Breast cancer prevention: patient decision making and risk communication in the high risk setting

Risk-management decision-making data from a community-based sample of racially diverse women at high risk of breast cancer: rationale, methods, and sample characteristics of the Daughter Sister Mother Project survey

BACKGROUND

To understand the dynamics that limit use of risk-management options by women at high risk of breast cancer, there is a critical need for research that focuses on patient perspectives. Prior research has left important gaps: exclusion of high-risk women not in risk-related clinical care, exclusion of non-white populations, and lack of attention to the decision-making processes that underlie risk-management choices. Our objective was to create a more inclusive dataset to facilitate research to address disparities related to decision making for breast cancer risk management.

METHODS

The Daughter Sister Mother Project survey collects comprehensive information about the experiences of women at high risk of breast cancer. We collected novel measures of feelings about and reactions to cancer screenings; knowledge, barriers, and facilitators of risk-management options; beliefs related to cancer risk and risk management; and involvement with loved ones who had cancer. Eligible individuals were non-Hispanic white and non-Hispanic Black adult women who self-identified as having high risk of breast cancer and had no personal history of cancer. Between October 2018 and August 2019, 1053 respondents completed the online survey. Of these, 717 were confirmed through risk prediction modeling to have a lifetime breast cancer risk of ≥ 20%. Sociodemographic characteristics of this sample were compared to those of nationally representative samples of the US population: the 2019 Health Information National Trends Survey and the Pew Research Center report: Jewish Americans in 2020.

RESULTS

The sample of 717 women at objectively high risk of breast cancer was largely (95%) recruited from non-clinical sources. Of these respondents, only 31% had seen a genetic counselor, 34% had had genetic testing specific to breast cancer risk, and 35% had seen at least one breast or cancer care specialist. The sample includes 35% Black respondents and 8% with Ashkenazi Jewish ancestry. Although encompassing a substantial range of ages, incomes, and education levels, respondents are overall somewhat younger, higher-income, and more educated than the US population as a whole.

CONCLUSIONS

The DSM dataset offers comprehensive data from a community-based, diverse sample of women at high risk of breast cancer. The dataset includes substantial proportions of Black and Ashkenazi Jewish women and women who are not already in clinical care related to their breast cancer risk. This sample will facilitate future studies of risk-management behaviors among women who are and are not receiving high-risk care, and of variations in risk-management experiences across race and ethnicity.

How do women who are informed that they are at increased risk of breast cancer appraise their risk? A systematic review of qualitative research

This review aimed to synthesise qualitative research on how women notified that they are at increased risk of breast cancer view their risk. Five electronic databases were systematically reviewed for qualitative research investigating how women who have received an increased breast cancer risk estimate appraise their risk status. Fourteen records reporting 12 studies were included and critically appraised. Data were thematically synthesised. Four analytical themes were generated. Women appraise their risk of breast cancer through comparison with their risk of other familial diseases. Clinically derived risk estimates were understood in relation to pre-conceived risk appraisals, with incongruences met with surprise. Family history is relied upon strongly, with women exploring similarities and differences in attributes between themselves and affected relatives to gauge the likelihood of diagnosis. Women at increased risk reported living under a cloud of inevitability or uncertainty regarding diagnosis, resulting in concerns about risk management. Women hold stable appraisals of their breast cancer risk which appear to be mainly formed through their experiences of breast cancer in the family. Healthcare professionals should explore women's personal risk appraisals prior to providing clinically derived risk estimates in order to address misconceptions, reduce concerns about inevitability and increase perceived control over risk reduction.

Views of health professionals on risk-based breast cancer screening and its implementation in the Spanish National Health System: A qualitative discussion group study

BACKGROUND

With the aim of increasing benefits and decreasing harms, risk-based breast cancer screening has been proposed as an alternative to age-based screening. This study explores barriers and facilitators to implementing a risk-based breast cancer screening program from the perspective of health professionals, in the context of a National Health Service.

METHODS

Socio-constructivist qualitative research carried out in Catalonia (Spain), in the year 2019. Four discussion groups were conducted, with a total of 29 health professionals from primary care, breast cancer screening programs, hospital breast units, epidemiology units, and clinical specialties. A descriptive-interpretive thematic analysis was performed.

RESULTS

Identified barriers included resistance to reducing the number of screening exams for low-risk women; resistance to change for health professionals; difficulties in risk communication; lack of conclusive evidence of the benefits of risk-based screening; limited economic resources; and organizational transformation. Facilitators include benefits of risk-based strategies for high and low-risk women; women's active role in their health care; proximity of women and primary care professionals; experience of health professionals in other screening programs; and greater efficiency of a risk-based screening program. Organizational and administrative changes in the health system, commitment by policy makers, training of health professionals, and educational interventions addressed to the general population will be required.

CONCLUSIONS

Despite the expressed difficulties, participants supported the implementation of risk-based screening. They highlighted its benefits, especially for women at high risk of breast cancer and those under 50 years of age, and assumed a greater efficiency of the risk-based program compared to the aged-based one. Future studies should assess the efficiency and feasibility of risk-based breast cancer screening for its transfer to clinical practice.

Epigenetic Biomarkers for Environmental Exposures and Personalized Breast Cancer Prevention

Environmental and lifestyle factors are believed to account for >80% of breast cancers; however, it is not well understood how and when these factors affect risk and which exposed individuals will actually develop the disease. While alcohol consumption, obesity, and hormone therapy are some known risk factors for breast cancer, other exposures associated with breast cancer risk have not yet been identified or well characterized. In this paper, it is proposed that the identification of blood epigenetic markers for personal, in utero, and ancestral environmental exposures can help researchers better understand known and potential relationships between exposures and breast cancer risk and may enable personalized prevention strategies.

Are we ready for the challenge of implementing risk-based breast cancer screening and primary prevention?

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.

Aromatase expression in atypical ductal hyperplasia in women

PURPOSE

To determine the levels of aromatase in atypical ductal hyperplasia (ADH) lesions, tissue surrounding the ADH, and in dense and non-dense normal breast tissue. We postulated that excess aromatase in breast tissue might, through production of increased estrogen, drive the carcinogenic process. Estrogens and their metabolites are thought to contribute to the development of breast cancer through estrogen receptor-mediated mechanisms and genotoxic effects of estrogen metabolites. ADH is a benign lesion of the breast which is associated with substantially increased risk for subsequent development of breast cancer. After 25 years, approximately 30% of women with ADH develop breast cancer. In women with three or more separate ADH lesions at the same time, 47% will develop breast cancer over that time period. Another important risk factor for breast cancer is the presence of mammographically dense breast tissue.

METHODS

We utilized quantitative immunochemical analysis of aromatase in biopsy tissue to test this possibility. Previously published results comparing dense with non-dense breast tissue in normal women (Vachon et al. Breast Cancer Res Treat 125:243-252, 2011) were used for comparisons with ADH. A well-characterized histochemical H-score was employed for quantitative assessment of aromatase in the various tissue studied.

RESULTS

The H-score of aromatase staining was statistically significantly higher (p = 0.003) in the ADH epithelium than surrounding epithelial tissue. In order of H-score from highest to lowest were ADH, issue surrounding ADH, dense normal and non-dense normal breast tissues. The levels of aromatase in a subset of women with ADH who went on to develop breast cancer were not higher than in women who did not.

CONCLUSIONS

We suggest from these studies that overexpression of aromatase in breast tissue and its resultant increase in estradiol levels may contribute to the later development of breast cancer in women with ADH.

Decision making in the context of breast cancer chemoprevention: patient perceptions and the meaning of risk

Chemoprevention with selective estrogen receptor modulators (SERMs) is considered one of the most promising risk reduction options to date in the United States. Tamoxifen and raloxifene are both approved by the U.S. Food and Drug Administration (FDA) for breast cancer risk reduction. However, despite endorsement from the American Society for Clinical Oncology and the National Comprehensive Cancer Network, uptake remains low. Decision aids have been successful in improving women's understanding and knowledge about the risk-benefit trade-offs in decision making regarding SERMs. However, increased knowledge does not lead to increased uptake of chemoprevention for the purpose of reducing breast cancer risk; instead, women become more reluctant to take medication that is itself associated with risks. Reasons for this include a lack of awareness that SERMs are effective in reducing breast cancer risk, an unwillingness to increase the risk of other disease, reluctance to take a daily medication, and the perception of tamoxifen as a "cancer drug." In studies on hypothetical decision making in the context of chemoprevention women indicate greater willingness to take a SERM when they are determined to be at risk. These findings suggest a differential understanding of what risk means among the general public, health professionals, and researchers. Feeling at risk is related to bodily signs and symptoms and not to population-derived probabilities. Such differential understanding may in part explain women's perception of the low efficacy of SERMs and their decision making regarding SERM use.

Chemoprevention for Breast Cancer

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.

Giving voice to study volunteers: comparing views of mentally ill, physically ill, and healthy protocol participants on ethical aspects of clinical research

MOTIVATION

Ethical controversy surrounds clinical research involving seriously ill participants. While many stakeholders have opinions, the extent to which protocol volunteers themselves see human research as ethically acceptable has not been documented. To address this gap of knowledge, authors sought to assess views of healthy and ill clinical research volunteers regarding the ethical acceptability of human studies involving individuals who are ill or are potentially vulnerable.

METHODS

Surveys and semi-structured interviews were used to query clinical research protocol participants and a comparison group of healthy individuals. A total of 179 respondents participated in this study: 150 in protocols (60 mentally ill, 43 physically ill, and 47 healthy clinical research protocol participants) and 29 healthy individuals not enrolled in protocols. Main outcome measures included responses regarding ethical acceptability of clinical research when it presents significant burdens and risks, involves people with serious mental and physical illness, or enrolls people with other potential vulnerabilities in the research situation.

RESULTS

Respondents expressed decreasing levels of acceptance of participation in research that posed burdens of increasing severity. Participation in protocols with possibly life-threatening consequences was perceived as least acceptable (mean = 1.82, sd = 1.29). Research on serious illnesses, including HIV, cancer, schizophrenia, depression, and post-traumatic stress disorder, was seen as ethically acceptable across respondent groups (range of means = [4.0, 4.7]). Mentally ill volunteers expressed levels of ethical acceptability for physical illness research and mental illness research as acceptable and similar, while physically ill volunteers expressed greater ethical acceptability for physical illness research than for mental illness research. Mentally ill, physically ill, and healthy participants expressed neutral to favorable perspectives regarding the ethical acceptability of clinical research participation by potentially vulnerable subpopulations (difference in acceptability perceived by mentally ill - healthy = -0.04, CI [-0.46, 0.39]; physically ill - healthy = -0.13, CI [-0.62, -.36]).

CONCLUSIONS

Clinical research volunteers and healthy clinical research-"naïve" individuals view studies involving ill people as ethically acceptable, and their responses reflect concern regarding research that poses considerable burdens and risks and research involving vulnerable subpopulations. Physically ill research volunteers may be more willing to see burdensome and risky research as acceptable. Mentally ill research volunteers and healthy individuals expressed similar perspectives in this study, helping to dispel a misconception that those with mental illness should be presumed to hold disparate views.

Seeking balance: decision support needs of women without cancer and a deleterious BRCA1 or BRCA2 mutation

Recommendations for women with a deleterious BRCA1 or BRCA2 gene mutation include complex medical approaches related to cancer risk reduction and detection. Current science has not yet fully elucidated decision support needs that women face when living with medical consequences associated with known hereditary cancer risk. The purpose of this study was to describe health communication and decision support needs in healthy women with BRCA1/2 gene mutations. The original researchers completed an interpretive secondary qualitative data analysis of 23 phenomenological narratives collected between 2008 and 2010. The Ottawa Decision Support and Patient Centered Communication frameworks guided the study design and analysis. Women described a pattern wherein breast and ovarian cancer risk, health related recommendations and decisions, and personal values were prioritized over time based on life contexts. Knowing versus acting on cancer risk was not a static process but an ongoing balancing act of considering current and future personal and medical values, further compounded by the complexity of recommendations. Women shared stories of anticipatory, physical and psychosocial consequences of the decision making experience. The findings have potential to generate future research questions and guide intervention development. Importantly, findings indicate a need for ongoing, long-term, support from genetics professionals and decision support interventions, which challenges the current practice paradigm.

Preferences for the "screen and treat" strategy of Helicobacter pylori to prevent gastric cancer in healthy Korean populations

BACKGROUND

Helicobacter pylori (HP) eradication may reduce the risk of gastric cancer, and professional guidelines recommend eradication based on patients' preference. However, little data exist regarding individual's preference for HP eradication to prevent gastric cancer. We explored healthy Korean populations' preference for HP "screen and treat" strategy and its associated factors.

METHODS

We conducted a cross-sectional survey with 604 healthy adults expected to undergo screening esophagogastroduodenoscopy during routine health checkups. Survey packages-including a decision aid about "screen and treat" strategy for the HP eradication-were sent to the eligible people 1-3 weeks before the health checkup. Within the survey package, we first assessed people's knowledge and experience with HP test and treatment, provided the decision aid, and evaluated participants' preference for screening and treatment for HP to prevent gastric cancer.

RESULTS

With the provision of the decision aid, most participants (73.7%) opted for the "screen and treat" strategy. Having family member(s) with gastric cancer (adjusted odds ratio (aOR) = 2.28; 95% confidence interval (CI), 1.16-4.47), previous treatment history of HP (aOR = 2.70; 95% CI, 1.38-5.29), and higher baseline knowledge (aOR = 1.16; 95% CI, 1.07-1.26) were significantly associated with accepting the strategy. Most participants (71.4%)-and even individuals who did not choose "screen and treat" strategy-agreed with the provision with the decision aid.

CONCLUSIONS

Individuals preferred to take the "screen and treat" strategy for the prevention of gastric cancer. Further intervention study is warranted to see if implementation of decisional support would improve decision quality and patient outcomes.

Intentions for bilateral mastectomy among newly diagnosed breast cancer patients

BACKGROUND

Recent trends suggest that bilateral mastectomy (BM) is on the rise among women diagnosed with unilateral breast cancer. Few studies have investigated the factors associated with the decision to have more aggressive surgery among young, high risk patients.

METHODS

As part of a larger study, 284 women aged 50 and under completed an initial survey within 6 weeks of a breast cancer diagnosis. We assessed sociodemographics, medical and family history variables, treatment recommendations, preferences and concerns, distress, perceived risk, knowledge, and neuroticism. We used multiple regression with backward entry to assess the relationship between these variables and our outcomes of decisional conflict and intentions for BM.

RESULTS

Higher decisional conflict was associated with being less educated, unmarried, more anxious and less likely to have received a surgical recommendation. Preference for BM was associated with higher neuroticism, perceived risk for contralateral breast cancer, pre-testing risk of carrying a BRCA1/2 mutation, having received either a surgical recommendation (vs. no recommendation), and lower preference for lumpectomy.

CONCLUSIONS

For younger women, a surgical recommendation is associated with lower decisional conflict and stronger intention for BM. Results highlight the importance of effective risk communication and decision support between a woman and her surgeon.

Premenopausal serum androgens and breast cancer risk: a nested case-control study

INTRODUCTION

Prospective epidemiologic studies have consistently shown that levels of circulating androgens in postmenopausal women are positively associated with breast cancer risk. However, data in premenopausal women are limited.

METHODS

A case-control study nested within the New York University Women's Health Study was conducted. A total of 356 cases (276 invasive and 80 in situ) and 683 individually-matched controls were included. Matching variables included age and date, phase, and day of menstrual cycle at blood donation. Testosterone, androstenedione, dehydroandrosterone sulfate (DHEAS) and sex hormone-binding globulin (SHBG) were measured using direct immunoassays. Free testosterone was calculated.

RESULTS

Premenopausal serum testosterone and free testosterone concentrations were positively associated with breast cancer risk. In models adjusted for known risk factors of breast cancer, the odds ratios for increasing quintiles of testosterone were 1.0 (reference), 1.5 (95% confidence interval (CI), 0.9 to 2.3), 1.2 (95% CI, 0.7 to 1.9), 1.4 (95% CI, 0.9 to 2.3) and 1.8 (95% CI, 1.1 to 2.9; Ptrend = 0.04), and for free testosterone were 1.0 (reference), 1.2 (95% CI, 0.7 to 1.8), 1.5 (95% CI, 0.9 to 2.3), 1.5 (95% CI, 0.9 to 2.3), and 1.8 (95% CI, 1.1 to 2.8, Ptrend = 0.01). A marginally significant positive association was observed with androstenedione (P = 0.07), but no association with DHEAS or SHBG. Results were consistent in analyses stratified by tumor type (invasive, in situ), estrogen receptor status, age at blood donation, and menopausal status at diagnosis. Intra-class correlation coefficients for samples collected from 0.8 to 5.3 years apart (median 2 years) in 138 cases and 268 controls were greater than 0.7 for all biomarkers except for androstenedione (0.57 in controls).

CONCLUSIONS

Premenopausal concentrations of testosterone and free testosterone are associated with breast cancer risk. Testosterone and free testosterone measurements are also highly reliable (that is, a single measurement is reflective of a woman's average level over time). Results from other prospective studies are consistent with our results. The impact of including testosterone or free testosterone in breast cancer risk prediction models for women between the ages of 40 and 50 years should be assessed. Improving risk prediction models for this age group could help decision making regarding both screening and chemoprevention of breast cancer.

How do women at increased, but unexplained, familial risk of breast cancer perceive and manage their risk? A qualitative interview study

Background

The perception of breast cancer risk held by women who have not had breast cancer, and who are at increased, but unexplained, familial risk of breast cancer is poorly described. This study aims to describe risk perception and how it is related to screening behaviour for these women.

Methods

Participants were recruited from a population-based sample (the Australian Breast Cancer Family Study - ABCFS). The ABCFS includes women diagnosed with breast cancer and their relatives. For this study, women without breast cancer with at least one first- or second-degree relative diagnosed with breast cancer before age 50 were eligible unless a BRCA1 or BRCA2 mutation had been identified in their family. Data collection consisted of an audio recorded, semi-structured interview on the topic of breast cancer risk and screening decision-making. Data was analysed thematically.

Results

A total of 24 interviews were conducted, and saturation of the main themes was achieved. Women were classified into one of five groups: don't worry about cancer risk, but do screening; concerned about cancer risk, so do something; concerned about cancer risk, so why don't I do anything?; cancer inevitable; cancer unlikely.

Conclusions

The language and framework women use to describe their risk of breast cancer must be the starting point in attempts to enhance women's understanding of risk and their prevention behaviour.

Reasons for risk-reducing mastectomy versus MRI-screening in a cohort of women at high hereditary risk of breast cancer

OBJECTIVE

To determine the reasons that motivate women in a cohort of women under intensive surveillance for breast cancer to undergo risk-reducing mastectomy (RRM).

PATIENTS AND METHODS

Women with a BRCA1 or BRCA2 mutation who were enrolled in an MRI-based breast screening study were eligible to participate in this survey. A self-administered questionnaire was given to women who did, and who did not terminate annual MRI-based surveillance in order to undergo RRM. The questionnaire included information on family history, risk perception and satisfaction with screening. In addition, women were asked to provide the principal reason for their choice of having preventive surgery or not, and were asked about their satisfaction with this choice.

RESULTS

246 women without breast cancer participated in the study. Of these, 39 women (16%) elected to have RRM at some point after initiating screening. Although women who had a mother or sister with breast cancer were more likely to opt for RRM than were women with no affected first-degree relative (21% versus 10%) this did not reach statistical significance. Women who perceived their breast cancer risk to be greater than 50% were more likely to opt for RRM than were women who estimated their risk to be less than 50% (19% versus 6%). Fear of cancer was the most common reason cited for choosing to have RRM (38% of respondents) followed by having had a previous cancer, (25%), then concern over their children (16%).

CONCLUSION

Among women with a BRCA mutation who are enrolled in an MRI-based screening program, a high perception of personal breast cancer risk and a history of breast cancer in a first-degree relative are predictors of the decision to have RRM.