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Wright SJ, Gray E, Rogers G, Donten A, Payne K. A structured process for the validation of a decision-analytic model: application to a cost-effectiveness model for risk-stratified national breast screening. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024:10.1007/s40258-024-00887-z. [PMID: 38755403 DOI: 10.1007/s40258-024-00887-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Decision-makers require knowledge of the strengths and weaknesses of decision-analytic models used to evaluate healthcare interventions to be able to confidently use the results of such models to inform policy. A number of aspects of model validity have previously been described, but no systematic approach to assessing the validity of a model has been proposed. This study aimed to consolidate the different aspects of model validity into a step-by-step approach to assessing the strengths and weaknesses of a decision-analytic model. METHODS A pre-defined set of steps were used to conduct the validation process of an exemplar early decision-analytic-model-based cost-effectiveness analysis of a risk-stratified national breast cancer screening programme [UK healthcare perspective; lifetime horizon; costs (£; 2021)]. Internal validation was assessed in terms of descriptive validity, technical validity and face validity. External validation was assessed in terms of operational validation, convergent validity (or corroboration) and predictive validity. RESULTS The results outline the findings of each step of internal and external validation of the early decision-analytic-model and present the validated model (called 'MANC-RISK-SCREEN'). The positive aspects in terms of meeting internal validation requirements are shown together with the remaining limitations of MANC-RISK-SCREEN. CONCLUSION Following a transparent and structured validation process, MANC-RISK-SCREEN has been shown to have satisfactory internal and external validity for use in informing resource allocation decision-making. We suggest that MANC-RISK-SCREEN can be used to assess the cost-effectiveness of exemplars of risk-stratified national breast cancer screening programmes (NBSP) from the UK perspective. IMPLICATIONS A step-by-step process for conducting the validation of a decision-analytic model was developed for future use by health economists. Using this approach may help researchers to fully demonstrate the strengths and limitations of their model to decision-makers.
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Affiliation(s)
- Stuart J Wright
- Division of Population Health, Health Services Research and Primary Care, Manchester Centre for Health Economics, The University of Manchester, Oxford Road, Manchester, M139PL, UK.
| | - Ewan Gray
- GRAIL, New Penderel House 4th Floor, 283-288 High Holborn, London, WC1V 7HP, UK
| | - Gabriel Rogers
- Division of Population Health, Health Services Research and Primary Care, Manchester Centre for Health Economics, The University of Manchester, Oxford Road, Manchester, M139PL, UK
| | - Anna Donten
- Division of Population Health, Health Services Research and Primary Care, Manchester Centre for Health Economics, The University of Manchester, Oxford Road, Manchester, M139PL, UK
| | - Katherine Payne
- Division of Population Health, Health Services Research and Primary Care, Manchester Centre for Health Economics, The University of Manchester, Oxford Road, Manchester, M139PL, UK
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Mao X, He W, Eriksson M, Lindström LS, Holowko N, Bajalica-Lagercrantz S, Hammarström M, Grassmann F, Humphreys K, Easton D, Hall P, Czene K. Prediction of breast cancer risk for sisters of women attending screening. J Natl Cancer Inst 2023; 115:1310-1317. [PMID: 37243694 PMCID: PMC10637039 DOI: 10.1093/jnci/djad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/17/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Risk assessment is important for breast cancer prevention and early detection. We aimed to examine whether common risk factors, mammographic features, and breast cancer risk prediction scores of a woman were associated with breast cancer risk for her sisters. METHODS We included 53 051 women from the Karolinska Mammography Project for Risk Prediction of Breast Cancer (KARMA) study. Established risk factors were derived using self-reported questionnaires, mammograms, and single nucleotide polymorphism genotyping. Using the Swedish Multi-Generation Register, we identified 32 198 sisters of the KARMA women (including 5352 KARMA participants and 26 846 nonparticipants). Cox models were used to estimate the hazard ratios of breast cancer for both women and their sisters, respectively. RESULTS A higher breast cancer polygenic risk score, a history of benign breast disease, and higher breast density in women were associated with an increased risk of breast cancer for both women and their sisters. No statistically significant association was observed between breast microcalcifications and masses in women and breast cancer risk for their sisters. Furthermore, higher breast cancer risk scores in women were associated with an increased risk of breast cancer for their sisters. Specifically, the hazard ratios for breast cancer per 1 standard deviation increase in age-adjusted KARMA, Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA), and Tyrer-Cuzick risk scores were 1.16 (95% confidence interval [CI] = 1.07 to 1.27), 1.23 (95% CI = 1.12 to 1.35), and 1.21 (95% CI = 1.11 to 1.32), respectively. CONCLUSION A woman's breast cancer risk factors are associated with her sister's breast cancer risk. However, the clinical utility of these findings requires further investigation.
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Affiliation(s)
- Xinhe Mao
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Wei He
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Chronic Disease Research Institute, The Children’s Hospital, and National Clinical Research Center for Child Health, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Department of Nutrition and Food Hygiene, School of Public Health, Zhejiang University, Hangzhou, Zhejiang, China
| | - Mikael Eriksson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Linda S Lindström
- Department of Oncology-Pathology, Karolinska Institutet and Hereditary Cancer Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Natalie Holowko
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Svetlana Bajalica-Lagercrantz
- Department of Oncology-Pathology, Karolinska Institutet and Hereditary Cancer Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Mattias Hammarström
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Felix Grassmann
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Institute for Clinical Research and Systems Medicine, Health and Medical University, Potsdam, Germany
| | - Keith Humphreys
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Douglas Easton
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Roberts E, van Veen EM, Byers H, Barnett-Griness O, Gronich N, Lejbkowicz F, Pinchev M, Smith MJ, Howell A, Newman WG, Woodward ER, Harkness EF, Brentnall AR, Cuzick J, Rennert G, Howell SJ, Evans DG. Breast cancer polygenic risk scores derived in White European populations are not calibrated for women of Ashkenazi Jewish descent. Genet Med 2023; 25:100846. [PMID: 37061873 DOI: 10.1016/j.gim.2023.100846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/17/2023] Open
Abstract
PURPOSE Polygenic risk scores (PRSs) are a major component of accurate breast cancer (BC) risk prediction but require ethnicity-specific calibration. Ashkenazi Jewish (AJ) population is assumed to be of White European (WE) origin in some commercially available PRSs despite differing effect allele frequencies (EAFs). We conducted a case-control study of WE and AJ women from the Predicting Risk of Cancer at Screening Study. The Breast Cancer in Northern Israel Study provided a separate AJ population-based case-control validation series. METHODS All women underwent Illumina OncoArray single-nucleotide variation (SNV; formerly single-nucleotide polymorphism [SNP]) analysis. Two PRSs were assessed, SNV142 and SNV78. A total of 221 of 2243 WE women (discovery: cases = 111; controls = 110; validation: cases = 651; controls = 1772) and 221 AJ women (cases = 121; controls = 110) were included from the UK study; the Israeli series consisted of 2045 AJ women (cases = 1331; controls = 714). EAFs were obtained from the Genome Aggregation Database. RESULTS In the UK study, the mean SNV142 PRS demonstrated good calibration and discrimination in WE population, with mean PRS of 1.33 (95% CI 1.18-1.48) in cases and 1.01 (95% CI 0.89-1.13) in controls. In AJ women from Manchester, the mean PRS of 1.54 (1.38-1.70) in cases and 1.20 (1.08-1.32) in controls demonstrated good discrimination but overestimation of BC relative risk. After adjusting for EAFs for the AJ population, mean risk was corrected (mean SNV142 PRS cases = 1.30 [95% CI 1.16-1.44] and controls = 1.02 [95% CI 0.92-1.12]). This was recapitulated in the larger Israeli data set with good discrimination (area under the curve = 0.632 [95% CI 0.607-0.657] for SNV142). CONCLUSION AJ women should not be given BC relative risk predictions based on PRSs calibrated to EAFs from the WE population. PRSs need to be recalibrated using AJ-derived EAFs. A simple recalibration using the mean PRS adjustment ratio likely performs well.
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Affiliation(s)
- Eleanor Roberts
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Elke M van Veen
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom; Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Helen Byers
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom; Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Ofra Barnett-Griness
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Naomi Gronich
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Flavio Lejbkowicz
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Mila Pinchev
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Miriam J Smith
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom; Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Anthony Howell
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; Nightingale/Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Manchester Breast Centre, Manchester Cancer Research Centre, The Christie Hospital, Manchester, United Kingdom
| | - William G Newman
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom; Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Emma R Woodward
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom; Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Elaine F Harkness
- Nightingale/Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Informatics, Imaging & Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Adam R Brentnall
- Queen Mary University of London, Centre for Cancer Prevention, Wolfson Institute of Population Health, Charterhouse Square, London, United Kingdom
| | - Jack Cuzick
- Queen Mary University of London, Centre for Cancer Prevention, Wolfson Institute of Population Health, Charterhouse Square, London, United Kingdom
| | - Gad Rennert
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Sacha J Howell
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; Nightingale/Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Manchester Breast Centre, Manchester Cancer Research Centre, The Christie Hospital, Manchester, United Kingdom
| | - D Gareth Evans
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom; Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; Nightingale/Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Manchester Breast Centre, Manchester Cancer Research Centre, The Christie Hospital, Manchester, United Kingdom.
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McWilliams L, Ruane H, Ulph F, Woof VG, Harrison F, Evans DG, French DP. What do women think about having received their breast cancer risk as part of a risk-stratified NHS Breast Screening Programme? A qualitative study. Br J Cancer 2023; 129:356-365. [PMID: 37225893 PMCID: PMC10206350 DOI: 10.1038/s41416-023-02268-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Risk-stratified screening is being considered for national breast screening programmes. It is unclear how women experience risk-stratified screening and receipt of breast cancer risk information in real time. This study aimed to explore the psychological impact of undergoing risk-stratified screening within England's NHS Breast Screening Programme. METHODS Individual telephone interviews were conducted with 40 women who participated in the BC-Predict study and received a letter indicating their estimated breast cancer risk as one of four risk categories: low (<2% 10-year risk), average (2-4.99%), above average (moderate; 5-7.99%) or high (≥8%). Audio-recorded interview transcriptions were analysed using reflexive thematic analysis. RESULTS Two themes were produced: 'From risk expectations to what's my future health story?' highlights that women overall valued the opportunity to receive risk estimates; however, when these were discordant with perceived risk, this causes temporary distress or rejection of the information. 'Being a good (woman) citizen' where women felt positive contributing to society but may feel judged if they then cannot exert agency over the management of their risk or access follow-up support CONCLUSIONS: Risk-stratified breast screening was generally accepted without causing long-lasting distress; however, issues related to risk communication and access to care pathways need to be considered for implementation.
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Affiliation(s)
- Lorna McWilliams
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Oxford Road, M13 9PL, Manchester, UK.
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.
| | - Helen Ruane
- Nightingale & Prevent Breast Cancer Research Unit, Manchester University NHS Foundation Trust (MFT), Southmoor Road, Wythenshawe, M23 9LT, Manchester, UK
| | - Fiona Ulph
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Oxford Road, M13 9PL, Manchester, UK
| | - Victoria G Woof
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Oxford Road, M13 9PL, Manchester, UK
| | | | - D Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Nightingale & Prevent Breast Cancer Research Unit, Manchester University NHS Foundation Trust (MFT), Southmoor Road, Wythenshawe, M23 9LT, Manchester, UK
- Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England
| | - David P French
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Oxford Road, M13 9PL, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England
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5
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Squires S, Harkness EF, Evans DG, Astley SM. The effect of variable labels on deep learning models trained to predict breast density. Biomed Phys Eng Express 2023; 9:035030. [PMID: 37023727 PMCID: PMC10114494 DOI: 10.1088/2057-1976/accaea] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 03/28/2023] [Accepted: 04/06/2023] [Indexed: 04/08/2023]
Abstract
Purpose. High breast density is associated with reduced efficacy of mammographic screening and increased risk of developing breast cancer. Accurate and reliable automated density estimates can be used for direct risk prediction and passing density related information to further predictive models. Expert reader assessments of density show a strong relationship to cancer risk but also inter-reader variation. The effect of label variability on model performance is important when considering how to utilise automated methods for both research and clinical purposes.Methods. We utilise subsets of images with density labels from the same 13 readers and 12 reader pairs, and train a deep transfer learning model which is used to assess how label variability affects the mapping from representation to prediction. We then create two end-to-end models: one that is trained on averaged labels across the reader pairs and the second that is trained using individual reader scores, with a novel alteration to the objective function. The combination of these two end-to-end models allows us to investigate the effect of label variability on the model representation formed.Results. We show that the trained mappings from representations to labels are altered considerably by the variability of reader scores. Training on labels with distribution variation removed causes the Spearman rank correlation coefficients to rise from 0.751 ± 0.002 to either 0.815 ± 0.026 when averaging across readers or 0.844 ± 0.002 when averaging across images. However, when we train different models to investigate the representation effect we see little difference, with Spearman rank correlation coefficients of 0.846 ± 0.006 and 0.850 ± 0.006 showing no statistically significant difference in the quality of the model representation with regard to density prediction.Conclusions. We show that the mapping between representation and mammographic density prediction is significantly affected by label variability. However, the effect of the label variability on the model representation is limited.
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Gareth Evans D, McWilliams L, Astley S, Brentnall AR, Cuzick J, Dobrashian R, Duffy SW, Gorman LS, Harkness EF, Harrison F, Harvie M, Jerrison A, Machin M, Maxwell AJ, Howell SJ, Wright SJ, Payne K, Qureshi N, Ruane H, Southworth J, Fox L, Bowers S, Hutchinson G, Thorpe E, Ulph F, Woof V, Howell A, French DP. Quantifying the effects of risk-stratified breast cancer screening when delivered in real time as routine practice versus usual screening: the BC-Predict non-randomised controlled study (NCT04359420). Br J Cancer 2023; 128:2063-2071. [PMID: 37005486 PMCID: PMC10066938 DOI: 10.1038/s41416-023-02250-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/28/2023] [Accepted: 03/20/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Risk stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) could provide a better balance of benefits and harms. We developed BC-Predict, to offer women when invited to the NHSBSP, which collects standard risk factor information; mammographic density; and in a sub-sample, a Polygenic Risk Score (PRS). METHODS Risk prediction was estimated primarily from self-reported questionnaires and mammographic density using the Tyrer-Cuzick risk model. Women eligible for NHSBSP were recruited. BC-Predict produced risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5-<8% 10-year) to have appointments to discuss prevention and additional screening. RESULTS Overall uptake of BC-Predict in screening attendees was 16.9% with 2472 consenting to the study; 76.8% of those received risk feedback within the 8-week timeframe. Recruitment was 63.2% with an onsite recruiter and paper questionnaire compared to <10% with BC-Predict only (P < 0.0001). Risk appointment attendance was highest for those at high risk (40.6%); 77.5% of those opted for preventive medication. DISCUSSION We have shown that a real-time offer of breast cancer risk information (including both mammographic density and PRS) is feasible and can be delivered in reasonable time, although uptake requires personal contact. Preventive medication uptake in women newly identified at high risk is high and could improve the cost-effectiveness of risk stratification. TRIAL REGISTRATION Retrospectively registered with clinicaltrials.gov (NCT04359420).
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Affiliation(s)
- D Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England.
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England.
- Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, England.
| | - Lorna McWilliams
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - Susan Astley
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Adam R Brentnall
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, England
| | - Jack Cuzick
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, England
| | - Richard Dobrashian
- East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital, Haslingden Road, Lancashire, BB2 3HH, Manchester, England
| | - Stephen W Duffy
- Centre for Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, England
| | - Louise S Gorman
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, M13 9PL, England
| | - Elaine F Harkness
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | | | - Michelle Harvie
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
| | - Andrew Jerrison
- Research IT, IT Services, University of Manchester, Manchester, M13 9PL, England
| | - Matthew Machin
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Anthony J Maxwell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
| | - Sacha J Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, England
| | - Stuart J Wright
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, England
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, England
| | - Nadeem Qureshi
- Primary Care Stratified Medicine research group, Centre for Academic Primary Care, University of Nottingham, University Park, Nottingham, NG7 2RD, England
| | - Helen Ruane
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Jake Southworth
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Lynne Fox
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Sarah Bowers
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Gillian Hutchinson
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Emma Thorpe
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Fiona Ulph
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - Victoria Woof
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - Anthony Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, England
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, England
| | - David P French
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
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7
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French DP, McWilliams L, Bowers S, Woof VG, Harrison F, Ruane H, Hendy A, Evans DG. Psychological impact of risk-stratified screening as part of the NHS Breast Screening Programme: multi-site non-randomised comparison of BC-Predict versus usual screening (NCT04359420). Br J Cancer 2023; 128:1548-1558. [PMID: 36774447 PMCID: PMC9922101 DOI: 10.1038/s41416-023-02156-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Adding risk stratification to standard screening via the NHS Breast Screening Programme (NHSBSP) allows women at higher risk to be offered additional prevention and screening options. It may, however, introduce new harms such as increasing cancer worry. The present study aimed to assess whether there were differences in self-reported harms and benefits between women offered risk stratification (BC-Predict) compared to women offered standard NHSBSP, controlling for baseline values. METHODS As part of the larger PROCAS2 study (NCT04359420), 5901 women were offered standard NHSBSP or BC-Predict at the invitation to NHSBSP. Women who took up BC-Predict received 10-year risk estimates: "high" (≥8%), "above average (moderate)" (5-7.99%), "average" (2-4.99%) or "below average (low)" (<2%) risk. A subset of 662 women completed questionnaires at baseline and at 3 months (n = 511) and 6 months (n = 473). RESULTS State anxiety and cancer worry scores were low with no differences between women offered BC-Predict or NHSBSP. Women offered BC-Predict and informed of being at higher risk reported higher risk perceptions and cancer worry than other women, but without reaching clinical levels. CONCLUSIONS Concerns that risk-stratified screening will produce harm due to increases in general anxiety or cancer worry are unfounded, even for women informed that they are at high risk.
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Affiliation(s)
- David P. French
- grid.5379.80000000121662407Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL England ,grid.498924.a0000 0004 0430 9101NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England ,grid.5379.80000000121662407Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ England
| | - Lorna McWilliams
- grid.5379.80000000121662407Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL England ,grid.498924.a0000 0004 0430 9101NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Sarah Bowers
- grid.498924.a0000 0004 0430 9101The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT England
| | - Victoria G. Woof
- grid.5379.80000000121662407Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL England
| | | | - Helen Ruane
- grid.498924.a0000 0004 0430 9101The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT England
| | - Alice Hendy
- grid.498924.a0000 0004 0430 9101The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT England
| | - D. Gareth Evans
- grid.498924.a0000 0004 0430 9101NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England ,grid.5379.80000000121662407Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ England ,grid.498924.a0000 0004 0430 9101The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT England ,grid.5379.80000000121662407Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL England
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Usher-Smith JA, Hindmarch S, French DP, Tischkowitz M, Moorthie S, Walter FM, Dennison RA, Stutzin Donoso F, Archer S, Taylor L, Emery J, Morris S, Easton DF, Antoniou AC. Proactive breast cancer risk assessment in primary care: a review based on the principles of screening. Br J Cancer 2023; 128:1636-1646. [PMID: 36737659 PMCID: PMC9897164 DOI: 10.1038/s41416-023-02145-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that women at moderate or high risk of breast cancer be offered risk-reducing medication and enhanced breast screening/surveillance. In June 2022, NICE withdrew a statement recommending assessment of risk in primary care only when women present with concerns. This shift to the proactive assessment of risk substantially changes the role of primary care, in effect paving the way for a primary care-based screening programme to identify those at moderate or high risk of breast cancer. In this article, we review the literature surrounding proactive breast cancer risk assessment within primary care against the consolidated framework for screening. We find that risk assessment for women under 50 years currently satisfies many of the standard principles for screening. Most notably, there are large numbers of women at moderate or high risk currently unidentified, risk models exist that can identify those women with reasonable accuracy, and management options offer the opportunity to reduce breast cancer incidence and mortality in that group. However, there remain a number of uncertainties and research gaps, particularly around the programme/system requirements, that need to be addressed before these benefits can be realised.
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Affiliation(s)
- Juliet A. Usher-Smith
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hindmarch
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Marc Tischkowitz
- grid.5335.00000000121885934Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Sowmiya Moorthie
- grid.5335.00000000121885934PHG Foundation, University of Cambridge, Cambridge, UK
| | - Fiona M. Walter
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca A. Dennison
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francisca Stutzin Donoso
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Psychology, University of Cambridge, Cambridge, UK
| | - Lily Taylor
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- grid.1008.90000 0001 2179 088XCentre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC Australia
| | - Stephen Morris
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Antonis C. Antoniou
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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9
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Roberts E, Howell S, Evans DG. Polygenic risk scores and breast cancer risk prediction. Breast 2023; 67:71-77. [PMID: 36646003 PMCID: PMC9982311 DOI: 10.1016/j.breast.2023.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/11/2023] Open
Abstract
Polygenic Risk Scores (PRS) are a major component of accurate breast cancer risk prediction and have the potential to improve screening and prevention strategies. PRS combine the risk from Single nucleotide polymorphisms (SNPs) associated with breast cancer in Genome Wide Association Studies (GWAS) and explain over 30% of breast cancer heritability. When incorporated into risk models, the more personalised risk assessment derived from PRS, help identify women at higher risk of breast cancer development and enables the implementation of stratified screening and prevention approaches. This review describes the role of PRS in breast cancer risk prediction including the development of PRS and their clinical application. We have also examined the role of PRS within more well-established risk prediction models which incorporate known classic risk factors and discuss the interaction of PRS with these factors and their capacity to predict breast cancer subtypes. Before PRS can be implemented on a population-wide scale, there are several challenges that must be addressed. Perhaps the most pressing of these is the use of PRS in women of non-White European origin, where PRS have been shown to have attenuated risk prediction both in discrimination and calibration. We discuss progress in developing and applying PRS in non-white European populations. PRS represent a significant advance in breast cancer risk prediction and their further development will undoubtedly enhance personalisation.
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Affiliation(s)
- Eleanor Roberts
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Sacha Howell
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Nightingale/Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, The Christie Hospital, Manchester, UK
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Nightingale/Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, The Christie Hospital, Manchester, UK.
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10
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Hawkins R, McWilliams L, Ulph F, Evans DG, French DP. Healthcare professionals' views following implementation of risk stratification into a national breast cancer screening programme. BMC Cancer 2022; 22:1058. [PMID: 36224549 PMCID: PMC9555254 DOI: 10.1186/s12885-022-10134-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background It is crucial to determine feasibility of risk-stratified screening to facilitate successful implementation. We introduced risk-stratification (BC-Predict) into the NHS Breast Screening Programme (NHSBSP) at three screening sites in north-west England from 2019 to 2021. The present study investigated the views of healthcare professionals (HCPs) on acceptability, barriers, and facilitators of the BC-Predict intervention and on the wider implementation of risk-based screening after BC-Predict was implemented in their screening site. Methods Fourteen semi-structured interviews were conducted with HCPs working across the breast screening pathway at three NHSBSP sites that implemented BC-Predict. Thematic analysis interpreted the data. Results Three pre-decided themes were produced. (1) Acceptability of risk-based screening: risk-stratification was perceived as a beneficial step for both services and women. HCPs across the pathway reported low burden of running the BC-Predict trial on routine tasks, but with some residual concerns; (2) Barriers to implementation: comprised capacity constraints of services including the inadequacy of current IT systems to manage women with different risk profiles and, (3) Facilitators to implementation: included the continuation of stakeholder consultation across the pathway to inform implementation and need for dedicated risk screening admin staff, a push for mammography staff recruitment and guidance for screening services. Telephone helplines, integrating primary care, and supporting access for all language needs was emphasised. Conclusion Risk-stratified breast screening was viewed as a progressive step providing it does not worsen inequalities for women. Implementation of risk-stratified breast screening requires staff to be reassured that there will be systems in place to support implementation and that it will not further burden their workload. Next steps require a comprehensive assessment of the resource needed for risk-stratification versus current resource availability, upgrades to screening IT and building screening infrastructure. The role of primary care needs to be determined. Simplification and clarification of risk-based screening pathways is needed to support HCPs agency and facilitate implementation. Forthcoming evidence from ongoing randomised controlled trials assessing effectiveness of breast cancer risk-stratification will also determine implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10134-0.
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Affiliation(s)
- Rachel Hawkins
- The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, UK. .,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England.
| | - Lorna McWilliams
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Fiona Ulph
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - D Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England.,Nightingale & Prevent Breast Cancer Research Unit, Manchester University NHS Foundation Trust, Southmoor Road, M23 9LT, Wythenshawe, Manchester, UK.,Department of Genomic Medicine, Division of Evolution and Genomic Science, Manchester Academic Health Science Centre, University of Manchester, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL, Manchester, UK
| | - David P French
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England
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11
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McWilliams L, Evans DG, Payne K, Harrison F, Howell A, Howell SJ, French DP. Implementing Risk-Stratified Breast Screening in England: An Agenda Setting Meeting. Cancers (Basel) 2022; 14:cancers14194636. [PMID: 36230559 PMCID: PMC9563640 DOI: 10.3390/cancers14194636] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
It is now possible to accurately assess breast cancer risk at routine NHS Breast Screening Programme (NHSBSP) appointments, provide risk feedback and offer risk management strategies to women at higher risk. These strategies include National Institute for Health and Care Excellence (NICE) approved additional breast screening and risk-reducing medication. However, the NHSBSP invites nearly all women three-yearly, regardless of risk. In March 2022, a one-day agenda setting meeting took place in Manchester to discuss the feasibility and desirability of implementation of risk-stratified screening in the NHSBSP. Fifty-eight individuals participated (38 face-to-face, 20 virtual) with relevant expertise from academic, clinical and/or policy-making perspectives. Key findings were presented from the PROCAS2 NIHR programme grant regarding feasibility of risk-stratified screening in the NHSBSP. Participants discussed key uncertainties in seven groups, followed by a plenary session. Discussions were audio-recorded and thematically analysed to produce descriptive themes. Five themes were developed: (i) risk and health economic modelling; (ii) health inequalities and communication with women; (iii); extending screening intervals for low-risk women; (iv) integration with existing NHSBSP; and (v) potential new service models. Most attendees expected some form of risk-stratified breast screening to be implemented in England and collectively identified key issues to be resolved to facilitate this.
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Affiliation(s)
- Lorna McWilliams
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Correspondence:
| | - D. Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Genomic Medicine, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
| | - Katherine Payne
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Manchester Centre for Health Economics, School of Health Sciences, Faculty of Biology Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | | | - Anthony Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Sacha J. Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - David P. French
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
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12
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Lippey J, Keogh L, Campbell I, Mann GB, Forrest L. Development and pilot testing of an online decision aid for women considering risk-stratified breast screening. J Community Genet 2022; 13:137-141. [DOI: 10.1007/s12687-021-00571-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 12/11/2021] [Indexed: 11/27/2022] Open
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13
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Bonnet E, Daures JP, Landais P. Determination of thresholds of risk in women at average risk of breast cancer to personalize the organized screening program. Sci Rep 2021; 11:19104. [PMID: 34580360 PMCID: PMC8476568 DOI: 10.1038/s41598-021-98604-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 09/06/2021] [Indexed: 11/08/2022] Open
Abstract
In France, more than 10 million women at "average" risk of breast cancer (BC), are included in the organized BC screening. Existing predictive models of BC risk are not adapted to the French population. Thus, we set up a new score in the French Hérault region and looked for subgroups at a graded level of risk in women at "average" risk. We recruited a retrospective cohort of women, aged 50 to 60, who underwent the organized BC screening, and included 2241 non-cancer women and 527 who developed a BC during a 12-year follow-up period (2006-2018). The risk factors identified were high breast density (ACR BI-RADS grading)(B vs A: HR = 1.41, 95%CI [1.05; 1.9], p = 0.023; C vs A: HR = 1.65 [1.2; 2.27], p = 0.02 ; D vs A: HR = 2.11 [1.25;3.58], p = 0.006), a history of maternal breast cancer (HR = 1.61 [1.24; 2.09], p < 0.001), and socioeconomic difficulties (HR 1.23 [1.09; 1.55], p = 0.003). While early menopause (HR = 0.36 [0.13; 0.99], p = 0.003) and an age at menarche after 12 years (HR = 0.77 [0.63; 0.95], p = 0.047) were protective factors. We identified 3 groups at risk: lower, average, and higher, respectively. A low threshold was characterized at 1.9% of 12-year risk and a high threshold at 4.5% 12-year risk. Mean 12-year risks in the 3 groups of risk were 1.37%, 2.68%, and 5.84%, respectively. Thus, 12% of women presented a level of risk different from the average risk group, corresponding to 600,000 women involved in the French organized BC screening, enabling to propose a new strategy to personalize the national BC screening. On one hand, for women at lower risk, we proposed to reduce the frequency of mammograms and on the other hand, for women at higher risk, we suggested intensifying surveillance.
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Affiliation(s)
- Emmanuel Bonnet
- Montpellier University, EA2415, Institut Universitaire de recherche clinique, 34093, Montpellier Cedex 5, France.
- Languedoc Mutualité, Nouvelles Technologies, AESIO, Montpellier, France.
| | - Jean-Pierre Daures
- Montpellier University, EA2415, Institut Universitaire de recherche clinique, 34093, Montpellier Cedex 5, France
- Languedoc Mutualité, Nouvelles Technologies, AESIO, Montpellier, France
| | - Paul Landais
- Montpellier University, EA2415, Institut Universitaire de recherche clinique, 34093, Montpellier Cedex 5, France
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14
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Li SX, Milne RL, Nguyen-Dumont T, Wang X, English DR, Giles GG, Southey MC, Antoniou AC, Lee A, Li S, Winship I, Hopper JL, Terry MB, MacInnis RJ. Prospective Evaluation of the Addition of Polygenic Risk Scores to Breast Cancer Risk Models. JNCI Cancer Spectr 2021; 5:pkab021. [PMID: 33977228 PMCID: PMC8099999 DOI: 10.1093/jncics/pkab021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/13/2020] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background The Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm and the International Breast Cancer Intervention Study breast cancer risk models are used to provide advice on screening intervals and chemoprevention. We evaluated the performance of these models, which now incorporate polygenic risk scores (PRSs), using a prospective cohort study. Methods We used a case-cohort design, involving women in the Melbourne Collaborative Cohort Study aged 50-75 years when surveyed in 2003-2007, of whom 408 had a first primary breast cancer diagnosed within 10 years (cases), and 2783 were from the subcohort. Ten-year risks were calculated based on lifestyle factors, family history data, and a 313-variant PRS. Discrimination was assessed using a C-statistic compared with 0.50 and calibration using the ratio of expected to observed number of cases (E/O). Results When the PRS was added to models with lifestyle factors and family history, the C-statistic (95% confidence interval [CI]) increased from 0.57 (0.54 to 0.60) to 0.62 (0.60 to 0.65) using IBIS and from 0.56 (0.53 to 0.59) to 0.62 (0.59 to 0.64) using BOADICEA. IBIS underpredicted risk (E/O = 0.62, 95% CI = 0.48 to 0.80) for women in the lowest risk category (<1.7%) and overpredicted risk (E/O = 1.40, 95% CI = 1.18 to 1.67) in the highest risk category (≥5%), using the Hosmer-Lemeshow test for calibration in quantiles of risk and a 2-sided P value less than .001. BOADICEA underpredicted risk (E/O = 0.82, 95% CI = 0.67 to 0.99) in the second highest risk category (3.4%-5%); the Hosmer-Lemeshow test and a 2-sided P value was equal to .02. Conclusions Although the inclusion of a 313 genetic variant PRS doubles discriminatory accuracy (relative to reference 0.50), models with and without this PRS have relatively modest discrimination and might require recalibration before their clinical and wider use are promoted.
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Affiliation(s)
- Sherly X Li
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Roger L Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Tu Nguyen-Dumont
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Clinical Pathology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Xiaochuan Wang
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Dallas R English
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
| | - Graham G Giles
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Melissa C Southey
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Clinical Pathology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, UK
| | - Andrew Lee
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, UK
| | - Shuai Li
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, UK
| | - Ingrid Winship
- Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Robert J MacInnis
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
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15
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Woodward ER, van Veen EM, Evans DG. From BRCA1 to Polygenic Risk Scores: Mutation-Associated Risks in Breast Cancer-Related Genes. Breast Care (Basel) 2021; 16:202-213. [PMID: 34248461 DOI: 10.1159/000515319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/16/2021] [Indexed: 12/12/2022] Open
Abstract
Background There has been huge progress over the last 30 years in identifying the familial component of breast cancer. Summary Currently around 20% is explained by the high-risk genes BRCA1 and BRCA2, a further 2% by other high-penetrance genes, and around 5% by the moderate risk genes ATM and CHEK2. In contrast, the more than 300 low-penetrance single-nucleotide polymorphisms (SNP) now account for around 28% and they are predicted to account for most of the remaining 45% yet to be found. Even for high-risk genes which confer a 40-90% risk of breast cancer, these SNP can substantially affect the level of breast cancer risk. Indeed, the strength of family history and hormonal and reproductive factors is very important in assessing risk even for a BRCA carrier. The risks of contralateral breast cancer are also affected by SNP as well as by the presence of high or moderate risk genes. Genetic testing using gene panels is now commonplace. Key-Messages There is a need for a more parsimonious approach to panels only testing those genes with a definite 2-fold increased risk and only testing those genes with challenging management implications, such as CDH1 and TP53, when there is strong clinical indication to do so. Testing of SNP alongside genes is likely to provide a more accurate risk assessment.
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Affiliation(s)
- Emma R Woodward
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Elke M van Veen
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,PREVENT Breast Cancer Prevention Centre, Nightingale Centre, Manchester Universities Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom.,Manchester Breast Centre, Manchester Cancer Research Centre, The Christie, University of Manchester, Manchester, United Kingdom
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16
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Godden AR, Micha A, Pitches C, Barry PA, Krupa KDC, Rusby JE. Development of an online research platform for use in a large-scale multicentre study. BJS Open 2021; 5:6133615. [PMID: 33609391 PMCID: PMC7893475 DOI: 10.1093/bjsopen/zraa054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/17/2020] [Indexed: 11/13/2022] Open
Abstract
Background Participation in research can be beneficial for patients and healthcare providers, but may prove demanding at patient, clinician and organizational levels. Patient representatives are supportive of online research to overcome these challenges. The aim of this pilot study was to develop an online recruitment platform and test its feasibility and acceptability while evaluating the accuracy of participant-reported data. Methods The online research platform was developed in a 1-day ‘hackathon’ with a digital design company. Women who underwent implant-based breast reconstruction in 2011–2016 were invited by letter containing the web address (URL) of the study site and their unique study number. Once online, participants learned about the study, consented, entered data on demographics, treatment received and patient-reported outcome measures (BREAST-Q™), and booked an appointment for a single hospital visit for three-dimensional surface imaging (3D-SI). Real-time process evaluation was performed. The primary endpoint was recruitment rate. Results The recruitment rate was 40 per cent. Of the 100 women, 50 logged on to the platform and 40 completed the process through to 3D-SI. The majority of discontinuations after logging on occurred between consenting and entering demographics (3 women, 6 per cent), and between completing the BREAST-Q and booking an appointment for 3D-SI using the online calendar (3 women, 6 per cent). All women completed the online BREAST-Q™ once started. Participants took a median of 23 minutes to complete the online process. Patient-reported clinical data were accurate in 12 of 13 domains compared with electronic records (95 per cent concordance). Process evaluation demonstrated acceptability. Conclusion The results of this pilot demonstrate the online platform to be acceptable, feasible, and accurate for this population from a single institution. The low-burden design may enable participation from centres with less research support and participants from hard-to-reach groups or dispersed geographical locations, but with online access.
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Affiliation(s)
- A R Godden
- Breast Surgical Unit, Royal Marsden Hospital, Sutton, UK.,Division of Breast Cancer Research, Institute of Cancer Research, Sutton, UK
| | - A Micha
- Breast Surgical Unit, Royal Marsden Hospital, Sutton, UK
| | - C Pitches
- Breast Surgical Unit, Royal Marsden Hospital, Sutton, UK
| | - P A Barry
- Breast Surgical Unit, Royal Marsden Hospital, Sutton, UK
| | - K D C Krupa
- Breast Surgical Unit, Royal Marsden Hospital, Sutton, UK
| | - J E Rusby
- Breast Surgical Unit, Royal Marsden Hospital, Sutton, UK.,Division of Breast Cancer Research, Institute of Cancer Research, Sutton, UK
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17
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Woof VG, McWilliams L, Donnelly LS, Howell A, Evans DG, Maxwell AJ, French DP. Introducing a low-risk breast screening pathway into the NHS Breast Screening Programme: Views from healthcare professionals who are delivering risk-stratified screening. WOMEN'S HEALTH (LONDON, ENGLAND) 2021; 17:17455065211009746. [PMID: 33877937 PMCID: PMC8060757 DOI: 10.1177/17455065211009746] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/01/2021] [Accepted: 03/24/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Proposals to stratify breast screening by breast cancer risk aim to produce a better balance of benefits to harms. Notably, risk estimation calculated from common risk factors and a polygenic risk score would enable high-risk women to benefit from more frequent screening or preventive medication. This service would also identify low-risk women who experience fewer benefits from attending, as lower grade and in situ cancers may be treated unnecessarily. It may therefore be appropriate for low-risk women to attend screening less. This study aimed to elicit views regarding implementing less frequent screening for low-risk women from healthcare professionals who implement risk-stratified screening. METHODS Healthcare professionals involved in the delivery of risk-stratified breast screening were invited to participate in a focus group within the screening setting in which they work or have a telephone interview. Primary care staff were also invited to provide their perspective. Three focus groups and two telephone interviews were conducted with 28 healthcare professionals. To identify patterns across the sample, data were analysed as a single dataset using reflexive thematic analysis. RESULTS Analysis yielded three themes: Reservations concerning the introduction of less frequent screening, highlighting healthcare professionals' unease and concerns towards implementing less frequent screening; Considerations for the management of public knowledge, providing views on media impact on public opinion and the potential for a low-risk pathway to cause confusion and raise suspicion regarding implementation motives; and Deliberating service implications and reconfiguration management, where the practicalities of implementation are discussed. CONCLUSIONS Healthcare professionals broadly supported less frequent screening but had concerns about implementation. It will be essential to address concerns regarding risk estimate accuracy, healthcare professional confidence, service infrastructure and public communication prior to introducing less frequent screening for low-risk women.
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Affiliation(s)
- Victoria G Woof
- Manchester Centre for Health
Psychology, Division of Psychology & Mental Health, School of Health Sciences,
Faculty of Biology, Medicine and Health, University of Manchester, MAHSC,
Manchester, UK
| | - Lorna McWilliams
- Manchester Centre for Health
Psychology, Division of Psychology & Mental Health, School of Health Sciences,
Faculty of Biology, Medicine and Health, University of Manchester, MAHSC,
Manchester, UK
| | - Louise S Donnelly
- Nightingale and Prevent Breast Cancer
Research Unit, Manchester University NHS Foundation Trust, Manchester, UK
- NIHR Greater Manchester Patient Safety
Translational Research Centre, Centre for Mental Health and Safety, School of Health
Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC,
Manchester, UK
| | - Anthony Howell
- Nightingale and Prevent Breast Cancer
Research Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - D Gareth Evans
- Nightingale and Prevent Breast Cancer
Research Unit, Manchester University NHS Foundation Trust, Manchester, UK
- Department of Genomic Medicine,
Division of Evolution and Genomic Science, University of Manchester, MAHSC,
Manchester University NHS Foundation Trust, Manchester, UK
| | - Anthony J Maxwell
- Nightingale and Prevent Breast Cancer
Research Unit, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Informatics, Imaging &
Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health,
University of Manchester, Manchester, UK
| | - David P French
- Manchester Centre for Health
Psychology, Division of Psychology & Mental Health, School of Health Sciences,
Faculty of Biology, Medicine and Health, University of Manchester, MAHSC,
Manchester, UK
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18
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French DP, Astley S, Brentnall AR, Cuzick J, Dobrashian R, Duffy SW, Gorman LS, Harkness EF, Harrison F, Harvie M, Howell A, Jerrison A, Machin M, Maxwell AJ, McWilliams L, Payne K, Qureshi N, Ruane H, Sampson S, Stavrinos P, Thorpe E, Ulph F, van Staa T, Woof V, Evans DG. What are the benefits and harms of risk stratified screening as part of the NHS breast screening Programme? Study protocol for a multi-site non-randomised comparison of BC-predict versus usual screening (NCT04359420). BMC Cancer 2020; 20:570. [PMID: 32552763 PMCID: PMC7302349 DOI: 10.1186/s12885-020-07054-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/09/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND In principle, risk-stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) should produce a better balance of benefits and harms. The main benefit is the offer of NICE-approved more frequent screening and/ or chemoprevention for women who are at increased risk, but are unaware of this. We have developed BC-Predict, to be offered to women when invited to NHSBSP which collects information on risk factors (self-reported information on family history and hormone-related factors via questionnaire; mammographic density; and in a sub-sample, Single Nucleotide Polymorphisms). BC-Predict produces risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5 to < 8% 10-year) to have discussion of prevention and early detection options at Family History, Risk and Prevention Clinics. Despite the promise of systems such as BC-Predict, there are still too many uncertainties for a fully-powered definitive trial to be appropriate or ethical. The present research aims to identify these key uncertainties regarding the feasibility of integrating BC-Predict into the NHSBSP. Key objectives of the present research are to quantify important potential benefits and harms, and identify key drivers of the relative cost-effectiveness of embedding BC-Predict into NHSBSP. METHODS A non-randomised fully counterbalanced study design will be used, to include approximately equal numbers of women offered NHSBSP (n = 18,700) and BC-Predict (n = 18,700) from selected screening sites (n = 7). In the initial 8-month time period, women eligible for NHSBSP will be offered BC-Predict in four screening sites. Three screening sites will offer women usual NHSBSP. In the following 8-months the study sites offering usual NHSBSP switch to BC-Predict and vice versa. Key potential benefits including uptake of risk consultations, chemoprevention and additional screening will be obtained for both groups. Key potential harms such as increased anxiety will be obtained via self-report questionnaires, with embedded qualitative process analysis. A decision-analytic model-based cost-effectiveness analysis will identify the key uncertainties underpinning the relative cost-effectiveness of embedding BC-Predict into NHSBSP. DISCUSSION We will assess the feasibility of integrating BC-Predict into the NHSBSP, and identify the main uncertainties for a definitive evaluation of the clinical and cost-effectiveness of BC-Predict. TRIAL REGISTRATION Retrospectively registered with clinicaltrials.gov (NCT04359420).
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Affiliation(s)
- David P French
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England.
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England.
| | - Susan Astley
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Adam R Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, England
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, England
| | - Richard Dobrashian
- East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital, Haslingden Road, Lancashire, BB2 3HH, England
| | - Stephen W Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, England
| | - Louise S Gorman
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, M13 9PL, England
| | - Elaine F Harkness
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | | | - Michelle Harvie
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England
| | - Anthony Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, England
| | - Andrew Jerrison
- Research IT, IT Services, University of Manchester, Manchester, M13 9PL, England
| | - Matthew Machin
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Anthony J Maxwell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Lorna McWilliams
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Katherine Payne
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, England
| | - Nadeem Qureshi
- School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, England
| | - Helen Ruane
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Sarah Sampson
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Paula Stavrinos
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
| | - Emma Thorpe
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Fiona Ulph
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Tjeerd van Staa
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, England
| | - Victoria Woof
- Manchester Centre of Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland Street, Manchester, M13 9PL, England
| | - D Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
- The Nightingale and Prevent Breast Cancer Centre, Manchester University NHS Foundation Trust, Manchester, M23 9LT, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 555 Wilmslow Rd, Manchester, M20 4GJ, England
- Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, England
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19
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Woof VG, Ruane H, French DP, Ulph F, Qureshi N, Khan N, Evans DG, Donnelly LS. The introduction of risk stratified screening into the NHS breast screening Programme: views from British-Pakistani women. BMC Cancer 2020; 20:452. [PMID: 32434564 PMCID: PMC7240981 DOI: 10.1186/s12885-020-06959-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND UK national guidelines suggest women at high-risk of breast cancer should be offered more frequent screening or preventative medications. Currently, only 1 in 6 high-risk women are identified. One route to identify more high-risk women is via multifactorial risk assessment as part of the UK's NHS Breast Screening Programme (NHSBSP). As lower socioeconomic and minority ethnic populations continue to experience barriers to screening, it is important that any new service does not exacerbate issues further. To inform service development, this study explored views of women from underserved backgrounds regarding the introduction of risk stratification into the NHSBSP. METHODS Nineteen semi-structured interviews were conducted with British-Pakistani women from low socioeconomic backgrounds from East Lancashire, UK. Fourteen interviews were conducted via an interpreter. RESULTS Thematic analysis produced three themes. Attitudes toward risk awareness concerns the positive views women have toward the idea of receiving personalised breast cancer risk information. Anticipated barriers to accessibility emphasises the difficulties associated with women's limited English skills for accessing information, and their I.T proficiency for completing an online risk assessment questionnaire. Acceptability of risk communication strategy highlights the diversity of opinion regarding the suitability of receiving risk results via letter, with the option for support from a healthcare professional deemed essential. CONCLUSIONS The idea of risk stratification was favourable amongst this underserved community. To avoid exacerbating inequities, this new service should provide information in multiple languages and modalities and offer women the opportunity to speak to a healthcare professional about risk. This service should also enable completion of personal risk information via paper questionnaires, as well as online.
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Affiliation(s)
- Victoria G Woof
- Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Room 1.13, Coupland 1, Coupland Street, Off Oxford Road, Manchester, M13 9PL, UK.
| | - Helen Ruane
- Nightingale & Prevent Breast Cancer Research Unit, Manchester University NHS Foundation Trust (MFT), Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
| | - David P French
- Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Room 1.13, Coupland 1, Coupland Street, Off Oxford Road, Manchester, M13 9PL, UK
| | - Fiona Ulph
- Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Room 1.13, Coupland 1, Coupland Street, Off Oxford Road, Manchester, M13 9PL, UK
| | - Nadeem Qureshi
- NIHR School of Primary Care, School of Medicine, Tower Building, University Park, Nottingham, NG7 2RD, UK
| | - Nasaim Khan
- Department of Genomic Medicine, Division of Evolution and Genomic Science, MAHSC, University of Manchester, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
| | - D Gareth Evans
- Nightingale & Prevent Breast Cancer Research Unit, Manchester University NHS Foundation Trust (MFT), Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK.,Department of Genomic Medicine, Division of Evolution and Genomic Science, MAHSC, University of Manchester, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
| | - Louise S Donnelly
- Nightingale & Prevent Breast Cancer Research Unit, Manchester University NHS Foundation Trust (MFT), Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
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20
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Renehan AG, Pegington M, Harvie MN, Sperrin M, Astley SM, Brentnall AR, Howell A, Cuzick J, Gareth Evans D. Young adulthood body mass index, adult weight gain and breast cancer risk: the PROCAS Study (United Kingdom). Br J Cancer 2020; 122:1552-1561. [PMID: 32203222 PMCID: PMC7217761 DOI: 10.1038/s41416-020-0807-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 01/15/2020] [Accepted: 03/03/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND We tested the hypothesis that body mass index (BMI) aged 20 years modifies the association of adult weight gain and breast cancer risk. METHODS We recruited women (aged 47-73 years) into the PROCAS (Predicting Risk Of Cancer At Screening; Manchester, UK: 2009-2013) Study. In 47,042 women, we determined BMI at baseline and (by recall) at age 20 years, and derived weight changes. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for new breast cancer using Cox models and explored relationships between BMI aged 20 years, subsequent weight changes and breast cancer risk. RESULTS With median follow-up of 5.6 years, 1142 breast cancers (post-menopausal at entry: 829) occurred. Among post-menopausal women at entry, BMI aged 20 years was inversely associated [HR per SD: 0.87 (95% CI: 0.79-0.95)], while absolute weight gain was associated with breast cancer [HR per SD:1.23 (95% CI: 1.14-1.32)]. For post-menopausal women who had a recall BMI aged 20 years <23.4 kg/m2 (75th percentile), absolute weight gain was associated with breast cancer [HR per SD: 1.31 (95% CIs: 1.21-1.42)], but there were no associations for women with a recall BMI aged 20 years of >23.4 kg/m2 (Pinteraction values <0.05). CONCLUSIONS Adult weight gain increased post-menopausal breast cancer risk only among women who were <23.4 kg/m2 aged 20 years.
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Affiliation(s)
- Andrew G Renehan
- Manchester Cancer Research Centre and NIHR Manchester Biomedical Research Centre, Manchester, UK.
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Mary Pegington
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Prevent Breast Cancer, Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK
| | - Michelle N Harvie
- Prevent Breast Cancer, Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK
| | - Matthew Sperrin
- MRC Health eResearch Centre (HeRC), Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Susan M Astley
- Centre for Imaging Science, Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Manchester, UK
| | - Adam R Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Anthony Howell
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Prevent Breast Cancer, Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - D Gareth Evans
- Manchester Cancer Research Centre and NIHR Manchester Biomedical Research Centre, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Prevent Breast Cancer, Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK
- Genomic Medicine, Manchester Academic Health Sciences Centre, University of Manchester and Central Manchester Foundation Trust, Manchester, UK
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21
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Rainey L, van der Waal D, Jervaeus A, Donnelly LS, Evans DG, Hammarström M, Hall P, Wengström Y, Broeders MJM. European women's perceptions of the implementation and organisation of risk-based breast cancer screening and prevention: a qualitative study. BMC Cancer 2020; 20:247. [PMID: 32209062 PMCID: PMC7092605 DOI: 10.1186/s12885-020-06745-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/12/2020] [Indexed: 01/28/2023] Open
Abstract
Background Increased knowledge of breast cancer risk factors has meant that we are currently exploring risk-based screening, i.e. determining screening strategies based on women’s varying levels of risk. This also enables risk management through primary prevention strategies, e.g. a lifestyle programme or risk-reducing medication. However, future implementation of risk-based screening and prevention will warrant significant changes in current practice and policy. The present study explores women’s perceptions of the implementation and organisation of risk-based breast cancer screening and prevention to optimise acceptability and uptake. Methods A total of 143 women eligible for breast cancer screening in the Netherlands, the United Kingdom, and Sweden participated in focus group discussions. The focus group discussions were transcribed verbatim and the qualitative data was analysed using thematic analysis. Results Women from all three countries generally agreed on the overall proceedings, e.g. a risk assessment after which the risk estimate is communicated via letter (for below average and average risk) or consultation (for moderate and high risk). However, discrepancies in information needs, preferred risk communication format and risk counselling professional were identified between countries. Additionally, a need to educate healthcare professionals on all aspects of the risk-based screening and prevention programme was established. Conclusion Women’s insights identified the need for country-specific standardised protocols regarding the assessment and communication of risk, and the provision of heterogeneous screening and prevention recommendations, monitoring the principle of solidarity in healthcare policy.
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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, Alfred, Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - Louise S Donnelly
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - D Gareth Evans
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK.,Genomic Medicine, Division of Evolution and Genomic Sciences, Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,The Christie NHS Foundation Trust, Withington, Manchester, M20 4BX, UK
| | - Mattias Hammarström
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 77, Stockholm, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 77, Stockholm, Sweden.,Department of Oncology, Södersjukhuset, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Alfred, Nobels allé 23, 23300, 14183, Huddinge, Sweden.,Theme Cancer, Karolinska University Hospital, Alfred Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - Mireille J M Broeders
- Radboud Institute for Health Sciences, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Dutch Expert Centre for Screening, PO Box 6873, 6503 GJ, Nijmegen, The Netherlands
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22
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In utero DDT exposure and breast density before age 50. Reprod Toxicol 2019; 92:85-90. [PMID: 31711904 DOI: 10.1016/j.reprotox.2019.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 10/28/2019] [Accepted: 11/04/2019] [Indexed: 02/06/2023]
Abstract
Prior studies in the Child Health and Development Studies (CHDS) found in utero exposure to the pesticide, dichlorodiphenyltrichloroethane (DDT), increased breast cancer risk by age 52. Mammographic density is considered a primary risk factor for breast cancer. We conducted a study of 309 daughters from the CHDS to examine in utero DDT exposure and mammographic density in midlife. Among daughters with high (>75th percentile) exposure to p,p'-Dichlorodiphenyldichloroethylene (DDE), p,p'-DDT was significantly correlated with increased dense area and percent density regardless of her body mass in midlife. In the subset of women with lower (<75th percentile) p,p-DDE, p,p'-DDT was associated with increased non-dense breast area. This was explained by adjustment for midlife BMI suggesting that p,p'-DDT may be obesogenic. In aggregate our findings indicate that early life p,p'-DDT exposure impacts breast density in a complex way that depends on the hosts biological ability to sequester and process DDT and levels of exposure.
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Velásquez García HA, Gotay CC, Wilson CM, Lohrisch CA, Lai AS, Aronson KJ, Spinelli JJ. Mammographic density parameters and breast cancer tumor characteristics among postmenopausal women. BREAST CANCER-TARGETS AND THERAPY 2019; 11:261-271. [PMID: 31496793 PMCID: PMC6702445 DOI: 10.2147/bctt.s192766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/18/2019] [Indexed: 01/11/2023]
Abstract
Purpose Mammographic density is an important breast cancer risk factor, although it is not clear whether the association differs across breast cancer tumor subtypes. We examined the association between indicators of mammographic density and breast cancer risk by tumor subtype among postmenopausal women by investigating heterogeneity across tumor characteristics. Methods Mammographic density measures were determined for 477 breast cancer cases and 588 controls, all postmenopausal, in Vancouver, British Columbia, using digitized screening mammograms and Cumulus software. Mammographic dense (DA), non-dense (NDA), and percent dense (PDA) areas were treated as continuous covariates and categorized into quartiles according to the distribution in controls. For cases only, tests for heterogeneity between tumor subtypes were assessed by multinomial logistic regression. Associations between mammographic density and breast cancer risk were modeled for each subtype separately through unconditional logistic regression. Results Heterogeneity was apparent for the association of PDA with tumor size (p-heterogeneity=0.04). Risk did not differ across the other assessed tumor characteristics (p-heterogeneity values >0.05). Conclusion These findings do not provide strong evidence that mammographic density parameters differentially affect specific breast cancer tumor characteristics.
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Affiliation(s)
- Héctor A Velásquez García
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Population Oncology, BC Cancer, Vancouver, BC, Canada
| | - Carolyn C Gotay
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Agnes S Lai
- Population Oncology, BC Cancer, Vancouver, BC, Canada
| | - Kristan J Aronson
- Department of Public Health Sciences and Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - John J Spinelli
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Population Oncology, BC Cancer, Vancouver, BC, Canada
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24
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Unim B, Pitini E, Lagerberg T, Adamo G, De Vito C, Marzuillo C, Villari P. Current Genetic Service Delivery Models for the Provision of Genetic Testing in Europe: A Systematic Review of the Literature. Front Genet 2019; 10:552. [PMID: 31275354 PMCID: PMC6593087 DOI: 10.3389/fgene.2019.00552] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 05/24/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The provision of genetic services, along with research in the fields of genomics and genetics, has evolved in recent years to meet the increasing demand of consumers interested in prediction of genetic diseases and various inherited traits. The aim of this study is to evaluate genetic services in order to identify and classify delivery models for the provision of genetic testing in European and in extra-European countries. Methods: A systematic review of the literature was conducted using five electronic resources. Inclusion criteria were that studies be published in English or Italian during the period 2000-2015 and carried out in European or extra-European countries (Canada, USA, Australia, or New Zealand). Results: 148 genetic programs were identified in 117 articles and were delivered mostly in the UK (59, 40%), USA (35, 24%) or Australia (16, 11%). The programs were available nationally (66; 45%), regionally (49; 33%) or in urban areas (21, 14%). Ninety-six (64%) of the programs were integrated into healthcare systems, 48 (32.21%) were pilot programs and five (3%) were direct-to-consumer genetic services. The genetic tests offered were mainly for BRCA1/2 (59, 40%), Lynch syndrome (23, 16%), and newborn screening (18, 12%). Healthcare professionals with different backgrounds are increasingly engaged in the provision of genetic services. Based on which healthcare professionals have prominent roles in the respective patient care pathways, genetic programs were classified into five models: (i) the geneticists model; (ii) the primary care model; (iii) the medical specialist model; (iv) the population screening programs model; and (v) the direct-to-consumer model. Conclusions: New models of genetic service delivery are currently under development worldwide to address the increasing demand for accessible and affordable services. These models require the integration of genetics into all medical specialties, collaboration among different healthcare professionals, and the redistribution of professional roles. An appropriate model for genetic service provision in a specific setting should ideally be defined according to the type of healthcare system, the genetic test provided within a genetic program, and the cost-effectiveness of the intervention. Only applications with proven efficacy and cost-effectiveness should be implemented in healthcare systems and made available to all citizens.
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Affiliation(s)
- Brigid Unim
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Erica Pitini
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Giovanna Adamo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Carolina Marzuillo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Paolo Villari
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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25
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Evans DGR, Harkness EF, Brentnall AR, van Veen EM, Astley SM, Byers H, Sampson S, Southworth J, Stavrinos P, Howell SJ, Maxwell AJ, Howell A, Newman WG, Cuzick J. Breast cancer pathology and stage are better predicted by risk stratification models that include mammographic density and common genetic variants. Breast Cancer Res Treat 2019; 176:141-148. [PMID: 30941651 PMCID: PMC6548748 DOI: 10.1007/s10549-019-05210-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 03/18/2019] [Indexed: 12/17/2022]
Abstract
Purpose To improve breast cancer risk stratification to enable more targeted early detection/prevention strategies that will better balance risks and benefits of population screening programmes. Methods 9362 of 57,902 women in the Predicting-Risk-Of-Cancer-At-Screening (PROCAS) study who were unaffected by breast cancer at study entry and provided DNA for a polygenic risk score (PRS). The PRS was analysed alongside mammographic density (density-residual-DR) and standard risk factors (Tyrer-Cuzick-model) to assess future risk of breast cancer based on tumour stage receptor expression and pathology. Results 195 prospective incident breast cancers had a prediction based on TC/DR/PRS which was informative for subsequent breast cancer overall [IQ-OR 2.25 (95% CI 1.89–2.68)] with excellent calibration-(0.99). The model performed particularly well in predicting higher stage stage 2+ IQ-OR 2.69 (95% CI 2.02–3.60) and ER + BCs (IQ-OR 2.36 (95% CI 1.93–2.89)). DR was most predictive for HER2+ and stage 2+ cancers but did not discriminate as well between poor and extremely good prognosis BC as either Tyrer-Cuzick or PRS. In contrast, PRS gave the highest OR for incident stage 2+ cancers, [IQR-OR 1.79 (95% CI 1.30–2.46)]. Conclusions A combined approach using Tyrer-Cuzick/DR/PRS provides accurate risk stratification, particularly for poor prognosis cancers. This provides support for reducing the screening interval in high-risk women and increasing the screening interval in low-risk women defined by this model. Electronic supplementary material The online version of this article (10.1007/s10549-019-05210-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- D Gareth R Evans
- Division of Evolution and Genomic Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Manchester, UK. .,Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK. .,The Christie NHS Foundation Trust, Manchester, UK. .,Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust (Central), Manchester, UK. .,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK. .,NIHR Manchester Biomedical Research Centre, Cancer Prevention Early Detection Theme, The Christie NHS Foundation Trust, Manchester, UK. .,Department of Genomic Medicine, Manchester Academic Health Sciences Centre (MAHSC), St Mary's Hospital, University of Manchester, Manchester, M13 9WL, UK.
| | - Elaine F Harkness
- Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK.,Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Cancer Prevention Early Detection Theme, The Christie NHS Foundation Trust, Manchester, UK
| | - Adam R Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Charterhouse Square, Barts and The London, Queen Mary University of London, London, UK
| | - Elke M van Veen
- Division of Evolution and Genomic Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Manchester, UK
| | - Susan M Astley
- Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK.,Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Cancer Prevention Early Detection Theme, The Christie NHS Foundation Trust, Manchester, UK
| | - Helen Byers
- Division of Evolution and Genomic Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Cancer Prevention Early Detection Theme, The Christie NHS Foundation Trust, Manchester, UK
| | - Sarah Sampson
- Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK
| | - Jake Southworth
- Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK
| | - Paula Stavrinos
- Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK
| | - Sacha J Howell
- Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK.,The Christie NHS Foundation Trust, Manchester, UK.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Cancer Prevention Early Detection Theme, The Christie NHS Foundation Trust, Manchester, UK
| | - Anthony J Maxwell
- Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK.,Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Cancer Prevention Early Detection Theme, The Christie NHS Foundation Trust, Manchester, UK
| | - Anthony Howell
- Prevention Breast Cancer Unit and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust (South), Manchester, UK.,The Christie NHS Foundation Trust, Manchester, UK.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Cancer Prevention Early Detection Theme, The Christie NHS Foundation Trust, Manchester, UK
| | - William G Newman
- Division of Evolution and Genomic Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, Manchester, UK.,Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust (Central), Manchester, UK.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Charterhouse Square, Barts and The London, Queen Mary University of London, London, UK
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Kelly KM, Dolly B, Kennedy S, Atkins E, Coon M, King K, Mbous Y, Rouse S. Insure Me Cancer Free: An Intervention Utilizing a Dynamic Communication Model. HEALTH BEHAVIOR RESEARCH 2019; 2. [PMID: 32542227 PMCID: PMC7295172 DOI: 10.4148/2572-1836.1028] [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] [Indexed: 11/04/2022] Open
Abstract
The purpose of this study was to examine the impact of a pilot insurance company-based intervention guided by a Dynamic Communication Model to increase breast and colorectal cancer screening in Appalachian WV, a medically-underserved population with low screening rates. Our team and key informants developed letters and a website to promote cancer screening, and these were mailed to patients needing screening (breast: n = 232; colorectal: n = 324). After 6 months, a sample of women (n = 22) and men (n = 27) continuing to need screening received telephonic case management counseling. Screening rates were assessed at baseline, 6 months, and 12 months. A final telephone interview was conducted at 12 months with a subset of participants. Key informants (n = 21) provided feedback on the letter/website, resulting in improved readability, organization, and informational content. The letter/website had minimal impact on screening (breast: n = 8; colon: n = 5). The final telephone interview of plan members (n = 12) found they liked the personalized approach and appreciated learning more about cancer, and that you need to "catch it early for good treatment." All understood the counseling and believed the information was correct. Nearly all intended to get screened. Following counseling, screening numbers increased (total breast: n = 39; total colon: n = 18). Our theoretically-driven, case management counseling intervention was well received and has the potential to increase cancer screening rates, particularly in a rural, medically-underserved populations.
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Affiliation(s)
| | - Brandon Dolly
- School of Pharmacy, West Virginia University, Morgantown, WV, USA
| | | | | | - Michelle Coon
- CoventryCares of WV Insurance Company, Charleston, WV, USA
| | - Kemi King
- CoventryCares of WV Insurance Company, Charleston, WV, USA
| | | | - Shelly Rouse
- CoventryCares of WV Insurance Company, Charleston, WV, USA
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27
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Ionescu GV, Fergie M, Berks M, Harkness EF, Hulleman J, Brentnall AR, Cuzick J, Evans DG, Astley SM. Prediction of reader estimates of mammographic density using convolutional neural networks. J Med Imaging (Bellingham) 2019; 6:031405. [PMID: 30746393 DOI: 10.1117/1.jmi.6.3.031405] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/17/2018] [Indexed: 01/16/2023] Open
Abstract
Mammographic density is an important risk factor for breast cancer. In recent research, percentage density assessed visually using visual analogue scales (VAS) showed stronger risk prediction than existing automated density measures, suggesting readers may recognize relevant image features not yet captured by hand-crafted algorithms. With deep learning, it may be possible to encapsulate this knowledge in an automatic method. We have built convolutional neural networks (CNN) to predict density VAS scores from full-field digital mammograms. The CNNs are trained using whole-image mammograms, each labeled with the average VAS score of two independent readers. Each CNN learns a mapping between mammographic appearance and VAS score so that at test time, they can predict VAS score for an unseen image. Networks were trained using 67,520 mammographic images from 16,968 women and for model selection we used a dataset of 73,128 images. Two case-control sets of contralateral mammograms of screen detected cancers and prior images of women with cancers detected subsequently, matched to controls on age, menopausal status, parity, HRT and BMI, were used for evaluating performance on breast cancer prediction. In the case-control sets, odd ratios of cancer in the highest versus lowest quintile of percentage density were 2.49 (95% CI: 1.59 to 3.96) for screen-detected cancers and 4.16 (2.53 to 6.82) for priors, with matched concordance indices of 0.587 (0.542 to 0.627) and 0.616 (0.578 to 0.655), respectively. There was no significant difference between reader VAS and predicted VAS for the prior test set (likelihood ratio chi square, p = 0.134 ). Our fully automated method shows promising results for cancer risk prediction and is comparable with human performance.
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Affiliation(s)
- Georgia V Ionescu
- University of Manchester, School of Computer Science, Manchester, United Kingdom
| | - Martin Fergie
- University of Manchester, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom
| | - Michael Berks
- University of Manchester, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom.,University of Manchester, School of Biological Sciences, Division of Neuroscience and Experimental Psychology, Manchester, United Kingdom
| | - Elaine F Harkness
- University of Manchester, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom.,University of Manchester, Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe, Manchester, United Kingdom
| | - Johan Hulleman
- University of Manchester, School of Biological Sciences, Division of Neuroscience and Experimental Psychology, Manchester, United Kingdom
| | - Adam R Brentnall
- Queen Mary University of London, Wolfson Institute of Preventive Medicine, Centre for Cancer Prevention, London, United Kingdom
| | - Jack Cuzick
- Queen Mary University of London, Wolfson Institute of Preventive Medicine, Centre for Cancer Prevention, London, United Kingdom
| | - D Gareth Evans
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Withington, Manchester, United Kingdom.,University of Manchester and Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Genomic Medicine, Division of Evolution and Genomic Science, Manchester, Manchester, United Kingdom
| | - Susan M Astley
- University of Manchester, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom.,University of Manchester, Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe, Manchester, United Kingdom
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28
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Wang C, Brentnall AR, Cuzick J, Harkness EF, Evans DG, Astley S. Exploring the prediction performance for breast cancer risk based on volumetric mammographic density at different thresholds. Breast Cancer Res 2018; 20:49. [PMID: 29884207 PMCID: PMC5994123 DOI: 10.1186/s13058-018-0979-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/08/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The percentage of mammographic dense tissue (PD) defined by pixel value threshold is a well-established risk factor for breast cancer. Recently there has been some evidence to suggest that an increased threshold based on visual assessment could improve risk prediction. It is unknown, however, whether this also applies to volumetric density using digital raw mammograms. METHOD Two case-control studies nested within a screening cohort (ages of participants 46-73 years) from Manchester UK were used. In the first study (317 cases and 947 controls) cases were detected at the first screen; whereas in the second study (318 cases and 935 controls), cases were diagnosed after the initial mammogram. Volpara software was used to estimate dense tissue height at each pixel point, and from these, volumetric and area-based PD were computed at a range of thresholds. Volumetric and area-based PDs were evaluated using conditional logistic regression, and their predictive ability was assessed using the Akaike information criterion (AIC) and matched concordance index (mC). RESULTS The best performing volumetric PD was based on a threshold of 5 mm of dense tissue height (which we refer to as VPD5), and the best areal PD was at a threshold level of 6 mm (which we refer to as APD6), using pooled data and in both studies separately. VPD5 showed a modest improvement in prediction performance compared to the original volumetric PD by Volpara with ΔAIC = 5.90 for the pooled data. APD6, on the other hand, shows much stronger evidence for better prediction performance, with ΔAIC = 14.52 for the pooled data, and mC increased slightly from 0.567 to 0.577. CONCLUSION These results suggest that imposing a 5 mm threshold on dense tissue height for volumetric PD could result in better prediction of cancer risk. There is stronger evidence that area-based density with a 6 mm threshold gives better prediction than the original volumetric density metric.
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Affiliation(s)
- Chao Wang
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Adam R. Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Elaine F. Harkness
- Centre for Imaging Science, School of Health Sciences, University of Manchester, Stopford Building, Oxford Road, Manchester, M13 9PT UK
| | - D. Gareth Evans
- Department of Genomic Medicine, University of Manchester, St Mary’s Hospital, M13 9WL, Manchester, UK
| | - Susan Astley
- Centre for Imaging Science, School of Health Sciences, University of Manchester, Stopford Building, Oxford Road, Manchester, M13 9PT UK
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Psychological impact of providing women with personalised 10-year breast cancer risk estimates. Br J Cancer 2018; 118:1648-1657. [PMID: 29736008 PMCID: PMC6008295 DOI: 10.1038/s41416-018-0069-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/28/2018] [Accepted: 03/05/2018] [Indexed: 01/27/2023] Open
Abstract
Background The Predicting Risk of Cancer at Screening (PROCAS) study estimated 10-year breast cancer risk for 53,596 women attending NHS Breast Screening Programme. The present study, nested within the PROCAS study, aimed to assess the psychological impact of receiving breast cancer risk estimates, based on: (a) the Tyrer–Cuzick (T-C) algorithm including breast density or (b) T-C including breast density plus single-nucleotide polymorphisms (SNPs), versus (c) comparison women awaiting results. Methods A sample of 2138 women from the PROCAS study was stratified by testing groups: T-C only, T-C(+SNPs) and comparison women; and by 10-year risk estimates received: 'moderate' (5–7.99%), 'average' (2–4.99%) or 'below average' (<1.99%) risk. Postal questionnaires were returned by 765 (36%) women. Results Overall state anxiety and cancer worry were low, and similar for women in T-C only and T-C(+SNPs) groups. Women in both T-C only and T-C(+SNPs) groups showed lower-state anxiety but slightly higher cancer worry than comparison women awaiting results. Risk information had no consistent effects on intentions to change behaviour. Most women were satisfied with information provided. There was considerable variation in understanding. Conclusions No major harms of providing women with 10-year breast cancer risk estimates were detected. Research to establish the feasibility of risk-stratified breast screening is warranted.
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Fürst N, Kiechle M, Strahwald B, Quante AS. Mammography Screening 2.0 - How Can Risk-Adapted Screening be Implemented in Clinical Practice?: Results of a Focus Group Discussion with Experts in the RISIKOLOTSE.DE Project. Geburtshilfe Frauenheilkd 2018; 78:506-511. [PMID: 29880986 PMCID: PMC5986567 DOI: 10.1055/a-0603-4314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The mammography screening programme has been the subject of criticism for some time. Invitation to take part is currently based only on the risk factors of age and female sex, whereby women with an above-average risk are screened too seldom and women with a low risk are possibly screened too often. In future, an individualised risk assessment could make a risk-adapted procedure possible in breast cancer screening. In the RISIKOLOTSE.DE project, schemes are devised to calculate the individual breast cancer risk and evaluate the results. The aim is to assist doctors and screening participants in participatory decision-making. To gauge the baseline situation in the target groups, qualitative and quantitative surveys were conducted. METHOD At the start of the project, a guideline-based focus group discussion was held with 15 doctors and representatives of the public health service. The transcript of this discussion was evaluated by means of a qualitative content analysis. RESULTS The participants assessed the concept of risk-adapted screening positively overall. At the same time, the majority of them were of the opinion that the results of individualised risk calculation can be understood and evaluated adequately only by doctors. The great communication requirement and lack of remuneration were given as practical obstacles to implementation. DISCUSSION The suggestions and new ideas from the focus group ranged from administrative and regulatory changes to new forms of counselling and adaptable practice aids. An important indicator for the RISIKOLOTSE.DE conception and for planning future surveys was that risk calculation for mammography screening 2.0 was regarded as a purely medical function and that the concept of participatory decision-making played hardly any part in the discussion.
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Affiliation(s)
- Nicole Fürst
- Frauenklinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Marion Kiechle
- Frauenklinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Brigitte Strahwald
- Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Pettenkofer School of Public Health, LMU München, München, Germany
| | - Anne S. Quante
- Frauenklinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany
- Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Lehrstuhl für Genetische Epidemiologie, LMU München, München, Germany
- Institut für Genetische Epidemiologie, Helmholtz Zentrum München – German Research Center for Environmental Health, Neuherberg, Germany
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31
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Stone J. Should breast cancer screening programs routinely measure mammographic density? J Med Imaging Radiat Oncol 2018; 62:151-158. [DOI: 10.1111/1754-9485.12652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 08/05/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Jennifer Stone
- Centre for Genetic Origins of Health and Disease; Curtin University and The University of Western Australia; Perth Western Australia Australia
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32
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van Veen EM, Brentnall AR, Byers H, Harkness EF, Astley SM, Sampson S, Howell A, Newman WG, Cuzick J, Evans DGR. Use of Single-Nucleotide Polymorphisms and Mammographic Density Plus Classic Risk Factors for Breast Cancer Risk Prediction. JAMA Oncol 2018; 4:476-482. [PMID: 29346471 PMCID: PMC5885189 DOI: 10.1001/jamaoncol.2017.4881] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/05/2017] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Single-nucleotide polymorphisms (SNPs) have demonstrated an association with breast cancer susceptibility, but there is limited evidence on how to incorporate them into current breast cancer risk prediction models. OBJECTIVE To determine whether a panel of 18 SNPs (SNP18) may be used to predict breast cancer in combination with classic risk factors and mammographic density. DESIGN, SETTING, AND PARTICIPANTS This cohort study enrolled a subcohort of 9363 women, aged 46 to 73 years, without a previous breast cancer diagnosis from the larger prospective cohort of the PROCAS study (Predicting Risk of Cancer at Screening) specifically to evaluate breast cancer risk-assessment methods. Enrollment took place from October 2009 through June 2015 from multiple population-based screening centers in Greater Manchester, England. Follow-up continued through January 5, 2017. EXPOSURES Genotyping of 18 SNPs, visual-assessment percentage mammographic density, and classic risk assessed by the Tyrer-Cuzick risk model from a self-completed questionnaire at cohort entry. MAIN OUTCOMES AND MEASURES The predictive ability of SNP18 for breast cancer diagnosis (invasive and ductal carcinoma in situ) was assessed using logistic regression odds ratios per interquartile range of the predicted risk. RESULTS A total of 9363 women were enrolled in this study (mean [range] age, 59 [46-73] years). Of these, 466 were found to have breast cancer (271 prevalent; 195 incident). SNP18 was similarly predictive when unadjusted or adjusted for mammographic density and classic factors (odds ratios per interquartile range, respectively, 1.56; 95% CI, 1.38-1.77 and 1.53; 95% CI, 1.35-1.74), with observed risks being very close to expected (adjusted observed-to-expected odds ratio, 0.98; 95% CI, 0.69-1.28). A combined risk assessment indicated 18% of the subcohort to be at 5% or greater 10-year risk, compared with 30% of all cancers, 35% of interval-detected cancers, and 42% of stage 2+ cancers. In contrast, 33% of the subcohort were at less than 2% risk but accounted for only 18%, 17%, and 15% of the total, interval, and stage 2+ breast cancers, respectively. CONCLUSIONS AND RELEVANCE SNP18 added substantial information to risk assessment based on the Tyrer-Cuzick model and mammographic density. A combined risk is likely to aid risk-stratified screening and prevention strategies.
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Affiliation(s)
- Elke M. van Veen
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England
| | - Adam R. Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Charterhouse Square, Barts and The London, Queen Mary University of London, London, England
| | - Helen Byers
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England
| | - Elaine F. Harkness
- Prevention Breast Cancer Centre and Nightingale Breast Screening Centre, Manchester University Hospital Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
- Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Susan M. Astley
- Prevention Breast Cancer Centre and Nightingale Breast Screening Centre, Manchester University Hospital Foundation Trust, Manchester, England
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
- Manchester Academic Health Science Centre, University of Manchester, Manchester, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, England
| | - Sarah Sampson
- Prevention Breast Cancer Centre and Nightingale Breast Screening Centre, Manchester University Hospital Foundation Trust, Manchester, England
| | - Anthony Howell
- Prevention Breast Cancer Centre and Nightingale Breast Screening Centre, Manchester University Hospital Foundation Trust, Manchester, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, England
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - William G. Newman
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, England
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Charterhouse Square, Barts and The London, Queen Mary University of London, London, England
| | - D. Gareth R. Evans
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England
- Prevention Breast Cancer Centre and Nightingale Breast Screening Centre, Manchester University Hospital Foundation Trust, Manchester, England
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, England
- The Christie NHS Foundation Trust, Manchester, United Kingdom
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Evans DG, Howell SJ, Howell A. Personalized prevention in high risk individuals: Managing hormones and beyond. Breast 2018; 39:139-147. [PMID: 29610032 DOI: 10.1016/j.breast.2018.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/17/2018] [Accepted: 03/24/2018] [Indexed: 12/01/2022] Open
Abstract
Increasing numbers of women are being identified at 'high-risk' of breast cancer, defined by The National Institute of Health and Care Excellence (NICE) as a 10-year risk of ≥8%. Classically women have been so identified through family history based risk algorithms or genetic testing of high-risk genes. Recent research has shown that assessment of mammographic density and single nucleotide polymorphisms (SNPs), when combined with established risk factors, trebles the number of women reaching the high risk threshold. The options for risk reduction in such women include endocrine chemoprevention with the selective estrogen receptor modulators tamoxifen and raloxifene or the aromatase inhibitors anastrozole or exemestane. NICE recommends offering anastrozole to postmenopausal women at high-risk of breast cancer as cost effectiveness analysis showed this to be cost saving to the National Health Service. Overall uptake to chemoprevention has been disappointingly low but this may improve with the improved efficacy of aromatase inhibitors, particularly the lack of toxicity to the endometrium and thrombogenic risks. Novel approaches to chemoprevention under investigation include lower dose and topical tamoxifen, denosumab, anti-progestins and metformin. Although oophorectomy is usually only recommended to women at increased risk of ovarian cancer it has been shown in numerous studies to reduce breast cancer risks in the general population and in those with mutations in BRCA1/2. However, recent evidence from studies that have confined analysis to true prospective follow up have cast doubt on the efficacy of oophorectomy to reduce breast cancer risk in BRCA1 mutation carriers, at least in the short-term.
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Affiliation(s)
- D Gareth Evans
- Manchester Centre for Genomic Medicine, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK.
| | - Sacha J Howell
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Anthony Howell
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
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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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McLean KE, Stone J. Role of breast density measurement in screening for breast cancer. Climacteric 2018; 21:214-220. [DOI: 10.1080/13697137.2018.1424816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- K. E. McLean
- Centre for Genetic Origins of Health and Disease, Curtin University and The University of Western Australia, Perth, WA, Australia
| | - J. Stone
- Centre for Genetic Origins of Health and Disease, Curtin University and The University of Western Australia, Perth, WA, Australia
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Astley SM, Harkness EF, Sergeant JC, Warwick J, Stavrinos P, Warren R, Wilson M, Beetles U, Gadde S, Lim Y, Jain A, Bundred S, Barr N, Reece V, Brentnall AR, Cuzick J, Howell T, Evans DG. A comparison of five methods of measuring mammographic density: a case-control study. Breast Cancer Res 2018; 20:10. [PMID: 29402289 PMCID: PMC5799922 DOI: 10.1186/s13058-018-0932-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 01/05/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND High mammographic density is associated with both risk of cancers being missed at mammography, and increased risk of developing breast cancer. Stratification of breast cancer prevention and screening requires mammographic density measures predictive of cancer. This study compares five mammographic density measures to determine the association with subsequent diagnosis of breast cancer and the presence of breast cancer at screening. METHODS Women participating in the "Predicting Risk Of Cancer At Screening" (PROCAS) study, a study of cancer risk, completed questionnaires to provide personal information to enable computation of the Tyrer-Cuzick risk score. Mammographic density was assessed by visual analogue scale (VAS), thresholding (Cumulus) and fully-automated methods (Densitas, Quantra, Volpara) in contralateral breasts of 366 women with unilateral breast cancer (cases) detected at screening on entry to the study (Cumulus 311/366) and in 338 women with cancer detected subsequently. Three controls per case were matched using age, body mass index category, hormone replacement therapy use and menopausal status. Odds ratios (OR) between the highest and lowest quintile, based on the density distribution in controls, for each density measure were estimated by conditional logistic regression, adjusting for classic risk factors. RESULTS The strongest predictor of screen-detected cancer at study entry was VAS, OR 4.37 (95% CI 2.72-7.03) in the highest vs lowest quintile of percent density after adjustment for classical risk factors. Volpara, Densitas and Cumulus gave ORs for the highest vs lowest quintile of 2.42 (95% CI 1.56-3.78), 2.17 (95% CI 1.41-3.33) and 2.12 (95% CI 1.30-3.45), respectively. Quantra was not significantly associated with breast cancer (OR 1.02, 95% CI 0.67-1.54). Similar results were found for subsequent cancers, with ORs of 4.48 (95% CI 2.79-7.18), 2.87 (95% CI 1.77-4.64) and 2.34 (95% CI 1.50-3.68) in highest vs lowest quintiles of VAS, Volpara and Densitas, respectively. Quantra gave an OR in the highest vs lowest quintile of 1.32 (95% CI 0.85-2.05). CONCLUSIONS Visual density assessment demonstrated a strong relationship with cancer, despite known inter-observer variability; however, it is impractical for population-based screening. Percentage density measured by Volpara and Densitas also had a strong association with breast cancer risk, amongst the automated measures evaluated, providing practical automated methods for risk stratification.
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Affiliation(s)
- Susan M. Astley
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PT UK
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Elaine F. Harkness
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PT UK
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Jamie C. Sergeant
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PT UK
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL UK
| | - Jane Warwick
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Paula Stavrinos
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Ruth Warren
- Department of Radiology, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mary Wilson
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Ursula Beetles
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Soujanya Gadde
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Yit Lim
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Anil Jain
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
- School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - Sara Bundred
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Nicola Barr
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Valerie Reece
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
| | - Adam R. Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, EC1M 6BQ UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, EC1M 6BQ UK
| | - Tony Howell
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Withington, Manchester, M20 4BX UK
| | - D. Gareth Evans
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Southmoor Road, Wythenshawe, Manchester, M23 9LT UK
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Withington, Manchester, M20 4BX UK
- Genomic Medicine, Division of Evolution and Genomic Science, Manchester Academic Health Sciences Centre, University of Manchester and Manchester University NHS Foundation Trust, Manchester, M13 9WL UK
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Howell A, Ashcroft L, Fallowfield L, Eccles DM, Eeles RA, Ward A, Brentnall AR, Dowsett M, Cuzick JM, Greenhalgh R, Boggis C, Motion J, Sergeant JC, Adams J, Evans DG. RAZOR: A Phase II Open Randomized Trial of Screening Plus Goserelin and Raloxifene Versus Screening Alone in Premenopausal Women at Increased Risk of Breast Cancer. Cancer Epidemiol Biomarkers Prev 2018; 27:58-66. [PMID: 29097444 DOI: 10.1158/1055-9965.epi-17-0158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 03/16/2017] [Accepted: 10/17/2017] [Indexed: 11/16/2022] Open
Abstract
Background: Ovarian suppression in premenopausal women is known to reduce breast cancer risk. This study aimed to assess uptake and compliance with ovarian suppression using the luteinizing hormone releasing hormone (LHRH) analogue, goserelin, with add-back raloxifene, as a potential regimen for breast cancer prevention.Methods: Women at ≥30% lifetime risk breast cancer were approached and randomized to mammographic screening alone (C-Control) or screening in addition to monthly subcutaneous injections of 3.6 mg goserelin and continuous 60 mg raloxifene daily orally (T-Treated) for 2 years. The primary endpoint was therapy adherence. Secondary endpoints were toxicity/quality of life, change in bone density, and mammographic density.Results: A total of 75/950 (7.9%) women approached agreed to randomization. In the T-arm, 20 of 38 (52%) of women completed the 2-year period of study compared with the C-arm (27/37, 73.0%). Dropouts were related to toxicity but also the wish to have established risk-reducing procedures and proven chemoprevention. As relatively few women completed the study, data are limited, but those in the T-arm reported significant increases in toxicity and sexual problems, no change in anxiety, and less cancer worry. Lumbar spine bone density declined by 7.0% and visually assessed mammographic density by 4.7% over the 2-year treatment period.Conclusions: Uptake is somewhat lower than comparable studies with tamoxifen for prevention with higher dropout rates. Raloxifene may preserve bone density, but reduction in mammographic density reversed after treatment was completed.Impact: This study indicates that breast cancer risk reduction may be possible using LHRH agonists, but reducing toxicity and preventing bone changes would make this a more attractive option. Cancer Epidemiol Biomarkers Prev; 27(1); 58-66. ©2017 AACR.
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Affiliation(s)
- Anthony Howell
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester, United Kingdom
| | - Linda Ashcroft
- Trials Centre, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lesley Fallowfield
- Sussex Health Outcomes Research and Education in Cancer (SHORE-C), Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
| | - Diana M Eccles
- Faculty of Medicine, Princess Anne Hospital, University of Southampton, Southampton, United Kingdom
| | - Rosalind A Eeles
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
| | - Ann Ward
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
- Department of Clinical Oncology, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Adam R Brentnall
- Centre for Cancer Prevention, Queen Mary, University of London, London, United Kingdom
| | - Mitchell Dowsett
- Department of Academic Biochemistry, Institute of Cancer Research, London, United Kingdom
| | - Jack M Cuzick
- Centre for Cancer Prevention, Queen Mary, University of London, London, United Kingdom
| | - Rosemary Greenhalgh
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester, United Kingdom
| | - Caroline Boggis
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester, United Kingdom
| | - Jamie Motion
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester, United Kingdom
| | - Jamie C Sergeant
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester, United Kingdom
| | - Judith Adams
- Department of Radiology, University of Manchester, Manchester, United Kingdom
| | - D Gareth Evans
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester, Manchester, United Kingdom.
- Division of Evolution and Genomic Science, Department of Genomic Medicine, Manchester Academic Health Science Centre, Central Manchester Foundation Trust, The University of Manchester, St. Mary's Hospital, Manchester, United Kingdom
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Wang C, Brentnall AR, Cuzick J, Harkness EF, Evans DG, Astley S. A novel and fully automated mammographic texture analysis for risk prediction: results from two case-control studies. Breast Cancer Res 2017; 19:114. [PMID: 29047382 PMCID: PMC5648465 DOI: 10.1186/s13058-017-0906-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/27/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The percentage of mammographic dense tissue (PD) is an important risk factor for breast cancer, and there is some evidence that texture features may further improve predictive ability. However, relatively little work has assessed or validated textural feature algorithms using raw full field digital mammograms (FFDM). METHOD A case-control study nested within a screening cohort (age 46-73 years) from Manchester UK was used to develop a texture feature risk score (264 cases diagnosed at the same time as mammogram of the contralateral breast, 787 controls) using the least absolute shrinkage and selection operator (LASSO) method for 112 features, and validated in a second case-control study from the same cohort but with cases diagnosed after the index mammogram (317 cases, 931 controls). Predictive ability was assessed using deviance and matched concordance index (mC). The ability to improve risk estimation beyond percent volumetric density (Volpara) was evaluated using conditional logistic regression. RESULTS The strongest features identified in the training set were "sum average" based on the grey-level co-occurrence matrix at low image resolutions (original resolution 10.628 pixels per mm; downsized by factors of 16, 32 and 64), which had a better deviance and mC than volumetric PD. In the validation study, the risk score combining the three sum average features achieved a better deviance than volumetric PD (Δχ2 = 10.55 or 6.95 if logarithm PD) and a similar mC to volumetric PD (0.58 and 0.57, respectively). The risk score added independent information to volumetric PD (Δχ2 = 14.38, p = 0.0008). CONCLUSION Textural features based on digital mammograms improve risk assessment beyond volumetric percentage density. The features and risk score developed need further investigation in other settings.
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Affiliation(s)
- Chao Wang
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Adam R. Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Elaine F. Harkness
- Centre for Imaging Science, School of Health Sciences, University of Manchester, Stopford Building, Oxford Road, Manchester, M13 9PT UK
| | - D. Gareth Evans
- Department of Genomic Medicine, University of Manchester, St Mary’s Hospital, Manchester, M13 9WL UK
| | - Susan Astley
- Centre for Imaging Science, School of Health Sciences, University of Manchester, Stopford Building, Oxford Road, Manchester, M13 9PT UK
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Johnston A, Sugrue M. Targeting breast cancer outcomes-what about the primary relatives? Mol Genet Genomic Med 2017; 5:317-322. [PMID: 28717658 PMCID: PMC5511799 DOI: 10.1002/mgg3.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/01/2017] [Accepted: 03/02/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Up to 65% of newly diagnosed breast cancer patients had not been screened correctly before diagnosis resulting in increased stage of cancer at presentation. This study assessed whether their primary relatives are, in turn, assessed appropriately. METHODS An ethically approved prospective study involving 274 primary relatives of women diagnosed with breast cancer, between 2009-2012, at a symptomatic breast unit in Ireland. Telephone interview established: demographics, menstrual history, family history verification, breast screening history. Personal risk level was calculated and whether current screening met screening guidelines. Participants were enrolled into appropriate screening programs if currently not in one and results analyzed. RESULTS Two hundred and fifteen of the 280 (76.8%) newly diagnosed patients responded giving details of their 274 primary relatives; this made up the study cohort. Mean age 50 ± 10 (35-75). Thirty two percent were low risk, 64% moderate and 4% high. 190/274 (69%) were being screened appropriately. Seventy five relatives were then assessed with: mammography in 55, Mg and US in 16. Four underwent a biopsy and to date none had cancer. Surveillance was: annual screening in 48%; national screening program and General Practitioner (GP) in 33%; GP only in over 65s in 13%; 6% await further assessment at specialist genetics clinics where their surveillance will be decided. CONCLUSIONS This study has identified an opportunity to improve the delivery of appropriate screening to higher risk primary relatives of patients with breast cancer. This necessitates an integrated national approach involving providers of primary care, patients and screening breast programs.
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Affiliation(s)
- Alison Johnston
- Breast Centre North WestLetterkenny University HospitalLetterkennyIreland.,Donegal Clinical Research AcademyDonegalIreland
| | - Michael Sugrue
- Breast Centre North WestLetterkenny University HospitalLetterkennyIreland.,Donegal Clinical Research AcademyDonegalIreland
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Online self-test identifies women at high familial breast cancer risk in population-based breast cancer screening without inducing anxiety or distress. Eur J Cancer 2017; 78:45-52. [PMID: 28412588 DOI: 10.1016/j.ejca.2017.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/02/2017] [Accepted: 03/13/2017] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Identifying high familial breast cancer (FBC) risk improves detection of yet unknown BRCA1/2-mutation carriers, for whom BC risk is both highly likely and potentially preventable. We assessed whether a new online self-test could identify women at high FBC risk in population-based BC screening without inducing anxiety or distress. METHODS After their visit for screening mammography, women were invited by email to take an online self-test for identifying highly increased FBC risk-based on Dutch guidelines. Exclusion criteria were previously diagnosed as increased FBC risk or a personal history of BC. Anxiety (State-Trait Anxiety Inventory Dutch Version), distress (Hospital Anxiety Depression Scale) and BC risk perception were assessed using questionnaires, which were completed immediately before and after taking the online self-test and 2 weeks later. RESULTS Of the 562 women invited by email, 406 (72%) completed the online self-test while 304 also completed questionnaires (response rate 54%). After exclusion criteria, 287 (51%) were included for data analysis. Median age was 56 years (range 50-74). A high or moderate FBC risk was identified in 12 (4%) and three (1%) women, respectively. After completion of the online self-test, anxiety and BC risk perception were decreased while distress scores remained unchanged. Levels were below clinical relevance. Most women (85%) would recommend the self-test; few (3%) would not. CONCLUSION The online self-test identified previously unknown women at high FBC risk (4%), who may carry a BRCA1/2-mutation, without inducing anxiety or distress. We therefore recommend offering this self-test to women who attend population-based screening mammography for the first time.
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Timmermans L, Bleyen L, Bacher K, Van Herck K, Lemmens K, Van Ongeval C, Van Steen A, Martens P, De Brabander I, Goossens M, Thierens H. Screen-detected versus interval cancers: Effect of imaging modality and breast density in the Flemish Breast Cancer Screening Programme. Eur Radiol 2017; 27:3810-3819. [PMID: 28289944 DOI: 10.1007/s00330-017-4757-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/22/2016] [Accepted: 01/19/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate if direct radiography (DR) performs better than screen-film mammography (SF) and computed radiography (CR) in dense breasts in a decentralized organised Breast Cancer Screening Programme. To this end, screen-detected versus interval cancers were studied in different BI-RADS density classes for these imaging modalities. METHODS The study cohort consisted of 351,532 women who participated in the Flemish Breast Cancer Screening Programme in 2009 and 2010. Information on screen-detected and interval cancers, breast density scores of radiologist second readers, and imaging modality was obtained by linkage of the databases of the Centre of Cancer Detection and the Belgian Cancer Registry. RESULTS Overall, 67% of occurring breast cancers are screen detected and 33% are interval cancers, with DR performing better than SF and CR. The interval cancer rate increases gradually with breast density, regardless of modality. In the high-density class, the interval cancer rate exceeds the cancer detection rate for SF and CR, but not for DR. CONCLUSIONS DR is superior to SF and CR with respect to cancer detection rates for high-density breasts. To reduce the high interval cancer rate in dense breasts, use of an additional imaging technique in screening can be taken into consideration. KEY POINTS • Interval cancer rate increases gradually with breast density, regardless of modality. • Cancer detection rate in high-density breasts is superior in DR. • IC rate exceeds CDR for SF and CR in high-density breasts. • DR performs better in high-density breasts for third readings and false-positives.
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Affiliation(s)
- Lore Timmermans
- Department of Basic Medical Sciences, QCC-Gent, Ghent University, Ghent, Belgium.
| | - Luc Bleyen
- Centrum voor Preventie en Vroegtijdige Opsporing van Kanker, Ghent University, Ghent, Belgium
| | - Klaus Bacher
- Department of Basic Medical Sciences, QCC-Gent, Ghent University, Ghent, Belgium
| | - Koen Van Herck
- Centrum voor Preventie en Vroegtijdige Opsporing van Kanker, Ghent University, Ghent, Belgium
| | - Kim Lemmens
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Andre Van Steen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | | | | | - Hubert Thierens
- Department of Basic Medical Sciences, QCC-Gent, Ghent University, Ghent, Belgium
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Nair KP, Harkness EF, Gadde S, Lim YY, Maxwell AJ, Moschidis E, Foden P, Cuzick J, Brentnall A, Evans DG, Howell A, Astley SM. The impact of using weight estimated from mammographic images vs self-reported weight on breast cancer risk calculation. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2017; 10134:101342V. [PMID: 34925706 PMCID: PMC7612113 DOI: 10.1117/12.2255619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Personalised breast screening requires assessment of individual risk of breast cancer, of which one contributory factor is weight. Self-reported weight has been used for this purpose, but may be unreliable. We explore the use of volume of fat in the breast, measured from digital mammograms. Volumetric breast density measurements were used to determine the volume of fat in the breasts of 40,431 women taking part in the Predicting Risk Of Cancer At Screening (PROCAS) study. Tyrer-Cuzick risk using self-reported weight was calculated for each woman. Weight was also estimated from the relationship between self-reported weight and breast fat volume in the cohort, and used to re-calculate Tyrer-Cuzick risk. Women were assigned to risk categories according to 10 year risk (below average <2%, average 2-3.49%, above average 3.5-4.99%, moderate 5-7.99%, high ≥8%) and the original and re-calculated Tyrer-Cuzick risks were compared. Of the 716 women diagnosed with breast cancer during the study, 15 (2.1%) moved into a lower risk category, and 37 (5.2%) moved into a higher category when using weight estimated from breast fat volume. Of the 39,715 women without a cancer diagnosis, 1009 (2.5%) moved into a lower risk category, and 1721 (4.3%) into a higher risk category. The majority of changes were between below average and average risk categories (38.5% of those with a cancer diagnosis, and 34.6% of those without). No individual moved more than one risk group. Automated breast fat measures may provide a suitable alternative to self-reported weight for risk assessment in personalized screening.
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Affiliation(s)
- Kalyani P Nair
- University of Manchester Medical School, Oxford Road, Manchester, UK
| | - Elaine F Harkness
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Stopford Building, Manchester, M13 9PT, UK
- Nightingale and Prevent Breast Cancer Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK, M23 9LT
| | - Soujanya Gadde
- Nightingale and Prevent Breast Cancer Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK
| | - Yit Y Lim
- Nightingale and Prevent Breast Cancer Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK
| | - Anthony J Maxwell
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Stopford Building, Manchester, M13 9PT, UK
- Nightingale and Prevent Breast Cancer Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK, M23 9LT
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Christie Hospital, Withington, Manchester, M20 4QL, UK
| | - Emmanouil Moschidis
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Stopford Building, Manchester, M13 9PT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK, M23 9LT
| | - Philip Foden
- Medical Statistics Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventative Medicine, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Adam Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventative Medicine, Queen Mary University of London, London, EC1M 6BQ, UK
| | - D Gareth Evans
- Nightingale and Prevent Breast Cancer Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK, M23 9LT
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Christie Hospital, Withington, Manchester, M20 4QL, UK
| | - Anthony Howell
- Nightingale and Prevent Breast Cancer Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK, M23 9LT
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Christie Hospital, Withington, Manchester, M20 4QL, UK
| | - Susan M Astley
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Stopford Building, Manchester, M13 9PT, UK
- Nightingale and Prevent Breast Cancer Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK, M23 9LT
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Christie Hospital, Withington, Manchester, M20 4QL, UK
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Usher-Smith JA, Silarova B, Ward A, Youell J, Muir KR, Campbell J, Warcaba J. Incorporating cancer risk information into general practice: a qualitative study using focus groups with health professionals. Br J Gen Pract 2017; 67:e218-e226. [PMID: 28193618 PMCID: PMC5325664 DOI: 10.3399/bjgp17x689401] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/25/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It is estimated that approximately 40% of all cases of cancer are attributable to lifestyle factors. Providing people with personalised information about their future risk of cancer may help promote behaviour change. AIM To explore the views of health professionals on incorporating personalised cancer risk information, based on lifestyle factors, into general practice. DESIGN AND SETTING Qualitative study using data from six focus groups with a total of 24 general practice health professionals from the NHS Nene Clinical Commissioning Group in England. METHOD The focus groups were guided by a schedule covering current provision of lifestyle advice relating to cancer and views on incorporating personalised cancer risk information. Data were audiotaped, transcribed verbatim, and then analysed using thematic analysis. RESULTS Providing lifestyle advice was viewed as a core activity within general practice but the influence of lifestyle on cancer risk was rarely discussed. The word 'cancer' was seen as a potentially powerful motivator for lifestyle change but the fact that it could generate health anxiety was also recognised. Most focus group participants felt that a numerical risk estimate was more likely to influence behaviour than generic advice. All felt that general practice should provide this information, but there was a clear need for additional resources for it to be offered widely. CONCLUSION Study participants were in support of providing personalised cancer risk information in general practice. The findings highlight a number of potential benefits and challenges that will inform the future development of interventions in general practice to promote behaviour change for cancer prevention.
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Affiliation(s)
| | | | - Alison Ward
- Institute of Health and Wellbeing, University of Northampton, Northampton
| | - Jane Youell
- Institute of Health and Wellbeing, University of Northampton, Northampton
| | - Kenneth R Muir
- Institute of Population Health, University of Manchester, Manchester
| | - Jackie Campbell
- Institute of Health and Wellbeing, University of Northampton, Northampton
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Fisher B, Wilkinson L, Valencia A. Women's interest in a personal breast cancer risk assessment and lifestyle advice at NHS mammography screening. J Public Health (Oxf) 2017; 39:113-121. [PMID: 26834190 PMCID: PMC5356472 DOI: 10.1093/pubmed/fdv211] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Although mortality from breast cancer is declining, incidence continues to increase and is often detected at routine NHS screening. Most middle aged and older women in England attend for screening every 3 years. Assessing their personal breast cancer risk and providing preventative lifestyle advice could help to further reduce breast cancer incidence. Methods A cross-sectional, self-complete postal survey measured attendees' interest in having a personal risk assessment, expected impact on screening attendance, knowledge of associations between lifestyle and breast cancer and preferred ways of accessing preventative lifestyle advice. Results A total of 1803/4948 (36.4%) completed questionnaires were returned. Most participants (93.7%) expressed interest in a personal risk assessment and 95% (1713/1803) believed it would make no difference or encourage re-attendance. Two-thirds (1208/1803) associated lifestyle with breast cancer, but many were unaware of specific risks such as weight gain, obesity, alcohol consumption and physical inactivity. NHS sourced advice was expected to be more credible than other sources, and booklets, brief counselling or an interactive website were most preferred for accessing this. Conclusions Attendees appear to welcome an intervention that would facilitate more proactive clinical and lifestyle prevention and address critical research gaps in breast cancer prevention and early detection.
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Affiliation(s)
- B.A. Fisher
- Institute of Applied Health Research, University of Birmingham, Edgbaston B15 2TT, UK
| | - L. Wilkinson
- South West London Breast Screening Service, The Rose Centre, St George's Hospital NHS Trust, Perimeter Road, London SW17 0QT, UK
| | - A. Valencia
- Avon Breast Screening, The Bristol Breast Care Centre, Beaufort House, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
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Flores KG, Steffen LE, McLouth CJ, Vicuña BE, Gammon A, Kohlmann W, Vigil L, Dayao ZR, Royce ME, Kinney AY. Factors Associated with Interest in Gene-Panel Testing and Risk Communication Preferences in Women from BRCA1/2 Negative Families. J Genet Couns 2016; 26:480-490. [PMID: 27496122 DOI: 10.1007/s10897-016-0001-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 07/18/2016] [Indexed: 12/12/2022]
Abstract
Scientific advances have allowed the development of multiplex gene-panels to assess many genes simultaneously in women who have tested negative for BRCA1/2. We examined correlates of interest in testing for genes that confer modest and moderate breast cancer risk and risk communication preferences for women from BRCA negative families. Female first-degree relatives of breast cancer patients who tested negative for BRCA1/2 mutations (N = 149) completed a survey assessing multiplex genetic testing interest and risk communication preferences. Interest in testing was high (70 %) and even higher if results could guide risk-reducing behavior changes such as taking medications (79 %). Participants preferred to receive genomic risk communications from a variety of sources including: primary care physicians (83 %), genetic counselors (78 %), printed materials (71 %) and the web (60 %). Factors that were independently associated with testing interest were: perceived lifetime risk of developing cancer (odds ratio (OR) = 1.67: 95 % confidence interval (CI) 1.06-2.65) and high cancer worry (OR = 3.12: CI 1.28-7.60). Findings suggest that women from BRCA1/2 negative families are a unique population and may be primed for behavior change. Findings also provide guidance for clinicians who can help develop genomic risk communications, promote informed decision making and customize behavioral interventions.
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Affiliation(s)
- Kristina G Flores
- University of New Mexico Comprehensive Cancer Center, University of New Mexico, MSC07 4025, 2325 Camino de Salud NE, Albuquerque, NM, 87131-0001, USA.
| | - Laurie E Steffen
- University of New Mexico Comprehensive Cancer Center, University of New Mexico, MSC07 4025, 2325 Camino de Salud NE, Albuquerque, NM, 87131-0001, USA.,Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | | | - Belinda E Vicuña
- University of New Mexico Comprehensive Cancer Center, University of New Mexico, MSC07 4025, 2325 Camino de Salud NE, Albuquerque, NM, 87131-0001, USA.,Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Amanda Gammon
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Wendy Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Lucretia Vigil
- University of New Mexico Comprehensive Cancer Center, University of New Mexico, MSC07 4025, 2325 Camino de Salud NE, Albuquerque, NM, 87131-0001, USA
| | - Zoneddy R Dayao
- University of New Mexico Comprehensive Cancer Center, University of New Mexico, MSC07 4025, 2325 Camino de Salud NE, Albuquerque, NM, 87131-0001, USA.,Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Melanie E Royce
- University of New Mexico Comprehensive Cancer Center, University of New Mexico, MSC07 4025, 2325 Camino de Salud NE, Albuquerque, NM, 87131-0001, USA.,Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Anita Y Kinney
- University of New Mexico Comprehensive Cancer Center, University of New Mexico, MSC07 4025, 2325 Camino de Salud NE, Albuquerque, NM, 87131-0001, USA.,Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
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Evans DG, Astley S, Stavrinos P, Harkness E, Donnelly LS, Dawe S, Jacob I, Harvie M, Cuzick J, Brentnall A, Wilson M, Harrison F, Payne K, Howell A. Improvement in risk prediction, early detection and prevention of breast cancer in the NHS Breast Screening Programme and family history clinics: a dual cohort study. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04110] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BackgroundIn the UK, women are invited for 3-yearly mammography screening, through the NHS Breast Screening Programme (NHSBSP), from the ages of 47–50 years to the ages of 69–73 years. Women with family histories of breast cancer can, from the age of 40 years, obtain enhanced surveillance and, in exceptionally high-risk cases, magnetic resonance imaging. However, no NHSBSP risk assessment is undertaken. Risk prediction models are able to categorise women by risk using known risk factors, although accurate individual risk prediction remains elusive. The identification of mammographic breast density (MD) and common genetic risk variants [single nucleotide polymorphisms (SNPs)] has presaged the improved precision of risk models.ObjectivesTo (1) identify the best performing model to assess breast cancer risk in family history clinic (FHC) and population settings; (2) use information from MD/SNPs to improve risk prediction; (3) assess the acceptability and feasibility of offering risk assessment in the NHSBSP; and (4) identify the incremental costs and benefits of risk stratified screening in a preliminary cost-effectiveness analysis.DesignTwo cohort studies assessing breast cancer incidence.SettingHigh-risk FHC and the NHSBSP Greater Manchester, UK.ParticipantsA total of 10,000 women aged 20–79 years [Family History Risk Study (FH-Risk); UK Clinical Research Network identification number (UKCRN-ID) 8611] and 53,000 women from the NHSBSP [aged 46–73 years; Predicting the Risk of Cancer At Screening (PROCAS) study; UKCRN-ID 8080].InterventionsQuestionnaires collected standard risk information, and mammograms were assessed for breast density by a number of techniques. All FH-Risk and 10,000 PROCAS participants participated in deoxyribonucleic acid (DNA) studies. The risk prediction models Manual method, Tyrer–Cuzick (TC), BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm) and Gail were used to assess risk, with modelling based on MD and SNPs. A preliminary model-based cost-effectiveness analysis of risk stratified screening was conducted.Main outcome measuresBreast cancer incidence.Data sourcesThe NHSBSP; cancer registration.ResultsA total of 446 women developed incident breast cancers in FH-Risk in 97,958 years of follow-up. All risk models accurately stratified women into risk categories. TC had better risk precision than Gail, and BOADICEA accurately predicted risk in the 6268 single probands. The Manual model was also accurate in the whole cohort. In PROCAS, TC had better risk precision than Gail [area under the curve (AUC) 0.58 vs. 0.54], identifying 547 prospective breast cancers. The addition of SNPs in the FH-Risk case–control study improved risk precision but was not useful inBRCA1(breast cancer 1 gene) families. Risk modelling of SNPs in PROCAS showed an incremental improvement from using SNP18 used in PROCAS to SNP67. MD measured by visual assessment score provided better risk stratification than automatic measures, despite wide intra- and inter-reader variability. Using a MD-adjusted TC model in PROCAS improved risk stratification (AUC = 0.6) and identified significantly higher rates (4.7 per 10,000 vs. 1.3 per 10,000;p < 0.001) of high-stage cancers in women with above-average breast cancer risks. It is not possible to provide estimates of the incremental costs and benefits of risk stratified screening because of lack of data inputs for key parameters in the model-based cost-effectiveness analysis.ConclusionsRisk precision can be improved by using DNA and MD, and can potentially be used to stratify NHSBSP screening. It may also identify those at greater risk of high-stage cancers for enhanced screening. The cost-effectiveness of risk stratified screening is currently associated with extensive uncertainty. Additional research is needed to identify data needed for key inputs into model-based cost-effectiveness analyses to identify the impact on health-care resource use and patient benefits.Future workA pilot of real-time NHSBSP risk prediction to identify women for chemoprevention and enhanced screening is required.FundingThe National Institute for Health Research Programme Grants for Applied Research programme. The DNA saliva collection for SNP analysis for PROCAS was funded by the Genesis Breast Cancer Prevention Appeal.
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Affiliation(s)
- D Gareth Evans
- Department of Genomic Medicine, Institute of Human Development, Manchester Academic Health Science Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Susan Astley
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
| | - Paula Stavrinos
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Elaine Harkness
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
| | - Louise S Donnelly
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Sarah Dawe
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Ian Jacob
- Department of Health Economics, University of Manchester, Manchester, UK
| | - Michelle Harvie
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Adam Brentnall
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Mary Wilson
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | | | - Katherine Payne
- Department of Health Economics, University of Manchester, Manchester, UK
| | - Anthony Howell
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
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Gibbons A, Groarke A, Curtis R, Groarke J. The effect of mode of detection of breast cancer on stress and distress. Psychooncology 2016; 26:787-792. [PMID: 27449013 DOI: 10.1002/pon.4227] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/26/2016] [Accepted: 07/16/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The number of women with screen-detected breast cancer is increasing, but it is not clear if these women experience the same levels of distress as women with symptomatic breast cancer. The current study compared stress and distress in women with screen-detected or symptomatic breast cancer at diagnosis and 12 months post-diagnosis. METHODS Ninety-two women with screen-detected breast cancer and 129 women with symptomatic breast cancer completed measures of perceived stress, anxiety, and depression at diagnosis and 12 months post-diagnosis. Women also completed a measure of cancer-related stress 12 months post-diagnosis. RESULTS Both groups reported similar levels of perceived stress, anxiety, and depression at diagnosis. A third of women in both groups reported clinical levels of anxiety at diagnosis, which decreased over time. There were no differences in depression. Analyses revealed that at 12 months post-diagnosis, the symptomatic group reported a significant reduction in anxiety, but the screen-detected group reported a nonsignificant trend for a reduction over time. The screen-detected group reported significantly higher cancer-related stress at 12 months than the symptomatic group. CONCLUSIONS Screen-detected women report similar distress at diagnosis but may be more at risk for greater distress requiring further psychological support 1 year after diagnosis. Future interventions that focus on preparation for screening may help to reduce ongoing levels of anxiety and cancer-related stress for this group.
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Affiliation(s)
- Andrea Gibbons
- Health Psychology Research Unit, Royal Holloway, University of London, Egham, Surrey, UK.,School of Psychology, National University of Ireland, Galway, Ireland
| | - AnnMarie Groarke
- School of Psychology, National University of Ireland, Galway, Ireland
| | - Ruth Curtis
- School of Psychology, National University of Ireland, Galway, Ireland
| | - Jenny Groarke
- School of Psychology, National University of Ireland, Galway, Ireland
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48
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Evans DGR, Donnelly LS, Harkness EF, Astley SM, Stavrinos P, Dawe S, Watterson D, Fox L, Sergeant JC, Ingham S, Harvie MN, Wilson M, Beetles U, Buchan I, Brentnall AR, French DP, Cuzick J, Howell A. Breast cancer risk feedback to women in the UK NHS breast screening population. Br J Cancer 2016; 114:1045-52. [PMID: 27022688 PMCID: PMC4984905 DOI: 10.1038/bjc.2016.56] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 01/20/2016] [Accepted: 02/11/2016] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION There are widespread moves to develop risk-stratified approaches to population-based breast screening. The public needs to favour receiving breast cancer risk information, which ideally should produce no detrimental effects. This study investigates risk perception, the proportion wishing to know their 10-year risk and whether subsequent screening attendance is affected. METHODS Fifty thousand women attending the NHS Breast Screening Programme completed a risk assessment questionnaire. Ten-year breast cancer risks were estimated using a validated algorithm (Tyrer-Cuzick) adjusted for visually assessed mammographic density. Women at high risk (⩾8%) and low risk (<1%) were invited for face-to-face or telephone risk feedback and counselling. RESULTS Of those invited to receive risk feedback, more high-risk women, 500 out of 673 (74.3%), opted to receive a consultation than low-risk women, 106 out of 193 (54.9%) (P<0.001). Women at high risk were significantly more likely to perceive their risk as high (P<0.001) and to attend their subsequent mammogram (94.4%) compared with low-risk women (84.2%; P=0.04) and all attendees (84.3%; ⩽0.0001). CONCLUSIONS Population-based assessment of breast cancer risk is feasible. The majority of women wished to receive risk information. Perception of general population breast cancer risk is poor. There were no apparent adverse effects on screening attendance for high-risk women whose subsequent screening attendance was increased.
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Affiliation(s)
- D Gareth R Evans
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Genomic Medicine, Manchester Academic Health Sciences Centre, University of Manchester and Central Manchester Foundation Trust, Manchester M13 9WL, UK
- The Christie NHS Foundation Trust, Withington, Manchester M20 4BX, UK
| | - Louise S Donnelly
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Elaine F Harkness
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Centre for Imaging Sciences, Institute for Population Health, University of Manchester, Oxford Road, Manchester M13 9PT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Susan M Astley
- Centre for Imaging Sciences, Institute for Population Health, University of Manchester, Oxford Road, Manchester M13 9PT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Paula Stavrinos
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- The University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Sarah Dawe
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Donna Watterson
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Lynne Fox
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Jamie C Sergeant
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester M13 9PT, UK
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
| | - Sarah Ingham
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Vaughan House, Portsmouth Street, Manchester M13 9GB, UK
| | - Michelle N Harvie
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Mary Wilson
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Ursula Beetles
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Iain Buchan
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Vaughan House, Portsmouth Street, Manchester M13 9GB, UK
| | - Adam R Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - David P French
- School of Psychological Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - Anthony Howell
- Genesis Breast Cancer Prevention Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- The Christie NHS Foundation Trust, Withington, Manchester M20 4BX, UK
- Centre for Imaging Sciences, Institute for Population Health, University of Manchester, Oxford Road, Manchester M13 9PT, UK
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Smith SG, Sestak I, Forster A, Partridge A, Side L, Wolf MS, Horne R, Wardle J, Cuzick J. Factors affecting uptake and adherence to breast cancer chemoprevention: a systematic review and meta-analysis. Ann Oncol 2016; 27:575-90. [PMID: 26646754 PMCID: PMC4803450 DOI: 10.1093/annonc/mdv590] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/29/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Preventive therapy is a risk reduction option for women who have an increased risk of breast cancer. The effectiveness of preventive therapy to reduce breast cancer incidence depends on adequate levels of uptake and adherence to therapy. We aimed to systematically review articles reporting uptake and adherence to therapeutic agents to prevent breast cancer among women at increased risk, and identify the psychological, clinical and demographic factors affecting these outcomes. DESIGN Searches were carried out in PubMed, CINAHL, EMBASE and PsychInfo, yielding 3851 unique articles. Title, abstract and full text screening left 53 articles, and a further 4 studies were identified from reference lists, giving a total of 57. This review was prospectively registered with PROSPERO (CRD42014014957). RESULTS Twenty-four articles reporting 26 studies of uptake in 21 423 women were included in a meta-analysis. The pooled uptake estimate was 16.3% [95% confidence interval (CI) 13.6-19.0], with high heterogeneity (I(2) = 98.9%, P < 0.001). Uptake was unaffected by study location or agent, but was significantly higher in trials [25.2% (95% CI 18.3-32.2)] than in non-trial settings [8.7% (95% CI 6.8-10.9)] (P < 0.001). Factors associated with higher uptake included having an abnormal biopsy, a physician recommendation, higher objective risk, fewer side-effect or trial concerns, and older age. Adherence (day-to-day use or persistence) over the first year was adequate. However, only one study reported a persistence of ≥ 80% by 5 years. Factors associated with lower adherence included allocation to tamoxifen (versus placebo or raloxifene), depression, smoking and older age. Risk of breast cancer was discussed in all qualitative studies. CONCLUSION Uptake of therapeutic agents for the prevention of breast cancer is low, and long-term persistence is often insufficient for women to experience the full preventive effect. Uptake is higher in trials, suggesting further work should focus on implementing preventive therapy within routine care.
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Affiliation(s)
- S G Smith
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London Health Behaviour Research Centre, University College London, London, UK
| | - I Sestak
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London
| | - A Forster
- Health Behaviour Research Centre, University College London, London, UK
| | - A Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - L Side
- Institute for Women's Health, University College London, London, UK
| | - M S Wolf
- Division of General Internal Medicine, Northwestern University, Chicago, USA
| | - R Horne
- Centre for Behavioural Medicine, University College London, London, UK
| | - J Wardle
- Health Behaviour Research Centre, University College London, London, UK
| | - J Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London
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50
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Mlikotic R, Parker B, Rajapakshe R. Assessing the Effects of Participant Preference and Demographics in the Usage of Web-based Survey Questionnaires by Women Attending Screening Mammography in British Columbia. J Med Internet Res 2016; 18:e70. [PMID: 27005707 PMCID: PMC4822030 DOI: 10.2196/jmir.5068] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/29/2015] [Accepted: 01/07/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Increased usage of Internet applications has allowed for the collection of patient reported outcomes (PROs) and other health data through Web-based communication and questionnaires. While these Web platforms allow for increased speed and scope of communication delivery, there are certain limitations associated with this technology, as survey mode preferences vary across demographic groups. OBJECTIVE To investigate the impact of demographic factors and participant preferences on the use of a Web-based questionnaire in comparison with more traditional methods (mail and phone) for women participating in screening mammography in British Columbia, Canada. METHODS A sample of women attending the Screening Mammography Program of British Columbia (SMPBC) participated in a breast cancer risk assessment project. The study questionnaire was administered through one of three modes (ie, telephone, mail, or website platform). Survey mode preferences and actual methods of response were analyzed for participants recruited from Victoria General Hospital. Both univariate and multivariate analyses were used to investigate the association of demographic factors (ie, age, education level, and ethnicity) with certain survey response types. RESULTS A total of 1192 women successfully completed the study questionnaire at Victoria General Hospital. Mail was stated as the most preferred survey mode (509/1192, 42.70%), followed by website platform (422/1192, 35.40%), and telephone (147/1192, 12.33%). Over 80% (955/1192) of participants completed the questionnaire in the mode previously specified as their most preferred; mail was the most common method of response (688/1192, 57.72%). Mail was also the most preferred type of questionnaire response method when participants responded in a mode other than their original preference. The average age of participants who responded via the Web-based platform (age 52.9, 95% confidence interval [CI] 52.1-53.7) was significantly lower than those who used mail and telephone methods (age 55.9, 95% CI 55.2-56.5; P<.001); each decade of increased age was associated with a 0.97-fold decrease in the odds of using the website platform (P<.001). Web-based participation was more likely for those who completed higher levels of education; each interval increase leading to a 1.83 increase in the odds of website platform usage (P<.001). Ethnicity was not shown to play a role in participant preference for the website platform (P=.96). CONCLUSIONS It is beneficial to consider participant survey mode preference when planning to collect PROs and other patient health data. Younger participants and those of higher education level were more likely to use the website platform questionnaire; Web-based participation failed to vary across ethnic group. Because mail questionnaires were still the most preferred survey mode, it will be important to employ strategies, such as user-friendly design and Web-based support, to ensure that the patient feedback being collected is representative of the population being served.
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Affiliation(s)
- Rebecca Mlikotic
- British Columbia Cancer Agency, Sindi Ahluwalia Hawkins Centre for the Southern Interior, Kelowna, BC, Canada.
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