Performance of the Gail and Tyrer-Cuzick breast cancer risk assessment models in women screened in a primary care setting with the FHS-7 questionnaire

Disparities in genetic testing for breast cancer among black and Hispanic women in the United States

Women from racial and ethnic minorities are at a higher risk for developing breast cancer. Despite significant advancements in breast cancer screening, treatment, and overall survival rates, disparities persist among Black and Hispanic women. These disparities manifest as breast cancer at an earlier age with worse prognosis, lower rates of genetic screening, higher rates of advanced-stage diagnosis, and higher rates of breast cancer mortality compared to Caucasian women. The underutilization of available resources, such as genetic testing, counseling, and risk assessment tools, by Black and Hispanic women is one of many reasons contributing to these disparities. This review aims to explore the racial disparities that exist in genetic testing among Black and Hispanic women. Barriers that contribute to racial disparities include limited access to resources, insufficient knowledge and awareness, inconsistent care management, and slow progression of incorporation of genetic data and information from women of racial/ethnic minorities into risk assessment models and genetic databases. These barriers continue to impede rates of genetic testing and counseling among Black and Hispanic mothers. Consequently, it is imperative to address these barriers to promote early risk assessment, genetic testing and counseling, early detection rates, and ultimately, lower mortality rates among women belonging to racial and ethnic minorities.

Impact of Affordable Care Act provisions on the racial makeup of patients enrolled at a Deep South, high-risk breast cancer clinic

Purpose

Black women are less likely to receive screening mammograms and are at a higher lifetime risk for developing breast cancer compared to their White counterparts. Affordable Care Act (ACA) provisions decreased cost sharing for women's preventive screening, potentially mitigating screening disparities. We examined enrollment of a high-risk screening program before and after ACA implementation stratified by race.

Methods

This retrospective, quasi-experimental study examined the ACA's impact on patient demographics at a high-risk breast cancer screening clinic from 02/28/2003-02/28/2019. Patient demographic data were abstracted from electronic medical records and descriptively compared in the pre- and post-ACA time periods. Interrupted time series (ITS) analysis using Poisson regression assessed yearly clinic enrollment rates by race using incidence rate ratios (IRR) and 95% confidence intervals (CI).

Results

2,767 patients enrolled in the clinic. On average, patients were 46 years old (SD, ± 12), 82% were commercially insured, and 8% lived in a highly disadvantaged neighborhood. In ITS models accounting for trends over time, Prior to ACA implementation, White patient enrollment was stable (IRR 1.01, 95% CI 1.00-1.02) while Black patient enrollment increased at 13% per year (IRR 1.13, 95% CI 1.05-1.22). Compared to the pre-ACA enrollment period, the post-ACA enrollment rate remained unchanged for White patients (IRR 0.99, 95% CI 0.97-1.01) but decreased by 17% for Black patients (IRR 0.83, 95% CI 0.74-0.92).

Conclusion

Black patient enrollment decreased at a high-risk breast cancer screening clinic post-ACA compared to the pre-ACA period, indicating a need to identify factors contributing to racial disparities in clinic enrollment.

Results of Magnetic Resonance Imaging (MRI) Screening in Patients at High Risk for Breast Cancer

BACKGROUND

Screening MRI as an adjunct to mammography is recommended by the ACS for patients with a lifetime risk for breast cancer > 20%. While the benefits are clear, MRI screening is associated with an increase in false-positive results. The purpose of this study was to analyze our institutional database of high-risk patients and assess the uptake of screening MRI examinations and the results of those screenings.

METHODS

Our institutional review board-approved High-Risk Breast Cancer Database was queried for patients enrolled from January 2017 to January 2023 who were at high risk for breast cancer in a comparative analysis between those who were screened versus not screened with MRIs. Variables of interest included risk factor, background, MRI screening uptake, and frequency and results of image-guided breast biopsies.

RESULTS

A total of 254 of 1106 high-risk patients (23%) had MRI screening. Forty-six of 852 (5.3%) patients in the non-MRI-screened cohort and nine of 254 (3.5%) patients in the MRI-screened cohort were diagnosed with a malignant lesion after image-guided biopsy (p = 0.6). There was no significant difference between MRI and non-MRI guided biopsies in detecting breast cancer. All malignant lesions were T1 or in situ disease. The 254 patients in the MRI-screened group underwent 185 biopsies. Fifty-seven percent of MRI-guided biopsies yielded benign results.

CONCLUSIONS

Although the addition of MRI screening in our high-risk cohort did not produce a significant number of additional cancer diagnoses, patients monitored in our high-risk cohort who developed breast cancer were diagnosed at very early stages of disease, underscoring the benefit of participation in the program.

Artificial Intelligence Applications in Breast Imaging: Current Status and Future Directions

Attempts to use computers to aid in the detection of breast malignancies date back more than 20 years. Despite significant interest and investment, this has historically led to minimal or no significant improvement in performance and outcomes with traditional computer-aided detection. However, recent advances in artificial intelligence and machine learning are now starting to deliver on the promise of improved performance. There are at present more than 20 FDA-approved AI applications for breast imaging, but adoption and utilization are widely variable and low overall. Breast imaging is unique and has aspects that create both opportunities and challenges for AI development and implementation. Breast cancer screening programs worldwide rely on screening mammography to reduce the morbidity and mortality of breast cancer, and many of the most exciting research projects and available AI applications focus on cancer detection for mammography. There are, however, multiple additional potential applications for AI in breast imaging, including decision support, risk assessment, breast density quantitation, workflow and triage, quality evaluation, response to neoadjuvant chemotherapy assessment, and image enhancement. In this review the current status, availability, and future directions of investigation of these applications are discussed, as well as the opportunities and barriers to more widespread utilization.

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

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

The Value of Tyrer-Cuzick Versus Gail Risk Modeling in Predicting Benefit from Screening MRI in Breast Cancer

OBJECTIVE

Breast cancer is the most commonly diagnosed malignancy in US women. Risk assessment tools such as the Gail and Tyrer-Cuzick (TC) models calculate risk for breast cancer based on modifiable and non-modifiable factors in order to guide screening and prevention for high-risk patients. Screening with magnetic resonance imaging (MRI) in addition to mammography is recommended in high-risk patients (>20% lifetime risk on TC or other familial based models). Currently, no published data indicate these recommendations improve cancer detection.

MATERIALS AND METHODS

With the aim to determine what percentage lifetime risk (LR%) is associated with a statistically significant increase in cancer detection, the Virginia Commonwealth University (VCU) breast imaging database was reviewed to identify patients who received screening MRI.

RESULTS

The receiver operating characteristics (ROC) curves for the Gail and TC models and the rate of cancer detection correlated to 20% LR% were calculated. The Gail model was considered the control model as it is NOT considered a validated screening tool for MRI. TC is not more accurate than Gail when predicting benefit of breast MRI screening. (area under the curve (AUC): 0.6841, 0.6543 respectively, p = 0.828). Univariate analysis failed to demonstrate a statistically significant relationship between the Gail or TC LR % and diagnosis of breast cancer when using 20% as the cutoff for high-risk classification (p = 1.0, 0.369 respectively). Neither the TC nor the Gail risk calculators demonstrated a significant correlation between risk and the likelihood of diagnosis of breast cancer when screened with MRI.

CONCLUSION

Larger cohort studies are necessary to determine the risk percentage most predictive of a breast cancer diagnosis using MRI as screening.

Supplemental Cancer Screening for Women With Dense Breasts: Guidance for Health Care Professionals

Mammography is the standard for breast cancer screening. The sensitivity of mammography in identifying breast cancer, however, is reduced for women with dense breasts. Thirty-eight states have passed laws requiring that all women be notified of breast tissue density results in their mammogram report. The notification includes a statement that differs by state, encouraging women to discuss supplemental screening options with their health care professionals (HCPs). Several supplemental screening tests are available for women with dense breast tissue, but no established guidelines exist to direct HCPs in their recommendation of preferred supplemental screening test. Tailored screening, which takes into consideration the patient's mammographic breast density and lifetime breast cancer risk, can guide breast cancer screening strategies that are more comprehensive. This review describes the benefits and limitations of the various available supplemental screening tests to guide HCPs and patients in choosing the appropriate breast cancer screening.

Histórico familiar para câncer de mama em mulheres: estudo populacional em Uberaba (MG) utilizando o Family History Screen-7

RESUMO Objetiva-se determinar a prevalência de mulheres com risco de desenvolvimento de câncer de mama pelo histórico familiar em Uberaba (MG), e essa prevalência nas diferentes condições socioeconômicas e epidemiológicas. Pesquisa quantitativa, analítica, observacional e transversal de base populacional. Amostra com 1.520 mulheres a partir de 20 anos. Dados coletados por entrevistas domiciliares sobre informações socioeconômicas e epidemiológicas. A avaliação do risco hereditário de câncer de mama foi realizada pelo Family History Screen-7 (FHS-7). Como resultado, 28,6% da amostra apresentaram risco hereditário para câncer de mama. Houve associação significativa do risco de câncer quanto a: faixa etária, sendo nas mulheres com idade de 70 anos ou mais a maior proporção com risco (33,5%); etnia, sendo a maior proporção entre mulheres de etnia branca (31,2%); renda familiar, com maior ocorrência para renda per capita > 2,5 salários-mínimos (31,6%); prática de exames preventivos (30,6%); e alterações benignas na mama (46,7%). Conclui-se que, a partir do histórico familiar pelo FHS-7, o risco de as mulheres desenvolverem câncer mostrou-se significativamente associado com maior faixa etária, etnia branca e maior renda per capita, com a prática de exames preventivos em dia e alterações benignas na mama. Tais resultados possibilitam melhores direcionamentos de políticas públicas.

Outcomes of Return to Routine Screening for BI-RADS 3 Lesions Detected at Supplemental Automated Whole-Breast Ultrasound in Women with Dense Breasts: A Prospective Study

Background: Supplemental screening breast ultrasound (US) detects additional cancers in women with dense breasts but identifies many BI-RADS 3 lesions that result in short-term follow-ups and biopsies. Objective: To evaluate outcomes in patients recommended for return to routine screening for lesions assessed as BI-RADS 3 on supplemental automated whole-breast US (ABUS). Methods: This prospective study invited patients with BI-RADS 1 or 2 on screening mammography and breast density C or D to undergo supplemental ABUS. ABUS was interpreted as BI-RADS 1, 2, 3, or 0. Return to routine screening was recommended for ABUS BI-RADS 1, 2, or 3. ABUS BI-RADS 0 lesions underwent targeted hand-held US. Remaining patients were followed for 2 years. Malignancy rates were compared using Fisher's exact tests. Results: A total of 2257 women (mean age, 58.0±11.2 years) were included. Supplemental ABUS was scored as BI-RADS 1 in 1186 (52.5%), BI-RADS 2 in 591 (26.2%), BI-RADS 3 in 395 (17.5%), and BI-RADS 0 in 85 (3.8%). A total of 394 patients with ABUS BI-RADS 3 had 2-year follow-up, during which no cancer (0%, 95% CI 0.0%-0.9%) was diagnosed in the quadrant of the lesion. Among patients with 2-year follow-up, breast cancer was diagnosed in 4/1117 (0.4%) with ABUS BI-RADS 1, 2/556 (0.4%) with ABUS BI-RADS 2, and 2/394 (0.5%) with ABUS BI-RADS 3 (cancer in other quadrant than the lesion). Malignancy rates were not different between ABUS BI-RADS 1, 2, and 3 (p=.28). ABUS recall rate was 3.8% (85/2257; 95% CI 3.6%-4.0%). If short-term follow-up had been recommended for ABUS BI-RADS 3, ABUS recall rate would have been 21.3% (480/2257, 95% CI 19.6%-23.0%). Biopsy rate was 0.4% (12/2257; 95% CI 0.3%-0.9%); positive biopsy rate was 58.3% (7/12). One of 7 patients diagnosed with cancer by initial supplemental ABUS, and none of 8 patients diagnosed with cancer during subsequent follow-up, had node-positive cancer. Conclusions: Return to routine screening for ABUS BI-RADS 3 lesions results in a substantial decrease in recall rate, while being unlikely to result in adverse outcome. Clinical Impact: This prospective study supports a recommendation for routine annual follow-up for BI-RADS 3 lesions at supplemental ABUS.

How extent of Barrett's metaplasia influences the risk of esophageal adenocarcinoma

PURPOSE OF REVIEW

This review will focus on how the extent of Barrett's metaplasia influences the risk of esophageal adenocarcinoma (EAC). More specifically, this review will discuss the concepts of long and short-segment Barrett's metaplasia and irregular Z line as they relate to EAC risk.

RECENT FINDINGS

The Prague classification can standardize reporting of Barrett's metaplasia. Recent literature has found significant associations between the length of Barrett's metaplasia and increased progression risk to EAC in multiple geographically distinct populations. Length of Barrett's metaplasia has been incorporated into the Progression of Barrett's esophagus (PIB) model that can predict individualized life-time risks of progression. The risk of malignant transformation appears to be very low in patients with irregular Z line.

SUMMARY

Length of Barrett's metaplasia has emerged as an important predictor that can influence the risk of EAC and should be reported using the Prague classification. The PIB model, if further validated, could help a practicing gastroenterologist to inform patients with Barrett's metaplasia about their personal risk of progression to tailor surveillance intervals. Current guidelines do not recommend surveillance in patients with irregular Z line, but careful examination is recommended.

[Desire for pregnancy and breast cancer]

Breast cancer affects about 3,000 new women of childbearing age each year. The desire for pregnancy is therefore a frequent issue in the management of breast cancer. We reviewed the current state of knowledge and recommendations in high-risk women, on the consideration of this desire for pregnancy in therapeutic management, the way to approach it, the preservation of fertility in the care process and finally on the outcomes of pregnancy after breast cancer. We evaluated the desire for pregnancy, qualitatively and quantitatively, after breast cancer through a literature review.