Efficacy of Cobas HPV testing for predicting grade 2+ cervical intraepithelial neoplasia in a cancer prevention center and a gynecologic oncology clinic: A single-institution experience

BACKGROUND

To evaluate the efficacy of Cobas human papillomavirus (HPV) testing to predict cervical intraepithelial neoplasia of grade 2 or higher (CIN2+), Cobas HPV testing results were correlated with follow-up biopsy in patients from Cancer Prevention Center (CPC) and Gynecologic Oncology Clinic (GOC) of The University of Texas MD Anderson Cancer Center.

METHODS

Institutional data for patients who underwent Cobas HPV and Papanicolaou (Pap) cytology cotesting from 2019 to 2020 were retrospectively reviewed. Surgical follow-up results were compared with Cobas HPV testing results in two populations.

RESULTS

A total of 2226 patients, including 921 women (mean age, 55.2 years) seen at the CPC and 1305 women (mean age, 49.3 years) seen at the GOC, were included. Specimens from GOC patients had a significantly higher HPV positivity rate than did those from CPC patients (22.9% vs. 10.1%; p < .001). Cobas HPV testing was positive in all seven CPC patients with surgical follow-up results showing CIN2+. Among 36 GOC patients with CIN2+ lesions, five patients had HPV-/Pap+ testing results. Although only seven CPC patients had CIN2+, Cobas HPV testing showed 100% sensitivity for predicting CIN2+ in this group. Sensitivity for CIN2+ was 86.5% in the GOC group, whereas 13.9% of GOC patients with CIN2+ had negative HPV testing results.

CONCLUSIONS

Cobas HPV testing was highly efficacious for predicting CIN2+ lesions in the low-risk CPC population, which supports HPV primary screening for cervical cancer in low-risk populations. For high-risk patients, especially those with a history of CIN2+/cervical cancer, HPV/Pap cotesting may still be necessary to maintain a high clinical sensitivity for CIN2+.

Talking numbers: how women and providers use risk scores during and after risk counseling - a qualitative investigation from the NRG Oncology/NSABP DMP-1 study

OBJECTIVES

Little research exists on how risk scores are used in counselling. We examined (a) how Breast Cancer Risk Assessment Tool (BCRAT) scores are presented during counselling; (b) how women react and (c) discuss them afterwards.

DESIGN

Consultations were video-recorded and participants were interviewed after the consultation as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1 (NSABP DMP-1).

SETTING

Two NSABP DMP-1 breast cancer care centres in the USA: one large comprehensive cancer centre serving a high-risk population and an academic safety-net medical centre in an urban setting.

PARTICIPANTS

Thirty women evaluated for breast cancer risk and their counselling providers were included.

METHODS

Participants who were identified as at increased risk of breast cancer were recruited to participate in qualitative study with a video-recorded consultation and subsequent semi-structured interview that included giving feedback and input after viewing their own consultation. Consultation videos were summarised jointly and inductively as a team.tThe interview material was searched deductively for text segments that contained the inductively derived themes related to risk assessment. Subgroup analysis according to demographic variables such as age and Gail score were conducted, investigating reactions to risk scores and contrasting and comparing them with the pertinent video analysis data. From this, four descriptive categories of reactions to risk scores emerged. The descriptive categories were clearly defined after 19 interviews; all 30 interviews fit principally into one of the four descriptive categories.

RESULTS

Risk scores were individualised and given meaning by providers through: (a) presenting thresholds, (b) making comparisons and (c) emphasising or minimising the calculated risk. The risk score information elicited little reaction from participants during consultations, though some added to, agreed with or qualified the provider's information. During interviews, participants reacted to the numbers in four primary ways: (a) engaging easily with numbers; (b) expressing greater anxiety after discussing the risk score; (c) accepting the risk score and (d) not talking about the risk score.

CONCLUSIONS

Our study highlights the necessity that patients' experiences must be understood and put into relation to risk assessment information to become a meaningful treatment decision-making tool, for instance by categorising patients' information engagement into types.

TRIAL REGISTRATION NUMBER

NCT01399359.

NCCN Guidelines® Insights: Breast Cancer Screening and Diagnosis, Version 1.2023

The NCCN Guidelines for Breast Cancer Screening and Diagnosis provide health care providers with a practical, consistent framework for screening and evaluating a spectrum of clinical presentations and breast lesions. The NCCN Breast Cancer Screening and Diagnosis Panel is composed of a multidisciplinary team of experts in the field, including representation from medical oncology, gynecologic oncology, surgical oncology, internal medicine, family practice, preventive medicine, pathology, diagnostic and interventional radiology, as well as patient advocacy. The NCCN Breast Cancer Screening and Diagnosis Panel meets at least annually to review emerging data and comments from reviewers within their institutions to guide updates to existing recommendations. These NCCN Guidelines Insights summarize the panel's decision-making and discussion surrounding the most recent updates to the guideline's screening recommendations.

Isolated Flat Epithelial Atypia: Upgrade Outcomes After Multidisciplinary Review-Based Management Using Excision or Imaging Surveillance

Objective

To compare flat epithelial atypia (FEA) upgrade rates after excision versus surveillance and to identify variables associated with upgrade.

Methods

This single-institution retrospective study identified isolated FEA cases determined by percutaneous biopsy from April 2005 through July 2022 with excision or ≥2 years surveillance. All cases were recommended for excision or surveillance based on multidisciplinary discussion of clinical, imaging, and pathologic variables with emphasis on sampling adequacy and significant atypia. Truth was determined by pathology at excision or the absence of cancer on surveillance. Upgrade was defined as cancer occurring ≤2 cm from the biopsy site. Demographic, imaging, and biopsy variables were compared between those that did and did not upgrade.

Results

Among 112 cases of isolated FEA, imaging findings included calcifications in 81.3% (91/112), MRI lesions in 11.6% (13/112), and distortions or masses in 7.1% (8/112). Excision was recommended in 12.5% (14/112) and surveillance in 87.5% (98/112) of cases. Among those recommended for excision, 28.6% (4/14) of cases were upgraded, all to ductal carcinoma in situ. In those recommended for surveillance, 1.0% (1/98) were upgraded to invasive cancer. Overall, FEA had a 4.5% (5/112) upgrade rate, and 2.7% (3/112) also developed cancer >2 cm from the FEA. There were no significant differences in demographic, imaging, and biopsy variables between those that did and did not upgrade to cancer.

Conclusion

Multidisciplinary management of isolated FEA distinguishes those at higher risk of upgrade to cancer (28.6%) in whom surgery is warranted from those at low risk of upgrade (1.0%) who can be managed non-operatively.

Aromatase inhibitors and contralateral breast cancer in BRCA mutation carriers

BACKGROUND

Deleterious BRCA mutations confer a significant lifetime risk of breast cancer (BC) as well as contralateral BC (CBC) in patients who do not undergo prophylactic mastectomy. Prior reports have suggested that tamoxifen reduces the risk of CBC in BRCA mutation carriers. Whether aromatase inhibitors (AI) have the same effect is unknown.

METHODS

This is a retrospective review of patients diagnosed with non-metastatic ER+ BC between 2004 and 2014 with known BRCA mutation status. Patients were followed from primary diagnosis until CBC diagnosis or death. Median follow-up was 11.5 years. Risk of CBC was evaluated as time to event.

RESULTS

935 subjects were included in this analysis, with 53 BRCA1 mutation carriers, and 94 BRCA2 mutation carriers. Median age at diagnosis was 42.7 years. Seventy-two percent (676) received tamoxifen and 43% (405) received AI. A total of 66 CBCs occurred, of which 10% (15/147) occurred in BRCA mutation carriers vs 6.5% (51/788) in BRCA wild type. Multivariate analyses indicated that BRCA status and AI use were significantly associated with CBC risk. AI use resulted in a significant reduction in risk of CBC (HR 0.44, p = 0.004) regardless of the BRCA mutation status. Tamoxifen use was not associated with reduced risk of CBC.

CONCLUSIONS

This is the first report showing that AIs reduce the risk of CBC in BRCA mutation carriers. The potential role of AIs as chemoprevention should be validated in larger independent cohorts.

Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI

RATIONALE AND OBJECTIVE

To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge.

MATERIALS AND METHODS

A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs).

RESULTS

Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001). The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis.

CONCLUSION

The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.

Perceptions of Conflicting Breast Cancer Screening Recommendations Among Racially/Ethnically Diverse Women: a Multimethod Study

BACKGROUND

Conflicting breast cancer screening recommendations have the potential to diminish informed decision making about screening.

OBJECTIVE

We examined the knowledge, attitudes, and intentions related to divergent recommendations for breast cancer screening among racially/ethnically diverse women.

DESIGN

We used a multimethod study design employing focus groups and questionnaires. Focus groups included: (1) two 10-min presentations on the national screening recommendations and the potential benefits and harms of screening and (2) an interactive discussion. Data were collected: 8/3/2017 to 11/19/2019. Analysis occurred from 1/21/2019 to 7/24/2020.

PARTICIPANTS

Participants were (1) women 40-75 years; (2) English or Spanish speaking; (3)self-identified as Latina, Black, or non-Latina White; and (4) no known increased risk for breast cancer.

MAIN MEASURES

Main outcomes were participants' knowledge and perceptions of benefits and harms of screening mammography and their screening intentions. Focus groups were transcribed and analyzed using a qualitative descriptive approach. Quantitative data were summarized using descriptive statistics.

KEY RESULTS

One hundred thirty-four women (n=52, 40-49 years; n=82, 50-75 years) participated in 28 focus groups. Participants were Latina (n=44); Black (n=51); and non-Latina White (n=39). Approximately one-quarter (n=32) had limited health literacy and almost one-fifth (n=23) had limited numeracy. In the context of differing national screening recommendations, participants questioned the motives of the recommendation-making agencies, including the role of costs and how costs were considered when making screening recommendations. Participants expressed concern that they were not represented (e.g., race/ethnicity) in the data informing the recommendations. Immediately following the focus groups, most participants expressed intention to screen within the upcoming year (pre n=100 vs. post n=107).

CONCLUSIONS

Divergent breast cancer screening recommendations may lead to mistrust and paradoxically reinforce high overall enthusiasm for screening.

Salutary effects of moderate but not high intensity aerobic exercise training on the frequency of peripheral T-cells associated with immunosenescence in older women at high risk of breast cancer: a randomized controlled trial

Background

Immunosenescence is described as age-associated changes within the immune system that are responsible for decreased immunity and increased cancer risk. Physically active individuals have fewer ‘senescent’ and more naïve T-cells compared to their sedentary counterparts, but it is not known if exercise training can rejuvenate ‘older looking’ T-cell profiles. We determined the effects of 12-weeks supervised exercise training on the frequency of T-cell subtypes in peripheral blood and their relationships with circulating levels of the muscle-derived cytokines (i.e. ‘myokines’) IL-6, IL-7, IL-15 and osteonectin in older women at high risk of breast cancer. The intervention involved 3 sessions/week of either high intensity interval exercise (HIIT) or moderate intensity continuous exercise (MICT) and were compared to an untrained control (UC) group.

Results

HIIT decreased total granulocytes, CD4+ T-cells, CD4+ naïve T-cells, CD4+ recent thymic emigrants (RTE) and the CD4:CD8 ratio after training, whereas MICT increased total lymphocytes and CD8 effector memory (EM) T-cells. The change in total T-cells, CD4+ naïve T-cells, CD4+ central memory (CM) T-cells and CD4+ RTE was elevated after MICT compared to HIIT. Changes in \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}}{\mathrm{O}}_{2\max } $$\end{document}V˙O2max after training, regardless of exercise prescription, was inversely related to the change in highly differentiated CD8+ EMRA T-cells and positively related to changes in β2-adrenergic receptor (β2-AR) expression on CM CD4+ and CM CD8+ T-cells. Plasma myokine levels did not change significantly among the groups after training, but individual changes in IL-7 were positively related to changes in the number of β2-AR expressing CD4 naïve T cells in both exercise groups but not controls. Further, CD4 T-cells and CD4 naive T-cells were negatively related to changes in IL-6 and osteonectin after HIIT but not MICT, whereas CD8 EMRA T-cells were inversely related to changes in IL-15 after MICT but not HIIT.

Conclusions

Aerobic exercise training alters the frequency of peripheral T-cells associated with immunosenescence in middle aged/older women at high risk of breast cancer, with HIIT (pro-senescent) and MICT (anti-senescent) evoking divergent effects. Identifying the underlying mechanisms and establishing whether exercise-induced changes in peripheral T-cell numbers can alter the risk of developing breast cancer warrants investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12979-022-00266-z.

The impact of high-intensity interval exercise training on NK-cell function and circulating myokines for breast cancer prevention among women at high risk for breast cancer

Purpose

Preclinical evidence suggests that natural killer cell (NK-cell) function and myokines facilitate the protective effects of exercise for breast cancer prevention. Since higher-intensity exercise acutely promotes greater mobilization and larger changes in NK-cell cytotoxicity than lower-intensity, high-intensity interval training (HIIT) might offer increased immune protection compared to moderate-intensity continuous-training (MICT). This study compared a 12-week HIIT program to a 12-week MICT program and usual care on changes in resting NK-cell function and circulating myokines among women at high risk for breast cancer.

Methods

Thirty-three women were randomized to HIIT, MICT, or usual care, for a supervised exercise intervention. Blood was collected at baseline and end-of-study. The cytotoxic activity of CD3−/CD56+ NK-cells against the K562 target cell line in vitro was determined by flow cytometry. Circulating myokines (IL-15, IL-6, irisin, OSM, osteonectin, IL-7) were assessed with luminex multiplex assays and ELISA. One-way ANOVA and paired sample t-tests assessed between- and within-group differences, respectively. Pearson correlation coefficients determined relationships between baseline fitness and change variables.

Results

Significant differences were not observed between groups for change in NK-cell function or circulating myokines (p > 0.05). Significant correlations were only observed for baseline peak aerobic capacity (ml/kg/min) and change in NK-cell-specific lysis (r = − 0.43, p = 0.02) and hemacytotoxicity for the total sample (r = − 0.46, p = 0.01).

Conclusion

Our findings suggest that exercise intensity may not significantly impact change in resting NK-cell function and circulating myokines among women at high risk for breast cancer. Structured exercise training may have a larger impact on NK-cell function in those with lower levels of cardiorespiratory fitness.

Clinical trial registration: NCT02923401; Registered on October 4, 2016

A Randomized Phase IIb Study of Low-dose Tamoxifen in Chest-irradiated Cancer Survivors at Risk for Breast Cancer

PURPOSE

Low-dose tamoxifen reduces breast cancer risk, but remains untested in chest-irradiated cancer survivors-a population with breast cancer risk comparable with BRCA mutation carriers. We hypothesized that low-dose tamoxifen would be safe and efficacious in reducing radiation-related breast cancer risk.

PATIENTS AND METHODS

We conducted an investigator-initiated, randomized, phase IIb, double-blinded, placebo-controlled trial (FDA IND107367) between 2010 and 2016 at 15 U.S. sites. Eligibility included ≥12 Gy of chest radiation by age 40 years and age at enrollment ≥25 years. Patients were randomized 1:1 to low-dose tamoxifen (5 mg/day) or identical placebo tablets for 2 years. The primary endpoint was mammographic dense area at baseline, 1 and 2 years. IGF-1 plays a role in breast carcinogenesis; circulating IGF-1 and IGF-BP3 levels at baseline, 1 and 2 years served as secondary endpoints.

RESULTS

Seventy-two participants (low-dose tamoxifen: n = 34, placebo: n = 38) enrolled at a median age of 43.8 years (35-49) were evaluable. They had received chest radiation at a median dose of 30.3 Gy. Compared with the placebo arm, the low-dose tamoxifen arm participants had significantly lower mammographic dense area (P = 0.02) and IGF1 levels (P < 0.0001), and higher IGFBP-3 levels (P = 0.02). There was no difference in toxicity biomarkers (serum bone-specific alkaline phosphatase, lipids, and antithrombin III; urine N-telopeptide cross-links) between the treatment arms. We did not identify any grade 3-4 adverse events related to low-dose tamoxifen.

CONCLUSIONS

In this randomized trial in chest-irradiated cancer survivors, we find that low-dose tamoxifen is effective in reducing established biomarkers of breast cancer risk and could serve as a risk-reduction strategy.

Biomarker Modulation Study of Celecoxib for Chemoprevention in Women at Increased Risk for Breast Cancer: A Phase II Pilot Study

In preclinical studies, celecoxib has been associated with reduced risk of breast cancer. In this study, the aim was to assess the biomodulatory effect of celecoxib on blood and benign breast tissue biomarkers in women at increased risk for breast cancer. Women at increased risk for breast cancer [5-year Gail risk score of >1.67%, history of atypical hyperplasia, lobular carcinoma in situ, or previous estrogen receptor (ER)-negative breast cancer] were treated with celecoxib at 400 mg orally twice daily for 6 months. Participants underwent random periareolar fine needle aspiration and blood draw at baseline and at 6 months for analysis of biomarkers: serum levels of insulin-like growth factor 1 (IGF-1), IGF-binding protein 1 (IGFBP-1), and IGFBP-3; tissue expression of Ki-67 and ER; as well as cytology. Forty-nine patients were eligible for analysis. Median IGFBP-1 levels increased significantly from 6.05 ng/mL at baseline to 6.93 ng/mL at 6 months (P = 0.04), and median IGFBP-3 levels decreased significantly from 3,593 ng/mL to 3,420 ng/mL (P = 0.01). We also detected favorable changes in cytology of 52% of tested sites after 6 months of celecoxib therapy. No changes in tissue Ki-67 and ER expression levels were observed. No grade 3 or 4 toxicity was recorded. Celecoxib was well tolerated and induced favorable changes in serum biomarkers as well as cytology in this pilot phase II trial. A phase IIb placebo-controlled study with celecoxib could be considered for women at increased risk for breast cancer.

Abstract A17: An innovative physical activity intervention in overweight and obese adults using continuous glucose monitor

Introduction: Regular physical activity (PA) lowers the risk of endometrial, breast, and colorectal cancer. However, nearly half of American adults are not sufficiently active. The physical inactivity rate is even higher among the overweight and obese population, which, in combination with the unfavorable effect of excess body weight, puts this population at a greater risk for cancer. Advancements in wearable sensor technology provide opportunities for personalized approaches to increase motivation to be active. The current pilot study used continuous glucose monitors (CGM) to demonstrate the immediate, physiologic benefits of PA.

Methods: Insufficiently active (&lt;150 mins of moderate intensity PA per week) overweight and obese (body mass index &gt;= 25 kg/m2) adults (18-65 years old) without diabetes are being recruited to participate in this pilot intervention. Upon enrollment, participants go through a one-on-one PA education session that includes a discussion about the health benefits of recommended PA levels, demonstration of the acute effect of PA on daily glucose patterns using a web-based glucose simulator, calculation of personal heart rate zones for moderate intensity PA, and development of an exercise plan. After the education session, participants are given a Fitbit Alta HR wristband and are instructed to wear it over the next 10 days. Participants are also given a Freestyle Libre CGM, which consists of a sensor and a reader. The sensor is inserted into the back of the upper arm to collect interstitial glucose data every 15 minutes for 10 days after activation. The reader displays current glucose readings and a graph of the 8 previous hours of glucose data upon scanning the sensor. Participants are instructed to scan the sensor at least 4 times a day and are encouraged to achieve at least 150 minutes of moderate-intensity PA each week. At the end of the self-monitoring period, participants return their Fitbit and have their CGM sensor removed.

Results: Thus far, 10 of 20 participants have enrolled in and completed the study. These participants have been 100% female, 70% obese, and 20% Hispanic with a mean age of 41.5 (SD = 8.6) years old. On average, participants scanned their sensor 6 times each day and wore the Fitbit for all 10 days. On average, participants highly rated each component of the education session (on a 5-point scale) for improving their PA knowledge (mean = 4.4), increasing their PA motivation (mean = 4.4), and providing personally relevant information (mean = 4.6). Participants also reported a very positive experience wearing the CGM, with mean ratings (on a 5-point scale) of 4.8 for usability, 4.6 for convenience, 4.9 for value, 4.9 for relevance, and 4.7 for motivating.

Conclusion: These preliminary data suggest that using a CGM to motivate PA among nondiabetic adults is feasible and acceptable. Future research will be conducted to examine the effect a CGM-based PA intervention has on changing PA behavior.

Citation Format: Yue Liao, Christopher J. Miller, Diana L. Urbauer, Therese B. Bevers, Ernest Hawk, Karen M. Basen-Engquist, Susan M. Schembre. An innovative physical activity intervention in overweight and obese adults using continuous glucose monitor [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr A17.

High-Intensity Interval Training Is Feasible in Women at High Risk for Breast Cancer

Purpose

This trial aimed to demonstrate the feasibility of high-intensity interval training (HIIT) in postmenopausal, overweight/obese women at high risk of invasive breast cancer and to explore HIIT on changes in cardiorespiratory fitness (CRF), body weight, and body mass index (BMI) compared with moderate-intensity continuous training (MICT) and usual care (UC).

Methods

Forty-four women were randomized to HIIT, MICT, or UC for a 12-wk, thrice weekly, supervised exercise intervention. HIIT included a 5-min warm-up at 50%–70% HR_peak, four cycles of 4 min at 90%–100% HR_peak, followed by 3 min at 50%–70% HR_peak. MICT consisted of 41 min at 60%–70% HR_peak. Feasibility was assessed by consent, adherence, compliance, and retention rates. CRF, body weight, and BMI were measured at baseline and end of study. Repeated-measures linear mixed models were used to assess within- and between-group differences.

Results

Average age was 63.9 ± 8.8 yr. BMI was 30.9 ± 5.7 kg·m⁻². Participants completed 90% and 89% of HIIT and MICT workouts, respectively, with 100% compliance to the exercise prescriptions. No serious adverse events were reported. Compared with MICT and UC, HIIT exhibited improvements in change in treadmill time (101 s greater than MICT, and 125 s greater than UC, respectively, P < 0.001). Compared with UC, HIIT exhibited improvement in changes in absolute and relative V˙O_2peak (a 0.15-L·min⁻¹ increase, P = 0.005, and a 2.3-mL·kg⁻¹⋅min⁻¹ increase, P = 0.004). There were no significant differences between groups for body weight or BMI (P > 0.05).

Conclusions

HIIT is feasible, safe, and seems to promote greater improvements in CRF compared with MICT and UC in women at high risk for breast cancer.

The role of magnetic resonance imaging in patients with palpable breast abnormalities and negative mammographic and sonographic findings

OBJECTIVE OR PURPOSE OF STUDY

The objective of this retrospective study was to determine the frequency of positive findings on breast magnetic resonance imaging (MRI) in patients with palpable breast abnormalities in the setting of negative mammographic and sonographic evaluations.

MATERIALS, METHODS, AND PROCEDURES

Consecutive patients undergoing breast MRI for palpable abnormalities from January 1, 2005 to December 31, 2015 were identified for this retrospective study. Those with preceding imaging (mammograms or ultrasounds) demonstrating positive findings related to the palpable abnormalities were excluded. The location and the duration of the symptoms, the type and the location of the abnormal MRI findings, and their relationships to the symptoms were recorded. Clinical and imaging follow-up as well as the type and the resultant biopsies were recorded. Patients with less than two years of imaging or clinical follow-up were excluded from the study.

RESULTS

22 004 women presented with palpable abnormalities at one breast imaging center between January 1, 2005 and December 31, 2015. Nine thousand and three hundred and thirty-four patients had negative or benign findings on mammography, ultrasound, or mammography plus ultrasound. Thirty-one patients underwent MRI with the complaint of palpable abnormalities despite negative or benign mammographic and/or sonographic findings. Their age range was between 32 and 74 years, and their mean age was 49 years. Of those who had MRI, twenty-one patients had negative MRI findings. Six patients had negative concordant results for the palpable abnormalities and benign incidental findings. Three patients had benign concordant results for the palpable abnormalities, and one patient had incidental atypia. Twenty-eight patients had negative MRI results in the area of the palpable abnormality, and none of these patients underwent biopsy. Of the 31 cases, four patients (13%) underwent additional examinations (three second-look ultrasounds and one bone scan) after MRI. Five patients (16%) underwent MRI-guided biopsies, two patients (6%) underwent ultrasound-guided biopsies, and one patient (3%) had an excision. All biopsies showed benign results. The Gail risk score was calculated for 22 of them and the mean 5-year risk was 1.64 and the mean lifetime risk was 12.51.

CONCLUSION

Breast MRI to evaluate palpable abnormalities after negative mammography and ultrasound results in a low yield for malignancy. The majority of patients (67.7%) had negative MRI examinations, and there were no malignancies detected. Our findings lead us to believe that there are no data to encourage the use of MRI in patients with palpable abnormalities and negative mammographic and/or ultrasound studies.

Using Continuous Glucose Monitoring to Motivate Physical Activity in Overweight and Obese Adults: A Pilot Study

BACKGROUND

Regular physical activity (PA) is associated with a lower risk of several types of cancers. However, two-thirds of overweight/obese adults are not sufficiently active; this, in combination with the unfavorable effect of excess body weight, puts them at a greater risk for cancer. One reason that these individuals do not engage in enough PA may be their lack of motivation to change their current behavior due to the perception of putting in effort for possible future gain without obvious short-term benefits. There is a need for innovative ways to help individuals recognize the immediate health benefits of PA and thus increase their motivation.

METHODS

This pilot intervention tested a PA education module that included a one-on-one counseling session highlighting the acute effects of PA on glucose patterns, followed by a 10-day self-monitoring period with a continuous glucose monitor (CGM) and a Fitbit tracker. Participants rated the acceptability of the education module on a 5-point Likert scale and completed surveys assessing stages of change for motivational readiness.

RESULTS

Nineteen overweight/obese adults (84% female) completed the study. Participants gave high ratings to the counseling session for improving their PA-related knowledge (mean = 4.22), increasing motivation (mean = 4.29), and providing personally relevant information (mean = 4.35). The summary acceptability scores for the self-monitoring period were 4.46 for CGM and 4.51 for Fitbit. Participants reported a significant decrease in the precontemplation stage and an increase in the action stage (P < 0.05).

CONCLUSIONS

CGM is a feasible tool for PA interventions.

IMPACT

Information from CGM could be used as biological-based feedback to motivate PA.See all articles in this CEBP Focus section, "Modernizing Population Science."

Effect of a Patient Decision Aid on Lung Cancer Screening Decision-Making by Persons Who Smoke: A Randomized Clinical Trial

IMPORTANCE

Lung cancer screening with low-dose computed tomography lowers lung cancer mortality but has potential harms. Current guidelines support patients receiving information about the benefits and harms of lung cancer screening during decision-making.

OBJECTIVE

To examine the effect of a patient decision aid (PDA) about lung cancer screening compared with a standard educational material (EDU) on decision-making outcomes among smokers.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted using 13 state tobacco quitlines. Current and recent tobacco quitline clients who met age and smoking history eligibility for lung cancer screening were enrolled from March 30, 2015, to September 12, 2016, and followed up for 6 months until May 5, 2017. Data analysis was conducted between May 5, 2017, and September 30, 2018.

INTERVENTIONS

Participants were randomized to the PDA video Lung Cancer Screening: Is It Right for Me? (n = 259) or to EDU (n = 257).

MAIN OUTCOMES AND MEASURES

The primary outcomes were preparation for decision-making and decisional conflict measured at 1 week. Secondary outcomes included knowledge, intentions, and completion of screening within 6 months of receiving the intervention measured by patient report.

RESULTS

Of 516 quit line clients enrolled, 370 (71.7%) were younger than 65 years, 320 (62.0%) were female, 138 (26.7%) identified as black, 47 (9.1%) did not have health insurance, and 226 (43.8%) had a high school or lower educational level. Of participants using the PDA, 153 of 227 (67.4%) were well prepared to make a screening decision compared with 108 of 224 participants (48.2%) using EDU (odds ratio [OR], 2.31; 95% CI, 1.56-3.44; P < .001). Feeling informed about their screening choice was reported by 117 of 234 participants (50.0%) using a PDA compared with 66 of 233 participants (28.3%) using EDU (OR, 2.56; 95% CI, 1.72-3.79; P < .001); 159 of 234 participants (68.0%) using a PDA compared with 110 of 232 (47.4%) participants using EDU reported being clear about their values related to the harms and benefits of screening (OR, 2.37; 95% CI, 1.60-3.51; P < .001). Participants using a PDA were more knowledgeable about lung cancer screening than participants using EDU at each follow-up assessment. Intentions to be screened and screening behaviors did not differ between groups.

CONCLUSIONS AND RELEVANCE

In this study, a PDA delivered to clients of tobacco quit lines improved informed decision-making about lung cancer screening. Many smokers eligible for lung cancer screening can be reached through tobacco quit lines.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02286713.

Reliability of self-reported smoking history and its implications for lung cancer screening

Clinical guidelines endorse either a 30 or 20 pack-year smoking history threshold when determining eligibility for lung cancer screening (LCS). However, self-reported smoking history is subject to recall bias that can affect patient eligibility. We examined the reliability of smokers’ self-reported tobacco use and its impact on eligibility for LCS. Current or former smokers aged 55–77 years completed questionnaires requesting demographic information and smoking history. Data were collected between December 2014 and September 2015. Total pack-year smoking history was calculated for each participant based on their responses at baseline and one month later. One hundred and two participants completed the study (mean age = 63.6 years). The intraclass correlation coefficient for the pack-year estimate was 0.93. For the 30 pack-year threshold, eight (7.8%) participants were eligible at one but not both assessment periods. For the 20 pack-year threshold, twelve participants (11.8%) were eligible at one but not both assessment periods. Inconsistent reporting was higher among current compared to former smokers. Smokers’ self-reported tobacco use appears highly reliable over short time periods. Nevertheless, there is some inconsistent reporting. We recommend that clinicians carefully assess smoking history, probe patients’ recall of duration and quantity of smoking, and collect tobacco use information at every encounter.

Does Animation Improve Comprehension of Risk Information in Patients with Low Health Literacy? A Randomized Trial

Introduction. Enhanced visual effects, like animation, have the potential to improve comprehension of probabilistic risk information, particularly for those with lower health literacy. We tested the effect of presentation format on comprehension of colorectal cancer (CRC) screening probabilities to identify optimal risk communication strategies. Methods. Participants from a community foodbank and a cancer prevention center were randomized to 1 of 3 CRC screening risk presentations. The presentations used identical content but varied in format: 1) video with animated pictographs, 2) video with static pictographs, and 3) audiobooklet with static pictographs. Participants completed pre- and postpresentation surveys. The primary outcome was knowledge of probability/risk information regarding CRC screening, calculated as total, verbatim, and gist scores. Results. In total, 187 participants completed the study and were included in this analysis. Median age was 58 years (interquartile range [IQR]: 14 years), most participants were women (63%), and almost half had a high school education or less (46%). Approximately one-quarter had inadequate health literacy (Short Test of Functional Health Literacy in Adults marginal/inadequate: 28%; Brief Health Literacy Screener low: 18%), and about half had low numeracy (Subjective Numeracy Scale low: 54%; Graphical Literacy Measure low: 50%). We found no significant differences in total, verbatim, or gist knowledge across presentation formats (all P > 0.05). Discussion. Use of an animated pictograph to communicate risk does not appear to augment or impede knowledge of risk information. Regardless of health literacy level, difficulty understanding pictographs presenting numerical information persists. There may be a benefit to teaching or priming individuals on how to interpret numerical information presented in pictographs before communicating risk using visual methods. Trial Registry: NCT02151032.

Screening Mammography for Average-Risk Women: The Controversy and NCCN's Position

Breast cancer remains the most common nonskin cancer among women and a leading cause of morbidity and mortality. Early detection through screening and advances in treatment have contributed to a 39% mortality reduction in the United States since 1990. The NCCN Guidelines for Breast Cancer Screening and Diagnosis recommend annual mammographic screening for average-risk women beginning at age 40 years. Mammographic screening and subsequent treatment reduces breast cancer mortality based on a wide range of studies. This article highlights NCCN's position on screening mammography and the screening controversy.

A Review of the Presentation of Overdiagnosis in Cancer Screening Patient Decision Aids

Introduction. Patient decision aid (PDA) certification standards recommend including the positive and negative features of each option of the decision. This review describes the inclusion of concepts related to overdiagnosis and overtreatment, negative features often ambiguously defined, in cancer screening PDAs. Methods. Our process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We reviewed 1) current systematic reviews of decision aids, 2) the Ottawa Hospital Research Institute Decision Aid Library Inventory, and 3) a web-based, gray literature search. Two independent reviewers identified and evaluated PDAs using content analysis. Reviewers coded whether overdiagnosis/overtreatment was described as 1) detecting cancer that would not lead to death, 2) detecting cancer that would not cause symptoms, and/or 3) a potential harm or consequence of screening. Coding discrepancies were resolved through consensus. Results. A total of 904 records (e.g., articles, PDAs) were reviewed and 85 PDAs were identified: prostate (n = 36), breast (n = 26), lung (n = 10), colorectal (n = 10), and other (n = 3). Sixty-seven PDAs included concepts related to overdiagnosis/overtreatment; 57 (67.1%) used a term other than overdiagnosis/overtreatment, 23 (27.1%) used the specific term "overdiagnosis," and 13 (15.3%) used "overtreatment." PDAs described overdiagnosis/overtreatment as a potential harm or consequence of screening (n = 62) and/or a detection of a cancer that would not cause symptoms (n = 49). Thirty-six described overdiagnosis as the detection of a cancer that would not result in death. Twenty PDAs described the probabilities associated with overdiagnosis/overtreatment. Conclusions. Over three quarters of cancer screening PDAs addressed concepts related to overdiagnosis/overtreatment, yet terminology was inconsistent and few included probability estimates. Consistent terminology and minimum standards to describe overdiagnosis/overtreatment would help guide the design and certification of cancer screening PDAs.

Preferences for Communicating about Breast Cancer Screening Among Racially/Ethnically Diverse Older Women

Differences exist across breast cancer screening guidelines regarding frequency of screening and age of discontinuation for older women (≥70 years) at average risk for breast cancer. These differences highlight concerns about the benefits and harms of screening, and may negatively impact older women's ability to make informed screening decisions. This study examined preferences for communicating about screening mammography among racially/ethnically diverse, older women. In-depth interviews were conducted with 59 women with no breast cancer history. Non-proportional quota sampling ensured roughly equal numbers on age (70-74 years, ≥75 years), race/ethnicity (non-Hispanic/Latina White, non-Hispanic/Latina Black, Hispanic/Latina), and education (≤high school diploma, >high school diploma). Interviews were audio-recorded, transcribed, and analyzed using NVivo 10. Thematic analyses revealed that rather than being told to get mammograms, participants wanted to hear about the benefits and harms of screening mammography, including overdiagnosis. Participants recommended that this information be communicated via physicians or other healthcare providers, included in brochures/pamphlets, and presented outside of clinical settings (e.g., in senior groups). Results were consistent regardless of participants' age, race/ethnicity, or education. Findings revealed that older women desire information about the benefits and harms of screening mammography, and would prefer to learn this information through discussions with healthcare providers and multiple other formats.

Abstract P4-10-02: Impact of raloxifene adherence in breast cancer risk

BACKGROUND: Raloxifene is a selective estrogen receptor modulator that has demonstrated to reduce breast cancer risk and reduce the incidence of vertebral fractures. Based on these effects, raloxifene is used as a risk reduction agent and to prevent osteoporosis in postmenopausal women. Little is known about the raloxifene adherence rates or the relationship between adherence and breast cancer incidence.

METHODS: Women 60 years or older without a breast cancer history were identified in the MarketScan database (2008-2015). We identified women who received raloxifene by searching for prescription claims. Proportion of days covered (PDC) were calculated, adherence was defined as a PDC &gt;80% in the first year after initial prescription claim. We identified factors associated with adherence. ICD-9 codes were used to identify incident cases of invasive breast cancer and cumulative incidence rates were calculated. A multivariable Cox model with propensity score method (matching variables included year of claim, age, comorbidities and family history of breast cancer) was used to evaluate the association between raloxifene adherence and breast cancer risk. All statistical tests were two-sided.

RESULTS: A total of 16,179 women were included in the analysis. We identified that during the first year of treatment 6,716 (40.2%) women had a PDC &gt;80% and thus were considered to be adherent. Factors associated with increased adherence included the use of generic drug, mail order of 90 days supply and family history of breast cancer (all p&lt;0.001). Using propensity score matching, the 5 year-cumulative incidence of invasive breast cancer was 1.5% among those not adherent and 0.9% among those adherent to raloxifene (p=0.01). Similarly, the 9 year-cumulative rates were 3.6% and 1.9% respectively (p=0.01). After adjusting for potential confounders, patients that were adherent to raloxifene during the first year of treatment had a lower risk of invasive breast cancer compared to those that were non-adherent (HR=0.64; 95%CI 0.04-0.9).

CONCLUSIONS: Among women 60 years of age or older receiving raloxifene, adherence to therapy was associated with lower risk of invasive breast cancer. Efforts to ensure adherence and compliance are crucial so patients can receive full benefit from this therapy.

Citation Format: Chavez-MacGregor M, Lei X, Zhao H, Bevers TB, Brewster A, Giordano SH. Impact of raloxifene adherence in breast cancer risk [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-02.

Whole body magnetic resonance imaging (WB-MRI) and brain MRI baseline surveillance in TP53 germline mutation carriers: experience from the Li-Fraumeni Syndrome Education and Early Detection (LEAD) clinic

Individuals with Li-Fraumeni syndrome (LFS) have a significantly increased lifetime cancer risk affecting multiple organ sites. Therefore, novel comprehensive screening approaches are necessary to improve cancer detection and survival in this population. The objective of this study was to determine the diagnostic performance of whole body MRI (WB-MRI) and dedicated brain MRI screening as part of a comprehensive screening clinic called Li-Fraumeni Education and Early Detection (LEAD) at MD Anderson Cancer Center. Adult (≥21 year old) and pediatric (<21 year old) patients were referred to the LEAD clinic by healthcare providers or self-referred and screened at 6 month intervals. During the study period, 63 LFS individuals were seen in the LEAD clinic including 49 adults (11 male, 38 female) and 14 children (7 male, 7 female). Fifty-three of 63 potentially eligible individuals underwent baseline WB-MRI (41 adults and 12 children) with primary tumors detected in six patients, tumor recurrence in one patient and cancer metastases in one patient. Thirty-five of 63 patients (24 adults and 11 children) underwent baseline brain MRI with primary brain tumors detected in three individuals, also noted on subsequent WB-MRI scans. Three additional tumors were diagnosed that in retrospect review were missed on the initial scan (false negatives) and one tumor noted, but not followed up clinically, was prospectively found to be malignant. The high incidence of asymptomatic tumors identified in this initial screening (13%), supports the inclusion of WB-MRI and brain MRI in the clinical management of individuals with LFS.

Randomized trial of a patient-centered decision aid for promoting informed decisions about lung cancer screening: Implementation of a PCORI study protocol and lessons learned

PURPOSE

We describe the methods, stakeholder engagement, and lessons learned from a study comparing a video decision aid to standard educational materials on lung cancer screening decisions.

METHODS

The study followed rigorous methodology standards from the Patient-Centered Outcomes Research Institute. The importance of patient-centeredness and patient/stakeholder engagement are reflected across the study's conceptualization, execution, interpretation, and dissemination efforts. Advisory groups of current and former smokers, quitline service providers, clinicians, and patient advocates were formed for the project. The study used both retrospective and prospective recruitment strategies. Randomization of patients occurred within state-based quitlines, with aggressive tracking of participants. We collected data at baseline and 1-week, 3-month and 6-months after receiving the intervention. The patient-centered outcomes included whether patients' receiving the decision aid a) felt better prepared to make a decision, b) felt more informed about the screening decision, c) had more clarity on their values regarding the benefits and harms of lung cancer screening, and d) were more knowledgeable about lung cancer screening than patients receiving the standard education materials. Exploratory outcomes included making an appointment with a health care provider to discuss screening, scheduling and completing lung cancer screening.

RESULTS

We have enrolled and randomized 516 quitline patients and learned many lessons about executing the trial based on significant patient and stakeholder engagement.

CONCLUSIONS

Conducting patient-centered outcomes research requires new ways of thinking and continuously checking-in with patients/stakeholders. The engagement of quitline service providers and patient advisors has been key to successful recruitment and dissemination planning. PCORI- CER-1306-03385 ClinicalTrials.gov NCT ID: NCT02286713.

Resistance to discontinuing breast cancer screening in older women: A qualitative study

OBJECTIVE

Screening mammography is associated with reduced breast cancer-specific mortality; however, among older women, evidence suggests that the potential harms of screening may outweigh the benefits. We used a qualitative approach to examine the willingness of older women from different racial/ethnic groups to discontinue breast cancer screening.

METHODS

Women ≥70 years of age who reported having a screening mammogram in the past 3 years and/or reported that they intended to continue screening in the future were recruited for in-depth interviews. Participants who intended to continue screening were asked to describe how the following hypothetical scenarios would impact a decision to discontinue screening: health concerns or limited life expectancy, a physician's recommendation to discontinue, reluctance to undergo treatment, and recommendations from experts or governmental panels to stop screening. Semi-structured, face-to-face interviews were audio-recorded. Data coding and analysis followed inductive and deductive approaches.

RESULTS

Regardless of the scenario, participants (n = 29) expressed a strong intention to continue screening. Based on the hypothetical physician recommendations, intentions to continue screening appeared to remain strong. They did not envision a change in their health status that would lead them to discontinue screening and were skeptical of expert/government recommendations. There were no differences observed according to age, race/ethnicity, or education.

CONCLUSIONS

Among older women who planned to continue screening, intentions to continue breast cancer screening appear to be highly resilient and resistant to recommendations from physicians or expert/government panels.

Deciding on breast cancer risk reduction: The role of counseling in individual decision-making - A qualitative study

OBJECTIVES

The presentation of risks and benefits in clinical practice is common particularly in situations in which treatment recommendations involve trade-offs. The treatment of breast cancer risk with selective estrogen receptor modulators (SERMs) is such a decision. We investigated the influence of health care provider (HCP) counseling on women's decision-making.

METHODS

Thirty breast cancer risk counseling sessions were recorded from April 2012-August 2013 at a comprehensive cancer center and at a safety-net, community hospital in the US. Participating women and HCPs were interviewed. A cross-case synthesis was used for analysis.

RESULTS

Of 30 participants 21 received a SERM-recommendation, 11 decided to take SERMs. Counseling impacted decision-making, but did not determine it. Three categories emerged: 1.) ability to change the decision anytime, 2.) perceptions on medications, and 3.) proximity of cancer.

CONCLUSION

Decision-making under conditions of a risk diagnosis such as increased breast cancer risk is a continuous process in which risk information is transformed into practical and experiential considerations.

PRACTICE IMPLICATIONS

Individuals' health care decision-making is only marginally dependent on the interactions in the clinic. Accepting patients' experiences and beliefs in their own right and letting them guide the discussion may be important for a satisfying decision-making process.

NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project-1 Results: Decision Making in Breast Cancer Risk Reduction

Selective estrogen receptor modulators (SERMs) reduce breast cancer risk. Adoption of SERMs as prevention medication remains low. This is the first study to quantify social, cultural, and psychologic factors driving decision making regarding SERM use in women counseled on breast cancer prevention options. A survey study was conducted with women counseled by a health care provider (HCP) about SERMs. A statistical comparison of responses was performed between those who decided to use and those who decided not to use SERMs. Independent factors associated with the decision were determined using logistic regression. Of 1,023 participants, 726 made a decision: 324 (44.6%) decided to take a SERM and 402 (55.4%) decided not to. The most important factor for deciding on SERM use was the HCP recommendation. Other characteristics associated with the decision included attitudes and perceptions regarding medication intake, breast cancer worry, trust in HCP, family members with blood clots, and others' experiences with SERMs. The odds of SERM intake when HCP recommended were higher for participants with a positive attitude toward taking medications than for those with a negative attitude (P_interaction = 0.01). This study highlights the importance of social and cultural aspects for SERM decision making, most importantly personal beliefs and experiences. HCPs' recommendations play a statistically significant role in decision making and are more likely to be followed if in line with patients' attitudes. Results indicate the need for developing interventions for HCPs that not only focus on the presentation of medical information but, equally as important, on addressing patients' beliefs and experiences. Cancer Prev Res; 10(11); 625-34. ©2017 AACRSee related editorial by Crew, p. 609.

Three-year risk of high-grade CIN for women aged 30 years or older who undergo baseline Pap cytology and HPV co-screening

BACKGROUND

Papanicolaou (Pap) cytology and high-risk human papillomavirus (HPV) DNA cotesting for women aged ≥30 years are recommended for the prevention of cervical cancer. The objective of the current study was to evaluate the efficacy of this cotesting for predicting the risk of high-grade cervical intraepithelial neoplasia 3 (CIN3) during a 3-year follow-up period.

METHODS

A retrospective database search identified women aged ≥30 years who had baseline HPV and Pap cytology cotesting results in 2007 or 2008 and for whom 3-year follow-up results were available. The cumulative 3-year risks of developing CIN-3 were calculated.

RESULTS

The 3-year follow-up data after baseline Pap/HPV cotesting were available for 1986 women (mean age, 53 years). Of the 1668 women who had a baseline Pap-negative (Pap-)/HPV- cotesting result, 1561 (93.6%) had a follow-up Pap cytology result that was negative for intraepithelial lesions or malignancy. Of the 1530 women who had follow-up Pap/HPV cotesting, 1504 (98.3%) had a Pap-/HPV- result. The 3-year cumulative risk of developing CIN-3 was found to be highest for women with a baseline Pap-positive (Pap+)/HPV+ cotesting result (12.5%); the risk of CIN-3 was lower in those with a Pap-/HPV+ result (1.5%; P = .0032) or a Pap-/HPV- result (0.06%; P<.0001). The 3-year cumulative risk of CIN-3 was found to be significantly greater for women with an HPV+ result (4.8%) compared with those with an HPV- result (0.06%; P<.0001).

CONCLUSIONS

Pap cytology and HPV cotesting are valuable for stratifying CIN-3 risk. Pap cytology and HPV co-screening at a 3-year screening interval appears to carry a low risk of CIN-3 for women who have a baseline Pap-/HPV- cotesting result. Cancer Cytopathol 2017;125:644-51. © 2017 American Cancer Society.

User Perceptions and Reactions to an Online Cancer Risk Assessment Tool: a Process Evaluation of Cancer Risk Check

Online cancer risk assessment tools, which provide personalized cancer information and recommendations based on personal data input by users, are a promising cancer education approach; however, few tools have been evaluated. A randomized controlled study was conducted to compare user impressions of one tool, Cancer Risk Check (CRC), to non-personalized educational information delivered online as series of self-advancing slides (the control). CRC users (N = 1452) rated the tool to be as interesting as the control (p > .05), but users were more likely to report that the information was difficult to understand and not applicable to them (p < .05). Information seeking and sharing also were lower among CRC users; thus, although impressions of CRC were favorable, it was not shown to be superior to existing approaches. We hypothesized CRC was less effective because it contained few visual and graphical elements; therefore, CRC was compared to a text-based control (online PDF file) post hoc. CRC users rated the information to be more interesting, less difficult to understand, and better able to hold their attention (p < .05). Post hoc results suggest the visual presentation of risk is critical to tool success.

Abstract P5-13-10: A patient centered intervention for adaptation of cancer risk reduction guidelines in breast cancer survivors

Background: Cancer survivors are susceptible to cancer recurrence and other cancers and this is an opportune time to focus on cancer prevention. The American Institute of Cancer Research (AICR) and the American Cancer Society estimate that modifications to the behaviors of diet and physical activity in addition to maintaining a normal body mass index (BMI) can help reduce cancer incidence by one third. The AICR and the American College of Sports Medicine (ACSM) have established guidelines on nutrition and physical activity respectively for cancer risk reduction. Cancer patients' transition to survivorship is an ideal time for them to make lifestyle modifications and adopt these guidelines. Although studies have evaluated structured exercise regimens and nutritional interventions, data is lacking on how to best achieve long term lifestyle changes in this population. By introducing a patient-centered intervention that utilizes motivational interviewing to our breast cancer survivors, we plan to increase the rate of adherence to the AICR and ACSM guidelines through tailored counseling focused on patient-driven lifestyle modifications.

Methods: Breast cancer survivors 5 years out from their diagnosis seen in the survivorship clinic were also scheduled to be seen by a health education specialist (HES) for a baseline visit. One year follow up visits were scheduled with the HES for reassessment of their nutrition and physical activity goals. All patients completed a survey of questions assessing their adherence to the nutritional and physical activity guidelines on cancer risk reduction at baseline and at 1 year follow up visit. Anthropometric measures including height, weight, BMI, pulse, respirations, and blood pressure were collected at each visit with their provider. Baseline demographic data was collected on all participants including age, race/ethnicity, cancer stage, previous cancer treatment(s), and comorbid conditions. Frequency of interactions (i.e clinic visit, telephone call, or secure message) with the HES were extracted from the medical record.

Results: From October 6, 2014 to May 31, 2016, 200 breast cancer survivors were seen in the survivorship clinic and by a HES. Fifty women who completed a baseline and 1 year follow up survey were selected to assess their adherence to the AICR and ACSM guidelines on cancer risk reduction. Sixty percent of patients decreased their BMI, 5% maintained their BMI, and 35% had an increase in BMI after one year follow up. There was an increase in the percentage of patients adhering to all of the guidelines after one year of follow up in comparison to baseline. There were notable increases in adherence to physical activity guidelines with 24% of survivors achieving at least 150 minutes of moderate exercise each week at baseline assessment and 34% of survivors meeting this guideline at the 1 year follow up visit.

Discussion: Through our intervention with a HES in our survivorship clinic, we were able to see trends toward increased adherence to the AICR and ACSM guidelines. Further analysis is ongoing to assess the frequency of interactions with the HES and their adherence to the guidelines. This analysis will give us a better understanding of the ideal target population for this intervention.

Citation Format: Thomas PS, Klimitchek A, Nelson B, Damani S, Bevers TB. A patient centered intervention for adaptation of cancer risk reduction guidelines in breast cancer survivors [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-10.

A brief measure of Smokers' knowledge of lung cancer screening with low-dose computed tomography

We describe the development and psychometric properties of a new, brief measure of smokers' knowledge of lung cancer screening with low-dose computed tomography (LDCT). Content experts identified key facts smokers should know in making an informed decision about lung cancer screening. Sample questions were drafted and iteratively refined based on feedback from content experts and cognitive testing with ten smokers. The resulting 16-item knowledge measure was completed by 108 heavy smokers in Houston, Texas, recruited from 12/2014 to 09/2015. Item difficulty, item discrimination, internal consistency and test-retest reliability were assessed. Group differences based upon education levels and smoking history were explored. Several items were dropped due to ceiling effects or overlapping constructs, resulting in a 12-item knowledge measure. Additional items with high item uncertainty were retained because of their importance in informed decision making about lung cancer screening. Internal consistency reliability of the final scale was acceptable (KR-20 = 0.66) and test-retest reliability of the overall scale was 0.84 (intraclass correlation). Knowledge scores differed across education levels (F = 3.36, p = 0.04), while no differences were observed between current and former smokers (F = 1.43, p = 0.24) or among participants who met or did not meet the 30-pack-year screening eligibility criterion (F = 0.57, p = 0.45). The new measure provides a brief, valid and reliable indicator of smokers' knowledge of key concepts central to making an informed decision about lung cancer screening with LDCT, and can be part of a broader assessment of the quality of smokers' decision making about lung cancer screening.

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Lung cancer screening with low-dose CT is recommended for high risk smokers.

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Smokers must understand harms and benefits in making informed screening decisions.

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A brief measure of lung cancer screening knowledge is offered.

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The measure assesses key concepts in making informed screening decisions.

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It can be part of a broader assessment of the quality of screening decisions.

Abstract P6-10-01: Results from NRG oncology/NSABP protocol DMP-1: Women's decision-making in breast cancer risk reduction

Background:

Tamoxifen and raloxifene are two selective receptor modulators (SERMs) that have been shown to reduce the risk of developing breast cancer in women at increased risk of the disease. Both drugs are infrequently used in the general U.S. population. Increased knowledge about the risks and benefits of SERM use for breast cancer risk reduction does not lead to increased uptake of chemoprevention. We know little about what influences decision-making regarding breast cancer risk reduction with SERMs.

Methods:

To better understand what influences SERM decision-making for breast cancer risk reduction we conducted a survey study assessing social, environmental, and psychological factors that may influence a woman's decision. Women who talked to a health care provider (HCP) about SERM use (N=1,023) received a questionnaire immediately after the HCP visit that asked about the counseling session, sociodemographics, experiences with breast cancer, breast cancer risk, and risk perception. After its completion a second survey was administered that inquired about issues surrounding medication intake such as attitudes about taking medicines in general, trust in pharmaceutical companies, and in their HCP. A statistical comparison of survey responses was performed between those who decided to take a SERM and those who decided not to take a SERM. Logistic regression was used to determine a key set of independent factors associated with the decision.

Results:

Of the 1,023 women, 716 made a decision about SERM intake (70%) and were included in the study. Of those, 324 (45%) decided to take a SERM and 392 (55%) decided not to take a SERM. Of SERM users 89.8% received a recommendation to take a SERM by the HCP compared to 44.4% of non-users. Only 15.7% of SERM users reported never having had a breast biopsy compared to 26.3% of non-users. Overall, SERM users had a higher breast cancer risk, risk perception, and worry about getting breast cancer. In multivariate analysis 11 factors were identified as having independent association with SERM use, including: recommendation from HCP, attitudes and perceptions regarding medication intake, influenced by someone's breast cancer diagnosis, breast cancer worry, trust in HCP, a diagnosis of atypical hyperplasia, and others' experiences with SERM intake. Women who had one or more first degree relatives with breast cancer were less likely to take a SERM. Neither breast cancer risk nor risk perception influenced SERM decision-making.

Discussion:

Factors that influence SERM decision-making are related to women's personal experiences with breast cancer, their HCP, and attitudes towards medications.

Conclusions:

Social, environmental, and psychological factors proved to be more important for SERM decision-making than breast cancer risk or risk perception. In addition to presenting risks and benefits in counseling, the importance of personal experiences and attitudes for decision-making need to be considered to understand and support women's decision-making on SERM use for breast cancer risk reduction.

SUPPORT: U10CA37377, -69974; -180868, -180822; -189867.

Citation Format: Holmberg C, Bandos H, Fagerlin A, Bevers TB, Battaglia TA, Wickerham DL, McCaskill-Stevens W. Results from NRG oncology/NSABP protocol DMP-1: Women's decision-making in breast cancer risk reduction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-10-01.

Chemoprevention for Breast Cancer

Background

Many women at increased risk for breast cancer could benefit from preventive therapy. Preventive therapy options for breast cancer risk reduction have expanded in the last few years to include both selective receptor modulators (tamoxifen and raloxifene) and aromatase inhibitors (anastrozole and exemestane).

Methods

Risk factors that place women at high risk for breast cancer, as well as risk calculation models appropriate for the selection of candidates for preventive therapy, are presented, followed by a review of current guidelines for chemoprevention and results of chemoprevention trials.

Results

The modified Gail model or Breast Cancer Risk Assessment Tool is the most widely utilized risk assessment calculator to determine eligibility for chemoprevention. Women most likely to benefit from preventive therapy include those at high risk under the age of 50 years and those with atypical hyperplasia. Physician and patient barriers limit widespread acceptance and adherence to preventive therapy.

Conclusions

Published guidelines on chemoprevention for breast cancer have been updated to increase awareness and encourage discussion between patients and their physicians regarding evidence-based studies evaluating the benefits of preventive options for women at increased risk for breast cancer. However, even with increasing awareness and established benefits of preventive therapy, the uptake of chemoprevention has been low, with both physician and patient barriers identified. It is prudent that these barriers be overcome to enable high-risk women with a favorable risk-to-benefit ratio to be offered chemoprevention to reduce their likelihood of developing hormone receptor-positive breast cancer.

Breast Cancer Risk Reduction, Version 2.2015

Breast cancer is the most frequently diagnosed malignancy in women in the United States and is second only to lung cancer as a cause of cancer death. To assist women who are at increased risk of developing breast cancer and their physicians in the application of individualized strategies to reduce breast cancer risk, NCCN has developed these guidelines for breast cancer risk reduction.

Abstract 4105: Prevalence of breast stem cells in high-risk benign breast lesions and association with breastfeeding

Background: Invasive breast cancers contain a subpopulation of cancer stem cells that are thought to maintain the heterogeneity and self-renewing potential of the tumor. In our previously published data, we demonstrated that stem cells in normal adjacent tissues were associated with triple negative breast cancer. The objective of this study is to determine the presence of stem cells in high risk breast lesions. We hypothesized that stem cells in high-risk lesions and normal adjacent breast tissue may represent a biomarker for increased breast cancer risk. Methods: We identified biopsies from 42 high-risk women seen in the Cancer Prevention Center at The University of Texas MD Anderson Cancer Center between 1988-2011. We collected information on breast cancer risk factors. The biopsies contained high-risk lesions including ductal carcinoma in situ (DCIS) n=21, lobular carcinoma in situ (LCIS) n=5, atypical ductal hyperplasia (ADH) n=7 and atypical lobular hyperplasia (ALH) n=6. The tissues were fluorescently labeled for stem cell markers CD44/CD49f/CD133, and were scored positive if more then 1% cells were positive for all markers using an automated fluorescent microscopy software. The presence of stem cell markers was compared in the normal adjacent tissues and high-risk lesions from a subset of 25 patients. Results: We identified stem cells in 46% of samples containing DCIS, 67% of LCIS, 63% of ALH, and 70% of ADH. There was a 79% concordance in stem cell positive status between the high-risk lesion and adjacent normal tissue. Women with positive stem cell high-risk lesions had no significant difference in age at first birth (24.4 years vs 26.6 years p=0.3), parity (1.7 vs 1.9, p=0.5), or body mass index (27.8 vs 31.8, p=0.07) compared to women without positive stem cell high-risk lesions. Women with positive stem cell high-risk lesions had shorter breastfeeding duration than women without (2.4 months vs 9.0 months p= 0.05). Conclusion: This is the first report, to our knowledge, that stem cells are present in some high-risk lesions and their associated normal breast tissue. Correlation with future development of invasive breast cancer could lay the foundation for future targeted breast cancer prevention strategies.

Citation Format: Rachel L. Atkinson, Fraser Symmans, Therese B. Bevers, Wendy A. Woodward, Abenaa M. Brewster. Prevalence of breast stem cells in high-risk benign breast lesions and association with breastfeeding. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4105. doi:10.1158/1538-7445.AM2014-4105

Effects of a green tea extract, Polyphenon E, on systemic biomarkers of growth factor signalling in women with hormone receptor-negative breast cancer

BACKGROUND

Observational and experimental data support a potential breast cancer chemopreventive effect of green tea.

METHODS

We conducted an ancillary study using archived blood/urine from a phase IB randomised, placebo-controlled dose escalation trial of an oral green tea extract, Polyphenon E (Poly E), in breast cancer patients. Using an adaptive trial design, women with stage I-III breast cancer who completed adjuvant treatment were randomised to Poly E 400 mg (n = 16), 600 mg (n = 11) and 800 mg (n = 3) twice daily or matching placebo (n = 10) for 6 months. Blood and urine collection occurred at baseline, and at 2, 4 and 6 months. Biological endpoints included growth factor [serum hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF)], lipid (serum cholesterol, triglycerides), oxidative damage and inflammatory biomarkers.

RESULTS

From July 2007-August 2009, 40 women were enrolled and 34 (26 Poly E, eight placebo) were evaluable for biomarker endpoints. At 2 months, the Poly E group (all dose levels combined) compared to placebo had a significant decrease in mean serum HGF levels (-12.7% versus +6.3%, P = 0.04). This trend persisted at 4 and 6 months but was no longer statistically significant. For the Poly E group, serum VEGF decreased by 11.5% at 2 months (P = 0.02) and 13.9% at 4 months (P = 0.05) but did not differ compared to placebo. At 2 months, there was a trend toward a decrease in serum cholesterol with Poly E (P = 0.08). No significant differences were observed for other biomarkers.

CONCLUSIONS

Our findings suggest potential mechanistic actions of tea polyphenols in growth factor signalling, angiogenesis and lipid metabolism.

Most lobular carcinoma in situ and atypical lobular hyperplasia diagnosed on core needle biopsy can be managed clinically with radiologic follow-up in a multidisciplinary setting

We evaluated the efficacy of using standard radiologic and histologic criteria to guide the follow-up of patients with lobular carcinoma in situ (LCIS), lobular neoplasia (LN), or atypical lobular hyperplasia (ALH). Patients with high-risk benign lesions diagnosed on biopsy were presented and reviewed in a multidisciplinary clinical management conference from 1 November 2003 through September 2011. Associations between patient characteristics and rates of upgrade were determined by univariate and multivariate logistic models, and times to diagnosis carcinoma were calculated. Of 853 cases reviewed, 124 (14.5%) were lobular neoplasms. In all, 104 patients were clinically and/or radiographically monitored. In 20 patients, who were found to have LN on core biopsy and were recommended to have immediate surgical excision, a more significant lesion was identified in 8 (40%) of the excised specimens. Factors associated with a more significant lesion on excisional biopsy included whether the lobular lesion had been targeted for biopsy and whether the extent of disease involved three or more terminal duct lobular units. Of the 104 patients radiographically and clinically monitored, the median follow-up time was 3.4 years with a range of 0.44–8.6 years. Five patients under surveillance were subsequently diagnosed with breast malignancy (three of the five at a site unrelated to the initial biopsy). Patients with incidental lobular lesions identified on percutaneous core needle biopsy have a small risk of upgrade and may not require an excisional biopsy. Clinical management of low-volume lobular lesions in a multidisciplinary setting is an efficacious alternative to surgical excision when radiologic and histologic characteristics are well-defined.

An Antibody-based Blood Test Utilizing a Panel of Biomarkers as a New Method for Improved Breast Cancer Diagnosis

In order to develop a new tool for diagnosis of breast cancer based on autoantibodies against a panel of biomarkers, a clinical trial including blood samples from 507 subjects was conducted. All subjects showed a breast abnormality on exam or breast imaging and final biopsy pathology of either breast cancer patients or healthy controls. Using an enzyme-linked immunosorbent assay, the samples were tested for autoantibodies against a predetermined number of biomarkers in various models that were used to determine a diagnosis, which was compared to the clinical status. Our new assay achieved a sensitivity of 95.2% [CI = 92.8–96.8%] at a fixed specificity of 49.5%. Receiver-operator characteristic curve analysis showed an area under the curve of 80.1% [CI = 72.6–87.6%]. These results suggest that a blood test which is based on models comprising several autoantibodies to specific biomarkers may be a new and novel tool for improving the diagnostic evaluation of breast cancer.

Relative effects of tamoxifen, raloxifene, and conjugated equine estrogens on cognition

OBJECTIVE

To compare the relative effects of conjugated equine estrogens (CEE), raloxifene, and tamoxifen therapies on cognition among women aged > or =65 years.

METHODS

Annual Modified Mini-Mental State (3MS) examinations were used to assess global cognitive function in the two randomized placebo-controlled clinical trials of CEE therapies of the Women's Health Initiative Memory Study (WHIMS) and the Cognition in the Study of Tamoxifen and Raloxifene (CoSTAR). Analyses were limited to women who had 3MS testing at baseline and the first 3 years of follow-up and, because of potential ethnic-related differences between studies, to Caucasian women (WHIMS n = 6211, CoSTAR n = 250). Covariate adjustment was used to compare the postrandomization mean 3MS scores among the three active therapies with placebo therapy while controlling for differences between groups with respect to dementia risk factors.

RESULTS

At baseline, the average (SD) 3MS scores by group were 95.24 (4.28) for placebo, 95.19 (4.33) for CEE, 94.60 (4.76) for raloxifene, and 95.02 (4.03) for tamoxifen. Compared with placebo, each active therapy was associated with a small mean relative deficit in 3MS scores of < or =0.5 units, which was fairly consistent between women with and without prior hysterectomy. Relative deficits were slightly greater for tamoxifen (p = 0.001) and less marked for raloxifene (p = 0.06) and CEE (p = 0.02) therapies. Relative deficits appeared to be greater among women with lower baseline 3MS scores: p = 0.009 (tamoxifen), p = 0.08 (raloxifene), and p = 0.03 (CEE).

CONCLUSIONS

Although unmeasured differences between trials may have confounded analyses, these findings raise the possibility that both tamoxifen and raloxifene adversely affect cognitive function in older women; however, the magnitude of the effect is small, and the long-term consequences are unknown.

The role of human papillomavirus type 16/18 genotyping in predicting high-grade cervical/vaginal intraepithelial neoplasm in women with mildly abnormal Papanicolaou results

BACKGROUND

The authors compared the predictive value of type 16 and/or 18 human papillomavirus (HPV) versus non-16/18 HPV types for high-grade (grade ≥2) cervical neoplasm/vaginal intraepithelial neoplasm and carcinoma (CIN/VAIN2+) in women with mildly abnormal Papanicolaou (Pap) results (ie, atypical squamous cells of undetermined significance [ASCUS] or low-grade squamous epithelial lesion [LSIL]).

METHODS

The authors retrospectively selected Pap specimens with HPV testing results obtained from 243 women (155 with ASCUS and 88 with LSIL Pap results) in their Department of Pathology. HPV genotyping was performed using the EasyChip HPV blot assay. The Pap specimens with HPV16/18 and non-16/18 HPV types were compared with follow-up biopsy results. Follow-up duration ranged from 1 month to 58 months (mean, 26 months).

RESULTS

In total, 58 of 155 specimens (37%) that had ASCUS and 29 of 88 specimens (33%) that had LSIL were positive for HPV16/18. CIN/VAIN2+ biopsies were identified in 43 of 155 women (28%) with ASCUS and in 28 of 88 women (32%) with LSIL. Women with ASCUS and HPV16/18 had a significantly higher rate (43%) of CIN/VAIN2+ than women with ASCUS and non-16/18 HPV types (19%; P = .003; odds ratio, 3.10; 95% confidence interval, 1.48-6.53). There was no statistically significant difference in the rate of CIN/VAIN2+ between women who had LSIL and HPV16/18 (45%) and those who had LSIL and non-16/18 HPV types (29%; P = .16; odds ratio, 1.96; 95% confidence interval, 0.77-4.97).

CONCLUSIONS

HPV genotyping for HPV16/18 improved risk assessment for women with ASCUS Pap results and may be used to predict the risk of CIN/VAIN2+ to better guide follow-up management.