Breast cancer prevention: a review of current evidence

Is using the Gail model to calculate the risk of breast cancer in the Venezuelan population justified?

Objective

To evaluate the accuracy of the Gail model (GM) in women who already have a diagnosis of breast cancer (BC) from the Breast Pathology Service, Hospital Oncology Department of the Venezuelan Social Security Institute (SOH-IVSS) in the period 2004-2014. To compare the accuracy of the GM in women aged above and below 40 years with a diagnosis of BC.

Method

Descriptive, retrospective, cross-sectional, 830 records of patients diagnosed with BC were reviewed between 2004 and 2014.

Results

The mean age for diagnosis of the disease was 46 ± 13 years; menarche age was 13 years ± 2; age at first birth 22 ± 5 years, with a history of biopsy 32 ± 11, the percentage of relatives with a primary history of BC reported (PHBC) 9.3%. Only 41% of women with a diagnosis of BC reported Gail >1.67 (positive Gail). In the dichotomous logistic regression that related positive Gail with the independent variables, it was observed: greater probability of positive Gail if menarche age <11 years (p < 0.036), PHBC (p = 0.005), previous biopsy (p = 0.007), age at first birth 25-29 years (p = 0.019). When stratifying by age, unlike the bivariate analysis, women over 40 years of age are more likely to have a positive Gail in menarche age <11 years (p = 0.008), PHBC (p = 0.001), previous biopsy (p = 0.025) when compared with younger women, the age at first birth between 25 and 29 years was statistically significant for both groups; however, the probability was higher in younger women (p = 0.008).

Conclusion

There is no conclusive evidence to consider that the GM is applicable to Venezuelan women due to its low precision since it only identified 41% of the patients who had BC as high risk; however, when the factors are analysed separately, we found a higher probability of a positive Gail with statistical significance in EM <11 years, PHBC, previous biopsy and age at first birth 25-29 years; When stratifying by age, we observed that the age at first birth 25-29 years in women aged 40 or less increases the probability of a positive Gail. It is necessary to develop new risk assessment models that are adapted to our female population.

Breast Cancer Knowledge, Attitudes and Practices amongst Women in Qatar

This cross-sectional study examines knowledge, attitudes, and practices surrounding breast cancer awareness and screening among women residents in Qatar. Females, >18 years old, registered with the Primary Health Care Corporation were invited to complete an Arabic or English online survey using a modified version of the Breast Cancer Awareness Module. Of the 9008 participants, 69% report awareness of breast cancer warning signs, but the results did not substantiate these claims. There remains a disconnect between participants’ perceived awareness of their ability to detect breast cancer and their actual recognition of individual signs and symptoms. Nearly half (45.4%) report rarely or never checking their breasts for abnormalities (44.6%). Breast self-examination (BSE) and Breast Cancer Screening (BCS) uptake is low and many are unaware of the starting age for invitation to Qatar’s BCS program. While only 18% of women report receiving an invitation, 94% attended, indicating that the BCS invitation is a remarkably effective means of improving screening uptake. Policymakers should capitalize on early recognition, which is possible in the youthful population. Broadening awareness campaigns and interventions targeting a broader audience including males, community and religious leaders and healthcare professionals may prove more effective in Arab communities.

The Evaluation of p53 Polymorphism at Codon 72 and Association With Breast Cancer in Iran: A Systematic Review and Meta-analysis

Background

Breast cancer is the most common cancer among women in Iran and the world. Multiple environmental factors and genetic variations such as genetic polymorphisms are of its main causes. p53 gene plays an important role in conserving and sustaining the genome as a tumor suppressing gene. Change and polymorphism at codon 72 of p53 gene are correlated with increased risk of lung, mouth, endometrial, prostate, and colorectal cancers, and could be considered an indicator of susceptibility to breast cancer.

Methods

Twelve studies (1,190 cases and 1,145 control studies with evaluation of three types of Arg/Arg, Arg/Pro, and Pro/Pro genotypes) have been conducted using keywords, such as polymorphism at codon 72, gene p53 polymorphisms, and the relation between polymorphisms and breast cancer, from databases in Iran, including Magiran, Medlibe, Sid, and Iranmedex, as well as Latin databases such as PubMed, Google Scholar, Science Direct, and Scopus.

Results

The OR for Arg/Arg is 1.58 (95% CI: 2.45 to 1.01), the OR for Arg/Pro is 0.75 (95% CI: 1.10 to 0.51), and the OR for Pro/Pro is 0.62 (95% CI: 0.93 to 0.42). p53 gene polymorphism at codon 72 is statistically significant in Arg/Arg and Pro/Pro genotypes.

Conclusions

Arg/Arg genotype can be considered as a risk factor for breast cancer, and Pro/Pro genotype can be accounted for as a protective factor against breast cancer.

Association between breastfeeding and breast cancer risk: evidence from a meta-analysis

BACKGROUND

Quantification of the association between breastfeeding and breast cancer risk is still conflicting. Therefore, we conducted a meta-analysis to summarize the evidence from epidemiological studies of breastfeeding with the risk of breast cancer.

MATERIALS AND METHODS

Pertinent studies were identified by a search of PubMed between January 1, 2008 and July 31, 2014. The random-effect model was used. Sensitivity analysis, subgroups analysis, and publication bias were conducted.

RESULTS

Twenty-four articles with 27 studies involving 13,907 breast cancer cases were included in this meta-analysis. Pooled results suggested that breastfeeding was inversely [corrected] associated with the risk of breast cancer. The summary relative risk (RR) of breast cancer for the ever compared with never categories of breastfeeding was 0.613 (95% confidence interval [CI], 0.442-0.850). An inverse association was also found for the longest compared with the shortest categories of breastfeeding with the risk of breast cancer (RR=0.471; 95% CI, 0.368-0.602). No evidence of publication bias was found.

CONCLUSIONS

Findings from this meta-analysis suggest that breastfeeding, particularly a longer duration of breastfeeding, was inversely associated with risk of breast cancer.

Determining the awareness of and compliance with breast cancer screening among Turkish residential women

BACKGROUND

Breast cancer is the leading cause of cancer-related deaths in women. Despite being associated with high morbidity and mortality, breast cancer is a disease that can be diagnosed and treated early.

MATERIALS AND METHODS

In this cross-sectional study of 321 women, data were collected by Questionnaire, Breast Cancer Risk Assessment Form and Champion's Health Belief Model Scale. Mann-Whitney U, Kruskal-Wallis, Chi- squared tests and logistic regression were used in the statistical analysis.

RESULTS

It was found that only 2.2% of women have high and very high risk levels of breast cancer risk. There is a positive correlation between early diagnosis techniques and Health Belief Model Sub-Dimension scores which are sensibility, health motivation, BSE (Breast self-examination) self-efficient perception and negative correlation between mammography barrier score and BSE barrier score (p 0.05). When factors for not having BSE were examined, it was determined that the women who do not have information about breast cancer and the women who smoke have a higher risk of not having BSE.

CONCLUSIONS

It is important to determine health beliefs and breast cancer risk levels of women to increase the frequency of early diagnosis. Women's health beliefs are thought to be a good guide for planning health education programs for nurses working in this area.

Perception of breast health amongst Malaysian female adolescents

BACKGROUND

Breast cancer is the most common cancer among women in Malaysia, about one in 19 women being at risk. This study aimed to investigate knowledge and practice of breast self-examination (BSE), as well as knowledge of risk factors for breast cancer amongst female adolescents in Malaysia. Subsequently, relationships between demographic characteristics and knowledge level of BSE, risk factors for breast cancer and BSE practice were assessed.

MATERIALS AND METHODS

A descriptive, cross sectional survey was conducted using a sample of 500 Malaysian adolescents from the age of 15 to 19 years. A self-administered questionnaire was used to gather socio- demographic characteristics, knowledge of BSE, knowledge of risk factors for breast cancer and BSE practices.

RESULTS

The findings of this study indicated that female adolescents in Malaysia demonstrated an inadequate knowledge level of BSE and risk factors for breast cancer. Only 27.8% of female adolescents performed BSE regularly. BSE practice, knowledge of BSE and knowledge of risk factors for breast cancer showed significant positive relationships.

CONCLUSIONS

The study highlighted the importance of planning and implementing breast health education programs for female students in secondary schools in Malaysia. It will also provide the health care providers an avenue to stress on the importance of imparting breast health education to adolescents.

Determination of information and support needs of first degree relatives of women with breast cancer

BACKGROUND

Breast cancer is the most frequent type of cancer among women in the world and the most common cause of deaths from cancer in females. In Turkey, breast cancer comes first in the list of the most frequent ten cancer types seen in women. As the incidence rate of breast cancer is high, many women having breast cancer in the family experience the breast cancer at secondhand. This study was carried out in an attempt to determine the information and support needs of women whose first-degree relatives have breast cancer and to what extent these needs are met.

METHODS

The research sample consisted of 156 women. Questionnaire Form and Information and Support Needs Questionnaires were used as the data collection tools.

RESULTS

Information need score averages (x?:3.72±0.19) of women included in the research sampling were found to be higher than their score averages of support needs (x?:3.24±0.41).

CONCLUSION

Information needs which were indicated by women as very important were related to treatment, symptoms of breast cancer and breast self examination (BSE), while support needs which were indicated by women as very important were learning how to perform BSE, women's anxiety for themselves and their relatives regarding breast cancer and having their breasts examined by a health professional. It is recommended that nurses and other medical staff should give information to women whose first-degree relatives have breast cancer about the disease, its etiology, scanning, diagnosis, treatment options and protection as well as prevention.

Risk of developing breast cancer by utilizing Gail model

The Gail model has been widely used to quantify an individual woman's risk of developing breast cancer by using important clinical parameters, usually for clinical counselling purposes or to determine eligibility for mammography and genetic tests. The aim of the present study was to estimate the five-year and lifetime breast cancer risk among women in Rasht, Iran. In this cross-sectional study, 314 women were evaluated at Alzahra Women Hospital in 2007. Participants were ≥35 years of age without a history of breast cancer. Risk estimation was performed using the computerized Gail model. A five-year risk >1.66% was considered high-risk; 5.1% of women were high-risk. The mean five-year breast cancer risk was 0.8% (SD±1). Mean breast cancer risk up to the age of 90 years (lifetime risk) was 9.0% (SD±3.9%); 16.2% of the participants had a five-year risk higher than the average woman of the same age, and 18.2% had the same risk. Also for the lifetime risk, 11.1% of the women had higher risk and 1.6% had the same risk as the average woman. Routine use of the Gail model is recommended for identifying women at high average risk for increasing the survival of women from breast cancer.

An overview of letrozole in postmenopausal women with hormone-responsive breast cancer

Third-generation aromatase inhibitors (AIs) have proven to be superior to tamoxifen in terms of time to disease progression in patients with hormone receptor (HR) positive (HR+) status and, nowadays, are used in the adjuvant and neoadjuvant settings, and first-line therapy for advanced breast cancer. Letrozole is a third generation AI, as are anastrozole and exemestane. In the past, clinical studies had demonstrated that letrozole was effective as a second-line treatment of metastatic breast cancer. In this paper, pharmacokinetic and pharmacodynamic properties of letrozole are reviewed along with its activity in preclinical and clinical settings. Additionally, the results of important clinical trials such as Breast International Group (BIG) 1-98, which tested the optimal initial adjuvant endocrine treatment and the sequential therapy with letrozole and tamoxifen, MA-17 that evaluates the benefits of extended adjuvant therapy, and other important studies in advanced and neoadjuvant disease, are reviewed. Safety comparisons of treatments are also addressed. Interestingly, about 50% of human epidermal growth factor receptor 2-positive (HER2+) breast cancers are HR+. However, HER2 positivity is a marker of antiestrogen treatment resistance. Because of this, a dual treatment is a logical approach when both receptors are overexpressed. The combination of lapatinib and letrozole leads to a significant improvement in the overall disease outcome. Also, the combination of everolimus plus letrozole has been tested in this setting. In fact, the coadministration of both agents seems to increase the efficacy of letrozole in newly-diagnosed HR+ patients. Once resistance to sequential trastuzumab and AI as monotherapy has been found, trastuzumab and letrozole combined in HR+ and HER2+ patients with advanced breast cancer can overcome resistance to both drugs administered as single agents, according to recently reported results.

Conhecimento e prática sobre os fatores de risco para o câncer de mama entre mulheres de 40 a 69 anos

OBJETIVO: investigar conhecimento e prática sobre os fatores de risco para o câncer de mama entre usuárias da Estratégia de Saúde da Família (ESF). MÉTODOS: estudo transversal com 393 mulheres com idades entre 40 e 69 anos usuárias da ESF na cidade de Dourados, MS. Realizou-se uma entrevista, por meio de um questionário semi-estruturado, investigando-se variáveis sociodemográficas, história familiar e conhecimento/prática sobre os fatores de risco para o câncer de mama. A descrição das variáveis foi feita através de frequência simples e porcentagem. A associação do conhecimento sobre os fatores de risco e as variáveis foram verificadas pelo teste exato de Fisher e qui-quadrado com nível de significância de 5%. RESULTADOS: a idade média foi de 52,5 ± 8,1 anos, o tempo médio de estudo foi de 4,4±3,6 anos, 52,4% das mulheres eram pardas/negras e 66,6% possuiam companheiro. Entre as mulheres, 86,5% receberam alguma informação sobre o câncer de mama. Os fatores de risco para a doença eram conhecidos por 54,2% das mulheres. O conhecimento sobre os fatores de risco associou-se com a história familiar (p=0,004) e anos de estudo (p=0,01). Diante dos fatores de risco conhecidos, a frequência de práticas preventivas entre as mulheres foi de 52,2%. CONCLUSÕES: a identificação de variáveis relacionadas a um menor conhecimento sobre a doença pode auxiliar na adoção de estratégias direcionadas aos grupos mais vulneráveis.

[Cytophotometric expressions of CASPASE-3 and CD-34 in breast cancer]

OBJECTIVE

Describe, correlate and compare the expression of the tumor markers CD 34 (angiogenesis) and caspase-3 (apoptosis) in invasive breast adenocarcinoma, through image cytometry with the system SAMBA4000.

METHODS

Twenty-two cases of invasive breast adenocarcinoma from paraffin-embedded archival tissue, and after specific prepare, fifteen cases presented a satisfactory lecture with SAMBA4000 and could, finally, be evaluated by the software IMMUNO(R) (n = 15). The parameters analysed were the label index - in percentage, indicating the marked surface - and the optical density, in pixels - indicator of the marker intensity. The results were tabulated and expressed in averages, mediums, minimum and maximum values. The statistic analysis was realized by the Shapiro-Wilkins, Student test, Pearson's and Spearman's correlation, with statistic significance for values from p < 0,05.

RESULTS

There was no data normality for the label index CD34 (p= 0,019), there was normality in the analysis of the optical density of both markers and label index of the marker Caspase-3. There was no difference relating to the average of the index marker and the optical density when they were compared.

CONCLUSIONS

There was a tendency to correlate the label index and the optical density of the tumor marker caspase-3, the same did not occur with the tumor marker CD 34. Other analysis did not show any correlation between the two studied markers. Other studies involving theses two cell processes are needed to extend the knowledge of the cancer biomolecular mechanic and to permit new diagnostic and therapeutic strategies.

Weight, height, body mass index and risk of breast cancer in postmenopausal women: a case-control study

Background

Many women in Iran have a relatively high body mass index. To investigate whether the condition contributes to excess breast cancer cases, a case-control study was conducted to assess the relationships between anthropometric variables and breast cancer risk in Tehran, Iran.

Methods

All incident cases of breast cancer in the Iranian Centre for Breast Cancer (ICBC) were identified through the case records. Eligible cases were all postmenopausal women with histological confirmed diagnosis of breast cancer during 1996 to year 2000. Controls were randomly selected postmenopausal women attending the ICBC for clinical breast examination during the same period. The body mass index (BMI) was calculated based on weights and heights as measured by the ICBC nursing staff. Both tests for trend and logistic regression analysis were performed to calculate odds ratios and 95% confidence intervals as measures of relative risk.

Results

In all, 116 breast cancer cases and 116 controls were studied. There were no significant differences between cases and control with regard to most independent variables studied. However, a significant difference was observed between cases and controls indicating that the mean BMI was higher in cases as compared to controls (P = 0.004). Performing logistic regression analysis while controlling for age, age at menopause, family history of breast cancer and parity, the results showed that women with a BMI in the obese range had a three fold increased risk of breast cancer [odds ratio (OR) = 3.21, 95% confidence interval (CI): 1.15–8.47].

Conclusion

The results suggest that obesity in postmenopausal women could increase risk of breast cancer and it merits further investigation in populations such as Iran where it seems that many women are short in height, and have a relatively high body mass index.

Expressive Writing in Women With Advanced Breast Cancer

PURPOSE/OBJECTIVES

To explore the relationships between patterns of affective word use (words with positive or negative connotations) in expressive writing conducted over four consecutive days and quality of life (QOL) three months after the writing exercise in women with metastatic breast cancer.

DESIGN

Descriptive, correlational.

SETTING

Six clinical sites in New England.

SAMPLE

68 women with metastatic breast cancer.

MAIN RESEARCH VARIABLES

Patterns of positive and negative affective word use and QOL.

METHODS

Usage patterns of affective words in expressive writing were identified through the Linguistic Inquiry and Word Count (LIWC). Relationships between patterns of affective word use and QOL were explored. QOL was measured at baseline and three months after the writing exercise by the Functional Assessment of Cancer Therapy-Breast. Correlations between patterns of word use and QOL were investigated using general linear regression.

FINDINGS

A significant relationship was found between positive-affect word use and emotional well-being. Manual scoring of 10 expressive writing texts to validate LIWC data identified a significant difference between LIWC and manual counts for negative language. Contextual evaluation suggested marked ambivalence in how the women wrote about cancer.

CONCLUSIONS

A positive relationship between affective language in disclosure and QOL was demonstrated, illustrating a cognitive process occurring in expressive writing.

IMPLICATIONS FOR NURSING

The findings suggest that expressive writing is a positive, helpful intervention for patients with cancer attempting to reintegrate the experience in life. Nurses should gain deeper understanding of underlying cognitive processes of disclosure to identify the most effective manner in which to use such interventions.

Lipídio: fator de risco e prevenção do câncer de mama

A hipótese de que uma dieta rica em gordura promova o desenvolvimento do câncer de mama na menopausa é fortalecida por estudos caso-controle, que mostram forte associação positiva entre uma dieta rica em lipídios e as taxas de incidência de câncer de mama. Por outro lado, a ingestão dietética de gordura não parece estar relacionada com o risco de câncer de mama em estudos de coorte. Em vista desses achados conflitantes, tem sido difícil propor qualquer recomendação nutricional para a prevenção do câncer de mama. Estudos com animais e observações recentes em humanos, entretanto, têm mostrado evidências de que a dieta rica em ácido graxo linoléico estimula vários estágios no desenvolvimento de câncer mamário. Alguns estudos ainda mostram que o óleo de peixe, constituído de ácidos graxos ômega-3, parece prevenir o câncer pela influência sobre a atividade de enzimas e proteínas relacionadas à proliferação celular. Assim, são necessários estudos epidemiológicos que integrem as interações de ácidos graxos específicos com o catabolismo hormonal, fatores nutricionais protetores e de risco relacionados com o câncer de mama. Nesse trabalho, abordaremos os fatores protetores, de risco e as implicações quali e quantitativas dos ácidos graxos da dieta sobre o câncer de mama.

The global breast cancer burden: variations in epidemiology and survival

Breast cancer is the most common type of cancer and the most common cause of cancer-related mortality among women worldwide. However, the burden is not evenly distributed, and, according to the best available data, there are large variations in the incidence, mortality, and survival between different countries and regions and within specific regions. Many complex factors underlie these variations, including population structure (eg, age, race, and ethnicity), lifestyle, environment, socioeconomic status, risk factor prevalence, mammography use, disease stage at diagnosis, and access to high-quality care. We review recent breast cancer incidence and mortality statistics and explore why these vary so greatly across the world. Further research is needed to fully understand the reasons for variations in breast cancer outcomes. This will aid the development of tailored strategies to improve outcomes in general as well as the standard of care for underserved populations and reduce the burden of breast cancer worldwide.

Coping with appraised breast cancer risk among women with family histories of breast cancer

This descriptive correlational study was based on Neuman's Systems Model and was designed to examine how women with family histories of breast cancer appraise and cope with breast cancer risk. Ninety percent of 209 women in the sample appraised their degree of breast cancer threat as moderate or high. Women with high degrees of appraised risk had low breast cancer risk scores, while women with moderate degrees of appraised risk had higher risk scores. The most common and effective coping modes used were confrontive, optimistic, and early detection behaviors. Over 75% of women either did not use evasive, emotive, palliative, and fatalistic modes of coping, or rated them as ineffective. Canonical correlation analyses revealed five different patterns of appraisal and coping behaviors and lent support to the premise that the type of coping behaviors used varies with how breast cancer risk is appraised.

Tamoxifen for breast cancer chemoprevention: low uptake by high-risk women after evaluation of a breast lump

PURPOSE

The Breast Cancer Prevention Trial (BCPT) published results in 1998 showing that the use of tamoxifen in high-risk women reduced the incidence of invasive breast cancer by 49%. We examined the clinical impact of the BCPT to determine whether high-risk women informed of these results would use tamoxifen for chemoprophylaxis and to investigate the factors influencing this decision.

METHODS

Of 345 women evaluated for a breast lump at a referral center, 89 were defined as high risk for but did not currently have cancer. These women were contacted about their elevated risk and informed that there exists a medication proved to reduce this risk. They were encouraged to discuss the issue with their family physician, to whom we sent copies of the 3 largest tamoxifen chemoprevention studies, including the BCPT. Follow-up was conducted by telephone to determine each woman's choice regarding tamoxifen use for chemoprevention and to ascertain her reasons for reaching this decision.

RESULTS

Of the 89 high-risk women, 1 decided to take tamoxifen for breast cancer chemoprevention. Only 48 women discussed tamoxifen with their family physician; in 3 cases (3.4%) the family physician recommended that the patient start taking tamoxifen, in 8 cases (9.1%) the family physician made no recommendations, and in 37 cases (42%) the family physician advised against tamoxifen. The most frequently cited factors influencing the decision not to start tamoxifen were a fear of adverse events (46.8%), the family physician's recommendation (31.9%), and a perceived low breast cancer risk (34%).

CONCLUSION

Family physicians recommended prophylactic tamoxifen to few women and even fewer women chose to take it. The major barrier appears to be concern about potential adverse effects of tamoxifen.

Multiparametric and multinuclear magnetic resonance imaging of human breast cancer: current applications

The exploration of novel imaging methods that have the potential to improve specificity for the identification of malignancy is still critically needed in breast imaging. Changes in physiologic alterations of soft tissue water associated with breast cancer can be visualized by magnetic resonance (MR) imaging. However, it is unlikely that a single MR parameter can characterize the complexity of breast tissue. Techniques such as multiparametric MR imaging, proton magnetic resonance spectroscopic (MRSI) imaging, and 23Na sodium MR imaging when used in combination provide a comprehensive data set with potentially more power to diagnose breast disease than any single measure alone. A combination of MR, MRSI, and 23Na sodium MR parameters may be examined in a single MR imaging examination, potentially resulting in improved specificity for radiologic evaluation of malignancy.

[Mammography in younger women: interpretation of abnormal findings]

The aim of this paper is to report the mammographic predictive positive value by decade of age using the assessment categories described within the BI-RADS lexicon.

Knowledge, attitudes, and practices surrounding breast cancer screening in educated Appalachian women

PURPOSE/OBJECTIVES

To determine how and what women learn about breast cancer and screening practices and which factors influence women's breast cancer screening practices.

DESIGN

Descriptive analysis of questionnaire data collected at the time of enrollment in a clinical trial.

SETTING

Breast care center of a mid-Atlantic academic health sciences center.

SAMPLE

185 women in a predominantly Appalachian, entirely rural state.

METHODS

Participants completed the Modified Toronto Breast Self-Examination Inventory and questions related to personal mammography practices at the time of enrollment before randomization in a longitudinal clinical intervention study.

MAIN RESEARCH VARIABLES

Women's demographics, knowledge of breast cancer screening practices, adherence to breast cancer screening guidelines, and motivation, knowledge, and practice proficiency surrounding breast cancer screening.

FINDINGS

These educated women had knowledge deficits about breast cancer, breast cancer risk factors, and screening guidelines, particularly the timing and practice behaviors of breast self-examination. Women who had received healthcare and cancer-screening instruction by healthcare providers, including advanced practice nurses, had greater knowledge of breast cancer and detection practices.

CONCLUSIONS

Women still have knowledge deficits about breast cancer, breast cancer detection, and personal risk factors. In addition, some educated women in this study failed to practice breast cancer screening according to current guidelines.

IMPLICATIONS FOR NURSING

Practitioners must continue to remind and update women about breast disease, and women's cancer-screening practices must be reinforced. All levels of providers should improve their rates of performing clinical breast examinations with physical examinations. Nurses, who greatly influence women's health care, must remain current in their knowledge of breast disease, screening, and treatment.

Ability of Medicaid claims data to identify incident cases of breast cancer in the Ohio Medicaid population

BACKGROUND

The use of Medicaid data to study cancer-related outcomes would be highly desirable. However, the accuracy of Medicaid claims data in the identification of incident cases of breast cancer is unknown.

OBJECTIVES

(1) To estimate the sensitivity of Medicaid claims data for case ascertainment of breast cancer, and (2) to determine the positive predictive value (PPV) of diagnostic and procedure codes retrieved from Medicaid claims, using the Ohio Cancer Incidence Surveillance System (OCISS) as the gold standard.

METHODS

The study used the linked OCISS and Medicaid enrollment files, 1997-1998 (n = 1,648). The claims search yielded 2,635 incident cases, of which 1,132 were also identified through the OCISS-Medicaid files. Sensitivity and PPV of Medicaid data were calculated in subgroups of the population.

RESULTS

The overall sensitivity was 68.7 percent, but varied greatly across the subgroups of the population. It was lower among women enrolled in Medicaid only for part of the study year than those enrolled in Medicaid for 12 months of the study year (56.7 percent and 78.0 percent respectively, p < 0.0001), and lower among those who are dual Medicare-Medicaid eligible compared to those not participating in the Medicare program (63.1 percent and 78.6 percent respectively, p < 0.0001). The overall PPV was 43.0 percent, increasing up to 86.6 percent in the presence of procedure codes indicating the presence of mastectomy and lumpectomy, in addition to that of breast cancer diagnosis.

CONCLUSIONS

The sensitivity of Medicaid claims for case ascertainment of breast cancer is somewhat low, but improves considerably when accounting for women enrolled in Medicaid for the entire duration of the study year. The PPV is poor due to a high rate of false positives. The higher PPV obtained in the presence of procedure codes, in addition to diagnosis codes, will help researchers to correctly identify incident cases of breast cancer using Medicaid claims data.

Update on the current use of hormonals as therapy in advanced breast cancer

Hormonal agents have a confirmed role in the management of postmenopausal women with receptor-positive advanced breast cancer. Until recently, tamoxifen has been the accepted agent for treating these patients. However, accumulating evidence suggests that the new antiaromatase agents will replace the antiestrogens as the preferable option in hormone-naive patients. Comparative trials indicate that the aromatase inhibitors, anastrozole and letrozole, and the aromatase inactivator, exemestane, have at least equivalent efficacy to tamoxifen with similar or superior tolerability. These agents are also more effective than the progestin, megestrol acetate, when studied in patients progressing on tamoxifen. The improved aromatase selectivity and high potency of these antiaromatase agents when compared with earlier agents have resulted in improved efficacy and tolerability. Additionally, no cross-resistance has been reported between the antiaromatase agents and tamoxifen or, in some instances, among the antiaromatase agents themselves. The role of antiaromatase agents will certainly expand in the near future to include not only treatment of metastatic breast cancer, but use in the adjuvant and neoadjuvant settings as well, and, ultimately, breast cancer prevention. The results of ongoing investigations are awaited with interest.

Survival impact of tamoxifen use for breast cancer risk reduction: projections from a patient-specific Markov model

The authors estimate tamoxifen's impact on life expectancy among healthy women. A Markov model compared the effects of 5 years of tamoxifen on survival among 50-year-old postmenopausal women. Scenarios were explored using alternative assumptions with regard to tamoxifen's long-term effects on breast and endometrial cancer. Postmenopausal women without a uterus had substantial life expectancy gains from tamoxifen (1 to 4 months), whereas women with a uterus had such gains only if they were at a very high breast cancer risk. If tamoxifen's impact on endometrial cancer persists after treatment is discontinued, women at high risk for endometrial cancer have life expectancy losses from tamoxifen unless they are at a very high risk for breast cancer. The authors conclude that tamoxifen use among postmenopausal women is associated with substantial life expectancy gains. However, this benefit is modulated in women at increased endometrial cancer risk and depends on assumptions concerning tamoxifen's lingering effects on breast and endometrial cancer.

Breast cancer risk-factor and screening awareness among women nurses and teachers in Amman, Jordan

Breast cancer awareness studies of women in Jordan do not exist. This study used data from 163 nurses and 178 teachers surveyed in Amman to determine 2 dimensions of breast cancer awareness: general breast cancer awareness, defined as knowledge of risk factors associated with the disease and breast cancer screening awareness, defined as knowledge of breast self-examination and mammography. The survey instrument was based on 2 previously validated knowledge-based questionnaires in the literature (Breast Cancer Knowledge Test and the Comprehensive Breast Cancer Questionnaire). Analysis of covariance indicated that family history was associated with general breast cancer awareness. Profession, age, and family history significantly influenced breast cancer screening awareness. The average percentage of correct responses to general breast cancer awareness was adjusted for select covariates (adjusted means). The adjusted mean general awareness score for nurses was not significantly different from that of teachers (P =.8470). Nurses were more aware than teachers of the importance of breast cancer screening and its techniques. The adjusted mean screening awareness score for nurses was 88.3%, compared with 73.1% for teachers (P <.0001). These results provide important information about the level of breast cancer awareness among women nurses and teachers in Jordan and may be useful for developing future prevention and screening education programs.

Addressing the support needs of women at high risk for breast cancer: evidence-based care by advanced practice nurses

PURPOSE/OBJECTIVES

To identify support needs of women at high risk for breast cancer and enhance an evidence-based service.

DESIGN

Descriptive study.

SETTING

A comprehensive, breast-health service for high-risk women.

SAMPLE

97 high-risk women with a 1.66% or greater five-year risk of breast cancer, atypical hyperplasia, lobular carcinoma in situ, or positive genetic screen.

METHODS

A self-assessment questionnaire completed previsit and a satisfaction survey completed postvisit.

MAIN RESEARCH VARIABLES

Women's perceived informational, emotional, and decisional support needs, current self-care practices, and satisfaction with the service provided.

FINDINGS

Women under age 50 (n = 54) wanted information on breast cancer screening, risk of breast cancer, lifestyle options to lower risk, and hormone replacement therapy; older women (n = 43) wanted information on risk of breast cancer, lifestyle options, breast cancer screening, and chemoprevention. More than 75% of all women wanted information to help them make decisions on breast cancer prevention options, benefits, and risks. The satisfaction survey (N = 61) revealed that most women's needs were met.

CONCLUSIONS

Support needs were consistent with the literature that focused primarily on younger women seeking genetic counseling. Proactive planning assisted with addressing the needs of these women.

IMPLICATIONS FOR NURSING

A previsit questionnaire facilitates individualized proactive planning before the visit. However, further assessment of self-care practices and emotional needs is required. Interventions should evaluate outcomes, such as accurate risk perception, lifestyle changes, screening follow-through, and decision quality. Advanced practice nurses require specialized skills, including evidence-based risk communication, behavior modification, and decision support.

Breast cancer chemoprevention: current challenges and a look toward the future

There is a need to develop new prevention agents for breast cancer risk reduction that would have fewer side effects than the approved agent, tamoxifen, and/or would be effective in preventing estrogen receptor-negative or tamoxifen-resistant, estrogen receptor-positive breast cancers. There also is a need to improve the accuracy of present risk assessment models and to incorporate tissue-based biomarkers to supplement risk prediction tools. Candidate risk biomarkers include the serum hormones insulin-like growth factor-1 and its binding protein-3, mammographic breast density, nipple aspirate fluid production, and breast tissue evidence of proliferative breast disease (intraepithelial neoplasia). A variety of techniques have been developed to randomly sample breast tissue to detect precancerous changes and/or detect modulation of proliferation in response to a prevention agent. Based on molecular abnormalities observed in breast intraepithelial neoplasia, a number of drug classes and combinations are suggested as potential chemoprevention approaches. Clinical trial models have been developed to select the appropriate drug dose for subsequent biomarker modulation chemoprevention trials in which the use of surrogate endpoint biomarkers as indicators of efficacy is being explored. If these biomarkers can be validated and shown to reliably predict and monitor response in phase I/II prevention trials, and if favorable modulation is correlated with subsequent decreased cancer incidence, biomarkers may replace cancer incidence as the endpoint in future phase III trials, dramatically reducing the time and expense associated with new prevention drug development.

Risk estimation for breast cancer development; a clinical perspective

Breast cancer is the commonest cancer among women and the second highest cause of cancer death. It remains a significant health problem and represents a significant worry for many women and their physician. During the last years, intensive research has been focused on accurate risk estimation for breast cancer development. The aim of these efforts is to identify the "high-risk" group of women for breast cancer development. Preventive strategies (including intensive surveillance, chemoprevention, or prophylactic mastectomy) may be applied for the women at high risk for breast cancer development. Given the many management options, it seems reasonable that management of the high-risk woman be tailored to the level of risk she is willing to accept. In estimating the risk for breast cancer development, several factors should be taken into account (including age, reproductive factors, such as age at menarche and age at menopause or pregnancy and age at first live birth, history of benign breast lesions or breast cancer in situ [LCIS/DCIS], prior history of breast cancer, history of familiar or hereditary breast cancer, and environmental and lifestyle factors). Recently, quantitative risk estimation is possible by combining multiple risk factors into a comprehensible risk expression; this is of significant clinical importance, since it will reduce the considerable variation in management among health care providers. The Gail and the Claus model are the most widely used models for quantitative risk estimation. However, the clinician should understand that all models have some limitations that should be recalled as they are applied. It should be emphasized that risk assessment is a serious undertaking and should only be performed by those who have in-depth knowledge about risk factors, family pedigree analysis, comparative statistics, genetics susceptibility testing and the science of probability.

Breast cancer risk reduction: strategies for women at increased risk

Breast cancer risk reduction now represents an achievable medical objective. Current interventions include selective estrogen receptor modulators (SERMs), prophylactic surgery, and lifestyle change. For SERMs, current evidence supports tamoxifen use for breast cancer risk reduction whereas raloxifene requires further study. Prophylactic mastectomy and prophylactic oophorectomy, effective in retrospective clinical experiences, should be considered only for women at substantial risk willing to accept the irreversible consequences of these procedures. Although dietary fat intake is under clinical trial evaluation, lifestyle change, including weight loss, dietary change, and increased physical activity, can be recommended based on other health considerations. Use of any intervention requires careful breast cancer risk assessment, risk-benefit calculations, and informed decision making with full patient participation. Future breast cancer risk assessment may incorporate additional biologic measures of estrogen exposure and/or analyses of collected breast cells. Under active evaluation are novel SERMs, aromatase inhibitors/inactivators, gonadotrophin-releasing hormone agonists, retinoids, statins, and tyrosine kinase and cyclooxygenase-2 inhibitors.

Optimal neural network architecture selection: improvement in computerized detection of microcalcifications

RATIONALE AND OBJECTIVES

The authors evaluated the effect of optimal neural network architecture selection on the performance of a computer-aided diagnostic system designed to detect microcalcification clusters on digitized mammograms.

MATERIALS AND METHODS

The authors developed a computer program to detect microcalcification clusters automatically on digitized mammograms. Previously, they found that a properly selected and trained convolution neural network (CNN) could reduce false-positive (FP) findings and therefore improve the accuracy of microcalcification detection. In the current study, they evaluated the effectiveness of the CNN optimized with an automated optimization technique in improving the accuracy of the microcalcification detection program, comparing it with the manually selected CNN. An independent test data set was used, which included 472 mammograms selected from the University of South Florida public database and contained 253 biopsy-proved malignant clusters.

RESULTS

At an FP rate of 0.7 cluster per image, the film-based sensitivity was 84.6% for the optimized CNN, compared with 77.2% for the manually selected CNN. For clusters imaged on both craniocaudal and mediolateral oblique views, a cluster could be considered detected when it was detected on one or both views. For this case-based approach, at an FP rate of 0.7 per image, the sensitivity was 93.3% for the optimized and 87.0% for the manually selected CNN.

CONCLUSION

The classification of true and false signals is an important step in the microcalcification detection program. An optimized CNN can effectively reduce FP findings and improve the accuracy of the computer-aided detection system.

Risk factors and health promotion in families of patients with breast cancer

Women with a family history of breast cancer have an increased risk of developing the disease. Women identified as "high risk" for developing breast cancer have been shown to exhibit increased levels of psychological distress and anxiety related to breast cancer. Oncology nurses can address this barrier and others, such as altered risk perception and lack of physician recommendation for screening. Oncology nurses also can identify high-risk families that may be candidates for genetic testing for breast cancer susceptibility, provide comprehensive teaching about breast self-examination (BSE), and clarify misconceptions about early detection. Primary prevention measures for hereditary breast cancer include prophylactic mastectomy and oophorectomy and chemopreventative agents. Secondary prevention measures include screening and early detection with mammography, clinical breast examinations, and BSE. Nurses have a responsibility to educate families of patients with breast cancer about risk factors, primary and secondary preventive measures, genetic testing, and screening recommendations.

Prophylactic surgery to reduce breast cancer risk: a brief literature review

Prophylactic mastectomy reduces the likelihood of developing breast cancer among women at heightened risk for breast cancer, but at significant personal cost. Women at increased breast cancer risk on the basis of hormonal history, family history and/or genetic mutation carrier status may consider bilateral prophylactic mastectomy with or without reconstruction to reduce their cancer risk and/or decrease their chances of cancer mortality. Women having received mastectomy as treatment for breast cancer may request contralateral mastectomy to decrease the chances of developing a second breast primary. The potential oncologic value of these procedures must be weighed carefully on a case-by-case basis against the operation's physical and psychological morbidity. The purpose of this literature review is to provide a practice-oriented summary of recent clinical studies attempting to address the relative risks and benefits of preventive surgery for breast cancer. Data are included regarding the psychological factors surrounding patient selection and quality of life outcomes, which become the cornerstone of patient satisfaction and acceptance. Taken together, these data support the Society of Surgical Oncology position statement regarding the proper application of prophylactic surgery for breast cancer.

Human oestrogenic 17beta-hydroxysteroid dehydrogenase specificity: enzyme regulation through an NADPH-dependent substrate inhibition towards the highly specific oestrone reduction

Human oestrogenic 17beta-hydroxysteroid dehydrogenase (17beta-HSD1) catalyses the final step in the biosynthesis of all active oestrogens. Here we report the steady-state kinetics for 17beta-HSD1 at 37 degrees C and pH 7.5, using a homogeneous enzyme preparation with oestrone, dehydroepiandrosterone (DHEA) or dihydrotestosterone (DHT) as substrate and NADP(H) as the cofactor. Kinetic studies made over a wide range of oestrone concentrations (10 nM-10 microM) revealed a typical substrate-inhibition phenomenon. Data analysis using the substrate-inhibition equation v=V.[s]/[K(m)+[s](1+[s]/K(i))] gave a K(m) of 0.07+/-0.01 microM, a k(cat) (for the dimer) of 1.5+/-0.1 s(-1), a specificity of 21 microM(-1) x s(-1) and a K(i) of 1.3 microM. When NADH was used instead of NADPH, substrate inhibition was no longer observed and the kinetic constants were significantly modified to 0.42+/-0.07 microM for the K(m), 0.8+/-0.04 s(-1) for the k(cat) and 1.9 microM(-1) x s(-1) for the specificity. The modification of an amino acid in the cofactor-binding site (Leu36Asp) eliminated the substrate inhibition observed in the presence of NADPH, confirming the NADPH-dependence of the phenomenon. The possible formation of an enzyme-NADP(+)-oestrone dead-end complex during the substrate-inhibition process is supported by the competitive inhibition of oestradiol oxidation by oestrone. Kinetic studies performed with either DHEA (K(m)=24+/-4 microM; k(cat)=0.47+/-0.06 s(-1); specificity=0.002 microM(-1) x s(-1)) or DHT (K(m)=26+/-6 microM; k(cat)=0.2+/-0.02 s(-1); specificity=0.0008 microM(-1) x s(-1)) in the presence of NADP(H) resulted in low specificities and no substrate inhibition. Taken together, our results demonstrate that the high specificity of 17beta-HSD1 towards oestrone is coupled with an NADPH-dependent substrate inhibition, suggesting that both the specificity and the enzyme control are provided for the cognate substrate.