.0001). There was no difference in stage at diagnosis, insurance, or race among women referred. Those patients who choose prophylactic contralateral mastectomy were likely to have been referred for genetic counseling (63.6% vs. 36.4%, P<0.0001). Among patients referred, 77.6% consulted with a genetics counselor, 95.2% underwent genetic testing, and 16.5% had a BRCA mutation. CONCLUSIONS Genetic counseling and testing is being underutilized in women who meet NCCN referral guidelines. Age and family history were noted to be predictive of referral for genetic evaluation. Further research is needed to determine additional factors that may impact not only referral rates but subsequent care for women with possible genetic predispositions to cancer.
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Trivedi MS, Coe AM, Vanegas A, Kukafka R, Crew KD. Chemoprevention Uptake among Women with Atypical Hyperplasia and Lobular and Ductal Carcinoma In Situ. Cancer Prev Res (Phila) 2017; 10:434-441. [PMID: 28611039 DOI: 10.1158/1940-6207.capr-17-0100] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/24/2017] [Accepted: 06/06/2017] [Indexed: 01/05/2023]
Abstract
Women with atypical hyperplasia and lobular or ductal carcinoma in situ (LCIS/DCIS) are at increased risk of developing invasive breast cancer. Chemoprevention with selective estrogen receptor modulators or aromatase inhibitors can reduce breast cancer risk; however, uptake is estimated to be less than 15% in these populations. We sought to determine which factors are associated with chemoprevention uptake in a population of women with atypical hyperplasia, LCIS, and DCIS. Women diagnosed with atypical hyperplasia/LCIS/DCIS between 2007 and 2015 without a history of invasive breast cancer were identified (N = 1,719). A subset of women (n = 73) completed questionnaires on breast cancer and chemoprevention knowledge, risk perception, and behavioral intentions. Descriptive statistics were generated and univariate and multivariable log-binomial regression were used to estimate the association between sociodemographic and clinical factors and chemoprevention uptake. In our sample, 29.3% had atypical hyperplasia, 23.3% had LCIS, and 47.4% had DCIS; 29.4% used chemoprevention. Compared with women with atypical hyperplasia, LCIS [RR, 1.43; 95% confidence interval (CI), 1.16-1.76] and DCIS (RR, 1.54; 95% CI, 1.28-1.86) were significantly associated with chemoprevention uptake, as was medical oncology referral (RR, 5.79; 95% CI, 4.80-6.98). Younger women were less likely to take chemoprevention (RR, 0.61; 95% CI, 0.42-0.87), and there was a trend toward increased uptake in Hispanic compared with non-Hispanic white women. The survey data revealed a strong interest in learning about chemoprevention, but there were misperceptions in personal breast cancer risk and side effects of chemoprevention. Improving communication about breast cancer risk and chemoprevention may allow clinicians to facilitate informed decision-making about preventative therapy. Cancer Prev Res; 10(8); 434-41. ©2017 AACR.
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Affiliation(s)
- Meghna S Trivedi
- Columbia University, College of Physicians and Surgeons, New York, New York. .,Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Austin M Coe
- Columbia University, Mailman School of Public Health, New York, New York
| | - Alejandro Vanegas
- Columbia University, College of Physicians and Surgeons, New York, New York.,Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Rita Kukafka
- Columbia University, College of Physicians and Surgeons, New York, New York.,Columbia University, Mailman School of Public Health, New York, New York
| | - Katherine D Crew
- Columbia University, College of Physicians and Surgeons, New York, New York.,Herbert Irving Comprehensive Cancer Center, New York, New York.,Columbia University, Mailman School of Public Health, New York, New York
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Crew KD, Albain KS, Hershman DL, Unger JM, Lo SS. How do we increase uptake of tamoxifen and other anti-estrogens for breast cancer prevention? NPJ Breast Cancer 2017. [PMID: 28649660 PMCID: PMC5460136 DOI: 10.1038/s41523-017-0021-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Several randomized controlled trials of anti-estrogens, such as tamoxifen and aromatase inhibitors, have demonstrated up to a 50–65% decrease in breast cancerincidence among high-risk women. Approximately 15% of women, age 35–79 years, in the U.S. meet criteria for breast cancer preventive therapies, but uptake of these medications remain low. Explanations for this low uptake includelack of awareness of breast cancer risk status, insufficient knowledge about breast cancer preventive therapies among patients and physicians, and toxicity concerns. Increasing acceptance of pharmacologic breast cancer prevention will require effective communication of breast cancer risk, accurate representation about the potential benefits and side effects of anti-estrogens, targeting-specific high-risk populations most likely to benefit from preventive therapy, and minimizing the side effects of current anti-estrogens with novel administration and dosing options. One strategy to improve the uptake of chemoprevention strategies is to consider lessons learned from the use of drugs to prevent other chronic conditions, such as cardiovascular disease. Enhancing uptake and adherence to anti-estrogens for primary prevention holds promise for significantly reducing breast cancer incidence, however, this will require a significant change in our current clinical practice and stronger advocacy and awareness at the national level.
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Affiliation(s)
- Katherine D Crew
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY USA
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL USA
| | - Dawn L Hershman
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY USA
| | - Joseph M Unger
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Shelly S Lo
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL USA
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Kishan AU, Gomez CL, Dawson NA, Dvorak R, Foster NM, Hoyt A, Hurvitz SA, Kusske A, Silver EL, Tseng C, McCloskey SA. Increasing Appropriate BRCA1/2 Mutation Testing: The Role of Family History Documentation and Genetic Counseling in a Multidisciplinary Clinic. Ann Surg Oncol 2016; 23:634-641. [PMID: 27619940 DOI: 10.1245/s10434-016-5545-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Findings show that 5-10 % of women with a diagnosis of breast cancer (BCa) have actionable genetic mutations. The National Comprehensive Cancer Network guidelines for testing to detect BRCA1/2 mutations include personal history (PH) variables such as age of 45 years or younger and a family history (FH) variables. Rates of FH documentation and overall rates of appropriate referral for genetic testing are low, ranging from about 30 to 60 %. The authors hypothesized that an upfront FH documentation and inclusion of a genetics counselor in a multidisciplinary clinic (MDC) setting would increase rates of appropriate referral for genetic testing. METHODS The study enrolled 609 consecutive women with non-metastatic BCa seen in consultation between June 2012 and December 2015 at a multidisciplinary clinic. Rates of FH documentation and referral for genetic testing to detect BRCA1/2 mutations were assessed before and after inclusion of a genetic counselor in the MDC. RESULTS The rates of FH documentation and appropriate referral were 100 and 89 %, respectively. Half (50 %) of the patients had only FH-based indications for testing. All the patients with PH-based indications were referred. The inclusion of a genetic counselor significantly increased appropriate referral rates among those with only FH-based indications (62 vs. 92 %) and overall (80 vs. 96 %) (p < 0.0001 for both). Among the 12 % of the patients with actionable mutations, 60 % were 45 years of age or younger, whereas 30 % had only FH-based testing indications. CONCLUSIONS This report shows substantially higher FH documentation and appropriate genetic testing rates than prior reports. Many patients with indications for genetic testing may have only FH-based indications for testing, and this subset may account for the sizable proportion of patients with newly diagnosed BCa who have actionable mutations.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA.
| | - Caitlin L Gomez
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Nicole A Dawson
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, CA, USA
| | - Robyn Dvorak
- Santa Monica-UCLA Breast Center, University of California, Los Angeles, CA, USA
| | - Nova M Foster
- Department of Surgery, Division of General Surgery, University of California, Los Angeles, CA, USA
| | - Anne Hoyt
- Department of Radiology, University of California, Los Angeles, CA, USA
| | - Sara A Hurvitz
- Department of Hematology and Oncology, University of California, Los Angeles, CA, USA
| | - Amy Kusske
- Department of Surgery, Division of General Surgery, University of California, Los Angeles, CA, USA
| | - Erica L Silver
- Santa Monica-UCLA Breast Center, University of California, Los Angeles, CA, USA
| | - Charles Tseng
- Department of Plastic Surgery, University of California, Los Angeles, CA, USA
| | - Susan A McCloskey
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
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Hum S, Wu M, Pruthi S, Heisey R. Physician and Patient Barriers to Breast Cancer Preventive Therapy. CURRENT BREAST CANCER REPORTS 2016; 8:158-164. [PMID: 27617055 PMCID: PMC4995234 DOI: 10.1007/s12609-016-0216-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The uptake of selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs) for the primary prevention of breast cancer is low, despite their proven efficacy in several randomized clinical trials. This review summarizes the latest data on physicians' and women's barriers to breast cancer preventive therapy. Physicians' challenges include: identifying suitable candidates for preventive therapy, inadequate training and confidence in risk assessment and counselling, insufficient knowledge of risk-reducing medications, and lack of time. High-risk women fear medication side effects, and they often weigh experiences of others more heavily than statistical probabilities to guide their decision-making. Despite decision aid interventions to help women make an informed decision, acceptance of preventive therapy will remain low until: risk/benefit profiles are more favorable, physicians are better educated and skilled in having these discussions, and suitable biomarkers to monitor drug efficacy and better clinical risk prediction models to assess true individual risk are available.
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Affiliation(s)
- Susan Hum
- Department of Family & Community Medicine, Women’s College Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
| | - Melinda Wu
- Department of Family & Community Medicine, University of Toronto, Women’s College Hospital, Princess Margaret Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
| | - Sandhya Pruthi
- Department of Medicine, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA
| | - Ruth Heisey
- Department of Family & Community Medicine, University of Toronto, Women’s College Hospital, Princess Margaret Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
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Brewster AM, Davidson NE, McCaskill-Stevens W. Chemoprevention for breast cancer: overcoming barriers to treatment. Am Soc Clin Oncol Educ Book 2016:85-90. [PMID: 24451714 DOI: 10.14694/edbook_am.2012.32.152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Evidence from placebo-controlled, randomized clinical trials supports the use of chemoprevention in women at high risk for developing breast cancer, and two agents-tamoxifen and raloxifene-are U.S. Food and Drug Administration (FDA)-approved for the indication. Despite clinical guidelines that recommend physicians counsel high-risk women about the use of chemoprevention and the estimated 2.4 million women in the United States who meet eligibility criteria for net benefit, the uptake of breast cancer chemoprevention has been exceedingly low. Assessments of the risks and benefits of chemoprevention are aided by the availability of models that can be used to estimate of the risk-benefit ratio. However, many physicians remain unaware of these resources to determine patient eligibility for chemoprevention and lack the time to provide informed counseling to their patients. The barriers for patients' acceptance of chemoprevention treatment include fear of side effects and the perception that chemoprevention will not substantially lower their risk of developing breast cancer. Despite these challenges, there are substantial opportunities to increase the utilization of chemoprevention. These strategies include education, dissemination of user-friendly risk-benefit models, and the support of research efforts focused on identifying biomarkers that can more accurately select women most likely to develop breast cancer and predict responsiveness of treatment.
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Affiliation(s)
- Abenaa M Brewster
- From the University of Texas M. D. Anderson Cancer Center, Houston, TX; University of Pittsburgh Cancer Institute, Pittsburgh, PA; and National Cancer Institute, Bethesda, MD
| | - Nancy E Davidson
- From the University of Texas M. D. Anderson Cancer Center, Houston, TX; University of Pittsburgh Cancer Institute, Pittsburgh, PA; and National Cancer Institute, Bethesda, MD
| | - Worta McCaskill-Stevens
- From the University of Texas M. D. Anderson Cancer Center, Houston, TX; University of Pittsburgh Cancer Institute, Pittsburgh, PA; and National Cancer Institute, Bethesda, MD
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Crew KD. Addressing barriers to uptake of breast cancer chemoprevention for patients and providers. Am Soc Clin Oncol Educ Book 2016:e50-8. [PMID: 25993215 DOI: 10.14694/edbook_am.2015.35.e50] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Breast cancer is the most common malignancy among women in the United States, and the primary prevention of this disease is a major public health issue. Because there are relatively few modifiable breast cancer risk factors, pharmacologic interventions with antiestrogens have the potential to significantly affect the primary prevention setting. Breast cancer chemoprevention with selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene, and with aromatase inhibitors (AIs) exemestane and anastrozole, is underutilized despite several randomized controlled trials demonstrating up to a 50% to 65% relative risk reduction in breast cancer incidence among women at high risk. An estimated 10 million women in the United States meet high-risk criteria for breast cancer and are potentially eligible for chemoprevention, but less than 5% of women at high risk who are offered antiestrogens for primary prevention agree to take it. Reasons for low chemoprevention uptake include lack of routine breast cancer risk assessment in primary care, inadequate time for counseling, insufficient knowledge about antiestrogens among patients and providers, and concerns about side effects. Interventions designed to increase chemoprevention uptake, such as decision aids and incorporating breast cancer risk assessment into clinical practice, have met with limited success. Clinicians can help women make informed decisions about chemoprevention by effectively communicating breast cancer risk and enhancing knowledge about the risks and benefits of antiestrogens. Widespread adoption of chemoprevention will require a major paradigm shift in clinical practice for primary care providers (PCPs). However, enhancing uptake and adherence to breast cancer chemoprevention holds promise for reducing the public health burden of this disease.
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Affiliation(s)
- Katherine D Crew
- From the Department of Medicine, College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
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Livaudais-Toman J, Karliner LS, Tice JA, Kerlikowske K, Gregorich S, Pérez-Stable EJ, Pasick RJ, Chen A, Quinn J, Kaplan CP. Impact of a primary care based intervention on breast cancer knowledge, risk perception and concern: A randomized, controlled trial. Breast 2015; 24:758-66. [PMID: 26476466 PMCID: PMC4698352 DOI: 10.1016/j.breast.2015.09.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/06/2015] [Accepted: 09/22/2015] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To estimate the effects of a tablet-based, breast cancer risk education intervention for use in primary care settings (BreastCARE) on patients' breast cancer knowledge, risk perception and concern. METHODS From June 2011-August 2012, we enrolled women from two clinics, aged 40-74 years with no personal breast cancer history, and randomized them to the BreastCARE intervention group or to the control group. All patients completed a baseline telephone survey and risk assessment (via telephone for controls, via tablet computer in clinic waiting room prior to visit for intervention). All women were categorized as high or average risk based on the Referral Screening Tool, the Gail model or the Breast Cancer Surveillance Consortium model. Intervention patients and their physicians received an individualized risk report to discuss during the visit. All women completed a follow-up telephone survey 1-2 weeks after risk assessment. Post-test comparisons estimated differences at follow-up in breast cancer knowledge, risk perception and concern. RESULTS 580 intervention and 655 control women completed follow-up interviews. Mean age was 56 years (SD = 9). At follow-up, 73% of controls and 71% of intervention women correctly perceived their breast cancer risk and 22% of controls and 24% of intervention women were very concerned about breast cancer. Intervention patients had greater knowledge (≥75% correct answers) of breast cancer risk factors at follow-up (24% vs. 16%; p = 0.002). In multivariable analysis, there were no differences in correct risk perception or concern, but intervention patients had greater knowledge ([OR] = 1.62; 95% [CI] = 1.19-2.23). CONCLUSIONS A simple, practical intervention involving physicians at the point of care can improve knowledge of breast cancer without increasing concern. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01830933.
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Affiliation(s)
- Jennifer Livaudais-Toman
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Leah S Karliner
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey A Tice
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Karla Kerlikowske
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; General Internal Medicine Section, Department of Veterans Affairs, San Francisco, CA, USA
| | - Steven Gregorich
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Eliseo J Pérez-Stable
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rena J Pasick
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Alice Chen
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Jessica Quinn
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Celia P Kaplan
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
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DeCensi A, Thorat MA, Bonanni B, Smith SG, Cuzick J. Barriers to preventive therapy for breast and other major cancers and strategies to improve uptake. Ecancermedicalscience 2015; 9:595. [PMID: 26635899 PMCID: PMC4664508 DOI: 10.3332/ecancer.2015.595] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Indexed: 12/31/2022] Open
Abstract
The global cancer burden continues to rise and the war on cancer can only be won if improvements in treatment go hand in hand with therapeutic cancer prevention. Despite the availability of several efficacious agents, utilisation of preventive therapy has been poor due to various barriers, such as the lack of physician and patient awareness, fear of side effects, and licensing and indemnity issues. In this review, we discuss these barriers in detail and propose strategies to overcome them. These strategies include improving physician awareness and countering prejudices by highlighting the important differences between preventive therapy and cancer treatment. The importance of the agent-biomarker-cohort (ABC) paradigm to improve effectiveness of preventive therapy cannot be overemphasised. Future research to improve therapeutic cancer prevention needs to include improvements in the prediction of benefits and harms, and improvements in the safety profile of existing agents by experimentation with dose. We also highlight the role of drug repurposing for providing new agents as well as to address the current imbalance between therapeutic and preventive research. In order to move the field of therapeutic cancer prevention forwards, engagement with policymakers to correct research imbalance as well as to remove practical obstacles to implementation is also urgently needed.
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Affiliation(s)
- Andrea DeCensi
- Division of Medical Oncology, E.O. Ospedali Galliera, Mura delle Cappuccine 14, Genoa 16128, Italy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
- Breast Services, Division of Surgery and Interventional Science, Whittington Hospital, Magdala Avenue, London N19 5NF, UK
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy
| | - Samuel G Smith
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
- Health Behaviour Research Centre, University College London, London WC1E 7HB, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
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Cuzick J, Sestak I, Thorat MA. Impact of preventive therapy on the risk of breast cancer among women with benign breast disease. Breast 2015; 24 Suppl 2:S51-5. [PMID: 26255741 PMCID: PMC4636510 DOI: 10.1016/j.breast.2015.07.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
There are three main ways in which women can be identified as being at high risk of breast cancer i) family history of breast and/or ovarian cancer, which includes genetic factors ii) mammographically identified high breast density, and iii) certain types of benign breast disease. The last category is the least common, but in some ways the easiest one for which treatment can be offered, because these women have already entered into the treatment system. The highest risk is seen in women with lobular carcinoma in situ (LCIS), but this is very rare. More common is atypical hyperplasia (AH), which carries a 4-5-fold risk of breast cancer as compared to general population. Even more common is hyperplasia of the usual type and carries a roughly two-fold increased risk. Women with aspirated cysts are also at increased risk of subsequent breast cancer. Tamoxifen has been shown to be particularly effective in preventing subsequent breast cancer in women with AH, with a more than 70% reduction in the P1 trial and a 60% reduction in IBIS-I. The aromatase inhibitors (AIs) also are highly effective for AH and LCIS. There are no published data on the effectiveness of tamoxifen or the AIs for breast cancer prevention in women with hyperplasia of the usual type, or for women with aspirated cysts. Improving diagnostic consistency, breast cancer risk prediction and education of physicians and patients regarding therapeutic prevention in women with benign breast disease may strengthen breast cancer prevention efforts.
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Affiliation(s)
- Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom.
| | - Ivana Sestak
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
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Abstract
Background Many women at increased risk for breast cancer could benefit from preventive therapy. Preventive therapy options for breast cancer risk reduction have expanded in the last few years to include both selective receptor modulators (tamoxifen and raloxifene) and aromatase inhibitors (anastrozole and exemestane). Methods Risk factors that place women at high risk for breast cancer, as well as risk calculation models appropriate for the selection of candidates for preventive therapy, are presented, followed by a review of current guidelines for chemoprevention and results of chemoprevention trials. Results The modified Gail model or Breast Cancer Risk Assessment Tool is the most widely utilized risk assessment calculator to determine eligibility for chemoprevention. Women most likely to benefit from preventive therapy include those at high risk under the age of 50 years and those with atypical hyperplasia. Physician and patient barriers limit widespread acceptance and adherence to preventive therapy. Conclusions Published guidelines on chemoprevention for breast cancer have been updated to increase awareness and encourage discussion between patients and their physicians regarding evidence-based studies evaluating the benefits of preventive options for women at increased risk for breast cancer. However, even with increasing awareness and established benefits of preventive therapy, the uptake of chemoprevention has been low, with both physician and patient barriers identified. It is prudent that these barriers be overcome to enable high-risk women with a favorable risk-to-benefit ratio to be offered chemoprevention to reduce their likelihood of developing hormone receptor-positive breast cancer.
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Affiliation(s)
- Sandhya Pruthi
- Division of General Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA,
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Reimers LL, Sivasubramanian PS, Hershman D, Terry MB, Greenlee H, Campbell J, Kalinsky K, Maurer M, Jayasena R, Sandoval R, Alvarez M, Crew KD. Breast Cancer Chemoprevention among High-risk Women and those with Ductal Carcinoma In Situ. Breast J 2015; 21:377-86. [PMID: 25879521 DOI: 10.1111/tbj.12418] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chemoprevention with the anti-estrogens, tamoxifen, raloxifene, and aromatase inhibitors, reduce breast cancer incidence in high-risk women; however, uptake has been poor (<5%) in the prevention setting. We assessed use of anti-estrogens for breast cancer prevention, among high-risk women seen at an academic breast center, to observe how uptake rates compare in this setting. We collected data on demographics, breast cancer risk factors, and health behaviors via self-administered questionnaires and medical chart abstraction. Women eligible for chemoprevention with anti-estrogens had a 5-year predicted breast cancer risk according to the Gail model of ≥1.67%, history of lobular or ductal carcinoma in situ (LCIS/DCIS), and/or BRCA mutation. We dichotomized anti-estrogen use as ever or never. Predictors of use were evaluated using multivariable log-binomial regression. Of 412 high-risk women enrolled, 316 (77%) were eligible for chemoprevention. Among eligible women, 55% were non-Hispanic white, 29% Hispanic, 8% non-Hispanic black, and 7% Asian. Women were grouped based upon their highest category of breast cancer risk (in descending order): BRCA mutation carriers (3%), DCIS (40%), LCIS (22%), and 5-year Gail risk ≥1.67% (36%). Among those eligible for chemoprevention, 162 (51%) had ever initiated anti-estrogen therapy (71% tamoxifen, 23% raloxifene, 5% aromatase inhibitor). Anti-estrogen use was highest among women with DCIS (73%). In multivariable analysis, women with a 5-year Gail risk ≥1.67% had approximately a 20% lower likelihood of anti-estrogen use compared to women with DCIS (p = 0.01). In the primary prevention setting, excluding women diagnosed with DCIS, anti-estrogen use was 37%. Multivariable analysis showed differences in uptake by education and potentially by race/ethnicity. Among high-risk women seen at a breast center, anti-estrogen use for chemoprevention was relatively high as compared to the published literature. Clinicians can support high-risk women by effectively communicating breast cancer risk and enhancing knowledge about the risks and benefits of chemoprevention.
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Affiliation(s)
- Laura L Reimers
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | | | - Dawn Hershman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Heather Greenlee
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Julie Campbell
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York
| | - Kevin Kalinsky
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Matthew Maurer
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Ramona Jayasena
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Rossy Sandoval
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Maria Alvarez
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Katherine D Crew
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
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Hartmann LC, Degnim AC, Santen RJ, Dupont WD, Ghosh K. Atypical hyperplasia of the breast--risk assessment and management options. N Engl J Med 2015; 372:78-89. [PMID: 25551530 PMCID: PMC4347900 DOI: 10.1056/nejmsr1407164] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Lynn C Hartmann
- From the Departments of Oncology (L.C.H.), Surgery (A.C.D.), and Internal Medicine (K.G.), Mayo Clinic, Rochester, MN; the Department of Endocrinology and Metabolism Medicine, University of Virginia, Charlottesville (R.J.S.); and the Department of Biostatistics, Vanderbilt University, Nashville (W.D.D.)
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Corbelli J, Borrero S, Bonnema R, McNamara M, Kraemer K, Rubio D, Karpov I, McNeil M. Use of the Gail model and breast cancer preventive therapy among three primary care specialties. J Womens Health (Larchmt) 2014; 23:746-52. [PMID: 25115368 DOI: 10.1089/jwh.2014.4742] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Breast cancer is an issue of serious concern among women of all ages. The extent to which providers across primary care specialties assess breast cancer risk and discuss chemoprevention is unknown. METHODS Cross-sectional web-based survey completed by 316 physicians in internal medicine (IM), family medicine (FM), and gynecology (GYN) from February to April of 2012. Survey items assessed respondents' frequency of use of the Gail model and chemoprevention, and their attitudes behind practice patterns. Descriptive statistics were used to generate response distributions, and chi-squared tests were used to compare responses among specialties. RESULTS The response rate was 55.0 % (316/575). Only 40% of providers report having used the Gail model (37% IM, 33% FM, 60% GYN) and 13% report having recommended or prescribed chemoprevention (9% IM, 8% FM, 30% GYN). Among providers who use the Gail model, a minority use it regularly in patients who may be at increased breast cancer risk. Among providers who have prescribed chemoprevention, most have done so five times or fewer. Lack of both time and familiarity were commonly cited barriers to use of the Gail score and chemoprevention. CONCLUSIONS An overall minority of providers, most notably in FM and IM, use the Gail model to assess, and chemoprevention to decrease, breast cancer risk. Until providers are more consistent in their use of the Gail model (or other breast cancer risk calculator) and chemoprevention, opportunities to intervene in women at increased risk will likely continue to be missed.
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Affiliation(s)
- Jennifer Corbelli
- 1 Division of General Internal Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
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Corbelli J, Borrero S, Bonnema R, McNamara M, Kraemer K, Rubio D, Karpov I, McNeil M. Physician adherence to U.S. Preventive Services Task Force mammography guidelines. Womens Health Issues 2014; 24:e313-9. [PMID: 24794545 DOI: 10.1016/j.whi.2014.03.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 03/06/2014] [Accepted: 03/07/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2009, the U.S. Preventive Services Task Force (USPSTF) guidelines for screening mammography changed significantly, and are now in direct conflict with screening guidelines of other major national organizations. The extent to which physicians in different primary care specialties adhere to current USPSTF guidelines is unknown. METHODS We conducted a cross-sectional web-based survey completed by 316 physicians in internal medicine, family medicine (FM), and gynecology (GYN) from February to April 2012. Survey items assessed respondents' breast cancer screening recommendations in women of different ages at average risk for breast cancer. We used descriptive statistics to generate response distribution for survey items, and logistic regression models to compare responses among specialties. FINDINGS The response rate was 55.0% (316/575). A majority of providers in internal medicine (65%), FM (64%), and GYN (92%) recommended breast cancer screening starting at age 40 versus 50. A majority of providers in internal medicine (77%), FM (74%), and GYN (98%) recommended annual versus biennial screening. Gynecologists were significantly more likely than both internists and family physicians to recommend initial mammography at age 40 (p ≤ .0001) and yearly mammography (p = .0003). There were no other differences by respondent demographic. CONCLUSIONS Primary care providers, especially gynecologists, have not implemented USPSTF guidelines. The extent to which these findings may be driven by patient versus provider preferences should be explored. These findings suggest that patients are likely to receive conflicting breast cancer screening recommendations from different providers.
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Affiliation(s)
- Jennifer Corbelli
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Sonya Borrero
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Research Health Equity and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Rachel Bonnema
- Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Megan McNamara
- Division of General Internal Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio; Louis Stokes VA Healthcare System, Cleveland, Ohio
| | - Kevin Kraemer
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Doris Rubio
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Irina Karpov
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Melissa McNeil
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Jbilou J, Halilem N, Blouin-Bougie J, Amara N, Landry R, Simard J. Medical genetic counseling for breast cancer in primary care: a synthesis of major determinants of physicians' practices in primary care settings. Public Health Genomics 2014; 17:190-208. [PMID: 24993835 DOI: 10.1159/000362358] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 03/20/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES This paper aims to identify relevant potential predictors of medical genetic counseling for breast cancer (MGC-BC) in primary care and to develop a comprehensive questionnaire to study MGC-BC. METHODS A scoping review was conducted to identify the predictors of MGC-BC among primary care physicians. Relevant articles were identified in selected databases (PubMed, Embase, CINAHL, ISI Web of Science, PsycINFO, and Cochrane CENTRAL) and 4 selected relevant electronic journals. RESULTS An inductive analysis of the 193 quantitatively tested variables, conducted by 3 researchers, showed that 6 conceptual categories of determinants, namely (1) demographic, (2) organizational, (3) experiential, (4) professional, (5) psychological, and (6) cognitive, influence MGC-BC practices. CONCLUSION There is a scarcity of literature addressing the medical behavior determinants of MGC-BC. Future research is needed to identify effective strategies put into action to support the integration of MGC-BC in primary care medical practices and routines. However, our results shed light on 2 levels of actions that could improve genetic counseling services in primary care: (1) medical training and educational efforts emphasizing family history collection (individual level), and (2) clarification of roles and responsibilities in ordering and referral practices in genetic counseling and genetic testing for better healthcare management (organizational level).
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Affiliation(s)
- Jalila Jbilou
- Centre de formation médicale du Nouveau-Brunswick, Université de Moncton, Moncton, N.B., Canada
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Kaplan CP, Livaudais-Toman J, Tice JA, Kerlikowske K, Gregorich SE, Pérez-Stable EJ, Pasick RJ, Chen A, Quinn J, Karliner LS. A randomized, controlled trial to increase discussion of breast cancer in primary care. Cancer Epidemiol Biomarkers Prev 2014; 23:1245-53. [PMID: 24762560 PMCID: PMC4167008 DOI: 10.1158/1055-9965.epi-13-1380] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Assessment and discussion of individual risk for breast cancer within the primary care setting are crucial to discussion of risk reduction and timely referral. METHODS We conducted a randomized controlled trial of a multiethnic, multilingual sample of women ages 40 to 74 years from two primary care practices (one academic, one safety net) to test a breast cancer risk assessment and education intervention. Patients were randomly assigned to control or intervention group. All patients completed a baseline telephone survey and risk assessment (via telephone for controls, via tablet computer in clinic waiting room before visit for intervention). Intervention (BreastCARE) patients and their physicians received an individualized risk report to discuss during the visit. One-week follow-up telephone surveys with all patients assessed patient-physician discussion of family cancer history, personal breast cancer risk, high-risk clinics, and genetic counseling/testing. RESULTS A total of 655 control and 580 intervention women completed the risk assessment and follow-up interview; 25% were high-risk by family history, Gail, or Breast Cancer Surveillance Consortium risk models. BreastCARE increased discussions of family cancer history [OR, 1.54; 95% confidence interval (CI), 1.25-1.91], personal breast cancer risk (OR, 4.15; 95% CI, 3.02-5.70), high-risk clinics (OR, 3.84; 95% CI, 2.13-6.95), and genetic counseling/testing (OR, 2.22; 95% CI, 1.34-3.68). Among high-risk women, all intervention effects were stronger. CONCLUSIONS An intervention combining an easy-to-use, quick risk assessment tool with patient-centered risk reports at the point of care can successfully promote discussion of breast cancer risk reduction between patients and primary care physicians, particularly for high-risk women. IMPACT Next steps include scaling and dissemination of BreastCARE with integration into electronic medical record systems.
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Affiliation(s)
- Celia P Kaplan
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine; Helen Diller Family Comprehensive Cancer Center; and Medical Effectiveness Research Center for Diverse Populations, University of California San Francisco, San Francisco, California
| | | | - Jeffrey A Tice
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine; Helen Diller Family Comprehensive Cancer Center; and
| | - Karla Kerlikowske
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine; Helen Diller Family Comprehensive Cancer Center; and
| | - Steven E Gregorich
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine; Medical Effectiveness Research Center for Diverse Populations, University of California San Francisco, San Francisco, California
| | - Eliseo J Pérez-Stable
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine; Helen Diller Family Comprehensive Cancer Center; and Medical Effectiveness Research Center for Diverse Populations, University of California San Francisco, San Francisco, California
| | - Rena J Pasick
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine; Helen Diller Family Comprehensive Cancer Center; and
| | - Alice Chen
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine; Helen Diller Family Comprehensive Cancer Center; and
| | - Jessica Quinn
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine
| | - Leah S Karliner
- Authors' Affiliations: Department of Medicine, Division of General Internal Medicine; Helen Diller Family Comprehensive Cancer Center; and Medical Effectiveness Research Center for Diverse Populations, University of California San Francisco, San Francisco, California
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Corbelli J, Borrero S, Bonnema R, McNamara M, Kraemer K, Rubio D, Karpov I, McNeil M. Differences Among Primary Care Physicians' Adherence to 2009 ACOG Guidelines for Cervical Cancer Screening. J Womens Health (Larchmt) 2014; 23:397-403. [DOI: 10.1089/jwh.2013.4475] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jennifer Corbelli
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonya Borrero
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research Health Equity and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Rachel Bonnema
- University of Nebraska Medical Center Division of General Internal Medicine, Omaha, Nebraska
| | - Megan McNamara
- Case Western Reserve University School of Medicine Division of General Internal Medicine, Cleveland, Ohio
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Kevin Kraemer
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Doris Rubio
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Irina Karpov
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Melissa McNeil
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Colditz GA, Bohlke K. Priorities for the primary prevention of breast cancer. CA Cancer J Clin 2014; 64:186-94. [PMID: 24647877 DOI: 10.3322/caac.21225] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 02/11/2014] [Accepted: 02/13/2014] [Indexed: 01/29/2023] Open
Abstract
Despite recent calls to intensify the search for new risk factors for breast cancer, acting on information that we already have could prevent thousands of cases each year. This article reviews breast cancer primary prevention strategies that are applicable to all women, discusses the underutilization of chemoprevention in high-risk women, highlights the additional advances that could be made by including young women in prevention efforts, and comments on how the molecular heterogeneity of breast cancer affects prevention research and strategies.
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Affiliation(s)
- Graham A Colditz
- Niess-Gain Professor of Surgery, Alvin J. Siteman Cancer Center and Department of Surgery, Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis, MO
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Ozanne EM, Howe R, Omer Z, Esserman LJ. Development of a personalized decision aid for breast cancer risk reduction and management. BMC Med Inform Decis Mak 2014; 14:4. [PMID: 24422989 PMCID: PMC3899602 DOI: 10.1186/1472-6947-14-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 01/02/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Breast cancer risk reduction has the potential to decrease the incidence of the disease, yet remains underused. We report on the development a web-based tool that provides automated risk assessment and personalized decision support designed for collaborative use between patients and clinicians. METHODS Under Institutional Review Board approval, we evaluated the decision tool through a patient focus group, usability testing, and provider interviews (including breast specialists, primary care physicians, genetic counselors). This included demonstrations and data collection at two scientific conferences (2009 International Shared Decision Making Conference, 2009 San Antonio Breast Cancer Symposium). RESULTS Overall, the evaluations were favorable. The patient focus group evaluations and usability testing (N = 34) provided qualitative feedback about format and design; 88% of these participants found the tool useful and 94% found it easy to use. 91% of the providers (N = 23) indicated that they would use the tool in their clinical setting. CONCLUSION BreastHealthDecisions.org represents a new approach to breast cancer prevention care and a framework for high quality preventive healthcare. The ability to integrate risk assessment and decision support in real time will allow for informed, value-driven, and patient-centered breast cancer prevention decisions. The tool is being further evaluated in the clinical setting.
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Affiliation(s)
- Elissa M Ozanne
- Department of Surgery, Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, 35 Centerra Parkway, Lebanon, NH 03766, USA
| | - Rebecca Howe
- Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Zehra Omer
- University of Massachusetts, Worcester, USA
| | - Laura J Esserman
- Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
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Waters EA, McNeel TS, Stevens WM, Freedman AN. Use of tamoxifen and raloxifene for breast cancer chemoprevention in 2010. Breast Cancer Res Treat 2012; 134:875-80. [PMID: 22622807 PMCID: PMC3771085 DOI: 10.1007/s10549-012-2089-2] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 05/02/2012] [Indexed: 10/28/2022]
Abstract
Two selective estrogen receptor modulators, tamoxifen and raloxifene, have been shown in randomized clinical trials to reduce the risk of developing primary invasive breast cancer in high-risk women. In 1998, the U.S. Food and Drug Administration (FDA) used these studies as a basis for approving tamoxifen for primary breast chemoprevention in both premenopausal and postmenopausal women at high risk. In 2007, the FDA approved raloxifene for primary breast cancer chemoprevention for postmenopausal women. Data from the year 2010 National Health Interview Survey were analyzed to estimate the prevalence of tamoxifen and raloxifene use for chemoprevention of primary breast cancers among U.S. women. Prevalence of use of chemopreventive agents for primary tumors was 20,598 (95 % CI, 518-114,864) for U.S. women aged 35-79 for tamoxifen. Prevalence was 96,890 (95 % CI, 41,277-192,391) for U.S. women aged 50-79 for raloxifene. Use of tamoxifen and raloxifene for prevention of primary breast cancers continues to be low. In 2010, women reporting medication use for breast cancer chemoprevention were primarily using the more recently FDA approved drug raloxifene. Multiple possible explanations for the low use exist, including lack of awareness and/or concern about side effects among primary care physicians and patients.
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Affiliation(s)
- Erika A Waters
- Department of Surgery (Division of Public Health Sciences), Washington University School of Medicine, Campus Box 8100, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA.
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