"They just looked at me like I was human": The experiences of parenting women and providers with substance use disorder treatment

BACKGROUND

The current US addiction treatment system does not effectively meet the needs of pregnant and parenting women with substance use disorder (SUD). The aim of this research was to identify barriers and facilitators to engagement and retention in SUD residential treatment for pregnant and parenting women. This research was part of a co-design process to collaboratively create a more patient-centered long-term residential program.

DESIGN AND METHODS

The study conducted semi-structured individual interviews with both parenting women with lived experience (WWLE) in residential SUD treatment and SUD treatment providers. Interviews aimed to elicit participants' experiences either receiving or providing care. The study team analyzed data in NVivo-12 using a deductive codebook based on the six principles of trauma informed care (TIC).

RESULTS

We conducted a total of 32 interviews (WWLE =13, SUD providers =19). The study identified four major themes: 1) peer relationships provide inspiration and diminish shame; 2) providing individuals safe space to stumble in recovery creates opportunities for growth and builds self-efficacy; 3) reasonable, clear boundaries create a structured, protective environment for early recovery; 4) nonjudgmental connections facilitate engagement and build trust. We identified small pivotal moments along the continuum of care that showed how the elements in the four themes enhanced engagement and retention in treatment. These interactions, along the care continuum, are either structural (workflow process) or relational (interpersonal).

CONCLUSION

This research increases understanding of the interplay of the structural and relational barriers and facilitators to engagement and retention in treatment. These seemingly minor positive or negative interactions along the care continuum are pivotal to fully operationalizing TIC and optimizing women's engagement in treatment. Improvement strategies that integrate the voices of WWLE and collaboratively co-design a more patient-centered system are critical steps to improving engagement in SUD treatment and more equitable SUD treatment services.

Heterogeneity in familial clustering of metabolic syndrome components in the multiethnic GENNID study

OBJECTIVE

Metabolic syndrome (MetS) is defined by clustering of cardiometabolic components, which may be present in different combinations. The authors evaluated clustering in individuals and extended families within and across ancestry groups.

METHODS

The prevalence of different combinations of MetS components (high fasting glucose, low high-density lipoprotein cholesterol, high triglycerides, high blood pressure, and abdominal obesity) was estimated in 1651 individuals (340 families) self-reporting as European American (EA), Hispanic/Mexican American (MA), African American (AA), and Japanese American (JA). Odds ratios were estimated using logistic regression with generalized estimating equations comparing individual MetS components, number, and combinations of components for each ancestry group versus EA.

RESULTS

Clustering of all five components (Combination #16) was more prevalent in EA (29.9%) and MA (25.2%) individuals than in AA (18.7%) and JA (15.5%) individuals. Compared with EA individuals, AA individuals were 64% and 66% less likely to have high triglycerides and low high-density lipoprotein cholesterol, whereas JA individuals were 85% and 56% less likely to have abdominal obesity and high blood pressure, respectively. Compared with EA individuals, the odds of having two, four, or five components were at least 77% lower in JA individuals, whereas the odds of having three, four, or five components were at least 3.79 times greater in MA individuals.

CONCLUSIONS

Understanding heterogeneity in MetS clustering may identify factors important in reducing health disparities.

Factors Associated with Longitudinal Changes in Mammographic Density in a Multiethnic Breast Screening Cohort of Postmenopausal Women

Background

Breast density is an important risk factor for breast cancer and is known to be associated with characteristics such as age, race, and hormone levels; however, it is unclear what factors contribute to changes in breast density in postmenopausal women over time. Understanding factors associated with density changes may enable a better understanding of breast cancer risk and facilitate potential strategies for prevention.

Methods

This study investigated potential associations between personal factors and changes in mammographic density in a cohort of 3,392 postmenopausal women with no personal history of breast cancer between 2011 and 2017. Self-reported information on demographics, breast and reproductive history, and lifestyle factors, including body mass index (BMI), alcohol intake, smoking, and physical activity, was collected by an electronic intake form, and breast imaging reporting and database system (BI-RADS) mammographic density scores were obtained from electronic medical records. Factors associated with a longitudinal increase or decrease in mammographic density were identified using Fisher's exact test and multivariate conditional logistic regression.

Results

7.9% of women exhibited a longitudinal decrease in mammographic density, 6.7% exhibited an increase, and 85.4% exhibited no change. Longitudinal changes in mammographic density were correlated with age, race/ethnicity, and age at menopause in the univariate analysis. In the multivariate analysis, Asian women were more likely to exhibit a longitudinal increase in mammographic density and less likely to exhibit a decrease compared to White women. On the other hand, obese women were less likely to exhibit an increase and more likely to exhibit a decrease compared to normal weight women. Women who underwent menopause at age 55 years or older were less likely to exhibit a decrease in mammographic density compared to women who underwent menopause at a younger age. Besides obesity, lifestyle factors (alcohol intake, smoking, and physical activity) were not associated with longitudinal changes in mammographic density.

Conclusions

The associations we observed between Asian race/obesity and longitudinal changes in BI-RADS density in postmenopausal women are paradoxical in that breast cancer risk is lower in Asian women and higher in obese women. However, the association between later age at menopause and a decreased likelihood of decreasing in BI-RADS density over time is consistent with later age at menopause being a risk factor for breast cancer and suggests a potential relationship between greater cumulative lifetime estrogen exposure and relative stability in breast density after menopause. Our findings support the complexity of the relationships between breast density, BMI, hormone exposure, and breast cancer risk.

Urinary glyphosate and AMPA levels in a cross-sectional study of postmenopausal women: Associations with organic eating behavior and dietary intake

Animal and epidemiologic studies suggest that there may be adverse health effects from exposure to glyphosate, the most highly used pesticide in the world, and its metabolite aminomethylphosphonic acid (AMPA). Meanwhile, consumption of organic foods (presumably grown free of chemical pesticides) has increased in recent years. However, there have been limited biomonitoring studies assessing the levels of human glyphosate and AMPA exposure in the United States. We examined urinary levels of glyphosate and AMPA in the context of organic eating behavior in a cohort of healthy postmenopausal women residing in Southern California and evaluated associations with demographics, dietary intake, and other lifestyle factors. 338 women provided two first-morning urine samples and at least one paired 24-h dietary recall reporting the previous day's dietary intake. Urinary glyphosate and AMPA were measured using LC-MS/MS. Participants reported on demographic and lifestyle factors via questionnaires. Potential associations were examined between these factors and urinary glyphosate and AMPA concentrations. Glyphosate was detected in 89.9% of urine samples and AMPA in 67.2%. 37.9% of study participants reported often or always eating organic food, 30.2% sometimes, and 32.0% seldom or never. Frequency of organic food consumption was associated with several demographic and lifestyle factors. Frequent organic eaters had significantly lower urinary glyphosate and AMPA levels, but not after adjustment for covariates. Grain consumption was significantly associated with higher urinary glyphosate levels, even among women who reported often or always eating organic grains. Soy protein and alcohol consumption as well as high frequency of eating fast food were associated with higher urinary AMPA levels. In conclusion, in the largest study to date examining paired dietary recall data and measurements of first-void urinary glyphosate and AMPA, the vast majority of subjects sampled had detectable levels, and significant dietary sources in the American diet were identified.

Validation Study on Risk-Reduction Activities after Exposure to a Personalized Breast Cancer Risk-Assessment Education Tool in High-Risk Women in the WISDOM Study

We performed a 318-participant validation study of an individualized risk assessment tool in women identified as having high- or highest-risk of breast cancer in the personalized arm of the Women Informed to Screen Depending on Measures of risk (WISDOM) trial. Per protocol, these women were educated about their risk and risk reducing options using the Breast Health Decisions (BHD) tool, which uses patient-friendly visuals and 8th grade reading level language to convey risk and prevention options. Prior to exposure to the educational tool, 4.7% of women were already taking endocrine risk reduction, 38.7% were reducing alcohol intake, and 62.6% were exercising. Three months after initial use of BHD, 8.4% of women who considered endocrine risk reduction, 33% of women who considered alcohol reduction, and 46% of women who considered exercise pursued the risk-reducing activities. Unlike lifestyle interventions which are under the control of the patient, additional barriers at the level of the healthcare provider may be impeding the targeted use of endocrine risk reduction medications in women with elevated breast cancer risk.

Development of the Successful Transitions Assessment Tool (STAT) for Crossover Youth (COY): Youth voice and expert feedback with a Delphi approach

BACKGROUND

Crossover youth (COY) are involved with child welfare and/or the justice system and experience multifaceted challenges in their transition into adulthood. A literature review identified eight critical indicators of successful transitions for COY and the absence of a validated comprehensive assessment that is youth informed and culturally sensitive.

OBJECTIVE

To develop a Successful Transitions Assessment Tool (STAT) that is informed by research, Critical Race Theory, and subject matter experts.

PARTICIPANTS AND SETTING

Field experts were approached to review the initial STAT, developed from literature findings, using the Delphi approach; 13 experts completed the first round and nine completed the second round. Child welfare youth participated in a focus group and youth justice youth completed interviews; 10 youth aged 16 to 24 provided feedback.

METHODS

A two-round Delphi study with experts used a survey link. The focus groups and interviews with youth experts were conducted virtually. Expert rankings in the examined areas were aggregated and qualitative data were thematically analyzed.

RESULTS

Responding experts in both rounds of the Delphi process ranked the STAT highly, achieving scores of 16.8 and 16.4 of 20 possible points, respectively (consensus >80 %). No additional rounds were deemed necessary. All suggested tool clarifications were incorporated. Additional questions were added based on suggestions relevant to the eight critical domains.

CONCLUSIONS

This innovative study created a single, brief, yet comprehensive assessment tool of eight key domains for successful transitions out of care settings, informed by experts through the Delphi approach and youth themselves.

Abstract 5892: Factors associated with longitudinal changes in mammographic density in a multiethnic breast screening cohort of postmenopausal women

Mammographic density is an important risk factor for breast cancer and is known to differ in women by characteristics such as age and race/ethnicity. Women who experience longitudinal decreases in breast density have a reduced risk of breast cancer; however, besides age, which correlates with decreases in breast density, it is unclear what other factors contribute to changes in breast density over time. Understanding factors associated with density changes may enable a better understanding of breast cancer risk and potential strategies for prevention. This study investigated factors associated with changes in mammographic density in a cohort of 3,392 postmenopausal women (mean age=61.3±8.8 years) with no history of breast cancer who had at least two mammograms spaced at least three months apart at a University of California, Irvine Health breast imaging facility between 2011-2017. Self-reported information on demographics, breast and reproductive history, and lifestyle factors, including body mass index (BMI), alcohol intake, smoking, and physical activity, was collected by an electronic intake form, and Breast Imaging Reporting and Database System (BI-RADS) mammographic density scores were obtained from electronic medical records. 7.9% of women exhibited a longitudinal decrease in mammographic density, 6.7% exhibited an increase, and 85.4% exhibited no change. Longitudinal changes in mammographic density were statistically significantly correlated with age, race/ethnicity, and age at menopause by univariate analysis using the Fisher’s exact test. Multivariate conditional logistic regression using baseline mammographic density as strata was performed to identify factors associated with a longitudinal increase or decrease in mammographic density. Variables were selected if they were nominally significant (p < 0.10) in the initial univariate analyses of women who exhibited a longitudinal change in mammographic density (race/ethnicity, age at baseline, menopause age) or were otherwise selected a priori based on previous literature showing an association with mammographic density (alcohol, physical activity, BMI). Asian women were more likely to exhibit a longitudinal increase in mammographic density (OR=1.78, 95% CI=1.02-3.09, p=0.04) and less likely to exhibit a decrease (OR = 0.58, 95% CI = 0.40-0.83, p=0.003) compared to white women. On the other hand, overweight and obese women were less likely to exhibit an increase compared to normal weight women (OR = 0.52, 95% CI = 0.31-0.87, p=0.01; OR = 0.41, 95% CI = 0.23-0.75, p=0.004, respectively). Other lifestyle factors (alcohol intake, smoking, and physical activity) were not associated with longitudinal changes in mammographic density. The potential interactions of Asian race and BMI with longitudinal breast density changes in influencing breast cancer risk should be further studied.

Citation Format: Roza L. Kirmizi, Christie J. Lee, Hannah Lui Park, Argyrios Ziogas, Andrea Alvarez, Rachel M. Lucia, Deborah Goodman, Kathryn M. Larsen, Richard Kelly, Hoda Anton-Culver, Stephen A. Feig. Factors associated with longitudinal changes in mammographic density in a multiethnic breast screening cohort of postmenopausal women [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5892.

A systematic literature review of the management, oncological outcomes and psychosocial implications of male breast cancer

BACKGROUND

Although male breast cancer (MBC) is a rare disease, accounting for <1% of all breast cancers, it has significant oncological, survival and psychosocial implications for patients. The aim of this study is to assess the latest literature in the diagnosis, management, oncological outcomes, and psychosocial impact of MBC.

METHODS

A systematic literature review was conducted using the PRISMA guidelines (Moher et al., 2009) [1] to explore the management of MBC, with particular focus on investigative imaging, surgical management, oncological outcomes, survival, genetic screening and psychosocial effects. Electronic databases were searched for randomised control trials, cohort studies and case series involving more than 10 patients. Imaging and surgical techniques, local and distant disease recurrence, survival, genetic screening and psychosocial implications in the setting of MBC were assessed.

RESULTS

The search criteria identified 199 articles, of which 59 met the inclusion criteria. This included 39,529 patients, with a mean age of 64.5 years (55-71), and a mean follow-up of 66.3 months (26.2-115). Mastectomy remains the most frequently used surgical technique, with an average of 89.6%. Loco-regional and distant recurrence rate was 10.1% and 21.4% respectively. Disease-free survival (DFS) at 5 and 10 years was 66.8% and 54.5% respectively. Disease-specific survival (DSS) at 5 and 10 years was 87.1% and 67.1% respectively. Overall survival (OS) at 5 and 10 years was 72.7% and 50.7% respectively. Genetic screening was conducted in 38.6% of patients of which 4.8% and 15.8% were found to be BRCA1 and BRCA2 carriers respectively. Psychosocial studies were conducted mainly using questionnaire and interview-based methodology focusing primarily on awareness of breast cancer in men, support available and impact on gender identity.

CONCLUSIONS

This review demonstrates that men present with later stage disease with subsequent impact on survival outcomes. There remains a paucity of high-level evidence and prospective studies are required. There is a need for increasing awareness amongst the public and health care professionals in order to improve outcomes and reduce stigma associated with MBC.

Implementation of a Prenatal Naloxone Distribution Program to Decrease Maternal Mortality from Opioid Overdose

INTRODUCTION

Maternal mortality rates have been increasing in the United States for decades. For several years, opioid overdoses have been a leading cause of maternal mortality in several states. New Hampshire (NH) is a particularly severe case, with 50% of all maternal deaths being caused by drug-related overdoses from 2016 to 2017. We report on the implementation of a point-of-care naloxone distribution program for an Ob/Gyn clinic in NH.

METHODS

Naloxone distribution was tracked to measure program implementation. Proportion of patients screened for naloxone need was calculated monthly. Proportion of patients with which discussions about naloxone took place was calculated quarterly. Patient and provider perspectives on the program were captured periodically. Statistical process control charts monitored change over time and evaluated for special-cause variation.

RESULTS

The clinic has distributed 12 doses of naloxone since program implementation in April 2020. Despite the challenges posed by the COVID-19 pandemic, screening for naloxone need has remained at pre-pandemic rates (moving average: 73%), except for a decrease in April-May 2020. Patient-provider discussions about naloxone have also remained at pre-pandemic rates (moving average: 51%). Qualitative feedback from patients and providers has indicated that the program has been well-received by both groups.

DISCUSSION

The purpose of this description is to provide a framework for other Ob/Gyn clinics to use in implementing similar naloxone distribution programs. Although too early to determine whether this intervention will result in a significant decrease in maternal mortality due to opioid overdose in our patients, this measure will continue to be tracked annually. Implementation of a naloxone program in the obstetrical context provides an important way to improve outcomes for a vulnerable perinatal population.

Association of Glyphosate Exposure with Blood DNA Methylation in a Cross-Sectional Study of Postmenopausal Women

BACKGROUND

Glyphosate is the most commonly used herbicide in the world and is purported to have a variety of health effects, including endocrine disruption and an elevated risk of several types of cancer. Blood DNA methylation has been shown to be associated with many other environmental exposures, but to our knowledge, no studies to date have examined the association between blood DNA methylation and glyphosate exposure.

OBJECTIVE

We conducted an epigenome-wide association study to identify DNA methylation loci associated with urinary glyphosate and its metabolite aminomethylphosphonic acid (AMPA) levels. Secondary goals were to determine the association of epigenetic age acceleration with glyphosate and AMPA and develop blood DNA methylation indices to predict urinary glyphosate and AMPA levels.

METHODS

For 392 postmenopausal women, white blood cell DNA methylation was measured using the Illumina Infinium MethylationEPIC BeadChip array. Glyphosate and AMPA were measured in two urine samples per participant using liquid chromatography-tandem mass spectrometry. Methylation differences at the probe and regional level associated with glyphosate and AMPA levels were assessed using a resampling-based approach. Probes and regions that had an false discovery rate q < 0.1 in ≥ 90 % of 1,000 subsamples of the study population were considered differentially methylated. Differentially methylated sites from the probe-specific analysis were combined into a methylation index. Epigenetic age acceleration from three epigenetic clocks and an epigenetic measure of pace of aging were examined for associations with glyphosate and AMPA.

RESULTS

We identified 24 CpG sites whose methylation level was associated with urinary glyphosate concentration and two associated with AMPA. Four regions, within the promoters of the MSH4, KCNA6, ABAT, and NDUFAF2/ERCC8 genes, were associated with glyphosate levels, along with an association between ESR1 promoter hypomethylation and AMPA. The methylation index accurately predicted glyphosate levels in an internal validation cohort. AMPA, but not glyphosate, was associated with greater epigenetic age acceleration.

DISCUSSION

Glyphosate and AMPA exposure were associated with DNA methylation differences that could promote the development of cancer and other diseases. Further studies are warranted to replicate our results, determine the functional impact of glyphosate- and AMPA-associated differential DNA methylation, and further explore whether DNA methylation could serve as a biomarker of glyphosate exposure. https://doi.org/10.1289/EHP10174.

Nonsuicidal Self-Injury: A Nurse-Led Quality Improvement Project to Address Self-Harm

Nonsuicidal self-injury (NSSI) behaviors, such as cutting, scratching, or more severe injuries, are frequently comorbid with neurodevelopmental, intellectual, trauma, personality, and major depressive disorders, complicating treatment and placing added care burdens on hospital nursing staff and advanced practice nurses. Although specific psychopharmacological treatment guidelines and approved medications for NSSI are non-existent, patients are treated with medications approved for co-morbid disorders and behavioral interventions targeting intrapersonal (poor emotional self-regulation) and interpersonal (communication of distress) functions. The current article describes a nurse-led quality improvement project, using the Plan-Do-Study-Act cycle, in a case example. Outcomes include improved staff competencies and policies, yet we remain challenged in implementing planned actions that add additional time burdens to already stretched care providers. [Journal of Psychosocial Nursing and Mental Health Services, 60(3), 7-10.].

Abstract P5-19-04: The WISDOM study: Reducing sequential steps and implementing parallel workflows in pragmatic trials

Background:The WISDOM Study is a preference-tolerant pragmatic study, comparing annual mammograms to a risk-based screening. Eligibility includes women ages 40-74 years with no history of breast cancer or DCIS. Participants are enrolled to one study arm: annual screening or risk-based screening (includes genetic testing). Pragmatic trials often involve gathering real-time data over multiple time points. Collecting real-time data sequentially can limit enrollment, delay study assignments, and reduce participant engagement. The WISDOM Study has identified such bottlenecks and has implemented parallel workflows, reducing the overall wait time for participants to complete required study steps. These data highlight how moving participants through the study more efficiently can improve enrollment and retention and inform other pragmatic trials. Methods: WISDOM participants have the option to either choose their study arm or be randomized into one as part of the preference tolerant randomized trial design. Participants then complete breast health questionnaires and genetic testing (if in the risk-based arm). This information is analyzed by the WISDOM breast cancer risk assessment algorithm, the result of which is then communicated to the participant through a screening assignment letter (SAL). Specific data elements, such as breast density found participants’ mammogram reports and genetic testing results are required for study randomization process and risk assessment calculations, respectively. The WISDOM randomization algorithm is stratified by several factors, including breast cancer risk estimated using the Breast Cancer Surveillance Consortium (BCSC) model, which uses mammographic density as a key input variable. The study team changed the workflow to allow participants to proceed to randomization without specific information by imputing both density and risk. Additionally, a parallel workflow improvement process was implemented to obtain mammogram reports while genetic testing was being completed. Results: Before the weighted BCSC and imputed density algorithms were introduced, it took an average of 47 days to randomize participants after completion of the baseline enrollment questionnaires. Now, participants are randomized immediately which has reduced delays by 100%. Prior to implementing the parallel workflow for genetic testing and mammogram ascertainment, genetic testing kits were sent only after mammogram reports were collected and validated. The expected turnaround time for genetic testing results was 30-60 days and on average, results were returned to participants in 42 days. Streamlining the study design to obtain mammogram reports while participants complete their genetic testing has shortened the time for participants to receive their screening assignment letters (SALs) from an average of 160 days to 78 days, a reduction by 49%. In comparison, participants in the annual arm of the study who do not complete genetic testing, receive their SALs after an average of 38 days from enrollment. This is due to long wait times to obtain mammographic densities from outside medical facilities. Conclusions: Creating parallel data ascertainment workflows and reducing sequential steps in the study process has increased completion of individual enrollment activities. Participants now are randomized immediately upon joining the study and have access to their SALs and genetic results more rapidly. This approach eliminated randomization wait times and improved efficiency of the early in the enrollment process. We are evaluating the impact on participant retention going forward. Workflow efficiency is critical to improve the patient experience, and our learnings can inform future trial design, particularly for studies requiring data from outside sources.

Citation Format: Tomiyuri Lewis, Stephanie Flores, Leah Sabacan, Patricia Choy, Halle Thannickal, Yiwey Shieh, Jeffrey Tice, Elad Ziv, Lisa Madlensky, Martin Eklund, Christina Yau, Amie Blanco, Barry Tong, Deborah Goodman, Nancy Anderson, Heather Harvey, Steele Fors, Hannah L Park, Samrrah Raouf, Skye Stewart, Janet Wernisch, Barbara Koenig, Celia Kaplan, Robert Hiatt, Neil Wenger, Vivian Lee, Diane Heditsian, Susie Brain, Dolores Moorehead, Barbara A Parker, Alexander Borowsky, Hoda Anton-Culver, Arash Naeim, Andrea Kaster, Laura van ‘t Veer, Andrea Z LaCroix, Olufunmilayo I Olopade, Deepa Sheth, Agustin Garcia, Rachel Lancaster, Michael Plaza, Wisdom Study, Athena Breast Health Network Investigators, Advocate Partners, Allison S Fiscalini, Laura Esserman. The WISDOM study: Reducing sequential steps and implementing parallel workflows in pragmatic trials [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-19-04.

Abstract P5-19-01: The impact of streamlined processes and patient-directed messaging to improve enrollment in a remote, pragmatic clinical trial

Background Recent advances in technology have made it possible to conduct remote clinical trials that allow individuals to participate from home with comfort, privacy, and ease. Despite these advances, challenges persist in running remote trials, such as survey question redundancies, lack of patient-initiated data-sharing tools, and unclear patient communication around critical enrollment steps. The Women Informed to Screen Depending on Measures of risk (WISDOM) Study is a pragmatic, preference-tolerant randomized control breast cancer screening trial comparing personalized risk-based screening to traditional, annual screening. The study population includes women ages 40-74 without a history of breast cancer or DCIS. Since 2016, study enrollment has been available to all women in the U.S. who meet study eligibility criteria. Since October 2020, WISDOM has implemented multiple strategies to improve participant experience: participant-initiated data-sharing tools and clear participant messaging. This abstract presents the efficacy of these interventions as they relate to increasing patient enrollment in remote, pragmatic clinical trials. Methods The WISDOM Study online enrollment process includes registration, participant study arm selection or randomization, online consent, and enrollment (submission of multiple study surveys over a secure, online platform). Barriers to online enrollment were uncovered through an internally-conducted needs assessment of participants who enrolled between 2019-2020, and participant feedback obtained through phone interviews conducted by WISDOM’s embedded ethics study. Improvements to our online enrollment procedures were executed in October 2020 and included: improving the clarity of study arm selection options, streamlining data collection surveys, and enacting a secure, patient-initiated online data-sharing tool and an online portal feature with auto-launch of critical information. Study metrics were obtained through Google Analytics and Salesforce. Results Prior to the end of 2020, only 62% of the 30,046 participants who registered for the WISDOM Study completed study enrollment. After improving the enrollment process, of the 5,334 participants registered for the study between Jan-June 2021, 69% completed the enrollment process finishing both the online consent and survey forms. Conversion from consent to enrollment went from 78% in January 2020 to 93% in June 2021. Currently, 56% participants complete enrollment in one day. Streamlining online patient questionnaires led to an increase in completion rates, with 75% of participants completing their yearly surveys, compared to 59% prior to April 2021. A secure patient upload feature for data sharing led to 1,054 participants successfully sharing their mammogram reports with WISDOM between March - June 2021. Previously, mammogram reports were missing for 20% of enrolled participants. This feature has enabled WISDOM to process 300 additional mammogram reports per month. Integration of an auto-launch feature in the participant’s portal in Feb 2021 has led to a 17% increase in participants viewing their screening recommendations in Yr 1. Prior to auto-launch, only 59% (n=6328) of Yr 1 screening recommendations and 61% (n=3681) of genetic testing reports were viewed by participants. Since implementation, the numbers increased to 78% (n=8406) and 85% (n=5160), respectively. Conclusions. Streamlining data to the most essential elements, and minimizing the steps required to share clinical documents, complete questionnaires and open key study notification is essential to improving enrollment rates in virtual, pragmatic trials. Patient-initiated data-sharing tools such as the ability for participants to share documents through secure, online portals is one example of success.

Citation Format: Patricia Choy, Tomiyuri Lewis, Stephanie Flores, Leah Sabacan, Halle Thannickal, Steffanie Goodman, Yiwey Shieh, Lisa Madlensky, Jeffrey A. Tice, Elad Ziv, Martin Eklund, Amie Blanco, Barry Tong, Deborah Goodman, Nancy Anderson, Heather Harvey, Steele Fors, Hannah Lui Park, Antonia Petruse, Skye Stewart, Samrrah Raouf, Janet Wernisch, Barbara Koenig, Celia Kaplan, Robert Hiatt, Neil Wenger, Vivian Lee, Diane Heditsian, Susie Brain, Dolores Moorehead, Barbara A Parker, Alexander Borowsky, Hoda Anton-Culver, Arash Naeim, Andrea Kaster, Laura van 't Veer, Andrea Z LaCroix, Olufunmilayo I. Olopade, Deepa Sheth, Agustin Garcia, Rachel Lancaster, Jennifer James, Galen Joseph, Wisdom Study, Athena Breast Health Network Investigators and Advocates, Allison Stover Fiscallini, Laura Esserman. The impact of streamlined processes and patient-directed messaging to improve enrollment in a remote, pragmatic clinical trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-19-01.

466 Surveillance Flexible Cystoscopy in Bladder Cancer Follow-up

Aim

This study addresses surveillance cystoscopy in patients diagnosed with bladder and upper tract cancer. Managed Clinical Network (MCN) guidelines have clear recommendations for the timetable of follow-up cystoscopy, and we conducted this audit to study regional compliance.

Method

Using a multisite pathology database of bladder cancer cases from 2016, we collected and analysed data on 100 non-muscle invasive bladder cancers. We took the first 10 cases from each month to ensure cross-regional representation. Each case was stratified according to MCN guidelines. Electronic medical records were examined to assess upper tract follow up. We allowed for +/- 1 month each side of the target timeframe.

Results

We had 64 male and 36 female subjects. In our risk categories, we had 31 low risk, 37 intermediate risk and 32 high risk bladder cancers. 67 were new cases, 33 were recurrent tumours.

10 (43.4%) of low-risk and 19 (79.2%) of intermediate-risk patients underwent surveillance cystoscopy earlier than the recommended 12-month timeframe. 18 (78.3%) of low-risk patients continued to have further surveillance cystoscopies after a 12-month disease-free period.

Conclusions

43.4% of low-risk bladder cancer patients are receiving surveillance cystoscopy earlier than recommended. 78.3% of these patients are then undergoing unnecessary procedures following a 12-month disease-free period against regional guidelines and recommendations. This places an increased burden on clinic/theatre time and contributes to patient anxiety surrounding cancer follow-up. Evidence-based medicine guidelines have shown that less is more when it comes to low-grade bladder cancer surveillance. We now need to assess why we are deviating from our own guidelines.

Caring Dads intervention for fathers who have perpetrated abuse within their families: Quasi-experimental evaluation of child protection outcomes over two years

BACKGROUND

In Canada, two of the most common forms of maltreatment substantiated by child protective services are child exposure to domestic violence and child physical abuse. Fathers are identified as the parent responsible for a substantial proportion of this maltreatment.

OBJECTIVE

This study examined whether providing a group-based intervention program for fathers was associated with greater engagement of fathers in child protection case management and with lower rates of subsequent father-perpetrated abuse.

PARTICIPANTS

A quasi-experimental design compared child protection outcomes in families in which fathers were referred to an intervention program (Caring Dads) and either completed the group (n = 85) or remained on a waitlist for future service (n = 100).

METHODS

Data were collected from a retrospective review of administrative files over two years, starting from the time of referral to Caring Dads.

RESULTS

Initial comparisons found no significant differences in intervention and comparison group fathers in demographic characteristics, child protection concerns, and all but one area of risk and needs. Completing intervention, as compared to being waitlisted, was associated with a greater number of contacts between child protection workers and fathers over two years (M = 30.3 vs. M = 16.7), a difference that was significant and large in size (d = 0.81) and with lower rates of verified re-referral due to fathers' maltreatment (20.5% vs. 36.0%), a difference that was significant and between small and medium in size (V = 0.17).

CONCLUSIONS

Current results suggest that there may be significant benefits of involving fathers in child protection-linked intervention.

Development and pilot of an online, personalized risk assessment tool for a breast cancer precision medicine trial

Breast cancer risk reduction has been validated by large-scale clinical trials, but uptake remains low. A risk communication tool could provide personalized risk-reduction information for high-risk women. A low-literacy-friendly, visual, and personalized tool was designed as part of the Women Informed to Screen Depending On Measures of risk (WISDOM) study. The tool integrates genetic, polygenic, and lifestyle factors, and quantifies the risk-reduction from undertaking medication and lifestyle interventions. The development and design process utilized feedback from clinicians, decision-making scientists, software engineers, and patient advocates. We piloted the tool with 17 study participants, collecting quantitative and qualitative feedback. Overall, participants felt they better understood their personalized breast cancer risk, were motivated to reduce their risk, and considered lifestyle interventions. The tool will be used to evaluate whether risk-based screening leads to more informed decisions and higher uptake of risk-reduction interventions among those most likely to benefit.

Association of mammographic density with blood DNA methylation

Background: Altered DNA methylation may be an intermediate phenotype between breast cancer risk factors and disease. Mammographic density is a strong risk factor for breast cancer. However, no studies to date have identified an epigenetic signature of mammographic density. We performed an epigenome-wide association study of mammographic density.

Methods: White blood cell DNA methylation was measured for 385 postmenopausal women using the Illumina Infinium MethylationEPIC BeadChip array. Differential methylation was assessed using genome-wide, probe-level, and regional analyses. We implemented a resampling-based approach to improve the stability of our findings.

Results: On average, women with elevated mammographic density exhibited DNA hypermethylation within CpG islands and gene promoters compared to women with lower mammographic density. We identified 250 CpG sites for which DNA methylation was significantly associated with mammographic density. The top sites were located within genes associated with cancer, including HDLBP, TGFB2, CCT4, and PAX8, and were more likely to be located in regulatory regions of the genome. We also identified differential DNA methylation in 37 regions, including within the promoters of PAX8 and PF4, a gene involved in the regulation of angiogenesis. Overall, our results paint a picture of epigenetic dysregulation associated with mammographic density.

Conclusion: Mammographic density is associated with differential DNA methylation throughout the genome, including within genes associated with cancer. Our results suggest the potential involvement of several genes in the biological mechanisms behind differences in breast density between women. Further studies are warranted to explore these potential mechanisms and potential links to breast cancer risk.

Factors Associated with Women's Unwillingness to Decrease Alcohol Intake to Decrease Breast Cancer Risk

OBJECTIVE

Alcohol intake is a known risk factor for breast cancer. National organizations recommend that women consume no more than one serving of alcohol per day, if at all; however, many women exceed this recommendation, and some are unwilling to decrease consumption. Our study sought to identify factors associated with women's unwillingness to decrease their alcohol intake to decrease their breast cancer risk.

METHODS

942 women in a screening mammography cohort were asked questions about their demographics, personal and family health history, lifestyle factors, and willingness/unwillingness to decrease alcohol intake to decrease their breast cancer risk. Univariate and multivariate analyzes of their responses were performed.

RESULTS

13.2% of women in our cohort indicated they were unwilling to decrease their alcohol intake to reduce their breast cancer risk. After adjusting for potential confounders, women who were 60 years and older were more than twice as unwilling to decrease their alcohol intake compared to their younger counterparts (P = .0002). Women who had an annual household income of more than $200,000 were 1.75 times more unwilling to decrease their alcohol intake compared to their less affluent counterparts (P = .033). Unwillingness was not significantly associated with race/ethnicity, education, having a first-degree family member with cancer, health perception, breast cancer risk perception, or BMI.

CONCLUSIONS

Levels of unwillingness to decrease alcohol intake differed by age and household income. An opportunity is present to potentially decrease breast cancer risk in the community by educating women, especially older and more affluent women, about alcohol as a risk factor for breast cancer and the importance of limiting one's alcohol intake.

Abstract PS7-43: Validation study results for a personalized prevention education aid in breast cancer risk reduction

BackgroundOptions for breast cancer risk reduction include endocrine medications (tamoxifen, raloxifene, aromatase inhibitors) and lifestyle modifications (increasing exercise, reducing BMI, or alcohol intake). At present, there are limited patient-facing resources that provide information on personalized risk and prevention strategies. To address this unmet need, the Breast Health Decisions (BHD) Tool was designed to educate and empower women in the WISDOM (Women Informed to Screen Depending on Measures of risk) Study, a preference-tolerant randomized control trial comparing personalized risk-based screening to traditional annual screening. The tool supports Aim 4 of the WISDOM Study: test whether risk-based screening, including individualized risk assessment and targeted risk reduction education for those in the top 2.5% risk, enables higher uptake of preventive interventions. We conducted a study of the first 100 participants counseled using the BHD Tool to assess its impact on risk-reduction strategies.

MethodsThe BHD Tool, built on the Salesforce platform, integrates WISDOM Study risk assessments to generate personalized education about risk and risk reduction, using concise wording, 8th-grade reading level or lower, and visual representations to support shared decision making for high-risk women. Changes to improve usability were incorporated from an initial pilot study. The study population was WISDOM Study participants in the top 2.5% 5-year risk by age, excluding mutation carriers. 5-year risk was calculated using the Breast Cancer Surveillance Consortium risk modified by a polygenic risk score. The tool was available through the participants’ online study portals. Study staff contacted these participants to schedule consultations via Zoom with a WISDOM Breast Health Specialist, who navigated the participant through the tool during an interactive 45-minute consultation. Participants could decline the consultation and use the tool independently. A survey was conducted afterward to assess the tool’s utility in motivating women to pursue risk-reducing options.

ResultsWe surveyed 100 high-risk participants who used the BHD Tool. 65% found it very helpful in understanding their breast cancer risk. 27 participants listed additional lifestyle improvements that they were practicing or hoping to begin, including yoga, walking, breast exams, self-exams, yard work, dietary improvements, meditation, and stress reduction. 37% of participants agreed that the tool eased their breast cancer worries and anxiety, while 44% were neutral and 17% disagreed. At the time of presentation, we will present 3-month follow up data and report which preventive actions were actually taken and barriers encountered.

ConclusionsThe BHD Tool synthesizes up-to-date chemoprevention literature in a patient-friendly interface to help educate women about their prevention options and to facilitate future discussions with a provider to empower informed decisions. Data from the first 100 high-risk women who used this tool suggest that the majority of women presented with information about their risk are interested in reducing it. More are considering lifestyle measures than medications. The BHD tool will be made available to all women in the personalized arm of the WISDOM Study. Future improvements include making the tool accessible to clinicians who counsel high-risk women.

Survey questionNumber of participants (N=100)Interested in reducing chance of developing breast cancer97Currently participating in a breast cancer risk reducing activity*77Reducing alcohol intake35Losing weight60Increasing exercise27Risk reducing medications5Considering participating in a breast cancer risk reducing activity*72Reducing alcohol intake12Losing weight26Increasing exercise24Risk reducing medications22*Participants can choose more than one risk-reducing activity

Citation Format: Tianyi Wang, Mandy Che, Yash Huilgol, Deborah Goodman, Holly Keane, Vivian Lee, Jeff Belkora, Allison Fiscalini, Laura Esserman. Validation study results for a personalized prevention education aid in breast cancer risk reduction [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-43.

Abstract OT-21-01: Personalized breast cancer screening in a population-based study: Women informed to screen depending on measures of risk (WISDOM)

Background: WISDOM is a 100,000 healthy women preference-tolerant, pragmatic study comparing traditional annual screening to personalized risk-based breast screening. The novelty of WISDOM personalized screening is the integration of previously validated genetic and clinical risk factors (age, family history, breast biopsy results, ethnicity, mammographic density) into a single risk assessment model that directs the starting age, timing, and frequency of screening. The goal of WISDOM is to determine if personalized screening, compared to annual screening, is as safe, less morbid, enables prevention, and is more accepted by women. The study is registered on ClinicalTrials.gov, NCT02620852. Methods: Women aged 40-74 years with no history of breast cancer, DCIS or previous double mastectomy can join the study online at wisdomstudy.org. Participants can either elect randomization or self-select a study arm. Then, they provide electronic consent and sign the Release for Medical Information via DocuSign. For all participants, 5-year risk of developing breast cancer is calculated according to the Breast Cancer Surveillance Consortium (BCSC) model. Participants in the personalized arm undergo panel-based mutation testing (BRCA1, BRCA2, TP53, PTEN, STK11, CDH1, ATM, PALB2, and CHEK2), and their 5-year risk is calculated using the BCSC score combined with a Polygenic Risk Score (BCSC-PRS) that includes 229 single nucleotide polymorphisms (SNPs) known to increase breast cancer risk. The SNPs and mutations are assessed by saliva-based testing through Color Genomics. Five-year risk level thresholds are used to stratify participants as low-, moderate- and high risk. Risk stratification determines age to start, stop, and frequency of screening in the personalized arm. Accrual: As of July 2020 the WISDOM Study is open to all eligible women in the United States. To date, 38,762 eligible women have registered, and 28,706 women have consented to participate in the trial. The median age is 56 years. Seventy-seven percent of participants are Caucasian, 2% African-American, 5% Asian, and 8% of self-reported Hispanic ethnicity. WISDOM is partnering with Blue Cross Blue Shield Association for regional plan opt-in coverage, self-insured companies (Salesforce, Genentech, Qualcomm, CalPERS) and Medi-Cal (Inland Empire Health Plan) using a coverage with evidence progression approach. Accrual expansion and diversity: To ensure that resulting data are meaningful and potentially practice-changing for all populations of women, the WISDOM Study is enhancing the diversity of our participant population by establishing WISDOM sites in diverse areas with large African-American (Alabama, Louisiana, Illinois) and Latina (Florida) populations. These new recruitment sites, intentionally selected for the diverse communities they serve, have established partnerships with community organizations and outreach navigators. Additionally, we have translated the WISDOM Study to Spanish to facilitate access by Latina communities. With the engagement of patient advocates and community partnerships, expanding diversity in the study population will strengthen our scientific knowledge of breast cancer risk and improve access to personalized breast cancer screening recommendations for all women. Enrollment will continue through 2022. Conclusions: Results of 5 years follow-up will enable us to demonstrate whether personalized screening improves outcomes for future patients and it improves healthcare value by reducing screen volumes and costs without jeopardizing outcomes.

Citation Format: Irene Acerbi, Allison Stover Fiscalini, Mandy Che, Yiwey Shieh, Lisa Madlensky, Jeffrey Tice, Elad Ziv, Martin Eklund, Amie Blanco, Barry Tong, Deborah Goodman, Lamees Nassereddine, Nancy Anderson, Heather Harvey, Steele Fors, Hannah L Park, Antonia Petruse, Skye Stewart, Janet Wernisch, Larissa Risty, Ian Hurley, Barbara Koenig, Celia Kaplan, Robert Hiatt, Neil Wenger, Vivian Lee, Diane Heditsian, Susie Brain, Leah Sabacan, Tianyi Wang, Barbara A Parker, Alexander Borowsky, Hoda Anton-Culver, Arash Naeim, Andrea Kaster, Melinda Talley, Laura van 't Veer, Andrea Z LaCroix, Olufunmilayo I Olopade, Deepa Sheth, Augustin Garcia, Rachel Lancaster, Wisdom Study and Athena Breast Health Network Investigators and Advocate Partners, Laura Esserman. Personalized breast cancer screening in a population-based study: Women informed to screen depending on measures of risk (WISDOM) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-21-01.

Abstract 3661: Association of mammographic density with blood DNA methylation

Background: Mammographic density is a strong risk factor for breast cancer. While numerous genetic variations have been shown to be associated with mammographic density, an epigenetic signature of mammographic density has not yet been identified. The objective of this study was to identify a DNA methylation signature associated with mammographic density.

Methods: Blood samples were collected from 197 postmenopausal women 45-65 years old with no personal history of breast cancer. For each participant, mammographic density according to the BI-RADs density classification was obtained from the most recent mammogram report. White blood cell DNA methylation at more than 850,000 CpG sites was measured using the Illumina HumanMethylationEPIC BeadChip. Differential methylation was assessed using genome-wide, probe-level, and regional approaches after filtering and normalization using the recommended steps for DNA methylation microarray data. All analyses were adjusted for appropriate confounding variables.

Results: On average, genome-wide DNA methylation was higher in women with elevated mammographic density. Additionally, DNA methylation at 343 individual sites and in 34 regions was significantly associated with mammographic density after false discovery rate correction. Most density-associated sites were hypermethylated. The top differentially methylated sites were located near cell cycle regulatory genes (ICMT, DESI2, TCF21/TARID, ROBO3), as well as those encoding cytoskeletal or plasma membrane proteins (PALLD, ANO7, ATP8B3, MTUS2). We observed hypermethylation near the promoters of genes including RUFY1 and SLFN12 and within the bodies of genes including LCN6, SNED1, and LRFN1. Functional analysis of the differentially methylated sites revealed enrichment of gene ontology categories including angiogenesis and regulation of cell adhesion, as well as apoptotic signaling in response to DNA damage.

Conclusions: White blood cell DNA methylation differed according to mammographic density in a sample of postmenopausal women. Probe-based and regional analysis identified differentially methylated regions located near genes implicated in cancer. These differentially methylated regions may serve as a signature of mammographic density, and future studies of the genes implicated may provide a deeper understanding of the connection between mammographic density and breast cancer risk.

Citation Format: Rachel McFarland Lucia, Wei-Lin Huang, Andrea Alvarez, Irene Masunaka, Argyrios Ziogas, Deborah Goodman, Andrew O. Odegaard, Trina M. Norden-Krichmar, Hannah Lui Park. Association of mammographic density with blood DNA methylation [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3661.

From surviving to thriving: factors associated with complete mental health among childhood sexual abuse survivors

BACKGROUND

Despite many negative health and social consequences of childhood sexual abuse (CSA), some of those with a history of adversity manage to thrive in adulthood and achieve complete mental health (CMH). CMH is defined as the absence of mental illness in combination with almost daily happiness and/or life satisfaction, as well as high levels of social and psychological well-being. The objectives of this study were (1) to identify the pathways linking CSA to CMH in adulthood and (2) to estimate the magnitude of risk and protective factors associated with CMH among those exposed to CSA.

METHODS

A sample of 17,014 respondents aged 20 years and older from the 2012 Canadian Community Health Survey-Mental Health was selected including 651 with a history of CSA. Path analysis was used to estimate indirect and direct pathways between CSA, a priori hypothesized risk and protective factors, and CMH. Multivariable logistic regression was then used to investigate the magnitude of effects of the same risk and protective factors on CMH among CSA survivors.

RESULTS

After controlling for age, sex, race, education, and marital status, the association between CSA and CMH was mediated by lifetime depression, anxiety, substance abuse, chronic pain, and having a confidant. The strongest predictor of past-year CMH among those with a history of CSA was lifetime depression (OR 0.12, 95% CI 0.07-0.20) followed by having a confidant (OR 6.78, 95% CI 1.89-24.38). The odds of CMH was decreased by over three times among those with a history of substance misuse, and halved for those with lifetime anxiety and/or presence of pain.

CONCLUSIONS

These findings suggest that CMH among survivors of CSA is related to social and emotional factors such as social support and lifetime history of mental health conditions. Future research should investigate the effectiveness of multilevel interventions for promoting recovery among CSA survivors.

Abstract OT3-03-02: Personalized breast cancer screening in a population-based study: Women informed to screen depending on measures of risk (WISDOM)

Background: WISDOM is a 100,000 healthy women preference-tolerant, pragmatic study comparing traditional annual screening to personalized risk-based breast screening. The novelty of WISDOM personalized screening is the integration of previously validated genetic and clinical risk factors (age, family history, breast biopsy results, ethnicity, mammographic density) into a single risk assessment model that directs the starting age, timing, and frequency of screening. The goal of WISDOM is to determine if personalized screening, compared to annual screening, is as safe, less morbid, enables prevention, and is more accepted by women. The study is registered on ClinicalTrials.gov, NCT02620852.

Methods: Women aged 40-74 years with no history of breast cancer or DCIS, and no previous double mastectomy can join the study online at wisdomstudy.org. Participants can either elect randomization or self-select a study arm. Then, they can provide electronic consent and sign the Release for Medical Information via DocuSign. For all participants, 5-year risk of developing breast cancer is calculated according to the Breast Cancer Screening Consortium (BCSC) model. Participants in the personalized arm undergo panel-based mutation testing (BRCA1, BRCA2, TP53, PTEN, STK11, CDH1, ATM, PALB2, and CHEK2), and their 5-year risk is calculated using the BCSC score combined with a Polygenic Risk Score (BCSC-PRS) that includes 75 single nucleotide polymorphisms (SNPs) known to increase breast cancer risk (will increase to 229). The SNPs and mutations are assessed by saliva-based testing through Color Genomics. 5-year risk level thresholds are used to stratify for low-, moderate- and high risk. Risk stratification determines age to start, stop, and frequency of screening.

Accrual: As of July 2019, the WISDOM study is open to all eligible women in California, North Dakota, South Dakota, Minnesota, Iowa, Illinois, and New Jersey. To date, 30,392 eligible women have registered, and 21,392 women have consented to participate in the trial. The median age was 56 years. 85% of participants were Caucasian, 2% African-American, and 5% Asian. 6% self-reported Hispanic ethnicity. WISDOM is actively partnering with Blue Cross Blue Shield Association for national coverage, self-insured companies (Salesforce, Genentech, Qualcomm, CalPERS) and Medi-Cal (Inland Empire Health Plan) using a coverage with evidence progression approach.

Accrual expansion and diversity: To strengthen generalizability, the WISDOM Study is enhancing the diversity of our potential participant population by expanding to other states (Alabama, Louisiana), and partnering with other health insurers and self-insured companies. Future expansion regions include Texas, Florida, South Carolina, Oklahoma, Montana, and New Mexico. Additionally, we have translated the whole study experience to Spanish to further reach Spanish-speaking communities. With the engagement of patient advocates and community partnerships, expanding diversity recruitment will strengthen our scientific knowledge of breast cancer risk and increase access to personalized breast cancer screening recommendations for all women. WISDOM enrollment will continue through 2020.

Conclusions: Results at 5 years will enable us to demonstrate that personalized screening improves healthcare value by reducing screen volumes and costs without jeopardizing outcomes.

Citation Format: Mandy Che, Allison Stover Fiscallini, Irene Acerbi, Yiweh Shieh, Lisa Madlensky, Jeffrey Tice, Elad Ziv, Martin Eklund, Amie Blanco, Barry Tong, Deborah Goodman, Lamees Nassereddine, Nancy Anderson, Heather Harvey, Steele Fors, Hannah L Park, Antonia Petruse, Skye Stewart, Janet Wernisch, Larissa Risty, Ian Hurley, Barbara Koenig, Celia Kaplan, Robert Hiatt, Neil Wenger, Vivian Lee, Diane Heditsian, Susie Brain, Leah Sabacan, Barbara Parker, Alexander Borowsky, Hoda Anton-Culver, Hoda Anton-Culver, Arash Naeim, Andrea Kaster, Melinda Talley, Laura van't Veer, Andrea LaCroix, Olufunmilayo I Olopade, Deepa Sheth, WISDOM Study and Athena Breast Health Network Investigators and Advocate Partners and Laura Esserman. Personalized breast cancer screening in a population-based study: Women informed to screen depending on measures of risk (WISDOM) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-03-02.

Evidence for gene-smoking interactions for hearing loss and deafness in Japanese American families

BACKGROUND

This study investigated the relationship between smoking and hearing loss and deafness (HLD) and whether the relationship is modified by genetic variation. Data for these analyses was from the subset of Japanese American families collected as part of the American Diabetes Association Genetics of Non-insulin Dependent Diabetes Mellitus study. Logistic regression with generalized estimating equations assessed the relationship between HLD and smoking. Nonparametric linkage analysis identified genetic regions harboring HLD susceptibility genes and ordered subset analysis was used to identify regions showing evidence for gene-smoking interactions. Genetic variants within these candidate regions were then each tested for interaction with smoking using logistic regression models.

RESULTS

After adjusting for age, sex, diabetes status and smoking duration, for each pack of cigarettes smoked per day, risk of HLD increased 4.58 times (odds ratio (OR) = 4.58; 95% Confidence Interval (CI): (1.40,15.03)), and ever smokers were over 5 times more likely than nonsmokers to report HLD (OR = 5.22; 95% CI: (1.24, 22.03)). Suggestive evidence for linkage for HLD was observed in multiple genomic regions (Chromosomes 5p15, 8p23 and 17q21), and additional suggestive regions were identified when considering interactions with smoking status (Chromosomes 7p21, 11q23, 12q32, 15q26, and 20q13) and packs-per-day (Chromosome 8q21).

CONCLUSIONS

To our knowledge this was the first report of possible gene-by-smoking interactions in HLD using family data. Additional work, including independent replication, is needed to understand the basis of these findings. HLD are important public health issues and understanding the contributions of genetic and environmental factors may inform public health messages and policies.

Not just substance use: the critical gap in nutritional interventions for pregnant women with opioid use disorders

OBJECTIVES

Pregnancy is a time when optimization of nutrition is critically important, yet pregnant women with substance use disorders face unique nutritional challenges. The aim of this short communication is to summarize existing knowledge about nutritional interventions used in substance use disorders for pregnant and parenting women with opioid use disorder (OUD) and substance use disorders and to inform program development by maternity care and treatment providers.

STUDY DESIGN

We conducted a narrative review of nutritional interventions for pregnant women with OUD and performed environmental scanning to explore current practice.

METHODS

To gain knowledge about the unique nutritional needs of pregnant women with OUD, we searched the medical literature using Medical Subject Headings terms and key words combining the concepts of nutrition, pregnancy, and substance use. To explore current practice, we interviewed staff of a geographically diverse sample of 35 programs treating women with substance use disorders across the United Stated and Canada on their approach to prenatal nutrition for clients.

RESULTS

Literature review identified two studies evaluating the nutritional status of pregnant women with substance use disorders, but neither described nutritional interventions. Lower body mass index and folate, B12, and iron deficiencies were found in women with OUD compared with women without OUD. Two additional studies integrated nutritional interventions in substance use treatment for non-pregnant populations, resulting in significant improvements in dietary habits and psychological well-being for participants. Of 15 substance use treatment programs that responded to our query, only two incorporated longitudinal nutrition curricula for pregnant women.

CONCLUSIONS

Pregnancy is a time when a healthy diet is critically important for maternal, fetal, and neonatal health; however, pregnant women with OUD are at significant risk of malnutrition. There is an urgent need to address food insecurity and develop targeted nutrition education programs for pregnant women in early recovery.

Abstract OT2-08-01: Personalized breast cancer screening in a population based study: Women Informed to Screen Depending On Measures of risk (WISDOM)

Background: WISDOM is a 100,000 healthy women preference-tolerant, pragmatic study comparing annual to personalized risk-based breast screening. The novelty of WISDOM personalized screening is the integration of previously validated genetic and clinical risk factors (age, family history, breast biopsy results, ethnicity, mammographic density) into a single risk assessment model that directs the starting age, timing, and frequency of screening. The goal of WISDOM is to determine if personalized screening, compared to annual screening, is as safe, less morbid, enables prevention, and is preferred by women. The study is registered on ClinicalTrials.gov, NCT02620852.

Methods: Women aged 40-74 years with no history of breast cancer or DCIS, and no previous double mastectomy can join the study online at wisdomstudy.org. Participants can elect randomization or self-select a study arm, and provide electronic consent and Release for Medical Information using DocuSign. For all participants, 5-year risk of developing breast cancer is calculated according to the Breast Cancer Screening Consortium (BCSC) model. Participants in the personalized arm undergo panel-based mutation testing, and their 5-year risk is calculated using the BCSC score combined with a Polygenic Risk Score (BCSC-PRS) that includes 75 single nucleotide polymorphisms (SNPs, increase to 229) known to increase breast cancer risk. SNPs and mutations (BRCA1, BRCA2, TP53, PTEN, STK11, CDH1, ATM, PALB2, and CHEK2) are assessed by saliva-based testing through Color Genomics. 5-year risk level thresholds are used to stratify for low-, moderate- and high risk. Risk stratification determines age to start, stop, and frequency of screening.

Enrollment: As of July 2018, the WISDOM study is open to all eligible women in California, North Dakota, South Dakota, Minnesota and Iowa. To date, 23,329 eligible women have registered and 14,393 women have consented to participate in the trial. We analyzed 3,255 participants who have completed risk assessment in the personalized arm. The median age was 56 years. 82% were Caucasian, 1% African-American, and 6% Asian. 9% self-reported as Hispanic. We are partnering with health insurers and self-insured companies using coverage with evidence progression. To strengthen generalizability, we are expanding to other states. WISDOM enrollment will continue past 2019.

Feasibility: To evaluate the addition of PRS, we used paired statistical tests (McNemar) to compare the distributions of BCSC, and BCSC-PRS risk estimates around low-risk (&lt;1.3%), and very-high risk (&gt;6%) thresholds, the latter corresponding to 5-year risk of a BRCA mutation carrier. The median 5-year risk was 1.5% (IQR 1.0-2.1%) using the BCSC model, and 1.4% (IQR 0.8-2.5%) using the BCSC-PRS model. The BCSC-PRS model classified more women into the low (&lt;1%) and very high (≥6%) risk categories compared to the BCSC model (p &lt; 0.001).

Conclusions: Our findings demonstrate that incorporating genetic variants into a validated clinical model is feasible and impacts risk classification compared to a model without genetic risk factors. Results at 5 years will reveal if this classification improves healthcare value by reducing screen volumes and costs without jeopardizing outcomes.

Citation Format: Acerbi I, Shieh Y, Madlensky L, Tice J, Ziv E, Eklund M, Blanco A, DeRosa D, Tong B, Goodman D, Nassereddine L, Anderson N, Harvey H, Layton T, Park HL, Petruse A, Stewart S, Wernisch J, Risty L, Koenig B, Sarrafan S, Firouzian R, Kaplan C, Hiatt R, Parker BA, Wenger N, Lee V, Heditsian D, Brain S, Stover Fiscalini A, Borowsky AD, Anton-Culver H, Naeim A, Kaster A, Talley M, van 't Veer LJ, LaCroix A, Wisdom Study and Athena Breast Health Network Investigators and Advocate Partners, Esserman LJ. Personalized breast cancer screening in a population based study: Women Informed to Screen Depending On Measures of risk (WISDOM) [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 OT2-08-01.

Controversies among Cancer Registry Participants, Genomic Researchers, and Institutional Review Boards about Returning Participants' Genomic Results

OBJECTIVES

Genomic information will increasingly be used to aid in the prevention, diagnosis, and treatment of disease. Several national initiatives are paving the way for this new reality, while also promoting new models of participant-engaged research. We compare the opinions of research participants in a cancer registry, human genetic researchers, and institutional review board (IRB) professionals about the return of individual-level genetic results (ROR).

METHODS

Online surveys were administered to participants in a cancer registry (n = 450) and overlapping questions were compared to our previous online national surveys of human genetic researchers (n = 351) and IRB professionals (n = 208).

RESULTS

The majority of respondents agreed that researchers have an obligation to return individual results when they would affect a participant's health. While 77% of registry participants favored ROR if the researcher feels the participant might be interested in the results, only 30% of the IRB professionals and 25% of the genetic researchers agreed with this statement.

CONCLUSIONS

Significant differences emerged between the stakeholder groups in several ROR scenarios. Policies that are acceptable to participants, researchers and IRBs, and that ensure human subject protections and facilitate research are needed.

Abstract P3-09-07: Breast cancer risk assessment in a multiethnic patient population

The United States Preventive Services Task Force recommends that women who are at increased risk for breast cancer and at low risk for adverse medication effects should be offered risk-reducing medications, such as tamoxifen or raloxifene, by their clinicians. In addition, the National Comprehensive Cancer Network recommends risk counseling for women with a 5-year risk of ≥1.7% as calculated by the NCI-developed Breast Cancer Risk Assessment Tool (BCRAT, based on the Gail model) or other risk model. Thus, breast cancer risk assessment is important for the identification of women at "high risk" who should be offered risk counseling and potentially intervention. The Athena Breast Health Network, which has served &gt;120,000 breast screening patients across California and the midwest, has integrated breast cancer risk assessment into its clinical breast screening programs. The goal of our study was to characterize breast cancer risk for &gt;10,000 mammography patients in the University of California Irvine Athena Breast Health Network, overall and by race/ethnicity, using several different risk models, including the BCRAT, BCSC, and IBIS models. Our cohort was comprised of 47% non-Hispanic White, 13% non-Hispanic Asian, 38% Hispanic, and 2% women of other race/ethnicities. Using data collected from electronic medical records and self-completed questionnaires, we determined that, as expected, non-Hispanic White and Asian women had higher breast cancer risk scores than Hispanic women for all risk models (5-year risks = 1.51-1.68% and 1.22-1.40% vs. 0.95-1.05%, respectively). In addition, when women were categorized as "increased risk" according to a given risk model if their 5-year risk score was ≥1.7%, the percentages of women at "increased risk" were higher in White women (26.5–42.2%) than in Asian (15.8–28.6%) and Hispanic (6.2–10.7%) women. However, the correlations between risk models were low to moderate in our cohort, overall (Pearson's r = 0.47-0.62) and especially for Asian women (Pearson's r = 0.29-0.49). Our results indicate that using only one risk model in a clinical breast cancer risk assessment program to identify "high risk" women would miss a significant proportion of women who would have been considered "high risk" according to another risk model. Conversely, some women who are identified as "high risk" according to one model may not need risk counseling and intervention since they are not considered "high risk" according to two other models. As our cohort expands and incident breast cancers occur, we will be able to determine which risk model or combination of risk models will have the highest discriminatory accuracy for predicting breast cancer risk in women of different race/ethnicities, which will enable our risk assessment programs to have a more targeted approach to risk counseling and intervention.

Citation Format: Park HL, Columbus A, Athena Breast Health Network Investigators and Advocate Partners, Kelly R, Alvarez A, Goodman D, Larsen K, Ziogas A, Anton-Culver H. Breast cancer risk assessment in a multiethnic patient population [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-09-07.

A comparison of views regarding the use of de-identified data

Data sharing of large genomic databases and biorepositories provides researchers adequately powered samples to advance the goals of precision medicine. Data sharing may also introduce, however, participant privacy concerns including possible reidentification. This study compares views of research participants, genetic researchers, and institutional review board (IRB) professionals regarding concerns about the use of de-identified data. An online survey was completed by cancer patients, their relatives, and controls from the Northwest Cancer Genetics Registry (n = 450) querying views about potential harms with the use of de-identified data. This was compared to our previous online national survey of human genetic researchers (n = 351) and IRB professionals (n = 208). Researchers were less likely to feel that participants would be personally identified or harmed from a study involving de-identified data or feel that a federal agency might compel researchers to disclose information about research participants. Compared to genetic researchers, IRB professionals and participants were significantly more likely to express that personal identification or harm was likely or that researchers might be forced to disclose information by a federal agency. An understanding of the differences in views regarding possible harm from the use of de-identified data between these three important stakeholder groups is necessary to move forward with genomic research.

The research participant perspective related to the conduct of genomic cohort studies: A systematic review of the quantitative literature

Observational genome-wide association studies require large sample sizes. Evaluating the interplay between genomic, environmental, and lifestyle factors can require even larger sample sizes. The All of Us Research Program will recruit 1 million participants to facilitate research on genomic, environmental, and lifestyle factors. Integrating participant preferences into the research process is a new paradigm and a necessary component of the All of Us Research Program. The purpose of the study is to summarize quantitative studies of participant preferences related to participation in observational genomic research studies, starting with consent through return of results. Integrating this information into the conduct of genomic studies may benefit participants, and improve participant satisfaction, recruitment, and retention. We conducted a systematic review of the literature regarding participant views related to reconsent and broad consent, use of de-identified data, contribution of data to a biorepository, risk of identification, return of individual genetic results, and motivation for participation in genomic studies. Twenty-three articles met our inclusion and exclusion criteria. Study results found that most participants support broad consent; however, significant differences related to reconsent preferences have been shown by gender and age. Most participants support the return of individual genomic results and do not feel it is necessary to maintain a link to their de-identified data. Reasons given for joining research studies varied by population source. These findings, in addition to the knowledge that participants are more accepting of broad informed consent methods when the rationale is explained, can assist in developing guidelines for future observational genomic research.

Sitting, physical activity, and serum oestrogen metabolism in postmenopausal women: the Women's Health Initiative Observational Study

BACKGROUND

Prolonged sitting and lower levels of physical activity have been associated with increased levels of parent oestrogens (oestrone and oestradiol), the key hormones in female cancers, in postmenopausal women. However, it is unknown whether sitting and physical activity are associated with circulating oestrogen metabolite levels.

METHODS

Among 1804 postmenopausal women enrolled in the Women's Health Initiative Observational Study, 15 serum oestrogens/oestrogen metabolites were quantified using liquid chromatography-tandem mass spectrometry. Physical activity and sitting were self-reported via questionnaire. Using baseline, cross-sectional data, geometric means (GM) of oestrogens/oestrogen metabolites (pmol l^-1) were estimated using inverse probability weighted linear regression, adjusting for potential confounders and stratified on menopausal hormone therapy (MHT) use.

RESULTS

Longer time spent sitting (⩾10 vs ⩽5h per day) was associated with higher levels of unconjugated oestrone, independent of moderate- to vigorous-intensity physical activity and body mass index, among both never/former (GM=70.6 vs 57.7) and current MHT users (GM=242 vs 179) (P-trend ⩽0.03). Among never/former MHT users, sitting (⩾10 vs ⩽5h per day) was positively associated with 2-methoxyestradiol (GM=16.4 vs 14.4) and 4-methoxyestradiol (GM=2.36 vs 1.98) (P-trend ⩽0.04), independent of parent oestrogens. Inverse associations between moderate- to vigorous-intensity physical activity (⩾15 vs 0 metabolic equivalent task-hours per week) and parent oestrogens were found as expected. After adjustment for parent oestrogens, physical activity was not associated with oestrogen metabolites.

CONCLUSIONS

Our data suggest that prolonged sitting and lower moderate- to vigorous-intensity physical activity are associated with higher levels of postmenopausal oestrogens/oestrogen metabolites, the oestrogen metabolism patterns that have previously been associated with higher endometrial and breast cancer risk.

Views of Cohort Study Participants about Returning Research Results in the Context of Precision Medicine

BACKGROUND

The practice of biorepository-based genetics research raises questions related to what ethical obligations researchers have to their participants. It is important to explore and include the thoughts of current biorepository participants as we move forward with this type of research.

METHODS

Thirty participants (17 cancer patients, 7 cancer-free controls, and 6 relatives) were drawn from the Northwest Cancer Genetics Registry and participated in qualitative interviews lasting between 45 and 90 min. Topics explored in this study include which types of genetic test results participants of large biorepositories expect and would like to receive from research analyzing their samples, as well as thoughts on best practice for conducting this type of research.

RESULTS

Cancer cases, controls, and first-degree relatives have differing views on what results they would like to receive from biorepository-based research. Participants across all groups attempted to balance the costs and benefits of returning individual research results.

DISCUSSION

In the wake of precision medicine, it is important to describe the range of ways participants in large biorepositories both think and talk about the utilization of their specimens for genetics research.

Alphabetic Entry Procedure with Small Keypads: Key Layout does Matter

Two experiments examined the entry of alphabetic characters on an enhanced telephone system. Size constraints with the overall unit resulted in a small keypad which restricted users to a one or two finger typing strategy. The first experiment compared the standard Sholes arrangement of keys (QWERTY), an alphabetically organized keypad (ABC) and a numeric code method of entry (NC) which utilized the touch telephone numeric pad. Thirty naive subjects were randomly assigned to one of the three conditions. Results showed that the NC method was significantly slower than the other approaches and was rated negatively by subjects. It was concluded that such an approach is unacceptable for a consumer product like the enhanced telephone. Experiment 2 further examined performance and preference for QWERTY versus ABC arrangements. Twenty subjects completed standardized text entry tasks on both arrangements with order counterbalanced. Performance was clearly faster on the QWERTY keypad and subjects recorded an overwhelming preference for it over the ABC arrangement, regardless of their previous keyboard experience. These results extend the superiority of QWERTY over ABC to small keypads and a restricted typing strategy.

Abstract 2599: Association of periodontal disease and breast health in women undergoing screening mammography

It is well established that chronic and persistent inflammation contributes to cancer development. Chronic inflammation is often associated with periodontal disease, or gum disease. Periodontal disease, which can be prevented or ameliorated by following proper oral hygiene, is known to be associated with various systemic disorders including coronary heart disease and some cancers, including head and neck cancer and pancreatic cancer. However, little is known about its potential association with breast cancer, with only one report in which periodontal disease was a positive predictor for breast cancer in a Swedish cohort. To examine if a potential link exists between periodontal disease and breast cancer in a separate cohort, mammography patients from the UC Irvine Athena Breast Health Network cohort were recruited to participate in a survey that included questions about their periodontal health. Diagnosis of invasive breast cancer, DCIS, and benign breast diseases was determined through data extraction from electronic medical records. There was no association between periodontal disease and DCIS or invasive breast cancer. However, there was a significant difference in the frequency of breast cysts among women with periodontal disease compared to women without periodontal disease (p&lt;0.01). Women with periodontal disease were at least 4-fold more likely to have breast cysts, even after adjusting for potential confounders including age, race/ethnicity, and smoking history (p&lt;0.05). To our knowledge, this is the first report on an association between periodontal disease and breast cysts. Our data suggest that further studies on potential links between periodontal disease and breast health are warranted.

Citation Format: Hannah Lui Park, Teofilia Acheampong, Kathleen Nguyen, Cindy Nguyen, Argyrios Ziogas, Richard Kelly, Andrea Alvarez, Kathryn M. Larsen, Deborah Goodman, Hoda Anton-Culver. Association of periodontal disease and breast health in women undergoing screening mammography. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2599.

Consent Issues in Genetic Research: Views of Research Participants

BACKGROUND

With the arrival of large-scale population-based genomic research studies, such as the Precision Medicine Initiative (PMI), the question of how to best consent participants is significant, and in an era of patient-centered research, few studies have evaluated participants' preferences about re-consent and broad consent. Using quantitative methods, this study evaluates participants' views regarding the acceptability of re-consent and broad consent in subjects from the Participant Issues Project.

METHODS

A total of 450 participants were recruited from a cancer genetics registry, including cancer patients, their relatives, and controls. Participants completed a secure online survey.

RESULTS

Most participants endorsed re-consent when investigating an unrelated health condition or sharing their de-identified data with an investigator at a different institution. Notification rather than re-consent was preferred when studying a different gene but the same disease. Over 80% of respondents endorsed re-consent when parents of a child gave the original consent and the child has now reached adulthood. Preferences for some scenarios varied by history of cancer at baseline, gender, stage of cancer, or case versus control group. The large majority of participants preferred the option to select broad consent categories of research.

CONCLUSION

Understanding research participants' preferences, including their views on the need for re-consent, are critical to the success of the PMI.

Participant views on consent in cancer genetics research: preparing for the precision medicine era

The Precision Medicine Initiative (PMI) has created considerable discussions about research participant issues including re-consent and how and when to incorporate the patient experience into clinical trials. Within the changing landscape of genetic and genomic research, the preferences of participants are lacking yet are needed to inform policy. With the growing use of biobanks intended to support studies, including the national research cohort proposed under the PMI, understanding participant preferences, including re-consent, is a pressing concern. The Participant Issues Project (PIP) addresses this gap, and here we present data on participant attitudes regarding re-consent and broad consent in research studies. PIP study participants came from the Northwest Cancer Genetics Registry and included cancer patients, relatives, and controls. Thirty telephone interviews were conducted and analyzed using content and thematic analysis. Results indicate that in some scenarios, re-consent is needed. Most participants agreed that re-consent was necessary when the study direction changed significantly or a child participant became an adult, but not if the genetic variant changed. Most participants' willingness to participate in research would not be affected if the researcher or institution profited or if a broad consent form were used. Participants emphasized re-consent to provide information and control of the use of their data, now relevant for tailored treatment, while also prioritizing research as important. In the era of precision medicine, it is essential that policy makers consider participant preferences with regard to use of their materials and that participants understand genetic and genomic research and its harms and benefits as well as what broad consent entails, including privacy and re-identification risks.

Updated survival analysis of two sequential prospective trials of R-MACLO-IVAM followed by maintenance for newly diagnosed mantle cell lymphoma

A phase II trial of R-MACLO-IVAM followed by thalidomide maintenance for mantle cell lymphoma (MCL) demonstrated promising progression-free survival (PFS) and overall survival (OS) rates. Thalidomide maintenance was associated with significant toxicity and was subsequently modified to rituximab maintenance. Herein, we present updated results and follow-up. Two sequential phase II trials included chemotherapy-naïve patients with MCL up to 75 years old. Four cycles of R-MACLO-IVAM chemotherapy were delivered as previously described. Patients who achieved complete responses (CR) were eligible for thalidomide or rituximab maintenance therapy. Among 36 patients enrolled, the MCL International Prognostic Index (MIPI) was low in 53%, intermediate in 36% and high in 11%. Thirty-five patients completed at least 2 cycles of chemotherapy; 34 (94%) achieved a CR. After a median follow-up of 74.4 months, the 5-year PFS was 51% (95% CI 33-68%) and the 5-year OS was 85% (95% CI 73-97%). Two deaths occurred during the chemotherapy phase due to disease progression and neutropenic sepsis, respectively. One patient developed secondary acute myeloid leukemia after 7 years. R-MACLO-IVAM chemotherapy is effective for patients with newly diagnosed MCL.

Abstract 3243: A pilot study comparing breast cancer risk scores using models with and without breast density among women of different race/ethnicities undergoing breast screening in the University of California, Irvine Athena Breast Health Network cohort

The USPSTF recommends that women who are at increased risk for breast cancer and at low risk for adverse medication effects should be offered risk-reducing medications, such as tamoxifen or raloxifene, by their clinicians. The NCCN also recommends risk counseling for women with a 5-year risk of ≥1.7% as calculated by the NCI-developed Breast Cancer Risk Assessment Tool (BCRAT, based on the Gail model) or other risk model. The integration of risk assessment into clinical breast screening holds promise in reducing breast cancer risk for many women; however, the criteria that contribute to elevated risk status are different according to different risk models. The University of California, Irvine (UCI) Athena Breast Health Network has integrated a computerized risk assessment largely based on the BCRAT into the screening mammography process at UCI mammography centers. Women identified to be at elevated risk are provided with personalized risk counseling by a Breast Health Specialist. In recent years, breast density has been increasingly recognized as a risk factor for breast cancer; however, it is not part of the BCRAT. In this pilot analysis, we sought to determine if incorporating breast density into the risk assessment program would affect the % of women in our cohort who have a 5-year risk of ≥1.7%. We hypothesized that an increased % of Asian women would reach this threshold since breast density is known to be higher in Asians. We used the BCSC model, which includes density as a variable, to calculate risk scores for a subset of our screening population (n=309), age-matched for three race/ethnic groups, and compared them to their scores according to the BCRAT. Our results showed that while Asians did exhibit significantly higher breast density (30.3% had BIRADS breast density classification 4, extremely dense) than White and Hispanic women (8.7% and 5.6%, respectively), their BCRAT and BCSC scores were significantly lower than in White women but higher than in Hispanic women, with 14.1% of Asians having a BCSC score ≥1.7% compared to 43.7% of Whites and 10.3% in Hispanics, and 17.2% of Asians having a BCRAT score of ≥1.7% compared to 34.0% of Whites and 6.5% of Hispanics. Interestingly, when differences were explored between BCRAT and BCSC scores within the same sub-group of women, the scores were not statistically different among White or Hispanic women but were approaching statistical significance in Asian women. Contrary to our hypothesis, in Asian women, BCSC-calculated risk was actually lower than according to the BCRAT. These findings suggest that, despite higher breast density, Asian women still exhibit lower breast cancer risk scores than White women; thus, a smaller proportion of Asian women in our cohort will be recommended for high risk counseling and chemoprevention.

Citation Format: Hannah Lui Park, Stephanie M. Tran, Jennifer Lee, Deborah Goodman, Argyrios Ziogas, Richard Kelly, Kathryn M. Larsen, Andrea Alvarez, Chris Tannous, Julie Strope, Wendy Lynch, Hoda Anton-Culver. A pilot study comparing breast cancer risk scores using models with and without breast density among women of different race/ethnicities undergoing breast screening in the University of California, Irvine Athena Breast Health Network cohort. [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 3243. doi:10.1158/1538-7445.AM2014-3243