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Mittmann N, Blackmore KM, Seung SJ, Diong C, Done SJ, Chiarelli AM. Healthcare and Cancer Treatment Costs of Breast Screening Outcomes among Higher than Average Risk Women. Curr Oncol 2023; 30:8550-8562. [PMID: 37754535 PMCID: PMC10529052 DOI: 10.3390/curroncol30090620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/23/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023] Open
Abstract
Concurrent cohorts of 644,932 women aged 50-74 screened annually due to family history, dense breasts or biennially in the Ontario Breast Screening Program (OBSP) from 2011-2014 were linked to provincial administrative datasets to determine health system resource utilization and costs. Age-adjusted mean and median total healthcare costs (2018 CAD) and incremental cost differences were calculated by screening outcome and compared by recommendation using regression models. Healthcare costs were compared overall and 1 year after a false positive (n = 46,081) screening mammogram and 2 years after a breast cancer diagnosis (n = 6011). Mean overall healthcare costs by age were highest for those 60-74, particularly with annual screening for family/personal history (CAD 5425; 95% CI: 5308 to 5557) compared to biennial. Although the mean incremental cost difference was higher (23.4%) by CAD 10,235 (95% CI: 6141 to 14,329) per breast cancer for women screened annually for density ≥ 75% compared to biennially, the cost difference was 12.0% lower (-CAD 461; 95% CI: -777 to -114) per false positive result. In contrast, for women screened annually for family/personal history, the mean cost difference per false positive was 19.7% higher than for biennially (CAD 758; 95% CI: 404 to 1118); however, the cost difference per breast cancer was only slightly higher (2.5%) by CAD 1093 (95% CI: -1337 to CAD 3760). Understanding that associated costs of annual compared to biennial screening may balance out by age and outcome can assist decision-making regarding the use of limited healthcare resources.
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Affiliation(s)
- Nicole Mittmann
- Department of Pharmacology & Toxicology, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON M4G 3M5, Canada
| | | | - Soo Jin Seung
- HOPE Research Centre, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Christina Diong
- ICES Central, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Susan J. Done
- Laboratory Medicine Program, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Anna M. Chiarelli
- Ontario Health, 525 University Avenue, 5th Floor, Toronto, ON M5G 2L3, Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, Canada
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2
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Brooks JD, Mah A, Christensen RAG, Arneja J, Eisen A, Chiarelli AM. Validation of the International Breast Cancer Intervention Study (IBIS) Model in the High Risk Ontario Breast Screening Program: A Retrospective Cohort Study. Genet Med 2023; 25:100820. [PMID: 36919844 DOI: 10.1016/j.gim.2023.100820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 03/04/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023] Open
Abstract
PURPOSE Women with a remaining lifetime risk of breast cancer ≥25%, estimated using the International Breast Cancer Intervention Study (IBIS) model, are eligible for the High Risk Ontario Breast Screening Program (OBSP). This study examined the performance of IBIS 10-year risk estimates in the Program. METHODS This retrospective study included 7487 women aged 30-69 years referred to the High Risk OBSP between July 1, 2011, and December 31, 2016, with follow-up until December 31, 2018. Model calibration and discrimination were assessed. Analyses were conducted overall and stratified by age (< or ≥50 years). Different 10-year risk thresholds were compared to the current eligibility criteria. RESULTS Overall, IBIS over-estimated the risk of breast cancer with an E/O ratio of 1.17, 95% CI 1.04, 1.35. Over-estimation was highest in women ages 50-69 years (E/O=1.29, 95% CI 1.03, 1.69), and for those in the top quartile of risk. Overall discrimination was fair with a c-statistic of 0.66 (95% CI 0.63, 0.70). Further, when using different 10-year risk eligibility thresholds most cases would have been missed in the 30-49 age group using the 8% 10-year risk threshold, while relatively few women aged 50-69 would have been ineligible at any of the thresholds examined. CONCLUSION We found IBIS over-estimates the risk of breast cancer in this screening cohort but has adequate discrimination. Age-specific risk thresholds should be considered to optimize Program eligibility criteria.
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Affiliation(s)
- Jennifer D Brooks
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Ashley Mah
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Jasleen Arneja
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Eisen
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anna M Chiarelli
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
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3
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Mavaddat N, Ficorella L, Carver T, Lee A, Cunningham AP, Lush M, Dennis J, Tischkowitz M, Downes K, Hu D, Hahnen E, Schmutzler RK, Stockley TL, Downs GS, Zhang T, Chiarelli AM, Bojesen SE, Liu C, Chung WK, Pardo M, Feliubadaló L, Balmaña J, Simard J, Antoniou AC, Easton DF. Incorporating Alternative Polygenic Risk Scores into the BOADICEA Breast Cancer Risk Prediction Model. Cancer Epidemiol Biomarkers Prev 2023; 32:422-427. [PMID: 36649146 PMCID: PMC9986688 DOI: 10.1158/1055-9965.epi-22-0756] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/09/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The multifactorial risk prediction model BOADICEA enables identification of women at higher or lower risk of developing breast cancer. BOADICEA models genetic susceptibility in terms of the effects of rare variants in breast cancer susceptibility genes and a polygenic component, decomposed into an unmeasured and a measured component - the polygenic risk score (PRS). The current version was developed using a 313 SNP PRS. Here, we evaluated approaches to incorporating this PRS and alternative PRS in BOADICEA. METHODS The mean, SD, and proportion of the overall polygenic component explained by the PRS (α2) need to be estimated. $\alpha $ was estimated using logistic regression, where the age-specific log-OR is constrained to be a function of the age-dependent polygenic relative risk in BOADICEA; and using a retrospective likelihood (RL) approach that models, in addition, the unmeasured polygenic component. RESULTS Parameters were computed for 11 PRS, including 6 variations of the 313 SNP PRS used in clinical trials and implementation studies. The logistic regression approach underestimates $\alpha $, as compared with the RL estimates. The RL $\alpha $ estimates were very close to those obtained by assuming proportionality to the OR per 1 SD, with the constant of proportionality estimated using the 313 SNP PRS. Small variations in the SNPs included in the PRS can lead to large differences in the mean. CONCLUSIONS BOADICEA can be readily adapted to different PRS in a manner that maintains consistency of the model. IMPACT : The methods described facilitate comprehensive breast cancer risk assessment.
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Affiliation(s)
- Nasim Mavaddat
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Lorenzo Ficorella
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Tim Carver
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Andrew Lee
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Alex P. Cunningham
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Michael Lush
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Joe Dennis
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Marc Tischkowitz
- Department of Medical Genetics and National Institute for Health Research, Cambridge Biomedical Research Centre, The University of Cambridge, Cambridge, United Kingdom
| | - Kate Downes
- Cambridge Genomics Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Donglei Hu
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Eric Hahnen
- Center for Familial Breast and Ovarian Cancer, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Center for Integrated Oncology (CIO), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Rita K. Schmutzler
- Center for Familial Breast and Ovarian Cancer, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Center for Integrated Oncology (CIO), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tracy L. Stockley
- Advanced Molecular Diagnostics Laboratory, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, The University of Toronto, Ontario, Canada
- Division of Clinical Laboratory Genetics, Laboratory Medicine Program, University Health Network, Toronto, Canada
| | - Gregory S. Downs
- Advanced Molecular Diagnostics Laboratory, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Division of Clinical Laboratory Genetics, Laboratory Medicine Program, University Health Network, Toronto, Canada
| | - Tong Zhang
- Advanced Molecular Diagnostics Laboratory, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Anna M. Chiarelli
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Ontario Health, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Stig E. Bojesen
- Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cong Liu
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York
| | - Wendy K. Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, New York
| | - Monica Pardo
- Hereditary Cancer Genetics Group, Vall d'Hebron Institut d'Oncologia, Barcelona, Spain
| | - Lidia Feliubadaló
- Hereditary Cancer Program, Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat, Spain
- Program in Molecular Mechanisms and Experimental Therapy in Oncology (Oncobell), IDIBELL, L'Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| | - Judith Balmaña
- Hereditary Cancer Genetics Group, Vall d'Hebron Institut d'Oncologia, Barcelona, Spain
- Medical Oncology Department, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Jacques Simard
- Department of Molecular Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Canada
| | - Antonis C. Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Douglas F. Easton
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Ward SV, Burton A, Tamimi RM, Pereira A, Garmendia ML, Pollan M, Boyd N, Dos-Santos-Silva I, Maskarinec G, Perez-Gomez B, Vachon C, Miao H, Lajous M, López-Ridaura R, Bertrand K, Kwong A, Ursin G, Lee E, Ma H, Vinnicombe S, Moss S, Allen S, Ndumia R, Vinayak S, Teo SH, Mariapun S, Peplonska B, Bukowska-Damska A, Nagata C, Hopper J, Giles G, Ozmen V, Aribal ME, Schüz J, Van Gils CH, Wanders JOP, Sirous R, Sirous M, Hipwell J, Kim J, Lee JW, Dickens C, Hartman M, Chia KS, Scott C, Chiarelli AM, Linton L, Flugelman AA, Salem D, Kamal R, McCormack V, Stone J. The association of age at menarche and adult height with mammographic density in the International Consortium of Mammographic Density. Breast Cancer Res 2022; 24:49. [PMID: 35836268 PMCID: PMC9284807 DOI: 10.1186/s13058-022-01545-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/29/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Early age at menarche and tall stature are associated with increased breast cancer risk. We examined whether these associations were also positively associated with mammographic density, a strong marker of breast cancer risk. METHODS Participants were 10,681 breast-cancer-free women from 22 countries in the International Consortium of Mammographic Density, each with centrally assessed mammographic density and a common set of epidemiologic data. Study periods for the 27 studies ranged from 1987 to 2014. Multi-level linear regression models estimated changes in square-root per cent density (√PD) and dense area (√DA) associated with age at menarche and adult height in pooled analyses and population-specific meta-analyses. Models were adjusted for age at mammogram, body mass index, menopausal status, hormone therapy use, mammography view and type, mammographic density assessor, parity and height/age at menarche. RESULTS In pooled analyses, later age at menarche was associated with higher per cent density (β√PD = 0.023 SE = 0.008, P = 0.003) and larger dense area (β√DA = 0.032 SE = 0.010, P = 0.002). Taller women had larger dense area (β√DA = 0.069 SE = 0.028, P = 0.012) and higher per cent density (β√PD = 0.044, SE = 0.023, P = 0.054), although the observed effect on per cent density depended upon the adjustment used for body size. Similar overall effect estimates were observed in meta-analyses across population groups. CONCLUSIONS In one of the largest international studies to date, later age at menarche was positively associated with mammographic density. This is in contrast to its association with breast cancer risk, providing little evidence of mediation. Increased height was also positively associated with mammographic density, particularly dense area. These results suggest a complex relationship between growth and development, mammographic density and breast cancer risk. Future studies should evaluate the potential mediation of the breast cancer effects of taller stature through absolute breast density.
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Affiliation(s)
- Sarah V Ward
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | - Anya Burton
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372, Lyon Cedex 08, France
- Translation Health Sciences, University of Bristol, Bristol, UK
| | - Rulla M Tamimi
- Population Health Sciences, Weill Cornell Medical College, Cornell University, New York, USA
| | - Ana Pereira
- Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile
| | | | - Marina Pollan
- Cancer and Environmental Epidemiology Unit, Instituto de Salud Carlos III, Madrid, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Norman Boyd
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Isabel Dos-Santos-Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Beatriz Perez-Gomez
- Cancer and Environmental Epidemiology Unit, Instituto de Salud Carlos III, Madrid, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Celine Vachon
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Hui Miao
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore City, Singapore
| | - Martín Lajous
- Instituto Nacional de Salud Pública, Cuernavaca, Mexico
| | | | | | - Ava Kwong
- Division of Breast Surgery, Faculty of Medicine, University of Hong Kong, Pok Fu Lam, Hong Kong, China
- Department of Surgery and Cancer Genetics Center, Hong Kong Sanatorium and Hospital, Pok Fu Lam, Hong Kong, China
- Hong Kong Hereditary Breast Cancer Family Registry, Pok Fu Lam, Hong Kong, China
| | - Giske Ursin
- Cancer Registry of Norway, Oslo, Norway
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Eunjung Lee
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Huiyan Ma
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA, USA
| | - Sarah Vinnicombe
- Division of Cancer Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland, UK
| | - Sue Moss
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Steve Allen
- Department of Imaging, Royal Marsden NHS Foundation Trust, London, UK
| | - Rose Ndumia
- Aga Khan University Hospital, Nairobi, Kenya
| | | | - Soo-Hwang Teo
- Breast Cancer Research Group, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
- Cancer Research Malaysia, Subang Jaya, Malaysia
| | | | - Beata Peplonska
- Department of Environmental Epidemiology, Nofer Institute of Occupational Medicine, Łódź, Poland
| | - Agnieszka Bukowska-Damska
- Department of Physiology, Pathophysiology and Clinical Immunology,, Medical University of Lodz., Łódź, Poland
| | - Chisato Nagata
- Department of Epidemiology and Preventive Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - John Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Graham Giles
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
- Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, VIC, Australia
| | - Vahit Ozmen
- Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mustafa Erkin Aribal
- Department of Radiology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Joachim Schüz
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | - Carla H Van Gils
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna O P Wanders
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Reza Sirous
- Radiology Department, George Washington University Hospital, Washington, DC, USA
| | - Mehri Sirous
- Radiology Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - John Hipwell
- Centre for Medical Image Computing, University College London, London, UK
| | - Jisun Kim
- Asan Medical Center, Seoul, Republic of Korea
| | | | - Caroline Dickens
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mikael Hartman
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore City, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Kee-Seng Chia
- NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore, Singapore
| | - Christopher Scott
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Anna M Chiarelli
- Ontario Breast Screening Program, Cancer Care Ontario, Toronto, ON, Canada
| | - Linda Linton
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Anath Arzee Flugelman
- National Cancer Control Center, Lady Davis Carmel Medical Center, Faculty of Medicine, Technion-Israel Institute Technology, Haifa, Israel
| | - Dorria Salem
- Woman Imaging Unit, Radiodiagnosis Department, Kasr El Aini, Cairo University Hospitals, Cairo, Egypt
| | - Rasha Kamal
- Woman Imaging Unit, Radiodiagnosis Department, Kasr El Aini, Cairo University Hospitals, Cairo, Egypt
| | - Valerie McCormack
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372, Lyon Cedex 08, France.
| | - Jennifer Stone
- School of Population and Global Health, The University of Western Australia, Perth, Australia
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Habbous S, Homenauth E, Barisic A, Kandasamy S, Majpruz V, Forster K, Yurcan M, Chiarelli AM, Groome P, Holloway CMB, Eisen A. Differences in breast cancer diagnosis by patient presentation in Ontario: a retrospective cohort study. CMAJ Open 2022; 10:E313-E330. [PMID: 35383035 PMCID: PMC9259434 DOI: 10.9778/cmajo.20210254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In Ontario, patients with breast cancer typically receive their diagnoses through the Ontario Breast Screening Program (OBSP) after an abnormal screen, through screening initiated by a primary care provider or other referring physician, or through follow-up of symptoms by patients' primary care providers. We sought to explore the association of the route to diagnosis (screening within or outside the OBSP or via symptomatic presentation) with use of OBSP-affiliated breast assessment sites (O-BAS), wait times until diagnosis or treatment, health care use and overall survival for patients with breast cancer. METHODS In this retrospective cohort study, we used the Ontario Cancer Registry to identify adults (aged 18-105 yr) who received a diagnosis of breast cancer from 2013 to 2017. We excluded patients if they were not Ontario residents or had missing age or sex, or who died before diagnosis. We used logistic regression to evaluate factors associated with categorical variables (whether patients were or were not referred to an OBAS, whether patients were screened or symptomatic) and Cox proportional hazards regression to identify factors associated with all-cause mortality. RESULTS Of 51 460 patients with breast cancer, 42 598 (83%) received their diagnoses at an O-BAS. Patients whose cancer was first detected through the OBSP were more likely than symptomatic patients to be given a diagnosis at an O-BAS (adjusted odds ratio 1.68, 95% confidence interval [CI] 1.57 to 1.80). Patients screened by the OBSP were given their diagnoses 1 month earlier than symptomatic patients, but diagnosis at an O-BAS did not affect the time until either diagnosis or treatment. Patients referred to an O-BAS had significantly better overall survival than those who were not referred (adjusted hazard ratio 0.73, 95% CI 0.66 to 0.80). INTERPRETATION Patients screened through the OBSP were given their diagnoses earlier than symptomatic patients and were more likely to be referred to an O-BAS, which was associated with better survival. Our findings suggest that individuals with signs and symptoms of breast cancer would benefit from similar referral processes, oversight and standards to those used by the OBSP.
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Affiliation(s)
- Steven Habbous
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont.
| | - Esha Homenauth
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Andriana Barisic
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Sharmilaa Kandasamy
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Vicky Majpruz
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Katharina Forster
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Marta Yurcan
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Anna M Chiarelli
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Patti Groome
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Claire M B Holloway
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Andrea Eisen
- Ontario Health (Cancer Care Ontario) (Habbous, Homenauth, Barisic, Kandasamy, Majpruz, Forster, Yurcan, Chiarelli, Holloway, Eisen); Dalla Lana School of Public Health (Chiarelli), Toronto, Ont.; ICES Queen's (Groome), Kingston, Ont.; Department of Surgery (Holloway), University of Toronto; Department of Medical Oncology (Eisen), Sunnybrook Health Sciences Centre, Toronto, Ont
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Walker MJ, Wang J, Mazuryk J, Skinner SM, Meggetto O, Ashu E, Habbous S, Nazeri Rad N, Espino-Hernández G, Wood R, Chaudhry M, Vahid S, Gao J, Gallo-Hershberg D, Gutierrez E, Zanchetta C, Langer D, Zwicker V, Rey M, Tammemägi MC, Tinmouth J, Kupets R, Chiarelli AM, Singh S, Warde P, Forbes L, Dobranowski J, Irish J, Rabeneck L. Delivery of Cancer Care in Ontario, Canada, During the First Year of the COVID-19 Pandemic. JAMA Netw Open 2022; 5:e228855. [PMID: 35467731 PMCID: PMC9039771 DOI: 10.1001/jamanetworkopen.2022.8855] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic has impacted cancer systems worldwide. Quantifying the changes is critical to informing the delivery of care while the pandemic continues, as well as for system recovery and future pandemic planning. OBJECTIVE To quantify change in the delivery of cancer services across the continuum of care during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study assessed cancer screening, imaging, diagnostic, treatment, and psychosocial oncological care services delivered in pediatric and adult populations in Ontario, Canada (population 14.7 million), from April 1, 2019, to March 1, 2021. Data were analyzed from May 1 to July 31, 2021. EXPOSURES COVID-19 pandemic. MAIN OUTCOMES AND MEASURES Cancer service volumes from the first year of the COVID-19 pandemic, defined as April 1, 2020, to March 31, 2021, were compared with volumes during a prepandemic period of April 1, 2019, to March 31, 2020. RESULTS During the first year of the pandemic, there were a total of 4 476 693 cancer care services, compared with 5 644 105 services in the year prior, a difference of 20.7% fewer services of cancer care, representing a potential backlog of 1 167 412 cancer services. While there were less pronounced changes in systemic treatments, emergency and urgent imaging examinations (eg, 1.9% more parenteral systemic treatments) and surgical procedures (eg, 65% more urgent surgical procedures), major reductions were observed for most services beginning in March 2020. Compared with the year prior, during the first pandemic year, cancer screenings were reduced by 42.4% (-1 016 181 screening tests), cancer treatment surgical procedures by 14.1% (-8020 procedures), and radiation treatment visits by 21.0% (-141 629 visits). Biopsies to confirm cancer decreased by up to 41.2% and surgical cancer resections by up to 27.8% during the first pandemic wave. New consultation volumes also decreased, such as for systemic treatment (-8.2%) and radiation treatment (-9.3%). The use of virtual cancer care increased for systemic treatment and radiation treatment and psychosocial oncological care visits, increasing from 0% to 20% of total new or follow-up visits prior to the pandemic up to 78% of total visits in the first pandemic year. CONCLUSIONS AND RELEVANCE In this population-based cohort study in Ontario, Canada, large reductions in cancer service volumes were observed. While most services recovered to prepandemic levels at the end of the first pandemic year, a substantial care deficit likely accrued. The anticipated downstream morbidity and mortality associated with this deficit underscore the urgent need to address the backlog and recover cancer care and warrant further study.
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Affiliation(s)
- Meghan J. Walker
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | | | | | | | - Eta Ashu
- Ontario Health–Cancer Care Ontario, Toronto, Canada
| | | | | | | | - Ryan Wood
- Ontario Health–Cancer Care Ontario, Toronto, Canada
| | | | - Saba Vahid
- Ontario Health–Cancer Care Ontario, Toronto, Canada
| | - Julia Gao
- Ontario Health–Cancer Care Ontario, Toronto, Canada
| | - Daniela Gallo-Hershberg
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | | | | | | | | | - Michelle Rey
- Ontario Health–Cancer Care Ontario, Toronto, Canada
| | - Martin C. Tammemägi
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Department of Health Sciences, Brock University, St Catharines, Canada
| | - Jill Tinmouth
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Rachel Kupets
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
| | - Anna M. Chiarelli
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Simron Singh
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, , Canada
| | - Padraig Warde
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Leta Forbes
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Department of Medical Oncology, R.S. McLaughlin Durham Regional Cancer Centre, Oshawa, Canada
| | - Julian Dobranowski
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Department of Radiology, McMaster University, Hamilton, Canada
- Niagara Health, St Catharines, Ontario, Canada
| | - Jonathan Irish
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Canada
- Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Linda Rabeneck
- Ontario Health–Cancer Care Ontario, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
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Blackmore KM, Chiarelli AM, Mirea L, Mittmann N, Muradali D, Rabeneck L, Done SJ. Annual Mammographic Screening Reduces the Risk of Interval or Higher Stage Invasive Breast Cancers Among Postmenopausal Women in the Ontario Breast Screening Program. Can Assoc Radiol J 2022; 73:524-534. [DOI: 10.1177/08465371211062883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: In the Ontario Breast Screening Program (OBSP) annual screening improved breast cancer detection for women 50–74 years with a family/personal history compared to biennial, while detection was equivalent for women screened annually for mammographic density ≥75%. This study compares the risk of interval or higher stage invasive cancers among postmenopausal women screened annually vs biennially by age and estrogen use. Methods: A retrospective design identified 4247 invasive breast cancers diagnosed among concurrent cohorts of women 50–74 screened in the OBSP with digital mammography between 2011 and 2014, followed until 2016. Polytomous logistic regression estimated the risk of interval or higher stage breast cancers by age and estrogen use between women screened annually because of first-degree relative with breast or ovarian cancer or personal history of ovarian cancer, or mammographic density ≥75%, and those screened biennially. Results: The risk of interval vs screen-detected cancers was significantly reduced in women screened annually for family/personal history (OR=.64; 95%CI:0.51–.80), particularly those 60–74 years (OR=.59; 95%CI:0.45–.77) or not currently using estrogen (OR=.66; 95%CI:0.52–.83) compared to those screened biennially. The risk of stage II–IV vs stage I tumors was also lower in women 60–74 years screened annually for family/personal history (OR=.79; 95%CI:0.64–.97) and in those screened annually for mammographic density ≥75% currently using estrogen (OR=.51; 95%CI:0.26–1.01) compared to women screened biennially. Conclusion: Postmenopausal women at increased risk screened annually had equivalent or reduced risks of interval or higher stage invasive breast cancers than those screened biennially, further supporting risk-based screening in this population.
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Affiliation(s)
| | - Anna M Chiarelli
- Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Lucia Mirea
- Phoenix Children’s Hospital, Phoenix, AZ, United States
| | | | - Derek Muradali
- Department of Medical Imaging, St Michael’s Hospital, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Linda Rabeneck
- Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Susan J Done
- Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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8
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Chiarelli AM, Walker MJ, Espino-Hernandez G, Gray N, Salleh A, Adhihetty C, Gao J, Fienberg S, Rey MA, Rabeneck L. Adherence to guidance for prioritizing higher risk groups for breast cancer screening during the COVID-19 pandemic in the Ontario Breast Screening Program: a descriptive study. CMAJ Open 2021; 9:E1205-E1212. [PMID: 34933878 PMCID: PMC8695571 DOI: 10.9778/cmajo.20200285] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Breast cancer screening in Ontario, Canada, was deferred during the first wave of the COVID-19 pandemic, and a prioritization framework to resume services according to breast cancer risk was developed. The purpose of this study was to assess the impact of the pandemic within the Ontario Breast Screening Program (OBSP) by comparing total volumes of screening mammographic examinations and volumes of screening mammographic examinations with abnormal results before and during the pandemic, and to assess backlogs on the basis of adherence to the prioritization framework. METHODS A descriptive study was conducted among women aged 50 to 74 years at average risk and women aged 30 to 69 years at high risk, who participated in the OBSP. Percentage change was calculated by comparing observed monthly volumes of mammographic examinations from March 2020 to March 2021 with 2019 volumes and proportions by risk group. We plotted estimates of backlog volumes of mammographic examinations by risk group, comparing pandemic with prepandemic screening practices. Volumes of mammographic examinations with abnormal results were plotted by risk group. RESULTS Volumes of mammographic examinations in the OBSP showed the largest declines in April and May 2020 (> 99% decrease) and returned to prepandemic levels as of March 2021, with an accumulated backlog of 340 876 examinations. As of March 2021, prioritization had reduced the backlog volumes of screens for participants at high risk for breast cancer by 96.5% (186 v. 5469 expected) and annual rescreens for participants at average risk for breast cancer by 13.5% (62 432 v. 72 202 expected); there was a minimal decline for initial screens. Conversely, the backlog increased by 7.6% for biennial rescreens (221 674 v. 206 079 expected). More than half (59.4%) of mammographic examinations with abnormal results were for participants in the higher risk groups. INTERPRETATION Prioritizing screening for those at higher risk for breast cancer may increase diagnostic yield and redirect resources to minimize potential long-term harms caused by the pandemic. This further supports the clinical utility of risk-stratified cancer screening.
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Affiliation(s)
- Anna M Chiarelli
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont.
| | - Meghan J Walker
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
| | - Gabriela Espino-Hernandez
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
| | - Natasha Gray
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
| | - Ayesha Salleh
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
| | - Chamila Adhihetty
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
| | - Julia Gao
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
| | - Samantha Fienberg
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
| | - Michelle A Rey
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
| | - Linda Rabeneck
- Cancer Care Ontario (Chiarelli, Walker, Espino-Hernandez, Gray, Salleh, Adhihetty, Gao, Fienberg, Rey, Rabeneck), Ontario Health, Toronto, Ont.; Dalla Lana School of Public Health (Chiarelli, Walker, Rabeneck), University of Toronto, Toronto, Ont.; Department of Radiology (Fienberg), Grand River Hospital, Kitchener, Ont
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9
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Walker MJ, Meggetto O, Gao J, Espino-Hernández G, Jembere N, Bravo CA, Rey M, Aslam U, Sheppard AJ, Lofters AK, Tammemägi MC, Tinmouth J, Kupets R, Chiarelli AM, Rabeneck L. Measuring the impact of the COVID-19 pandemic on organized cancer screening and diagnostic follow-up care in Ontario, Canada: A provincial, population-based study. Prev Med 2021; 151:106586. [PMID: 34217413 PMCID: PMC9755643 DOI: 10.1016/j.ypmed.2021.106586] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/16/2021] [Accepted: 04/25/2021] [Indexed: 12/14/2022]
Abstract
It is essential to quantify the impacts of the COVID-19 pandemic on cancer screening, including for vulnerable sub-populations, to inform the development of evidence-based, targeted pandemic recovery strategies. We undertook a population-based retrospective observational study in Ontario, Canada to assess the impact of the pandemic on organized cancer screening and diagnostic services, and assess whether patterns of cancer screening service use and diagnostic delay differ across population sub-groups during the pandemic. Provincial health databases were used to identify age-eligible individuals who participated in one or more of Ontario's breast, cervical, colorectal, and lung cancer screening programs from January 1, 2019-December 31, 2020. Ontario's screening programs delivered 951,000 (-41%) fewer screening tests in 2020 than in 2019 and volumes for most programs remained more than 20% below historical levels by the end of 2020. A smaller percentage of cervical screening participants were older (50-59 and 60-69 years) during the pandemic when compared with 2019. Individuals in the oldest age groups and in lower-income neighborhoods were significantly more likely to experience diagnostic delay following an abnormal breast, cervical, or colorectal cancer screening test during the pandemic, and individuals with a high probability of living on a First Nation reserve were significantly more likely to experience diagnostic delay following an abnormal fecal test. Ongoing monitoring and management of backlogs must continue. Further evaluation is required to identify populations for whom access to cancer screening and diagnostic care has been disproportionately impacted and quantify impacts of these service disruptions on cancer incidence, stage, and mortality. This information is critical to pandemic recovery efforts that are aimed at achieving equitable and timely access to cancer screening-related care.
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Affiliation(s)
- Meghan J Walker
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Olivia Meggetto
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Julia Gao
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | | | | | | | - Michelle Rey
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Usman Aslam
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Amanda J Sheppard
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Aisha K Lofters
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, Ontairo, Canada; IC/ES, Toronto, Ontario, Canada; Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Martin C Tammemägi
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Brock University, St. Catharines, Ontario, Canada
| | - Jill Tinmouth
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; IC/ES, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Kupets
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Division of Gynecologic Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Anna M Chiarelli
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Linda Rabeneck
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; IC/ES, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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10
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Pashayan N, Antoniou AC, Lee A, Wolfson M, Chiquette J, Eloy L, Eisen A, Stockley TL, Nabi H, Brooks JD, Dorval M, Easton DF, Knoppers BM, Chiarelli AM, Simard J. Should Age-Dependent Absolute Risk Thresholds Be Used for Risk Stratification in Risk-Stratified Breast Cancer Screening? J Pers Med 2021; 11:916. [PMID: 34575693 PMCID: PMC8469877 DOI: 10.3390/jpm11090916] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/03/2021] [Accepted: 09/13/2021] [Indexed: 12/16/2022] Open
Abstract
In risk-stratified cancer screening, multiple risk factors are incorporated into the risk assessment. An individual's estimated absolute cancer risk is linked to risk categories with tailored screening recommendations for each risk category. Absolute risk, expressed as either remaining lifetime risk or shorter-term (five- or ten-year) risk, is estimated from the age at assessment. These risk estimates vary by age; however, some clinical guidelines (e.g., enhanced breast cancer surveillance guidelines) and ongoing personalised breast screening trials, stratify women based on absolute risk thresholds that do not vary by age. We examine an alternative approach in which the risk thresholds used for risk stratification vary by age and consider the implications of using age-independent risk thresholds on risk stratification. We demonstrate that using an age-independent remaining lifetime risk threshold approach could identify high-risk younger women but would miss high-risk older women, whereas an age-independent 5-year or 10-year absolute risk threshold could miss high-risk younger women and classify lower-risk older women as high risk. With risk misclassification, women with an equivalent risk level would be offered a different screening plan. To mitigate these problems, age-dependent absolute risk thresholds should be used to inform risk stratification.
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Affiliation(s)
- Nora Pashayan
- Department of Applied Health Research, University College London, London WC1E 7HB, UK
| | - Antonis C. Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health & Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge CB1 8RN, UK; (A.C.A.); (A.L.); (D.F.E.)
| | - Andrew Lee
- Centre for Cancer Genetic Epidemiology, Department of Public Health & Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge CB1 8RN, UK; (A.C.A.); (A.L.); (D.F.E.)
| | - Michael Wolfson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada;
| | - Jocelyne Chiquette
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 4G2, Canada;
- CHU de Québec-Université Laval Research Centre, Quebec City, QC G1S 4L8, Canada; (H.N.); (M.D.); (J.S.)
| | - Laurence Eloy
- Quebec Cancer Program, Ministère de la Santé et des Services Sociaux, Quebec City, QC G1S 2M1, Canada;
| | - Andrea Eisen
- Sunnybrook Health Science Centre, Toronto, ON M4N 3M5, Canada;
| | - Tracy L. Stockley
- Division Clinical Laboratory Genetics, Laboratory Medicine Program, University Health Network, Toronto, ON M5G 2C4, Canada;
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Hermann Nabi
- CHU de Québec-Université Laval Research Centre, Quebec City, QC G1S 4L8, Canada; (H.N.); (M.D.); (J.S.)
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 0A6, Canada
| | - Jennifer D. Brooks
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Michel Dorval
- CHU de Québec-Université Laval Research Centre, Quebec City, QC G1S 4L8, Canada; (H.N.); (M.D.); (J.S.)
- Faculty of Pharmacy, Université Laval, Quebec City, QC G1V 0A6, Canada
- CISSS de Chaudière-Appalaches Research Center, Lévis, QC G6V 3Z1, Canada
| | - Douglas F. Easton
- Centre for Cancer Genetic Epidemiology, Department of Public Health & Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge CB1 8RN, UK; (A.C.A.); (A.L.); (D.F.E.)
| | | | - Anna M. Chiarelli
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada;
- Ontario Health, Cancer Care Ontario, Toronto, ON M5G 2L3, Canada;
| | - Jacques Simard
- CHU de Québec-Université Laval Research Centre, Quebec City, QC G1S 4L8, Canada; (H.N.); (M.D.); (J.S.)
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, Québec City, QC G1V 0A6, Canada
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11
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Walker MJ, Hartman K, Majpruz V, Leung YW, Fienberg S, Rabeneck L, Chiarelli AM. The Impact of Radiologist Screening Mammogram Reading Volume on Performance in the Ontario Breast Screening Program. Can Assoc Radiol J 2021; 73:362-370. [PMID: 34423685 DOI: 10.1177/08465371211031186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Although some studies have shown increasing radiologists' mammography volumes improves performance, there is a lack of evidence specific to digital mammography and breast screening program performance targets. This study evaluates the relationship between digital screening volume and meeting performance targets. METHODS This retrospective cohort study included 493 radiologists in the Ontario Breast Screening Program who interpreted 1,762,173 screening mammograms in participants ages 50-90 between 2014 and 2016. Associations between annual screening volume and meeting performance targets for abnormal call rate, positive predictive value (PPV), invasive cancer detection rate (CDR), sensitivity, and specificity were modeled using mixed-effects multivariate logistic regression. RESULTS Most radiologists read 500-999 (36.7%) or 1,000-1,999 (31.0%) screens annually, and 18.5% read ≥2,000. Radiologists who read ≥2,000 annually were more likely to meet abnormal call rate (OR = 3.85; 95% CI: 1.17-12.61), PPV (OR = 5.36; 95% CI: 2.53-11.34), invasive CDR (OR = 4.14; 95% CI: 1.50-11.46), and specificity (OR = 4.07; 95% CI: 1.89-8.79) targets versus those who read 100-499 screens. Radiologists reading 1,000-1,999 screens annually were more likely to meet PPV (OR = 2.32; 95% CI: 1.22-4.40), invasive CDR (OR = 3.36; 95% CI: 1.49-7.59) and specificity (OR = 2.00; 95% CI: 1.04-3.84) targets versus those who read 100-499 screens. No significant differences were observed for sensitivity. CONCLUSIONS Annual reading volume requirements of 1,000 in Canada are supported as screening volume above 1,000 was strongly associated with achieving performance targets for nearly all measures. Increasing the minimum volume to 2,000 may further reduce the potential limitations of screening due to false positives, leading to improvements in overall breast screening program quality.
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Affiliation(s)
- Meghan J Walker
- Prevention and Cancer Control, 573450Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Krystal Hartman
- Prevention and Cancer Control, 573450Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Vicky Majpruz
- Prevention and Cancer Control, 573450Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Yvonne W Leung
- Prevention and Cancer Control, 573450Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Samantha Fienberg
- Prevention and Cancer Control, 573450Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada.,Radiology, McMaster University, Hamilton, Ontario, Canada.,Medical Imaging, Grand River Hospital, Kitchener, Ontario, Canada
| | - Linda Rabeneck
- Prevention and Cancer Control, 573450Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,IC/ES, Toronto, Ontario, Canada
| | - Anna M Chiarelli
- Prevention and Cancer Control, 573450Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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12
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Alarie S, Hagan J, Dalpé G, Faraji S, Mbuya-Bienge C, Nabi H, Pashayan N, Brooks JD, Dorval M, Chiquette J, Eloy L, Turgeon A, Lambert-Côté L, Paquette JS, Walker MJ, Lapointe J, Granados Moreno P, Blackmore K, Wolfson M, Broeders M, Knoppers BM, Chiarelli AM, Simard J, Joly Y. Risk-Stratified Approach to Breast Cancer Screening in Canada: Women's Knowledge of the Legislative Context and Concerns about Discrimination from Genetic and Other Predictive Health Data. J Pers Med 2021; 11:jpm11080726. [PMID: 34442372 PMCID: PMC8398750 DOI: 10.3390/jpm11080726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/17/2021] [Accepted: 07/26/2021] [Indexed: 12/16/2022] Open
Abstract
The success of risk-stratified approaches in improving population-based breast cancer screening programs depends in no small part on women’s buy-in. Fear of genetic discrimination (GD) could be a potential barrier to genetic testing uptake as part of risk assessment. Thus, the objective of this study was twofold. First, to evaluate Canadian women’s knowledge of the legislative context governing GD. Second, to assess their concerns about the possible use of breast cancer risk levels by insurance companies or employers. We use a cross-sectional survey of 4293 (age: 30–69) women, conducted in four Canadian provinces (Alberta, British Colombia, Ontario and Québec). Canadian women’s knowledge of the regulatory framework for GD is relatively limited, with some gaps and misconceptions noted. About a third (34.7%) of the participants had a lot of concerns about the use of their health information by employers or insurers; another third had some concerns (31.9%), while 20% had no concerns. There is a need to further educate and inform the Canadian public about GD and the legal protections that exist to prevent it. Enhanced knowledge could facilitate the implementation and uptake of risk prediction informed by genetic factors, such as the risk-stratified approach to breast cancer screening that includes risk levels.
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Affiliation(s)
- Samuel Alarie
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (S.A.); (G.D.); (S.F.); (P.G.M.); (B.M.K.); (Y.J.)
| | - Julie Hagan
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (S.A.); (G.D.); (S.F.); (P.G.M.); (B.M.K.); (Y.J.)
- Correspondence: ; Tel.: +1-(514)-398-8155
| | - Gratien Dalpé
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (S.A.); (G.D.); (S.F.); (P.G.M.); (B.M.K.); (Y.J.)
| | - Sina Faraji
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (S.A.); (G.D.); (S.F.); (P.G.M.); (B.M.K.); (Y.J.)
| | - Cynthia Mbuya-Bienge
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (H.N.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 0A6, Canada
| | - Hermann Nabi
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (H.N.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 0A6, Canada
- Université Laval Cancer Research Center, Quebec City, QC G1R 3S3, Canada
| | - Nora Pashayan
- Department of Applied Health Research, Institute of Epidemiology and Healthcare, University College London, London WC1E 6BT, UK;
| | - Jennifer D. Brooks
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada; (J.D.B.); (M.J.W.); (A.M.C.)
| | - Michel Dorval
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (H.N.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- Faculty of Pharmacy, Université Laval, Quebec City, QC G1V 4G2, Canada
- CISSS de Chaudière-Appalaches Research Center, Lévis, QC G6V 3Z1, Canada
| | - Jocelyne Chiquette
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (H.N.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- CHU de Québec-Université Laval, Quebec City, QC G1S 4L8, Canada
- Département de Médecine Familiale et de Médecine D’urgence, Université Laval, Quebec City, QC G1V 4G2, Canada;
| | - Laurence Eloy
- Québec Cancer Program, Ministère de la Santé et des Services Sociaux, Quebec City, QC G1S 2M1, Canada;
- Department of Social and Preventive Medicine, CISSS de Lanaudière-Université Laval, Quebec City, QC G1V 0A6, Canada
| | - Annie Turgeon
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (H.N.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
| | - Laurence Lambert-Côté
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (H.N.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
| | - Jean-Sébastien Paquette
- Département de Médecine Familiale et de Médecine D’urgence, Université Laval, Quebec City, QC G1V 4G2, Canada;
| | - Meghan J. Walker
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada; (J.D.B.); (M.J.W.); (A.M.C.)
- Ontario Health (Cancer Care Ontario), Toronto, ON M5G 2L3, Canada;
| | - Julie Lapointe
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (H.N.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
| | - Palmira Granados Moreno
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (S.A.); (G.D.); (S.F.); (P.G.M.); (B.M.K.); (Y.J.)
| | | | - Michael Wolfson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada;
| | - Mireille Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, 525 EZ Nijmegen, The Netherlands;
- Dutch Expert Centre for Screening, 6538 SW Nijmegen, The Netherlands
| | | | - Bartha M. Knoppers
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (S.A.); (G.D.); (S.F.); (P.G.M.); (B.M.K.); (Y.J.)
| | - Anna M. Chiarelli
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada; (J.D.B.); (M.J.W.); (A.M.C.)
- Department of Social and Preventive Medicine, CISSS de Lanaudière-Université Laval, Quebec City, QC G1V 0A6, Canada
| | - Jacques Simard
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (H.N.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 4G2, Canada
| | - Yann Joly
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (S.A.); (G.D.); (S.F.); (P.G.M.); (B.M.K.); (Y.J.)
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13
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Seely JM, Peddle SE, Yang H, Chiarelli AM, McCallum M, Narasimhan G, Zakaria D, Earle CC, Fung S, Bryant H, Nicholson E, Politis C, Berg W. Breast Density and Risk of Interval Cancers: The Effect of Annual Versus Biennial Screening Mammography Policies in Canada. Can Assoc Radiol J 2021; 73:90-100. [PMID: 34279132 DOI: 10.1177/08465371211027958] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Regular screening mammography reduces breast cancer mortality. However, in women with dense breasts, the performance of screening mammography is reduced, which is reflected in higher interval cancer rates (ICR). In Canada, population-based screening mammography programs generally screen women biennially; however, some provinces and territories offer annual mammography for women with dense breast tissue routinely and/or on recommendation of the radiologist. This study compared the ICRs in those breast screening programs with a policy of annual vs. those with biennial screening for women with dense breasts. Among 148,575 women with dense breasts screened between 2008 to 2010, there were 288 invasive interval breast cancers; screening programs with policies offering annual screening for women with dense breasts had fewer interval cancers 63/70,814 (ICR 0.89/1000, 95% CI: 0.67-1.11) compared with those with policies of usual biennial screening 225/77,761 (ICR 1.45 /1000 (annualized), 95% CI: 1.19-1.72) i.e. 63% higher (p = 0.0016). In screening programs where radiologists' screening recommendations were able to be analyzed, a total of 76,103 women were screened, with 87 interval cancers; the ICR was lower for recommended annual (65/69,650, ICR 0.93/1000, 95% CI: 0.71, 1.16) versus recommended biennial screening (22/6,453, ICR 1.70/1000 (annualized), 95%CI: 0.70, 2.71)(p = 0.0605). Screening program policies of annual as compared with biennial screening in women with dense breasts had the greatest impact on reducing interval cancer rates. We review our results in the context of current dense breast notification in Canada.
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Affiliation(s)
- Jean Morag Seely
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Radiology and Surgery, University of Ottawa, Ottawa, Ontario, Canada.,Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Huiming Yang
- Alberta Health Services, Edmonton, Alberta, Canada
| | | | - Megan McCallum
- Government of the Northwest Territories, Yellowknife, Northwest Territories, Canada
| | | | | | - Craig C Earle
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Sharon Fung
- Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Heather Bryant
- Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Erika Nicholson
- Canadian Partnership Against Cancer, Halifax, Nova Scotia, Canada
| | - Chris Politis
- Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | - Wendie Berg
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
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14
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Mbuya-Bienge C, Pashayan N, Brooks JD, Dorval M, Chiquette J, Eloy L, Turgeon A, Lambert-Côté L, Paquette JS, Lévesque E, Hagan J, Walker MJ, Lapointe J, Dalpé G, Granados Moreno P, Blackmore K, Wolfson M, Joly Y, Broeders M, Knoppers BM, Chiarelli AM, Simard J, Nabi H. Women's Views on Multifactorial Breast Cancer Risk Assessment and Risk-Stratified Screening: A Population-Based Survey from Four Provinces in Canada. J Pers Med 2021; 11:jpm11020095. [PMID: 33540785 PMCID: PMC7912955 DOI: 10.3390/jpm11020095] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 01/27/2021] [Accepted: 01/30/2021] [Indexed: 12/03/2022] Open
Abstract
Risk-stratified screening for breast cancer (BC) is increasingly considered as a promising approach. However, its implementation is challenging and needs to be acceptable to women. We examined Canadian women’s attitudes towards, comfort level about, and willingness to take part in BC risk-stratified screening. We conducted an online survey in women aged 30 to 69 years in four Canadian provinces. In total, 4293 women completed the questionnaire (response rate of 63%). The majority of women (63.5% to 72.8%) expressed favorable attitudes towards BC risk-stratified screening. Most women reported that they would be comfortable providing personal and genetic information for BC risk assessment (61.5% to 67.4%) and showed a willingness to have their BC risk assessed if offered (74.8%). Most women (85.9%) would also accept an increase in screening frequency if they were at higher risk, but fewer (49.3%) would accept a reduction in screening frequency if they were at lower risk. There were few differences by province; however, outcomes varied by age, education level, marital status, income, perceived risk, history of BC, prior mammography, and history of genetic test for BC (all p ≤ 0.01). Risk-based BC screening using multifactorial risk assessment appears to be acceptable to most women. This suggests that the implementation of this approach is likely to be well-supported by Canadian women.
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Affiliation(s)
- Cynthia Mbuya-Bienge
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 0A6, Canada
| | - Nora Pashayan
- Department of Applied Health Research, Institute of Epidemiology and Healthcare, University College, London WC1E 6BT, UK;
| | - Jennifer D. Brooks
- Dalla Lana School of Public Health Science, University of Toronto, Toronto, ON M5S 1A1, Canada; (J.D.B.); (M.J.W.); (A.M.C.)
| | - Michel Dorval
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- Faculty of Pharmacy, Université Laval, Quebec City, QC G1V 4G2, Canada
- CISSS de Chaudière-Appalaches Research Center, Lévis, QC G6V 3Z1, Canada
| | - Jocelyne Chiquette
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- CHU de Québec—Université Laval, Quebec City, QC G1S 4L8, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Université Laval, Quebec City, QC G1V 4G2, Canada;
| | - Laurence Eloy
- Québec Cancer Program, Ministère de la Santé et des Services Sociaux, Quebec City, QC G1S 2M1, Canada;
| | - Annie Turgeon
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
| | - Laurence Lambert-Côté
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
| | - Jean-Sébastien Paquette
- Département de Médecine Familiale et de Médecine d’Urgence, Université Laval, Quebec City, QC G1V 4G2, Canada;
| | - Emmanuelle Lévesque
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (E.L.); (J.H.); (G.D.); (P.G.M.); (Y.J.); (B.M.K.)
| | - Julie Hagan
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (E.L.); (J.H.); (G.D.); (P.G.M.); (Y.J.); (B.M.K.)
| | - Meghan J. Walker
- Dalla Lana School of Public Health Science, University of Toronto, Toronto, ON M5S 1A1, Canada; (J.D.B.); (M.J.W.); (A.M.C.)
- Ontario Health, Cancer Care Ontario, Toronto, ON M5G 2L3, Canada;
| | - Julie Lapointe
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
| | - Gratien Dalpé
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (E.L.); (J.H.); (G.D.); (P.G.M.); (Y.J.); (B.M.K.)
| | - Palmira Granados Moreno
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (E.L.); (J.H.); (G.D.); (P.G.M.); (Y.J.); (B.M.K.)
| | | | - Michael Wolfson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada;
| | - Yann Joly
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (E.L.); (J.H.); (G.D.); (P.G.M.); (Y.J.); (B.M.K.)
| | - Mireille Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, 525 EZ Nijmegen, The Netherlands;
- Dutch Expert Centre for Screening, 6538 SW Nijmegen, The Netherlands
| | - Bartha M. Knoppers
- Centre of Genomics and Policy, McGill University, Montreal, QC H3A 0G1, Canada; (E.L.); (J.H.); (G.D.); (P.G.M.); (Y.J.); (B.M.K.)
| | - Anna M. Chiarelli
- Dalla Lana School of Public Health Science, University of Toronto, Toronto, ON M5S 1A1, Canada; (J.D.B.); (M.J.W.); (A.M.C.)
- Ontario Health, Cancer Care Ontario, Toronto, ON M5G 2L3, Canada;
| | - Jacques Simard
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 4G2, Canada
| | - Hermann Nabi
- CHU de Québec-Université Laval Research Center, Quebec City, QC G1V 4G2, Canada; (C.M.-B.); (M.D.); (J.C.); (A.T.); (L.L.-C.); (J.L.); (J.S.)
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 0A6, Canada
- Université Laval Cancer Research Center, Quebec City, QC G1R 3S3, Canada
- Correspondence: ; Tel.: +1-418-682-7511 (ext. 82800)
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15
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Chiarelli AM, Blackmore KM, Mirea L, Done SJ, Majpruz V, Weerasinghe A, Rabeneck L, Muradali D. Annual vs Biennial Screening: Diagnostic Accuracy Among Concurrent Cohorts Within the Ontario Breast Screening Program. J Natl Cancer Inst 2020; 112:400-409. [PMID: 31233138 DOI: 10.1093/jnci/djz131] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/18/2019] [Accepted: 06/20/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The Ontario Breast Screening Program recommends annual mammography to women age 50-74 years at increased risk because of family history of breast or ovarian cancer or personal history of ovarian cancer or mammographic density 75% or greater. Few studies have examined the diagnostic accuracy of recommendations based on risk factors and included screen film as well as digital mammography. METHODS A retrospective design identified concurrent cohorts of women age 50-74 years screened annually or biennially with digital mammography only between 2011 and 2014 and followed until 2016 or breast cancer diagnosis. Diagnostic accuracy measures were compared between women screened annually because of first-degree relative of breast or ovarian cancer or personal history of ovarian cancer (n = 67 795 women), mammographic density 75% or greater (n = 51 956), or both (n = 3758) and those screened biennially (n = 526 815). The association between recommendation and sensitivity and specificity was assessed using generalized estimating equation models. All P values are two-sided. RESULTS For annual screening because of family or personal history vs biennial, sensitivity was statistically significantly higher (81.7% vs 70.6%; OR = 1.86, 95% CI = 1.48 to 2.34), particularly for invasive cancers and postmenopausal women. Although there was no statistically significant difference in sensitivity for annual screening for mammographic density 75% or greater, specificity was statistically significantly lower (91.3%; OR = 0.87, 95% CI = 0.80 to 0.96) vs biennial (92.3%), particularly for women age 50-59 years. CONCLUSION Compared with biennial screening, annual screening improved detection for women with a family or personal history of breast and/or ovarian cancer, supporting screening that is more frequent. The benefit for annual screening for women with higher mammographic density must be weighed against possible harms of increased false positives.
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Affiliation(s)
- Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Lucia Mirea
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Susan J Done
- Laboratory Medicine Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Vicky Majpruz
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
| | | | - Linda Rabeneck
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Phoenix Children's Hospital, Phoenix, AZ.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Derek Muradali
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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16
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Chiarelli AM, Blackmore KM, Muradali D, Done SJ, Majpruz V, Weerasinghe A, Mirea L, Eisen A, Rabeneck L, Warner E. Performance Measures of Magnetic Resonance Imaging Plus Mammography in the High Risk Ontario Breast Screening Program. J Natl Cancer Inst 2020; 112:136-144. [PMID: 31233143 DOI: 10.1093/jnci/djz079] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/11/2019] [Accepted: 04/16/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The Ontario Breast Screening Program expanded in July 2011 to screen high-risk women age 30-69 years with annual magnetic resonance imaging (MRI) and digital mammography. This study examined the benefits of screening with mammography and MRI by age and risk criteria. METHODS This prospective cohort study included 8782 women age 30-69 years referred to the High Risk Ontario Breast Screening Program from July 2011 to June 2015, with final results to December 2016. Cancer detection rates, sensitivity, and specificity of MRI and mammography combined were compared with each modality individually within risk groups stratified by age using generalized estimating equation models. Prognostic features of screen-detected breast cancers were compared by modality using Fisher exact test. All P values are two-sided. RESULTS Among 20 053 screening episodes, there were 280 screen-detected breast cancers (cancer detection rate = 14.0 per 1000, 95% confidence interval [CI] = 12.4 to 15.7). The sensitivity of mammography was statistically significantly lower than that of MRI plus mammography (40.8%, 95% CI = 29.3% to 53.5% vs 96.0%, 95% CI = 92.2% to 98.0%, P < .001). In mutation carriers age 30-39 years, sensitivity of the combination was comparable with MRI alone (100.0% vs 96.8%, 95% CI = 79.2% to 100.0%, P = .99) but with statistically significantly decreased specificity (78.0%, 95% CI = 74.7% to 80.9% vs 86.2%, 95% CI = 83.5% to 88.5%, P < .001). In women age 50-69 years, combining MRI and mammography statistically significantly increased sensitivity compared with MRI alone (96.3%, 95% CI = 90.6% to 98.6% vs 90.9%, 95% CI = 83.6% to 95.1%, P = .02), with a small but statistically significant decrease in specificity (84.2%, 95% CI = 83.1% to 85.2% vs 90.0%, 95% CI = 89.2% to 90.9%, P < .001). CONCLUSIONS Screening high risk women age 30-39 years with annual MRI only may be sufficient for cancer detection and should be evaluated further, particularly for mutation carriers. Among women age 50-69 years, detection is most effective when mammography is included with annual MRI.
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Affiliation(s)
- Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Derek Muradali
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada.,St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Susan J Done
- Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Vicky Majpruz
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Ashini Weerasinghe
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Lucia Mirea
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Phoenix Children's Hospital, Phoenix, AZ
| | - Andrea Eisen
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Linda Rabeneck
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ellen Warner
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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17
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Sheppard AJ, Chiarelli AM, Hanley AJ, Marrett LD. Influence of Preexisting Diabetes on Survival After a Breast Cancer Diagnosis in First Nations Women in Ontario, Canada. JCO Glob Oncol 2020; 6:99-107. [PMID: 32031452 PMCID: PMC6998021 DOI: 10.1200/jgo.19.00061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Survival after a breast cancer diagnosis is poorer in First Nations women with a preexisting comorbidity compared with comorbidity-free First Nations women in Ontario, Canada. Given the high prevalence of diabetes in this population, it is important to determine whether preexisting diabetes is related to poorer survival after a breast cancer diagnosis. METHODS All First Nations women were identified from a cohort of First Nations people diagnosed with breast cancer in diagnostic periods-1995 to 1999 and 2000 to 2004-and seen at a regional cancer program (RCP) in Ontario. Preexisting diabetes status and other factors, such as age at diagnosis, body mass index, and stage at diagnosis, were collected from medical charts at the regional cancer programs. The association between preexisting diabetes and First Nations status was examined by each of the demographic, personal, tumor, and treatment factors using logistic regression models. Survival was compared between First Nations women with (n = 67) and without (n = 215) preexisting diabetes, adjusted by significant study factors using a Cox proportional hazards regression model. RESULTS The 5-year survival rate among First Nations women with diabetes was 59.8% versus 78.7% among those without diabetes (P < .01). Preexisting diabetes significantly increased the risk of death among First Nations women with breast cancer (hazard ratio, 1.87; 95% CI, 1.12 to 3.13) after adjustment for age group, period of diagnosis, body mass index, other comorbidities at diagnosis, and stage. CONCLUSION This study recommends awareness of this survival discrepancy among the treatment team for First Nations patients with breast cancer with preexisting diabetes.
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Affiliation(s)
- Amanda J. Sheppard
- Indigenous Cancer Care Unit, Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Anna M. Chiarelli
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Cancer Screening, Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Anthony J.G. Hanley
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Loraine D. Marrett
- Indigenous Cancer Care Unit, Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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18
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Chiarelli AM, Giaconia GC, Perpetuini D, Greco G, Mistretta L, Rizzo R, Vinciguerra V, Romeo MF, Merla A, Fallica PG. Wearable, Fiber-less, Multi-Channel System for Continuous Wave Functional Near Infrared Spectroscopy Based on Silicon Photomultipliers Detectors and Lock-In Amplification. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2019:60-66. [PMID: 31945845 DOI: 10.1109/embc.2019.8857206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Development and in-vivo validation of a Continuous Wave (CW) functional Near Infrared Spectroscopy (fNIRS) system is presented. The system is wearable, fiber-less, multi-channel (16×16, 256 channels) and expandable and it relies on silicon photomultipliers (SiPMs) for light detection. SiPMs are inexpensive, low voltage and resilient semiconductor light detectors, whose performances are analogous to photomultiplier tubes (PMTs). The advantage of SiPMs with respect to PMTs is that they allow direct contact with the scalp and avoidance of optical fibers. In fact, the coupling of SiPMs and light emitting diodes (LEDs) allows the transfer of the analog signals to and from the scalp through thin electric cables that greatly increase the system flexibility. Moreover, the optical probes, mechanically resembling electroencephalographic electrodes, are robust against motion artifacts. In order to increase the signal-to-noise-ratio (SNR) of the fNIRS acquisition and to decrease ambient noise contamination, a digital lock-in technique was implemented through LEDs modulation and SiPMs signal processing chain. In-vivo validation proved the system capabilities of detecting functional brain activity in the sensorimotor cortices. When compared to other state-of-the-art wearable fNIRS systems, the single photon sensitivity and dynamic range of SiPMs can exploit the long and variable interoptode distances needed for estimation of brain functional hemodynamics using CW-fNIRS.
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19
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Blackmore KM, Weerasinghe A, Holloway CMB, Majpruz V, Mirea L, O'Malley FP, Paroschy Harris C, Hendry A, Hey A, Kornecki A, Lougheed G, Maier BA, Marchand P, McCready D, Rand C, Raphael S, Segal-Nadler R, Sehgal N, Muradali D, Chiarelli AM. Comparison of wait times across the breast cancer treatment pathway among screened women undergoing organized breast assessment versus usual care. Can J Public Health 2019; 110:595-605. [PMID: 31037608 PMCID: PMC6964595 DOI: 10.17269/s41997-019-00210-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/28/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The benefit of organized breast assessment on wait times to treatment among asymptomatic women is unknown. The Ontario Breast Screening Program (OBSP) offers screening and organized assessment through Breast Assessment Centres (BAC). This study compares wait times across the treatment pathway among screened women diagnosed with breast cancer through BAC and usual care (UC). METHODS A retrospective design identified two concurrent cohorts of postmenopausal women aged 50-69 within the OBSP diagnosed with screen-detected invasive breast cancer and assessed in BAC (n = 2010) and UC (n = 1844) between 2002 and 2010. Demographic characteristics were obtained from the OBSP. Medical chart abstraction provided prognostic and treatment data. Multinomial logistic regression examined associations of assessment type with wait times from abnormal mammogram to surgery, chemotherapy or radiotherapy. RESULTS Compared with through UC, postmenopausal women diagnosed through BAC were significantly less likely to have longer wait times (days) from an abnormal mammogram to definitive surgery (> 89 vs. ≤ 47; OR = 0.63; 95% CI = 0.52-0.77), from final surgery to radiotherapy (> 88 vs. ≤ 55; OR = 0.71; 95% CI = 0.54-0.93) and from final chemotherapy to radiotherapy (> 41 vs. ≤ 28; OR = 0.52; 95% CI = 0.36-0.76). Conversely, women assessed through BAC compared with through UC were more likely to experience longer wait times from final surgery to chemotherapy (> 64 vs. ≤ 40; OR = 1.49; 95% CI = 1.04-2.14). CONCLUSION Shorter wait times to most treatments for postmenopausal women diagnosed in BAC further supports that women with an abnormal mammogram should be managed through organized assessment. Continued evaluation of factors influencing wait times to treatment is essential for quality improvement and patient outcomes.
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Affiliation(s)
- Kristina M Blackmore
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario, M5G 2L7, Canada
| | - Ashini Weerasinghe
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario, M5G 2L7, Canada
| | - Claire M B Holloway
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
- Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, Ontario, M5T 1P5, Canada
| | - Vicky Majpruz
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario, M5G 2L7, Canada
| | - Lucia Mirea
- Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ, 85016, USA
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada
| | - Frances P O'Malley
- Department of Laboratory Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - Cathy Paroschy Harris
- Prevention and Screening Services, Thunder Bay Regional Health Sciences Centre, 980 Oliver Road, Thunder Bay, Ontario, P7B 6V4, Canada
| | - Ashley Hendry
- South East Regional Cancer Program, 25 King Street, West Kingston, Ontario, K7L 5P9, Canada
| | - Amanda Hey
- North East Regional Cancer Program, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada
| | - Anat Kornecki
- South West Regional Cancer Program, 790 Commissioners Road, East London, Ontario, N6A 4L6, Canada
| | - George Lougheed
- North Simcoe Muskoka Regional Cancer Program, 201 Georgian Drive, Barrie, ON, L4M 6M2, Canada
| | - Barbara-Anne Maier
- Waterloo Wellington Regional Cancer Program, 835 King Street, West Kitchener, Ontario, N2G 1G3, Canada
| | - Patricia Marchand
- Central East Regional Cancer Program, 1 Hospital Court, Oshawa, Ontario, L1G 2B9, Canada
| | - David McCready
- Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, Ontario, M5T 1P5, Canada
- Princess Margaret Cancer Centre, 610 University Ave, Toronto, Ontario, M5G 2M9, Canada
| | - Carol Rand
- Hamilton Niagara Haldimand Brant Regional Cancer Program, 699 Concession Street, Hamilton, Ontario, L8V 5C2, Canada
| | - Simon Raphael
- North York General Hospital, 4001 Leslie St., North York, Ontario, M2K 1E1, Canada
| | - Roanne Segal-Nadler
- Champlain Regional Cancer Program, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Neelu Sehgal
- Erie St. Clair Regional Cancer Program, 2220 Kildare Road, Windsor, Ontario, N8W 2X3, Canada
| | - Derek Muradali
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario, M5G 2L7, Canada
- St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
- Department of Medical Imaging, University of Toronto, 263 McCaul Street, 4th Floor, Toronto, Ontario, M5T 1W7, Canada
| | - Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario, M5G 2L7, Canada.
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada.
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Meggetto O, Peirson L, Yakubu M, Farid-Kapadia M, Costa-Fagbemi M, Baidoobonso S, Moffatt J, Chun L, Chiarelli AM, Muradali D. Breast cancer risk and breast screening for trans people: an integration of 3 systematic reviews. CMAJ Open 2019; 7:E598-E609. [PMID: 31575606 PMCID: PMC6773550 DOI: 10.9778/cmajo.20180028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Trans people face uncertain risk for breast cancer and barriers to accessing breast screening. Our objectives were to identify and synthesize primary research evidence on the effect of cross-sex hormones (CSHs) on breast cancer risk, prognosis and mortality among trans people, the benefits and harms of breast screening in this population, and existing clinical practice recommendations on breast screening for trans people. METHODS We conducted 2 systematic reviews of primary research, 1 on the effect of CSHs on breast cancer risk, prognosis and mortality, and the other on the benefits and harms of breast screening, and a third systematic review of guidelines on existing screening recommendations for trans people. We searched PubMed, MEDLINE, Embase, CINAHL, the Cochrane Database of Systematic Reviews and grey literature sources for primary research, guidelines and position statements published in English between 1997 and 2017. Citations were screened by 2 independent reviewers. One reviewer extracted data and assessed methodological quality of included articles; a second reviewer verified these in full. The results were synthesized narratively. RESULTS Four observational studies, 6 guidelines and 5 position statements were included. Observational evidence of very low certainty did not show an effect of CSHs on breast cancer risk in trans men or trans women. Among trans women, painfulness of mammography and ultrasonography was low. There was no evidence on the effect of CSHs on breast cancer prognosis and mortality, or on benefits and other harms of screening. Existing clinical practice documents recommended screening for distinct trans subpopulations; however, recommendations varied. INTERPRETATION The limited evidence does not show an effect of CSHs on breast cancer risk. Although there is insufficient evidence to determine the potential benefits and harms of breast screening, existing clinical practice documents generally recommend screening for trans people; further large-scale prospective comparative research is needed.
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Affiliation(s)
- Olivia Meggetto
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont.
| | - Leslea Peirson
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
| | - Mafo Yakubu
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
| | - Mufiza Farid-Kapadia
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
| | - Michelle Costa-Fagbemi
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
| | - Shamara Baidoobonso
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
| | - Jessica Moffatt
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
| | - Lauren Chun
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
| | - Anna M Chiarelli
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
| | - Derek Muradali
- Prevention and Cancer Control (Meggetto, Peirson, Yakubu, Farid-Kapadia, Costa-Fagbemi, Baidoobonso, Moffatt, Chun, Chiarelli, Muradali), Cancer Care Ontario; Dalla Lana School of Public Health (Chiarelli), University of Toronto; Department of Medical Imaging (Muradali), St. Michael's Hospital; Department of Medical Imaging (Muradali), University of Toronto, Toronto, Ont
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21
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Jiang H, Walter SD, Brown P, Raina P, Chiarelli AM. Estimation of the benefit and harms of including clinical breast examination in an organized breast screening program. Breast 2018; 43:105-112. [PMID: 30544057 DOI: 10.1016/j.breast.2018.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There is controversy about the value of clinical breast examination (CBE) in addition to mammography for breast screening. The study investigates the associations between risk factors such as mammographic density, hormone therapy use and family history and the effectiveness of screening mammography with or without CBE. METHODS The cohort consists of women 50-69 years old screened at the Ontario Breast Screening Program. The associations of the risk factors were investigated using a joint logistic regression model that accommodates the partially unobserved disease status, clustered data structures, individual risk factors, and the dependence between true and false detection. RESULTS Having high mammographic density, a first degree relative with breast cancer and using hormone therapy generally increased a woman's probability of being referred correctly. For low risk group (defined as without dense breasts, family history, and not currently using hormone therapy), the average loss of specificity ranged from 3.6% to 5.7% and the gain of sensitivity was between 10.6% and 21.2% with the addition of CBE. CONCLUSIONS The addition of CBE to mammography would increase the overall sensitivity and decrease the specificity. CBE can be targeted to those women in which it has the highest net benefit.
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Affiliation(s)
- Huan Jiang
- Prevention and Cancer Control, Cancer Care Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Canada.
| | - Stephen D Walter
- Department of Health Research Methods, Evidence & Impact, McMaster University, Canada
| | - Patrick Brown
- Dalla Lana School of Public Health, University of Toronto, Canada
| | - Parminder Raina
- Department of Health Research Methods, Evidence & Impact, McMaster University, Canada
| | - Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Canada
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22
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Smith CR, Chiarelli AM, Holloway CM, Mirea L, O'Malley FP, Blackmore KM, Pandya A, Majpruz V, Harris CP, Hendry A, Hey A, Kornecki A, Lougheed G, Maier BA, Marchand P, McCready D, Rand C, Raphael S, Segal-Nadler R, Sehgal N, Muradali D. The impact of organized breast assessment on survival by stage for screened women diagnosed with invasive breast cancer. Breast 2018; 41:25-33. [PMID: 29957557 DOI: 10.1016/j.breast.2018.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 10/14/2022] Open
Abstract
PURPOSE Since 1998, the Ontario Breast Screening Program (OBSP) has offered organized assessment through Breast Assessment Centres (BAC). This study compares survival between screened women diagnosed with breast cancer who have undergone assessment through a BAC and usual care (UC). METHODS A retrospective design identified two concurrent cohorts of women aged 50 to 69 within the OBSP diagnosed with screen-detected invasive breast cancer at a BAC (n = 2010) and UC (n = 1844) between 2002 and 2010 and followed until 2016. Demographic and assessment characteristics were obtained from the OBSP. Abstraction of medical charts provided prognostic and treatment data. Death data were assessed from the Registered Person's Database and the Ontario Registrar General All-Cause Mortality File. Multivariable Cox proportional hazards models compared overall survival by assessment type (BAC/UC), stratified by stage. RESULTS There were 505 deaths during the study (BAC = 239; UC = 266). Among women with stage I screen-detected breast cancer, those diagnosed through a BAC had 31% reduced risk of all-cause mortality (HR = 0.69, 95% CI = 0.53-0.90) compared to UC. Diagnosis within 7 weeks of an abnormal mammogram reduced the hazard of death from all causes by 34% among all women with stage I breast cancers (HR = 0.66, 95% CI = 0.47-0.91), and was more likely in BAC (79.7%) than UC (66.9%). CONCLUSION The significant improvement in overall survival for women with stage I screen-detected invasive breast cancer assessed through BACs further supports the recommendation that women with abnormal mammograms should be managed through organized assessment.
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Affiliation(s)
- Courtney R Smith
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue Toronto, Ontario M5G 2L7, Canada
| | - Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue Toronto, Ontario M5G 2L7, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor Toronto, Ontario M5T 3M7, Canada.
| | - Claire Mb Holloway
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, Ontario M5T 1P5, Canada
| | - Lucia Mirea
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor Toronto, Ontario M5T 3M7, Canada; Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, United States
| | - Frances P O'Malley
- Department of Laboratory Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Kristina M Blackmore
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue Toronto, Ontario M5G 2L7, Canada
| | - Anjali Pandya
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue Toronto, Ontario M5G 2L7, Canada
| | - Vicky Majpruz
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue Toronto, Ontario M5G 2L7, Canada
| | - Cathy Paroschy Harris
- Prevention and Screening Services, Northwestern Ontario, 980 Oliver Road, Thunder Bay, ON, Canada P7B 6V4
| | - Ashley Hendry
- South East Regional Cancer Program, 25 King Street West Kingston, Ontario K7L 5P9, Canada
| | - Amanda Hey
- North East Regional Cancer Program, 41 Ramsey Lake Road, Sudbury, ON P3E 5J1, Canada
| | - Anat Kornecki
- South West Regional Cancer Program, 790 Commissioners Road East London, Ontario N6A 4L6, Canada
| | - George Lougheed
- North Simcoe Muskoka Regional Cancer Program, 201 Georgian Drive Barrie, ON L4M 6M2, Canada
| | - Barbara-Anne Maier
- Waterloo Wellington Regional Cancer Program, 835 King Street West Kitchener, Ontario N2G 1G3, Canada
| | - Patricia Marchand
- Central East Regional Cancer Program, 1 Hospital Court Oshawa, ON L1G 2B9, Canada
| | - David McCready
- Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, Ontario M5T 1P5, Canada; Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Carol Rand
- Hamilton Niagara Haldimand Brant Regional Cancer Program, 699 Concession Street Hamilton, Ontario L8V 5C2, Canada
| | - Simon Raphael
- North York General Hospital, 4001 Leslie St, North York, ON, M2K 1E1, Canada
| | - Roanne Segal-Nadler
- Champlain Regional Cancer Program, 501 Smyth Road Ottawa, Ontario K1H 8L6, Canada
| | - Neelu Sehgal
- Erie St. Clair Regional Cancer Program, 2220 Kildare Road Windsor, Ontario N8W 2X3, Canada
| | - Derek Muradali
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue Toronto, Ontario M5G 2L7, Canada; St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Medical Imaging, University of Toronto, 263 McCaul Street, 4th Floor Toronto, Ontario M5T 1W7, Canada
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23
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Boyd N, Berman H, Zhu J, Martin LJ, Yaffe MJ, Chavez S, Stanisz G, Hislop G, Chiarelli AM, Minkin S, Paterson AD. The origins of breast cancer associated with mammographic density: a testable biological hypothesis. Breast Cancer Res 2018. [PMID: 29514672 PMCID: PMC5842598 DOI: 10.1186/s13058-018-0941-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Our purpose is to develop a testable biological hypothesis to explain the known increased risk of breast cancer associated with extensive percent mammographic density (PMD), and to reconcile the apparent paradox that although PMD decreases with increasing age, breast cancer incidence increases. Methods We used the Moolgavkar model of carcinogenesis as a framework to examine the known biological properties of the breast tissue components associated with PMD that includes epithelium and stroma, in relation to the development of breast cancer. In this model, normal epithelial cells undergo a mutation to become intermediate cells, which, after further mutation, become malignant cells. A clone of such cells grows to become a tumor. The model also incorporates changes with age in the number of susceptible epithelial cells associated with menarche, parity, and menopause. We used measurements of the radiological properties of breast tissue in 4454 healthy subjects aged from 15 to 80+ years to estimate cumulative exposure to PMD (CBD) in the population, and we examined the association of CBD with the age-incidence curve of breast cancer in the population. Results Extensive PMD is associated with a greater number of breast epithelial cells, lobules, and fibroblasts, and greater amounts of collagen and extracellular matrix. The known biological properties of these tissue components may, singly or in combination, promote the acquisition of mutations by breast epithelial cells specified by the Moolgavkar model, and the subsequent growth of a clone of malignant cells to form a tumor. We also show that estimated CBD in the population from ages 15 to 80+ years is closely associated with the age-incidence curve of breast cancer in the population. Conclusions These findings are consistent with the hypothesis that the biological properties of the breast tissue components associated with PMD increase the probability of the transition of normal epithelium to malignant cells, and that the accumulation of mutations with CBD may influence the age-incidence curve of breast cancer. This hypothesis gives rise to several testable predictions. Electronic supplementary material The online version of this article (10.1186/s13058-018-0941-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Norman Boyd
- Princess Margaret Cancer Centre, 610 University Avenue, Room 9-502, Toronto, ON, M5G 2M9, Canada.
| | - Hal Berman
- Princess Margaret Cancer Centre, 610 University Avenue, Room 9-502, Toronto, ON, M5G 2M9, Canada
| | - Jie Zhu
- Princess Margaret Cancer Centre, 610 University Avenue, Room 9-502, Toronto, ON, M5G 2M9, Canada
| | - Lisa J Martin
- Princess Margaret Cancer Centre, 610 University Avenue, Room 9-502, Toronto, ON, M5G 2M9, Canada
| | - Martin J Yaffe
- Imaging Research, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sofia Chavez
- Imaging Research, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Greg Stanisz
- Imaging Research, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | - Salomon Minkin
- Princess Margaret Cancer Centre, 610 University Avenue, Room 9-502, Toronto, ON, M5G 2M9, Canada
| | - Andrew D Paterson
- Genetics and Genome Biology, Hospital for Sick Children Research Institute, Toronto, ON, Canada.,Divisions of Epidemiology and Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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24
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Eisen A, Blackmore KM, Meschino WS, Muradali D, Carroll JC, Majpruz V, Warner E, Rabeneck L, Chiarelli AM. Genetic assessment wait time indicators in the High Risk Ontario Breast Screening Program. Mol Genet Genomic Med 2018; 6:213-223. [PMID: 29368425 PMCID: PMC5902387 DOI: 10.1002/mgg3.359] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/14/2017] [Accepted: 11/16/2017] [Indexed: 12/13/2022] Open
Abstract
Background The Ontario Breast Screening Program (OBSP) expanded in July 2011 to screen high‐risk women aged 30–69 with annual MRI and mammography. This study evaluated wait time (WT) indicators along the genetic assessment (GA) pathway for women referred to the High Risk OBSP. Methods Information was collected for 27,170 women referred to the High Risk OBSP from July 2011 to June 2015 and followed for GA until June 2016. Median duration (days), interquartile range (IQR) were measured for each WT indicator by program year, age, prior breast cancer, and risk criteria. Results Among 24,811 women who completed GA, 16,367 (66.0%) had genetic counseling only, 8,444 (34.0%) had counseling and testing and 8,027 (32.4%) met the high risk criteria. Median WT from physician visit to first screen was longer for women having genetic counseling only compared to those having counseling and testing (244 vs. 197 days). Women having counseling only also experienced the longest WT from physician visit to genetic counseling (88 days; IQR = 10–174), which increased by year from 71 to 100 days (p < .0001). Among women having counseling and testing, WT from physician visit to counseling was shortest for mutation carriers (39 days; IQR = 4–100). Median WT from testing to laboratory report issue was 41 days (IQR = 22–70) and 17 days to disclosure of test results (IQR = 7–33). Both WTs decreased with year and were shorter for mutation carriers (33 days, IQR = 19–58; 15 days, IQR = 7–28, respectively). Conclusions After implementation of the High Risk OBSP, women received timely genetic counseling, in particular those having counseling and testing. Effective triage models for physicians could reduce WT to GA after physician referral.
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Affiliation(s)
- Andrea Eisen
- Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | - Derek Muradali
- Ontario Breast Screening Program, Cancer Care Ontario, Toronto, ON, Canada
| | - June C Carroll
- Department of Family Medicine, Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Vicky Majpruz
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
| | - Ellen Warner
- Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Linda Rabeneck
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada.,Ontario Breast Screening Program, Cancer Care Ontario, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Tavasoli SM, Kane E, Chiarelli AM, Kupets R. Women's Behaviors Toward Mammogram and Pap Test: Opportunities to Increase Cervical Cancer Screening Participation Rates among Older Women. Womens Health Issues 2018; 28:42-50. [DOI: 10.1016/j.whi.2017.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/13/2017] [Accepted: 10/19/2017] [Indexed: 12/18/2022]
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Muradali D, Kennedy EB, Eisen A, Holloway CMB, Smith CR, Chiarelli AM. Breast screening for survivors of breast cancer: A systematic review. Prev Med 2017; 103:70-75. [PMID: 28765083 DOI: 10.1016/j.ypmed.2017.07.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/22/2017] [Accepted: 07/24/2017] [Indexed: 01/08/2023]
Abstract
There is a large and growing population of women who have a personal history of breast cancer (PHBC). This systematic review was undertaken to explore the outcomes of surveillance mammography in breast cancer survivors, and to examine the evidence for screening these women within an organized population-based screening program. We searched Cochrane Central Register of Controlled Trials (CENTRAL Issue 6, 2015), OVID MEDLINE and EMBASE (January 2012 to June 22, 2015) for English-language studies of surveillance of the target population. A study author extracted study outcomes, which were audited by a research assistant. One systematic review and 5 primary studies were included. These showed that surveillance mammography may reduce breast cancer-specific mortality through early/asymptomatic detection (Hazard Ratio for those without compared to with symptoms:HR: 0.64, 95% CI 0.55 - 0.74). Three studies showed that semi-annual mammography is likely not of greater benefit than annual mammography. No evidence was found to suggest that surveillance mammography for women with a PHBC should not be conducted within an organized screening program. The small evidence-base had a high level of heterogeneity in populations, interventions and outcomes. Based on this review, organized screening programs should reassess their guidelines on surveillance mammography and consider including women with a PHBC.
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Affiliation(s)
- Derek Muradali
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada; Department of Medical Imaging, University of Toronto, 263 McCaul Street, 4th Floor, Toronto, Ontario M5T 1W7, Canada; St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
| | - Erin B Kennedy
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada; McMaster University, Hamilton, Canada
| | - Andrea Eisen
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada; Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Claire M B Holloway
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada; Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, Ontario M5T 1P5, Canada
| | - Courtney R Smith
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada
| | - Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario M5T 3M7, Canada
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27
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Burton A, Maskarinec G, Perez-Gomez B, Vachon C, Miao H, Lajous M, López-Ridaura R, Rice M, Pereira A, Garmendia ML, Tamimi RM, Bertrand K, Kwong A, Ursin G, Lee E, Qureshi SA, Ma H, Vinnicombe S, Moss S, Allen S, Ndumia R, Vinayak S, Teo SH, Mariapun S, Fadzli F, Peplonska B, Bukowska A, Nagata C, Stone J, Hopper J, Giles G, Ozmen V, Aribal ME, Schüz J, Van Gils CH, Wanders JOP, Sirous R, Sirous M, Hipwell J, Kim J, Lee JW, Dickens C, Hartman M, Chia KS, Scott C, Chiarelli AM, Linton L, Pollan M, Flugelman AA, Salem D, Kamal R, Boyd N, dos-Santos-Silva I, McCormack V. Mammographic density and ageing: A collaborative pooled analysis of cross-sectional data from 22 countries worldwide. PLoS Med 2017; 14:e1002335. [PMID: 28666001 PMCID: PMC5493289 DOI: 10.1371/journal.pmed.1002335] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/24/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Mammographic density (MD) is one of the strongest breast cancer risk factors. Its age-related characteristics have been studied in women in western countries, but whether these associations apply to women worldwide is not known. METHODS AND FINDINGS We examined cross-sectional differences in MD by age and menopausal status in over 11,000 breast-cancer-free women aged 35-85 years, from 40 ethnicity- and location-specific population groups across 22 countries in the International Consortium on Mammographic Density (ICMD). MD was read centrally using a quantitative method (Cumulus) and its square-root metrics were analysed using meta-analysis of group-level estimates and linear regression models of pooled data, adjusted for body mass index, reproductive factors, mammogram view, image type, and reader. In all, 4,534 women were premenopausal, and 6,481 postmenopausal, at the time of mammography. A large age-adjusted difference in percent MD (PD) between post- and premenopausal women was apparent (-0.46 cm [95% CI: -0.53, -0.39]) and appeared greater in women with lower breast cancer risk profiles; variation across population groups due to heterogeneity (I2) was 16.5%. Among premenopausal women, the √PD difference per 10-year increase in age was -0.24 cm (95% CI: -0.34, -0.14; I2 = 30%), reflecting a compositional change (lower dense area and higher non-dense area, with no difference in breast area). In postmenopausal women, the corresponding difference in √PD (-0.38 cm [95% CI: -0.44, -0.33]; I2 = 30%) was additionally driven by increasing breast area. The study is limited by different mammography systems and its cross-sectional rather than longitudinal nature. CONCLUSIONS Declines in MD with increasing age are present premenopausally, continue postmenopausally, and are most pronounced over the menopausal transition. These effects were highly consistent across diverse groups of women worldwide, suggesting that they result from an intrinsic biological, likely hormonal, mechanism common to women. If cumulative breast density is a key determinant of breast cancer risk, younger ages may be the more critical periods for lifestyle modifications aimed at breast density and breast cancer risk reduction.
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Affiliation(s)
- Anya Burton
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Gertraud Maskarinec
- University of Hawaii Cancer Center, Honolulu, Hawaii, United States of America
| | | | - Celine Vachon
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Hui Miao
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Martín Lajous
- Instituto Nacional de Salud Pública, Cuernavaca, Mexico
| | | | - Megan Rice
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ana Pereira
- Instituto de Nutrición y Tecnología de los Alimentos, Universidad de Chile, Santiago, Chile
| | - Maria Luisa Garmendia
- Instituto de Nutrición y Tecnología de los Alimentos, Universidad de Chile, Santiago, Chile
| | - Rulla M. Tamimi
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kimberly Bertrand
- Slone Epidemiology Center, Boston University, Boston, Massachusetts, United States of America
| | - Ava Kwong
- Division of Breast Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
- Department of Surgery and Cancer Genetics Center, Hong Kong Sanatorium and Hospital, Hong Kong, China
- Hong Kong Hereditary Breast Cancer Family Registry, Hong Kong, China
| | - Giske Ursin
- Cancer Registry of Norway, Oslo, Norway
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, United States of America
| | - Eunjung Lee
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, United States of America
| | - Samera A. Qureshi
- Norwegian Centre for Migrant and Minority Health (NAKMI), Oslo, Norway
| | - Huiyan Ma
- Department of Population Sciences, City of Hope National Medical Center, Duarte, California, United States of America
| | - Sarah Vinnicombe
- Division of Cancer Research, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Sue Moss
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Steve Allen
- Department of Diagnostic Radiology, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rose Ndumia
- Aga Khan University Hospital, Nairobi, Kenya
| | | | - Soo-Hwang Teo
- Breast Cancer Research Group, University of Malaya Medical Centre, University of Malaya, Kuala Lumpur, Malaysia
- Cancer Research Malaysia, Subang Jaya, Malaysia
| | | | - Farhana Fadzli
- Breast Cancer Research Unit, Faculty of Medicine, University of Malaya Cancer Research Institute, University of Malaya, Kuala Lumpur, Malaysia
- Biomedical Imaging Department, University of Malaya Medical Centre, University of Malaya, Kuala Lumpur, Malaysia
| | | | | | - Chisato Nagata
- Department of Epidemiology & Preventive Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Jennifer Stone
- Centre for Genetic Origins of Health and Disease, University of Western Australia, Crawley, Western Australia, Australia
| | - John Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Graham Giles
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Vahit Ozmen
- Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mustafa Erkin Aribal
- Department of Radiology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Joachim Schüz
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Carla H. Van Gils
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna O. P. Wanders
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Reza Sirous
- Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehri Sirous
- Radiology Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - John Hipwell
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Jisun Kim
- Asan Medical Center, Seoul, Republic of Korea
| | | | - Caroline Dickens
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mikael Hartman
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Surgery, Yong Loo Lin School of Medicine, Singapore
| | - Kee-Seng Chia
- Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore
| | - Christopher Scott
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Anna M. Chiarelli
- Ontario Breast Screening Program, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Linda Linton
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Marina Pollan
- Instituto de Salud Carlos III, Madrid, Spain
- CIBERESP, Madrid, Spain
| | - Anath Arzee Flugelman
- National Cancer Control Center, Lady Davis Carmel Medical Center, Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Dorria Salem
- Woman Imaging Unit, Radiodiagnosis Department, Kasr El Aini, Cairo University Hospitals, Cairo, Egypt
| | - Rasha Kamal
- Woman Imaging Unit, Radiodiagnosis Department, Kasr El Aini, Cairo University Hospitals, Cairo, Egypt
| | - Norman Boyd
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Isabel dos-Santos-Silva
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Valerie McCormack
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
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Chiarelli AM, Muradali D, Blackmore KM, Smith CR, Mirea L, Majpruz V, O'Malley FP, Quan ML, Holloway CM. Evaluating wait times from screening to breast cancer diagnosis among women undergoing organised assessment vs usual care. Br J Cancer 2017; 116:1254-1263. [PMID: 28359079 PMCID: PMC5482732 DOI: 10.1038/bjc.2017.87] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/27/2017] [Accepted: 02/25/2017] [Indexed: 11/12/2022] Open
Abstract
Background: Timely coordinated diagnostic assessment following an abnormal screening mammogram reduces patient anxiety and may optimise breast cancer prognosis. Since 1998, the Ontario Breast Screening Program (OBSP) has offered organised assessment through Breast Assessment Centres (BACs). For OBSP women seen at a BAC, an abnormal mammogram is followed by coordinated referrals through the use of navigators for further imaging, biopsy, and surgical consultation as indicated. For OBSP women seen through usual care (UC), further diagnostic imaging is arranged directly from the screening centre and/or through their physician; results must be communicated to the physician who is then responsible for arranging any necessary biopsy and/or surgical consultation. This study aims to evaluate factors associated with diagnostic wait times for women undergoing assessment through BAC and UC. Methods: Of the 2 147 257 women aged 50–69 years screened in the OBSP between 1 January 2002 and 31 December 2009, 155 866 (7.3%) had an abnormal mammogram. A retrospective design identified two concurrent cohorts of women diagnosed with screen-detected breast cancer at a BAC (n=4217; 47%) and UC (n=4827; 53%). Multivariable logistic regression analyses examined associations between wait times and assessment and prognostic characteristics by pathway. A two-sided 5% significance level was used. Results: Screened women with breast cancer were two times more likely to be diagnosed within 7 weeks when assessed through a BAC vs UC (OR=1.91, 95% CI=1.73–2.10). In addition, compared with UC, women assessed through a BAC were significantly more likely to have their first assessment procedure within 3 weeks of their abnormal mammogram (OR=1.25, 95% CI=1.12–1.39), ⩽3 assessment procedures (OR=1.54, 95% CI=1.41–1.69), ⩽2 assessment visits (OR=1.86, 95% CI=1.70–2.05), and ⩾2 procedures per visit (OR=1.41, 95% CI=1.28–1.55). Women diagnosed through a BAC were also more likely than those in UC to have imaging (OR=1.99, 95% CI=1.44–2.75) or a biopsy (OR=3.69, 95% CI=2.64–5.15) vs consultation only at their first assessment visit, and two times more likely to have a core or FNA biopsy than a surgical biopsy (OR=2.08, 95% CI=1.81–2.40). Having ⩽2 assessment visits was more likely to reduce time to diagnosis for women assessed through a BAC compared with UC (BAC OR=10.58, 95% CI=8.96–12.50; UC OR=4.47, 95% CI=3.94–5.07), as was having ⩽3 assessment procedures (BAC OR=4.97, 95% CI=4.26–5.79; UC OR=2.95, 95% CI=2.61–3.33). Income quintile affected wait times only in women diagnosed in UC, with those in the two highest quintiles more likely to receive a diagnosis in 7 weeks. Conclusions: Women with screen-detected breast cancer in OBSP were more likely to have shorter wait times if they were diagnosed through organised assessment. This might be as a result of women diagnosed through a BAC having more procedures per visit, procedures scheduled in shorter intervals, and imaging or biopsy on their first visit. Given the significant improvement in timeliness to diagnosis, women with abnormal mammograms should be managed through organised assessment.
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Affiliation(s)
- Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario M5T 3M7, Canada
| | - Derek Muradali
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada.,St Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.,Department of Medical Imaging, University of Toronto, 263 McCaul Street, 4th Floor, Toronto, Ontario M5T 1W7, Canada
| | - Kristina M Blackmore
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada
| | - Courtney R Smith
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada
| | - Lucia Mirea
- Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, Arizona 85016, USA
| | - Vicky Majpruz
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7, Canada
| | - Frances P O'Malley
- Department of Laboratory Medicine, St Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - May Lynn Quan
- Calgary Breast Health Program, Foothills Medical Centre, 1403-29 Street NW, Calgary, Alberta T2N 2T9, Canada.,Department of Surgery and Surgical Oncology, University of Calgary, 1331-29 Street NW, Calgary, Alberta T2N 4N2, Canada
| | - Claire Mb Holloway
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.,Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, Ontario M5T 1P5, Canada
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Jonah L, Pefoyo AK, Lee A, Hader J, Strasberg S, Kupets R, Chiarelli AM, Tinmouth J. Evaluation of the effect of an audit and feedback reporting tool on screening participation: The Primary Care Screening Activity Report (PCSAR). Prev Med 2017; 96:135-143. [PMID: 27923667 DOI: 10.1016/j.ypmed.2016.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/28/2016] [Accepted: 12/01/2016] [Indexed: 02/07/2023]
Abstract
Participation in cancer screening is critical to its effectiveness in reducing the burden of cancer. The Primary Care Screening Activity Report (PCSAR), an electronic report, was developed as an innovative audit and feedback tool to increase screening participation in Ontario's cancer screening programs. This study aims to assess its impact on patient screening participation. This study used a retrospective cohort design to evaluate the effectiveness of the 2014 PCSAR on screening participation in Ontario's three screening programs (breast, cervix and colorectal). The 3 cohorts comprised all participants eligible for each of the programs enrolled with a primary care physician in Ontario. Two exposures were evaluated for each cohort: enrollment with a physician who was registered to receive the PCSAR and enrollment with a registered physician who also logged into the PCSAR. Logistic regression modelling was used to assess the magnitude of the effect of PCSAR on participation, adjusting for participant and physician characteristics. Across all three screening programs, 63% of eligible physicians registered to receive the PCSAR and 38% of those registered logged-in to view it. Patients of physicians who registered were significantly more likely to participate in screening, with odds ratios ranging from 1.06 [1.04;1.09] to 1.15 [1.12;1.19]. The adjusted odds ratios associated with PCSAR log-in were 1.07 [1.03;1.12] to 1.18 [1.14;1.22] across all screening programs. Implementation of the PCSAR was associated with a small increase in screening participation. The PCSAR appears to be modestly effective in assisting primary care physicians in optimizing cancer screening participation among their patients.
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Affiliation(s)
- Leigh Jonah
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
| | - Anna Kone Pefoyo
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Alex Lee
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
| | - Joanne Hader
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada
| | | | - Rachel Kupets
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada; Division of Gynecologic Oncology, Sunnybrook Regional Cancer Centre, Toronto, ON, Canada
| | - Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jill Tinmouth
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Canada.
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30
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Burton A, Byrnes G, Stone J, Tamimi RM, Heine J, Vachon C, Ozmen V, Pereira A, Garmendia ML, Scott C, Hipwell JH, Dickens C, Schüz J, Aribal ME, Bertrand K, Kwong A, Giles GG, Hopper J, Pérez Gómez B, Pollán M, Teo SH, Mariapun S, Taib NAM, Lajous M, Lopez-Riduara R, Rice M, Romieu I, Flugelman AA, Ursin G, Qureshi S, Ma H, Lee E, Sirous R, Sirous M, Lee JW, Kim J, Salem D, Kamal R, Hartman M, Miao H, Chia KS, Nagata C, Vinayak S, Ndumia R, van Gils CH, Wanders JOP, Peplonska B, Bukowska A, Allen S, Vinnicombe S, Moss S, Chiarelli AM, Linton L, Maskarinec G, Yaffe MJ, Boyd NF, dos-Santos-Silva I, McCormack VA. Mammographic density assessed on paired raw and processed digital images and on paired screen-film and digital images across three mammography systems. Breast Cancer Res 2016; 18:130. [PMID: 27993168 PMCID: PMC5168805 DOI: 10.1186/s13058-016-0787-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/23/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inter-women and intra-women comparisons of mammographic density (MD) are needed in research, clinical and screening applications; however, MD measurements are influenced by mammography modality (screen film/digital) and digital image format (raw/processed). We aimed to examine differences in MD assessed on these image types. METHODS We obtained 1294 pairs of images saved in both raw and processed formats from Hologic and General Electric (GE) direct digital systems and a Fuji computed radiography (CR) system, and 128 screen-film and processed CR-digital pairs from consecutive screening rounds. Four readers performed Cumulus-based MD measurements (n = 3441), with each image pair read by the same reader. Multi-level models of square-root percent MD were fitted, with a random intercept for woman, to estimate processed-raw MD differences. RESULTS Breast area did not differ in processed images compared with that in raw images, but the percent MD was higher, due to a larger dense area (median 28.5 and 25.4 cm2 respectively, mean √dense area difference 0.44 cm (95% CI: 0.36, 0.52)). This difference in √dense area was significant for direct digital systems (Hologic 0.50 cm (95% CI: 0.39, 0.61), GE 0.56 cm (95% CI: 0.42, 0.69)) but not for Fuji CR (0.06 cm (95% CI: -0.10, 0.23)). Additionally, within each system, reader-specific differences varied in magnitude and direction (p < 0.001). Conversion equations revealed differences converged to zero with increasing dense area. MD differences between screen-film and processed digital on the subsequent screening round were consistent with expected time-related MD declines. CONCLUSIONS MD was slightly higher when measured on processed than on raw direct digital mammograms. Comparisons of MD on these image formats should ideally control for this non-constant and reader-specific difference.
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Affiliation(s)
- Anya Burton
- Section of Environment and Radiation, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon, Cedex 09, France
| | - Graham Byrnes
- Section of Environment and Radiation, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon, Cedex 09, France
| | - Jennifer Stone
- Centre for Genetic Origins of Health and Disease, Curtin University and the University of Western Australia, Perth, Australia
| | - Rulla M. Tamimi
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | | | - Celine Vachon
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN USA
| | - Vahit Ozmen
- Department of Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ana Pereira
- Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile
| | | | - Christopher Scott
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN USA
| | - John H. Hipwell
- Centre for Medical Image Computing, University College London, London, UK
| | - Caroline Dickens
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joachim Schüz
- Section of Environment and Radiation, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon, Cedex 09, France
| | | | | | - Ava Kwong
- Division of Breast Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, People’s Republic of China
- Department of Surgery, Hong Kong Sanatorium and Hospital, Hong Kong, People’s Republic of China
| | - Graham G. Giles
- Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Victoria Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria Australia
| | - John Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria Australia
| | - Beatriz Pérez Gómez
- Cancer Epidemiology Unit, Instituto de Salud Carlos III and CIBERESP, Madrid, Spain
| | - Marina Pollán
- Cancer Epidemiology Unit, Instituto de Salud Carlos III and CIBERESP, Madrid, Spain
| | - Soo-Hwang Teo
- Breast Cancer Research Group, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
- Cancer Research Malaysia, Subang Jaya, Malaysia
| | | | - Nur Aishah Mohd Taib
- Breast Cancer Research Group, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Martín Lajous
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
- Center for Research on Population Health, Instituto Nacional de Salud Pública, Mexico City, Mexico
| | - Ruy Lopez-Riduara
- Center for Research on Population Health, Instituto Nacional de Salud Pública, Mexico City, Mexico
| | - Megan Rice
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Isabelle Romieu
- Section of Nutrition and Metabolism, International Agency for Research on Cancer, Lyon, France
| | | | - Giske Ursin
- Cancer Registry of Norway, Oslo, Norway
- Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA USA
| | - Samera Qureshi
- Norwegian Center for Minority and Migrant Health Research (NAKMI), Oslo, Norway
| | - Huiyan Ma
- Department of Population Sciences, Beckman Research Institute, City of Hope, CA USA
| | - Eunjung Lee
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA USA
| | - Reza Sirous
- Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehri Sirous
- Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jong Won Lee
- Department of Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Jisun Kim
- Department of Surgery, Asan Medical Center, Seoul, Republic of Korea
| | | | - Rasha Kamal
- Woman Imaging Unit, Radiodiagnosis Department, Kasr El Aini, Cairo University Hospitals, Cairo, Egypt
| | - Mikael Hartman
- Department of Surgery, Yong Loo Lin School of Medicine, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Hui Miao
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Kee-Seng Chia
- NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore, Singapore
| | | | | | - Rose Ndumia
- Aga Khan University Hospital, Nairobi, Kenya
| | - Carla H. van Gils
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna O. P. Wanders
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - Steve Allen
- Department of Imaging, Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah Vinnicombe
- Division of Cancer Research, Ninewells Hospital & Medical School, Dundee, UK
| | - Sue Moss
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Anna M. Chiarelli
- Ontario Breast Screening Program, Cancer Care Ontario, Toronto, Canada
| | - Linda Linton
- Princess Margaret Cancer Centre, Toronto, Canada
| | | | | | | | - Isabel dos-Santos-Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Valerie A. McCormack
- Section of Environment and Radiation, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon, Cedex 09, France
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Abstract
Objective: To determine the association between initial screen result and returning for a second screen in an organised breast screening programme for women with a biennial screening recommendation. Setting: Women who attended the Ontario Breast Screening Program (OBSP). Methods: A retrospective cohort study was conducted of 140,723 Ontario women aged 50 years ond older who had an initial screen at the OBSP between 1 July 1990 and 31 December 1995 and were followed until 30 June 1998. Rescreening rates at 36 months and risk ratio estimates were calculated using survival methods. Age of women, year of screen, region (within Ontario) and initial screen result were compared. For initial screen results, returning for a second screen was examined by integration of screening centre with an assessment programme and by modality of referral. Results: Women with a false-positive result were less likely to return for a second screen as were women aged 70 and older and those living in regions of Ontario with fewer OBSP screening centres. However, there were minimal differences in reattendance behaviour by initial screen result for women screened at the OBSP centre with an assessment programme. Conclusions: Integration of breast screening and assessment services improved reattendance of women with false-positive screen results within an organised screening programme.
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Affiliation(s)
- A M Chiarelli
- Cancer Care Ontario, Department of Public Health Sciences, University of Toronto, Canada.
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32
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McCormack VA, Burton A, dos-Santos-Silva I, Hipwell JH, Dickens C, Salem D, Kamal R, Hartman M, Lee CPL, Chia KS, Ozmen V, Aribal ME, Flugelman AA, Lajous M, Lopez-Riduara R, Rice M, Romieu I, Ursin G, Qureshi S, Ma H, Lee E, van Gils CH, Wanders JOP, Vinayak S, Ndumia R, Allen S, Vinnicombe S, Moss S, Won Lee J, Kim J, Pereira A, Garmendia ML, Sirous R, Sirous M, Peplonska B, Bukowska A, Tamimi RM, Bertrand K, Nagata C, Kwong A, Vachon C, Scott C, Perez-Gomez B, Pollan M, Maskarinec G, Giles G, Hopper J, Stone J, Rajaram N, Teo SH, Mariapun S, Yaffe MJ, Schüz J, Chiarelli AM, Linton L, Boyd NF. International Consortium on Mammographic Density: Methodology and population diversity captured across 22 countries. Cancer Epidemiol 2016; 40:141-51. [PMID: 26724463 PMCID: PMC4738079 DOI: 10.1016/j.canep.2015.11.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/12/2015] [Accepted: 11/30/2015] [Indexed: 12/31/2022]
Abstract
Mammographic density (MD) is a quantitative trait, measurable in all women, and is among the strongest markers of breast cancer risk. The population-based epidemiology of MD has revealed genetic, lifestyle and societal/environmental determinants, but studies have largely been conducted in women with similar westernized lifestyles living in countries with high breast cancer incidence rates. To benefit from the heterogeneity in risk factors and their combinations worldwide, we created an International Consortium on Mammographic Density (ICMD) to pool individual-level epidemiological and MD data from general population studies worldwide. ICMD aims to characterize determinants of MD more precisely, and to evaluate whether they are consistent across populations worldwide. We included 11755 women, from 27 studies in 22 countries, on whom individual-level risk factor data were pooled and original mammographic images were re-read for ICMD to obtain standardized comparable MD data. In the present article, we present (i) the rationale for this consortium; (ii) characteristics of the studies and women included; and (iii) study methodology to obtain comparable MD data from original re-read films. We also highlight the risk factor heterogeneity captured by such an effort and, thus, the unique insight the pooled study promises to offer through wider exposure ranges, different confounding structures and enhanced power for sub-group analyses.
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Affiliation(s)
- Valerie A McCormack
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France.
| | - Anya Burton
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Isabel dos-Santos-Silva
- Dept of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - John H Hipwell
- Centre for Medical Image Computing, University College London, UK
| | | | | | - Rasha Kamal
- Woman Imaging Unit, Radiodiagnosis Department, Kasr El Aini, Cairo University Hospitals, Cairo, Egypt
| | - Mikael Hartman
- Department of Surgery, Yong Loo Lin School of Medicine and Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Charmaine Pei Ling Lee
- Department of Surgery, Yong Loo Lin School of Medicine and Saw Swee Hock School of Public Health, National University of Singapore, Singapore; NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore
| | - Kee-Seng Chia
- NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore
| | | | | | | | - Martín Lajous
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA; Center for Research on Population Health, Instituto Nacional de Salud Pública, Mexico, Mexico City, Mexico
| | - Ruy Lopez-Riduara
- Center for Research on Population Health, Instituto Nacional de Salud Pública, Mexico, Mexico City, Mexico
| | - Megan Rice
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Isabelle Romieu
- Section of Nutrition and Metabolism, International Agency for Research on Cancer, Lyon, France
| | - Giske Ursin
- Cancer Registry of Norway, Oslo, Norway; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Department of Preventive Medicine, University of Southern California, Los Angeles, California, USA
| | - Samera Qureshi
- Norwegian Center for Minority Health Research (NAKMI), Oslo, Norway
| | - Huiyan Ma
- Department of Population Sciences, Beckman Research Institute, City of Hope, Duarte, USA
| | - Eunjung Lee
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, USA
| | - Carla H van Gils
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Johanna O P Wanders
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | | | - Rose Ndumia
- Aga Khan University Hospital, Nairobi, Kenya
| | - Steve Allen
- Department of Imaging, Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah Vinnicombe
- Division of Cancer Research, Ninewells Hospital & Medical School, Dundee, UK
| | - Sue Moss
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, UK
| | | | - Jisun Kim
- Asan Medical Center, Seoul, Republic of Korea
| | - Ana Pereira
- Institute of Nutrition and Food Technology, University of Chile, Chile
| | | | - Reza Sirous
- Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehri Sirous
- Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | | - Rulla M Tamimi
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | | | - Ava Kwong
- Division of Breast Surgery, The University of Hong Kong Faculty of Medicine, and Department of Surgery, Hong Kong Sanatorium and Hospital, Hong Kong, People's Republic of China
| | - Celine Vachon
- Dept Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher Scott
- Dept Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Beatriz Perez-Gomez
- Cancer Epidemiology Unit, Instituto de Salud Carlos III and CIBERESP, Madrid, Spain
| | - Marina Pollan
- Cancer Epidemiology Unit, Instituto de Salud Carlos III and CIBERESP, Madrid, Spain
| | | | - Graham Giles
- Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia; School of Population and Global Health, The University of Melbourne, Australia
| | - John Hopper
- School of Population and Global Health, The University of Melbourne, Australia
| | - Jennifer Stone
- Centre for Genetic Origins of Health and Disease, University of Western Australia, Australia
| | - Nadia Rajaram
- Breast Cancer Research Group, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Soo-Hwang Teo
- Breast Cancer Research Group, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia; Cancer Research Malaysia, Subang Jaya, Malaysia
| | - Shivaani Mariapun
- Breast Cancer Research Group, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | | | - Joachim Schüz
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Anna M Chiarelli
- Ontario Breast Screening Program, Cancer Care Ontario, Toronto, Canada
| | - Linda Linton
- Princess Margaret Cancer Centre, Toronto, Canada
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33
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Chiarelli AM, Prummel MV, Muradali D, Shumak RS, Majpruz V, Brown P, Jiang H, Done SJ, Yaffe MJ. Digital versus screen-film mammography: impact of mammographic density and hormone therapy on breast cancer detection. Breast Cancer Res Treat 2015; 154:377-87. [PMID: 26518019 DOI: 10.1007/s10549-015-3622-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/24/2015] [Indexed: 11/25/2022]
Abstract
Most studies that have examined the effects of mammographic density and hormone therapy use on breast cancer detection have included screen-film mammography. This study further examines this association in post-menopausal women screened by digital mammography. Approved by the University of Toronto Research Ethics Board, this study identified 688,418 women of age 50-74 years screened with digital or screen-film mammography from 2008 to 2009 within the Ontario Breast Screening Program. Of 2993 eligible women with invasive breast cancer, 2450 were contacted and 1421 participated (847 screen-film mammography, 574 digital direct radiography). Mammographic density was measured by study radiologists using the standard BI-RADS classification system and by a computer-assisted method. Information on hormone therapy use was collected by a telephone-administered questionnaire. Logistic regression and two-tailed tests for significance evaluated associations between factors and detection method by mammography type. Women with >75 % radiologist-measured mammographic density compared to those with <25 % were more likely to be diagnosed with an interval than screen-detected cancer, with the difference being greater for those screened with screen-film (OR = 6.40, 95 % CI 2.30-17.85) than digital mammography (OR = 2.41, 95 % CI 0.67-8.58) and aged 50-64 years screened with screen-film mammography (OR = 10.86, 95 % CI 2.96-39.57). Recent former hormone therapy users were also at an increased risk of having an interval cancer with the association being significant for women screened with digital mammography (OR = 2.08, 95 % CI 1.17-3.71). Breast screening using digital mammography lowers the risk of having an interval cancer for post-menopausal women aged 50-64 with greater mammographic density.
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Affiliation(s)
- Anna M Chiarelli
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Maegan V Prummel
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
| | - Derek Muradali
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
| | - Rene S Shumak
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
| | - Vicky Majpruz
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
| | - Patrick Brown
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Hedy Jiang
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
| | - Susan J Done
- The Campbell Family Institute for Breast Cancer Research and Laboratory Medicine Program, University Health Network, Toronto, Canada
| | - Martin J Yaffe
- Women's College Hospital, Sunnybrook Health Sciences Centre, Toronto, Canada
- Imaging Research, Sunnybrook Health Sciences Centre, Toronto, Canada
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34
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Prummel MV, Muradali D, Shumak R, Majpruz V, Brown P, Jiang H, Done SJ, Yaffe MJ, Chiarelli AM. Digital Compared with Screen-Film Mammography: Measures of Diagnostic Accuracy among Women Screened in the Ontario Breast Screening Program. Radiology 2015; 278:365-73. [PMID: 26334680 DOI: 10.1148/radiol.2015150733] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To compare measures of diagnostic accuracy between large concurrent cohorts of women screened with digital computed radiography (CR), direct radiography (DR), and screen-film mammography (SFM). MATERIALS AND METHODS This study was approved by the University of Toronto Research Ethics Board; informed consent was not required. Three concurrent cohorts of women aged 50-74 years who were screened from 2008-2009 in the Ontario Breast Screening Program with SFM (487,334 screening examinations, 403,688 women), DR (254,758 screening examinations, 220,520 women), or CR (74,140 screening examinations, 64,210 women) were followed for 2 years or until breast cancer diagnosis. Breast cancers were classified as screening-detected or interval on the basis of the woman's final screening and assessment results. Interval cancer rate (per 10 000 negative screening examinations), sensitivity, and specificity were compared across the cohorts by using mixed-effects logistic regression analysis. RESULTS Interval cancer rates were higher, although not significantly so, for CR (15.2 per 10,000; 95% confidence interval [CI]: 12.8, 17.8) and were similar for DR (13.7 per 10,000; 95% CI: 12.4, 15.0) compared with SFM (13.0 per 10,000; 95% CI: 12.1, 13.9). For CR versus SFM, specificity was similar while sensitivity was significantly lower (odds ratio [OR] = 0.62; 95% CI: 0.47, 0.83; P = .001), particularly for invasive cancers detected at a rescreening examination, for women with breast density of less than 75%, for women with no family history, and for postmenopausal women. For DR versus SFM, sensitivity was similar while specificity was lower (OR = 0.92; 95% CI: 0.87, 0.98; P = .01), particularly for rescreening examinations, for women aged 60-74 years, for women with breast density of less than 75%, for women with a family history, and for women who were postmenopausal. CONCLUSION Given the 38% lower sensitivity of CR imaging systems compared with SFM, programs should assess the continued use of this technology for breast screening.
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Affiliation(s)
- Maegan V Prummel
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
| | - Derek Muradali
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
| | - Rene Shumak
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
| | - Vicky Majpruz
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
| | - Patrick Brown
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
| | - Hedy Jiang
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
| | - Susan J Done
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
| | - Martin J Yaffe
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
| | - Anna M Chiarelli
- From the Department of Prevention and Cancer Control, Cancer Care Ontario, 505 University Ave, Toronto, ON, Canada M5G 1X3 (M.V.P., D.M., R.S., V.M., P.B., H.J., A.M.C.); Dalla Lana School of Public Health, University of Toronto, Toronto, Ont, Canada (P.B., A.M.C.); Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, Ont, Canada (S.J.D.); and Department of Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada (M.J.Y.)
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35
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Coldman A, Phillips N, Wilson C, Decker K, Chiarelli AM, Brisson J, Zhang B, Payne J, Doyle G, Ahmad R. Pan-Canadian Study of Mammography Screening and Mortality from Breast Cancer. J Natl Cancer Inst 2014. [DOI: 10.1093/jnci/dju261 10.1093/jnci/dju404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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36
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Coldman A, Phillips N, Wilson C, Decker K, Chiarelli AM, Brisson J, Zhang B, Payne J, Doyle G, Ahmad R. Pan-Canadian Study of Mammography Screening and Mortality from Breast Cancer. ACTA ACUST UNITED AC 2014; 106:dju261. [DOI: 10.1093/jnci/dju261] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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37
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Prummel MV, Done SJ, Muradali D, Majpruz V, Brown P, Jiang H, Shumak RS, Yaffe MJ, Holloway CMB, Chiarelli AM. Digital compared to screen-film mammography: breast cancer prognostic features in an organized screening program. Breast Cancer Res Treat 2014; 147:389-99. [PMID: 25108740 DOI: 10.1007/s10549-014-3088-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 07/27/2014] [Indexed: 11/29/2022]
Abstract
Our previous study found cancer detection rates were equivalent for direct radiography compared to screen-film mammography, while rates for computed radiography were significantly lower. This study compares prognostic features of invasive breast cancers by type of mammography. Approved by the University of Toronto Research Ethics Board, this study identified invasive breast cancers diagnosed among concurrent cohorts of women aged 50-74 screened by direct radiography, computed radiography, or screen-film mammography from January 1, 2008 to December 31, 2009. During the study period, 816,232 mammograms were performed on 668,418 women, and 3,323 invasive breast cancers were diagnosed. Of 2,642 eligible women contacted, 2,041 participated (77.3 %). The final sample size for analysis included 1,405 screen-detected and 418 interval cancers (diagnosed within 24 months of a negative screening mammogram). Polytomous logistic regression was performed to evaluate the association between tumour characteristics and type of mammography, and between tumour characteristics and detection method. Odds ratios (OR) and 95 % confidence intervals (CI) were recorded. Cancers detected by computed radiography compared to screen-film mammography were significantly more likely to be lymph node positive (OR 1.94, 95 %CI 1.01-3.73) and have higher stage (II:I, OR 2.14, 95 %CI 1.11-4.13 and III/IV:I, OR 2.97, 95 %CI 1.02-8.59). Compared to screen-film mammography, significantly more cancers detected by direct radiography (OR 1.64, 95 %CI 1.12-2.38) were lymph node positive. Interval cancers had worse prognostic features compared to screen-detected cancers, irrespective of mammography type. Screening with computed radiography may lead to the detection of cancers with a less favourable stage distribution compared to screen-film mammography that may reflect a delayed diagnosis. Screening programs should re-evaluate their use of computed radiography for breast screening.
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Affiliation(s)
- Maegan V Prummel
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada,
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38
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Chiarelli AM, Prummel MV, Muradali D, Majpruz V, Horgan M, Carroll JC, Eisen A, Meschino WS, Shumak RS, Warner E, Rabeneck L. Effectiveness of Screening With Annual Magnetic Resonance Imaging and Mammography: Results of the Initial Screen From the Ontario High Risk Breast Screening Program. J Clin Oncol 2014; 32:2224-30. [DOI: 10.1200/jco.2013.52.8331] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The Ontario Breast Screening Program expanded in July 2011 to screen women age 30 to 69 years at high risk for breast cancer with annual magnetic resonance imaging (MRI) and digital mammography. To the best of our knowledge, this is the first organized screening program for women at high risk for breast cancer. Patients and Methods Performance measures after assessment were compared with screening results for 2,207 women with initial screening examinations. The following criteria were used to determine eligibility: known mutation in BRCA1, BRCA2, or other gene predisposing to a markedly increased risk of breast cancer, untested first-degree relative of a gene mutation carrier, family history consistent with hereditary breast cancer syndrome and estimated personal lifetime breast cancer risk ≥ 25%, or radiation therapy to the chest (before age 30 years and at least 8 years previously). Results The recall rate was significantly higher among women who had abnormal MRI alone (15.1%; 95% CI, 13.8% to 16.4%) compared with mammogram alone (6.4%; 95% CI, 5.5% to 7.3%). Of the 35 breast cancers detected (16.3 per 1,000; 95% CI, 11.2 to 22.2), none were detected by mammogram alone, 23 (65.7%) were detected by MRI alone (10.7 per 1,000; 95% CI, 6.7 to 15.8), and 25 (71%) were detected among women who were known gene mutation carriers (30.8 per 1,000, 95% CI, 19.4 to 43.7). The positive predictive value was highest for detection based on mammogram and MRI (12.4%; 95% CI, 7.3% to 19.3%). Conclusion Screening with annual MRI combined with mammography has the potential to be effectively implemented into an organized breast screening program for women at high risk for breast cancer. This could be considered an important management option for known BRCA gene mutation carriers.
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Affiliation(s)
- Anna M. Chiarelli
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Maegan V. Prummel
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Derek Muradali
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Vicky Majpruz
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Meaghan Horgan
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - June C. Carroll
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Andrea Eisen
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Wendy S. Meschino
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Rene S. Shumak
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Ellen Warner
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
| | - Linda Rabeneck
- Anna M. Chiarelli, Maegan V. Prummel, Derek Muradali, Vicky Majpruz, Meaghan Horgan, Rene S. Shumak, and Linda Rabeneck, Cancer Care Ontario; Anna M. Chiarelli, Derek Muradali, June C. Carroll, Andrea Eisen, Ellen Warner, and Linda Rabeneck, University of Toronto; June C. Carroll, Mount Sinai Hospital; Andrea Eisen and Ellen Warner, Sunnybrook Health Sciences Centre; and Wendy S. Meschino, North York General Hospital, Toronto, Ontario, Canada
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Pettersson A, Graff RE, Ursin G, Santos Silva ID, McCormack V, Baglietto L, Vachon C, Bakker MF, Giles GG, Chia KS, Czene K, Eriksson L, Hall P, Hartman M, Warren RML, Hislop G, Chiarelli AM, Hopper JL, Krishnan K, Li J, Li Q, Pagano I, Rosner BA, Wong CS, Scott C, Stone J, Maskarinec G, Boyd NF, van Gils CH, Tamimi RM. Mammographic density phenotypes and risk of breast cancer: a meta-analysis. J Natl Cancer Inst 2014; 106:dju078. [PMID: 24816206 PMCID: PMC4568991 DOI: 10.1093/jnci/dju078] [Citation(s) in RCA: 235] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 02/03/2014] [Accepted: 02/24/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Fibroglandular breast tissue appears dense on mammogram, whereas fat appears nondense. It is unclear whether absolute or percentage dense area more strongly predicts breast cancer risk and whether absolute nondense area is independently associated with risk. METHODS We conducted a meta-analysis of 13 case-control studies providing results from logistic regressions for associations between one standard deviation (SD) increments in mammographic density phenotypes and breast cancer risk. We used random-effects models to calculate pooled odds ratios and 95% confidence intervals (CIs). All tests were two-sided with P less than .05 considered to be statistically significant. RESULTS Among premenopausal women (n = 1776 case patients; n = 2834 control subjects), summary odds ratios were 1.37 (95% CI = 1.29 to 1.47) for absolute dense area, 0.78 (95% CI = 0.71 to 0.86) for absolute nondense area, and 1.52 (95% CI = 1.39 to 1.66) for percentage dense area when pooling estimates adjusted for age, body mass index, and parity. Corresponding odds ratios among postmenopausal women (n = 6643 case patients; n = 11187 control subjects) were 1.38 (95% CI = 1.31 to 1.44), 0.79 (95% CI = 0.73 to 0.85), and 1.53 (95% CI = 1.44 to 1.64). After additional adjustment for absolute dense area, associations between absolute nondense area and breast cancer became attenuated or null in several studies and summary odds ratios became 0.82 (95% CI = 0.71 to 0.94; P heterogeneity = .02) for premenopausal and 0.85 (95% CI = 0.75 to 0.96; P heterogeneity < .01) for postmenopausal women. CONCLUSIONS The results suggest that percentage dense area is a stronger breast cancer risk factor than absolute dense area. Absolute nondense area was inversely associated with breast cancer risk, but it is unclear whether the association is independent of absolute dense area.
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Affiliation(s)
- Andreas Pettersson
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Rebecca E Graff
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Giske Ursin
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Isabel Dos Santos Silva
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Valerie McCormack
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Laura Baglietto
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Celine Vachon
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Marije F Bakker
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Graham G Giles
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Kee Seng Chia
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Kamila Czene
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Louise Eriksson
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Per Hall
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Mikael Hartman
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Ruth M L Warren
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Greg Hislop
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Anna M Chiarelli
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - John L Hopper
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Kavitha Krishnan
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Jingmei Li
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Qing Li
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Ian Pagano
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Bernard A Rosner
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Chia Siong Wong
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Christopher Scott
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Jennifer Stone
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Gertraud Maskarinec
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Norman F Boyd
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Carla H van Gils
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
| | - Rulla M Tamimi
- Affiliations of authors: Department of Epidemiology (AP, REG, RMT), and Department of Biostatistics (BAR), Harvard School of Public Health, Boston, MA; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (GU); Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA (GU); Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (IdSS); Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France (VM); Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, Australia (LB, GGG, KK); Centre for Molecular, Environmental, Genetic and Analytical Epidemiology, University of Melbourne, Melbourne, Australia (LB, GGG, JLH, KK, JS); Division of Epidemiology (CV) and Division of Biomedical Statistics and Informatics (CS), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (MFB, CHvG); Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (GGG); Saw Swee Hock School of Public Health (KSC, MH, CSW), and Department of Surgery, Yong Loo Lin School of Medicine (MH), National University of Singapore, National University Health System, Singapore, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (KC, LE, PH, MH); Department of Radiology, Addenbrooke's Hospital, Cambridge, UK (RMLW); School of Population and Public Health, University of British Columbia, Vancouver, BC , Canada (GH); Prevention and Cancer Control, Cancer Care, Toronto, ON, Canada (AMC); Human Genetics, Genome Institute of Singapore, Singapore, Singapore (JL); Campbell Family Institute for Breast Cancer Research, Ontario Cancer Institute, Toronto, ON, Canada (QL, NFB); University of Hawaii Cancer Center, Honolu
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Plotogea A, Chiarelli AM, Mirea L, Prummel MV, Chong N, Shumak RS, O'Malley FP, Holloway CM. Clinical and prognostic factors associated with diagnostic wait times by breast cancer detection method. Springerplus 2014; 3:125. [PMID: 24741470 PMCID: PMC3979977 DOI: 10.1186/2193-1801-3-125] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 02/28/2014] [Indexed: 01/07/2023]
Abstract
Introduction Although prognostic differences between screen-detected, interval and symptomatic breast cancers are known, factors associated with wait times to diagnosis among these three groups have not been studied. Methods Of the 16,373 invasive breast cancers diagnosed between January 1, 1995 and December 31, 2003 in a cohort of Ontario women aged 50 to 69, a random sample (N = 2,615) were selected for chart abstraction. Eligible women were classified according to detection method; screen-detected (n = 1181), interval (n = 319) or symptomatic (n = 406). Diagnostic wait time was calculated from the initial imaging or biopsy to breast cancer diagnosis. Logistic regression analysis examined associations between diagnostic wait times dichotomized as greater or less than the median and demographic, clinical and prognostic factors separately for each detection cohort. Results Women who underwent an open biopsy had significantly longer than median wait times to diagnosis, compared to women who underwent a fine needle aspiration or core biopsy; (screen-detected OR = 2.76, 95% CI = 2.14-3.56; interval OR = 2.56, 95% CI = 1.50-4.35; symptomatic OR = 5.56, 95% CI = 3.33-9.30). Additionally, screen-detected breast cancers diagnosed with stage II and symptomatic cancers diagnosed at stage III or IV had significantly shorter diagnostic wait times compared to those diagnosed at stage 1 (OR = 0.66 95% CI = 0.50-0.87 and OR = 0.46, 95% CI = 0.25-0.85 respectively). Conclusions Our study is consistent with expedited diagnostic work-up for breast cancers with more advanced prognostic features. Furthermore, women who had an open surgical biopsy had a greater than the median diagnostic wait time, irrespective of detection method.
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Affiliation(s)
- Amalia Plotogea
- Institute for Clinical Evaluative Sciences, Toronto, Canada ; Department of Laboratory Medicine and Pathobiology, University of Toronto and St. Michaels Hospital, Toronto, Canada
| | - Anna M Chiarelli
- Institute for Clinical Evaluative Sciences, Toronto, Canada ; Department of Laboratory Medicine and Pathobiology, University of Toronto and St. Michaels Hospital, Toronto, Canada
| | - Lucia Mirea
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St. Michaels Hospital, Toronto, Canada ; Women's College Hospital Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Nelson Chong
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Rene S Shumak
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Frances P O'Malley
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St. Michaels Hospital, Toronto, Canada
| | - Claire Mb Holloway
- Women's College Hospital Sunnybrook Health Sciences Centre, Toronto, Canada
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Yaffe MJ, Bloomquist AK, Hunter DM, Mawdsley GE, Chiarelli AM, Muradali D, Mainprize JG. Comparative performance of modern digital mammography systems in a large breast screening program. Med Phys 2013; 40:121915. [PMID: 24320526 DOI: 10.1118/1.4829516] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Martin J Yaffe
- Physical Sciences Division, Sunnybrook Research Institute, Departments of Medical Biophysics and Medical Imaging, University of Toronto, Ontario M4N 3M5, Canada
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Valentini A, Lubinski J, Byrski T, Ghadirian P, Moller P, Lynch HT, Ainsworth P, Neuhausen SL, Weitzel J, Singer CF, Olopade OI, Saal H, Lyonnet DS, Foulkes WD, Kim-Sing C, Manoukian S, Zakalik D, Armel S, Senter L, Eng C, Grunfeld E, Chiarelli AM, Poll A, Sun P, Narod SA. The impact of pregnancy on breast cancer survival in women who carry a BRCA1 or BRCA2 mutation. Breast Cancer Res Treat 2013; 142:177-85. [PMID: 24136669 DOI: 10.1007/s10549-013-2729-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 10/03/2013] [Indexed: 11/25/2022]
Abstract
Physicians are often approached by young women with a BRCA mutation and a recent history of breast cancer who wish to have a baby. They wish to know if pregnancy impacts upon their future risks of cancer recurrence and survival. To date, there is little information on the survival experience of women who carry a mutation in one of the BRCA genes and who become pregnant. From an international multi-center cohort study of 12,084 women with a BRCA1 or BRCA2 mutation, we identified 128 case subjects who were diagnosed with breast cancer while pregnant or who became pregnant after a diagnosis of breast cancer. These women were age-matched to 269 mutation carriers with breast cancer who did not become pregnant (controls). Subjects were followed from the date of breast cancer diagnosis until the date of last follow-up or death from breast cancer. The Kaplan-Meier method was used to estimate 15-year survival rates. The hazard ratio for survival associated with pregnancy was calculated using a left-truncated Cox proportional hazard model, adjusting for other prognostic factors. Among women who were diagnosed with breast cancer when pregnant or who became pregnant thereafter, the 15-year survival rate was 91.5 %, compared to a survival of 88.6 % for women who did not become pregnant (adjusted hazard ratio = 0.76; 95 % CI 0.31-1.91; p = 0.56). Pregnancy concurrent with or after a diagnosis of breast cancer does not appear to adversely affect survival among BRCA1/2 mutation carriers.
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Walker MJ, Mirea L, Cooper K, Nabavi M, Glendon G, Andrulis IL, Knight JA, O'Malley FP, Chiarelli AM. Impact of familial risk and mammography screening on prognostic indicators of breast disease among women from the Ontario site of the Breast Cancer Family Registry. Fam Cancer 2013; 13:163-72. [PMID: 24097051 DOI: 10.1007/s10689-013-9689-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Although several studies have found screen-detected cancers in women with familial breast cancer risk have favorable prognostic features compared with symptomatic cancers, the impact of level of familial risk is unknown. A cohort of 899 first-degree female relatives of cases of breast cancer from the Ontario site of the Breast Cancer Family Registry was followed for 2 years. Logistic regression analyses compared diagnoses of breast cancer or benign breast disease (BBD) between women at high (n = 258, 28.7 %) versus low/moderate (n = 641, 71.3 %) familial risk. Similar analyses compared prognostic features of invasive cancers and BBD by level of familial risk and mammography screening status. Among 899 women, 44 (4.9 %) were diagnosed with invasive breast cancer and/or ductal carcinoma in situ, and 56 (6.2 %) with BBD. Women with high familial risk were significantly more likely to be diagnosed with breast cancer [odds ratio (OR) = 2.84, 95 % confidence interval (CI) 1.50-5.38] than low/moderate risk women, particularly if diagnosed at age ≥50 (OR = 2.99, 95 % CI 1.37-6.56) or screened with mammography (OR = 3.33, 95 % CI 1.54-7.18). High risk women were more likely to be diagnosed with BBD (OR = 1.94, 95 % CI 1.03-3.66). Level of familial risk was not associated with prognostic features. Cancers among unscreened women were larger (OR = 9.72, 95 % CI 1.01-93.61) and diagnosed at stage II or above (OR = 7.80, 95 % CI 1.18-51.50) compared with screen-detected cancers. Screening mammography may be effective for women with a first-degree family history of breast cancer, irrespective of level of familial risk.
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Affiliation(s)
- Meghan J Walker
- Division of Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada,
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Chiarelli AM, Edwards SA, Prummel MV, Muradali D, Majpruz V, Done SJ, Brown P, Shumak RS, Yaffe MJ. Digital Compared with Screen-Film Mammography: Performance Measures in Concurrent Cohorts within an Organized Breast Screening Program. Radiology 2013; 268:684-93. [DOI: 10.1148/radiol.13122567] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Plotogea A, Chiarelli AM, Mirea L, Prummel MV, Chong N, Shumak RS, O'Malley FP, Holloway CMB. Factors associated with wait times across the breast cancer treatment pathway in Ontario. Springerplus 2013; 2:388. [PMID: 24255823 PMCID: PMC3828452 DOI: 10.1186/2193-1801-2-388] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 08/14/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Longer times from diagnosis to breast cancer treatment are associated with poorer prognosis. This study examined factors associated with wait times by phase in the breast cancer treatment pathway. METHODS There were 1760 women eligible for the study, aged 50-69 diagnosed in Ontario with invasive breast cancer from 1995-2003. Multivariate logistic regression examined factors associated with greater than median wait times for each phase of the treatment pathway; from diagnosis to definitive surgery; from final surgery to radiotherapy without chemotherapy and from final surgery to chemotherapy. RESULTS The median wait times were 17 days (Inter Quartile Range (IQR) = 0-31) from diagnosis to definitive surgery, 44 days (IQR = 34-56) from final surgery to postoperative chemotherapy and 75 days (IQR = 57-97) from final surgery to postoperative radiotherapy. Diagnosis during 2000-2003 compared to 1995-1999 was associated with significantly longer wait times for each phase of the treatment pathway. Higher income quintile was associated with longer wait time from diagnosis to surgery (OR = 1.47, 95% CI = 1.05-2.06) and shorter wait times from final surgery to radiotherapy (OR = 0.60, 95% CI = 0.37-0.96). Greater stage at diagnosis was associated with shorter wait times from diagnosis to definitive surgery (stage III vs I: OR = 0.49, 95% CI = 0.34-0.71). CONCLUSIONS While diagnosis during the latter part of the study period was associated with significantly longer wait times for all phases of the treatment pathway, there were variations in the associations of stage and income quintile with wait times by treatment phase. Continued assessment of factors associated with wait times across the breast cancer treatment pathway is important, as they indicate areas to be targeted for quality improvement with the ultimate goal of improving prognosis.
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Affiliation(s)
- Amalia Plotogea
- Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON M5G 2L7 Canada ; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Walker MJ, Chiarelli AM, Knight JA, Mirea L, Glendon G, Ritvo P. Perceived risk and adherence to breast cancer screening guidelines among women with a familial history of breast cancer: a review of the literature. Breast 2013; 22:395-404. [PMID: 23313062 DOI: 10.1016/j.breast.2012.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 10/12/2012] [Accepted: 12/17/2012] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES A small positive association has been consistently demonstrated between perceived breast cancer risk and mammography use. Evidence specific to women with familial breast cancer risk has not been previously reviewed. METHODS A literature search was conducted. 186 studies were identified for abstract/full-text review, of which 10 articles were included. Manual searching identified 10 additional articles. Twenty articles examining the association between perceived breast cancer risk and adherence to mammography, clinical breast examination (CBE) or breast self-examination (BSE) guidelines among women with familial breast cancer risk were reviewed. Studies were classified according to screening modality, categorized by finding and ordered by year of publication. Studies assessing mammography were further classified according to the applied method of measuring perceived risk. RESULTS Our review found a weak positive association between higher perceived risk and adherence to mammography guidelines among women with familial breast cancer risk. Consistent associations between perceived risk and adherence to CBE and BSE guidelines were not observed. CONCLUSIONS Our ability to understand the relationship between perceived breast cancer risk and adherence to breast screening guidelines is limited, because most previous research is cross-sectional. Future studies with prospective methodologies that use consistent measurement methods and are adequately powered are warranted.
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Affiliation(s)
- Meghan J Walker
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada.
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Eisen A, Carroll J, Chiarelli AM, Horgan M, Meschino W, Rabeneck L, Shumak R, Warner E. Abstract P3-02-10: Implementation and uptake of a provincial, population-based, organized breast screening program for high risk women in Ontario: The Ontario breast screening program (OBSP) high risk program. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p3-02-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Genetic testing for mutations in BRCA1/2 has been clinically available in Ontario since 2000. Over 15000 individuals have been tested. Evidence from clinical trials has consistently shown that women at high risk of breast cancer (BrCa) benefit from BrCa screening that includes both magnetic resonance imaging (MRI) of the breast and mammography, yet access to MRI in Ontario was variable. In 2011, Cancer Care Ontario (CCO) established an expert panel to develop a protocol for expanding the OBSP, initially created for average risk women 50–74, to include MRI and mammography for eligible high risk women.
Methods: The panel's tasks included: 1. determining high risk criteria 2. estimating the prevalence of high risk women 3. selecting a cancer risk model 4. developing a referral and assessment pathway for potentially eligible subjects 5. developing educational resources, training plan and communication strategy for relevant stakeholders 6. developing indicators for program evaluation, 7. providing guidance for post-implementation issues.
Results: The program was initiated July, 2011 and now includes 28 sites. Women aged 30–69 with and without a history of breast cancer are eligible if they 1. are BRCA1/2 mutation carriers or untested first degree relatives of carriers, 2. have a lifetime risk of breast cancer >=25% based on family history according to IBIS or BOADICEA risk models, or 3. received prior radiation therapy to the chest. It is estimated that 34000 high risk women in the target age group live in Ontario. Preliminary volume data for the first 9 mos are shown in Table 1. Of the 5037 women participating, 802 have been referred directly by their physician and 4,235 have been referred for genetic assessment. Of the 2,946 women who received genetic assessment, 31% met the high risk criteria. To date, 729 high risk MRI scans have been performed.
Conclusions: A population based organized screening program for high risk women that includes genetic risk assessment has been implemented in Ontario. Further evaluation of risk assessment and screen results are underway. To our knowledge, this is the first organized screening program for women at high risk of breast cancer.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-02-10.
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Affiliation(s)
- A Eisen
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; North York General Hospital, Toronto, ON, Canada
| | - J Carroll
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; North York General Hospital, Toronto, ON, Canada
| | - AM Chiarelli
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; North York General Hospital, Toronto, ON, Canada
| | - M Horgan
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; North York General Hospital, Toronto, ON, Canada
| | - W Meschino
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; North York General Hospital, Toronto, ON, Canada
| | - L Rabeneck
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; North York General Hospital, Toronto, ON, Canada
| | - R Shumak
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; North York General Hospital, Toronto, ON, Canada
| | - E Warner
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; North York General Hospital, Toronto, ON, Canada
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Ritvo P, Edwards SA, Glendon G, Mirea L, Knight JA, Andrulis IL, Chiarelli AM. Beliefs about optimal age and screening frequency predict breast screening adherence in a prospective study of female relatives from the Ontario site of the Breast Cancer Family Registry. BMC Public Health 2012; 12:518. [PMID: 22788119 PMCID: PMC3432622 DOI: 10.1186/1471-2458-12-518] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 07/12/2012] [Indexed: 11/13/2022] Open
Abstract
Background Although few studies have linked cognitive variables with adherence to mammography screening in women with family histories of breast and/or ovarian cancer, research studies suggest cognitive phenomena can be powerful adherence predictors. Methods This prospective study included 858 women aged 30 to 71 years from the Ontario site of the Breast Cancer Family Registry with at least one first-degree relative diagnosed with breast and/or ovarian cancer. Data on beliefs about breast cancer screening and use of mammography were obtained from annual telephone interviews spanning three consecutive years. Self-reported mammogram dates were confirmed with medical imaging reports. Associations between beliefs about breast cancer screening and adherence with annual mammography were estimated using polytomous logistic regression models corrected for familial correlation. Models compared adherers (N = 329) with late-screeners (N = 382) and never-screeners (N = 147). Results Women who believed mammography screening should occur annually were more likely to adhere to annual screening recommendations than women who believed it should happen less often (OR: 5.02; 95% CI: 2.97-8.49 for adherers versus late-screeners; OR: 6.82; 95% CI: 3.29-14.16 for adherers versus never-screeners). Women who believed mammography screening should start at or before age 50 (rather than after) (OR: 9.72; 95% CI: 3.26-29.02) were significantly more likely to adhere when compared with never-screeners. Conclusions Study results suggest that women with a family history of breast cancer should be strongly communicated recommendations about initial age of screening and screening intervals as related beliefs significantly predict adequate adherence.
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Affiliation(s)
- Paul Ritvo
- Research, Prevention and Cancer Control, Cancer Care Ontario, 620 University Ave, Toronto, ON M5G 2L7, Canada.
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Eisen A, Carroll J, Chiarelli AM, Heale E, Horgan M, Meschino W, Rabeneck L, Shumak R, Warner E. Implementation of a population-based breast screening program for high-risk women in Ontario: The Ontario Breast Screening Program (OBSP) High-Risk Program. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.e12034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12034 Background: Genetic testing for mutations in BRCA1 and BRCA2 has been clinically available in Ontario since 2000. It is estimated that over 15000 individuals have been tested. Evidence from clinical trials have consistently shown that women at high risk of breast cancer such as BRCA1/2 mutation carriers benefit from breast cancer screening that includes both magnetic resonance imaging (MRI) of the breast and mammography, yet access to MRI in Ontario was variable. In 2011, Cancer Care Ontario established an expert panel to develop a protocol for expanding the Ontario Breast Screening Program, initially created for average risk women 50-74, to include MRI and mammography for eligible high risk women. Methods: The panel’s tasks included: 1. determining the criteria for high risk, 2. estimating the prevalence of high risk women, 3. selecting a model to estimate cancer risk, 4. developing a referral and assessment pathway for potentially eligible subjects to receive genetic counseling/risk assessment and screening if eligible, 5. developing educational resources, training plan and communication strategy for relevant stakeholders including primary care providers, oncologists, geneticists and genetic counselors, 6. developing indicators to permit program evaluation, 7. providing guidance for post-implementation issues such as subject eligibility and interpretation of genetic test results. Results: The program was initiated July, 2011 at 19 sites. Women aged 30-69 with and without a history of breast cancer are eligible if they 1. are BRCA1/2 mutation carriers or untested first degree relatives of carriers, 2. have a lifetime risk of breast cancer >=25% based on family history, or 3. received prior radiation therapy to the chest. It is estimated that 34000 high risk women in the target age group live in Ontario. Conclusions: A population based organized screening program for high risk women that includes genetic risk assessment has been implemented in Ontario. To our knowledge, this is the first organized screening program for women at high risk of breast cancer.
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Affiliation(s)
- Andrea Eisen
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - June Carroll
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Esti Heale
- Cancer Care Ontario, Toronto, ON, Canada
| | | | | | | | - Rene Shumak
- OBSP Cancer Care Ontario, Toronto, ON, Canada
| | - Ellen Warner
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Quan ML, Shumak RS, Majpruz V, Holloway CMD, O'Malley FP, Chiarelli AM. Improving work-up of the abnormal mammogram through organized assessment: results from the ontario breast screening program. J Oncol Pract 2012; 8:107-12. [PMID: 23077438 DOI: 10.1200/jop.2011.000413] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2011] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Women with an abnormal screening mammogram should ideally undergo an organized assessment to attain a timely diagnosis. This study evaluated outcomes of women undergoing work-up after abnormal mammogram through a formal breast assessment affiliate (BAA) program with explicit care pathways compared with usual care (UC) using developed quality indicators for screening mammography programs. METHODS Between January 1 and December 31, 2007, a total of 320,635 women underwent a screening mammogram through the Ontario Breast Screening Program (OBSP), of whom 25,543 had an abnormal result requiring further assessment. Established indicators assessing timeliness, appropriateness of follow-up, and biopsy rates were compared between women who were assessed through either a BAA or UC using χ(2) analysis. RESULTS Work-up of the abnormal mammogram for patients screened through a BAA resulted in a greater proportion of women attaining a definitive diagnosis within the recommended time interval when a histologic diagnosis was required. In addition, use of other quality measures including specimen radiography for both core biopsies and surgical specimens and preoperative core needle biopsy was greater in BAA facilities. CONCLUSION These findings support future efforts to increase the number of BAAs within the OBSP, because the pathways and reporting methods associated with them result in improvements in our ability to provide timely and appropriate care for women requiring work-up of an abnormal mammogram.
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Affiliation(s)
- May Lynn Quan
- Foothills Medical Center, University of Calgary, Calgary, Alberta; Cancer Care Ontario; Dalla Lana School of Public Health, University of Toronto; Sunnybrook Health Sciences Centre, University of Toronto; and St Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
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