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 and evaluation of a novel educational program for providers on the use of polygenic risk scores

PURPOSE

This study aimed to develop an online educational program for using PRS for breast and ovarian cancer risk-assessments and evaluate the impact on genetic healthcare providers' (GHP) attitudes, confidence, knowledge, and preparedness.

METHODS

The educational program comprised of an online module covering theoretical aspects of PRS, and a facilitated virtual workshop with pre-recorded roleplays and case discussions. Data were collected in pre-and post-education surveys. Eligible participants were GHPs working in Australian familial cancer clinics registered to recruit patients for a breast and ovarian cancer PRS clinical trial (n=12).

RESULTS

124 GHPs completed the PRS education, of whom 80 (64%) and 67 (41%) completed the pre-and post-education surveys, respectively. Pre-education, GHPs reported limited experience, confidence and preparedness using PRS, but recognized its potential benefits. Post-education GHPs indicated improved attitudes (p=<0.001), confidence (p=<0.001), knowledge (p=<0.001), and preparedness (p=<0.001) to use PRS. Most GHPs felt the program entirely met their learning needs (73%) and was completely relevant to their clinical practice (88%). GHPs identified PRS implementation barriers, including limited funding models, diversity issues, and need for clinical guidelines.

CONCLUSIONS

Our education program improved GHP attitudes, confidence, knowledge, and preparedness for using PRS/personalized risk and provides a framework for development of future programs.

Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief

Post-mastectomy pain syndrome (PMPS) is a common and often debilitating condition. The syndrome is defined by chest wall pain unresponsive to standard pain medications and the presence of exquisite point tenderness along the inframammary fold at the site of the T4 and T5 cutaneous intercostal nerve branches as they exit from the chest wall. Pressure at the site triggers and reproduces the patient's spontaneous or motion-evoked pain. The likely pathogenesis is neuroma formation after injury to the T4 and T5 intercostal nerves during breast surgery. We assessed the rate of long-term resolution of post-mastectomy pain after trigger point injections (2 mL of 1:1 mixture of 0.5% bupivacaine and 4 mg/mL dexamethasone) to relieve neuropathic pain in a prospective single-arm cohort study. Fifty-two women (aged 31-92) who underwent partial mastectomy with reduction mammoplasty or mastectomy with or without reconstruction, and who presented with PMPS were enrolled at the University of California San Francisco Breast Care Center from August 2010 through April 2018. The primary outcome was a long-term resolution of pain, defined as significant or complete relief of pain for greater than 3 months. A total of 91 trigger points were treated with mean follow-up 43.9 months with a 91.2% (83/91) success rate. Among those with a long-term resolution of pain, 60 trigger points (72.3%) required a single injection to achieve long-lasting relief. Perineural infiltration with bupivacaine and dexamethasone is a safe, simple, and effective treatment for PMPS presenting as trigger point pain along the inframammary fold.

Multicentre evaluation of magnetic technology for localisation of non-palpable breast lesions and targeted axillary nodes

BACKGROUND

Magseed technology is a recently introduced localisation technique for impalpable breast lesions with possible advantages over traditional techniques. These include improved theatre logistics, flexibility in incision placement and improved patient experience. This multicentre study evaluates the experience of introducing Magseed technology into routine surgical practice.

METHODS

A prospective multicentre study of Magseed localised procedures was performed. Insertion data were recorded by the radiologist including lesion characteristics and Magseed insertion accuracy. The surgical team recorded time from insertion to operation, operating time and surgical satisfaction. Pathology results were reviewed for specimen weight and margins.

RESULTS

Between February 2019 and June 2020, 100 patients were enrolled. Magseed localised procedures included 18 excisional biopsies, 23 wide local excisions (WLE), 50 WLE with axillary surgery and four cases of Magseed localised breast WLE with Magseed localised axillary surgery. There were three therapeutic mammoplasties and two cases of Magseed localised targeted axillary node dissection alone. A total of 90% of Magseeds were radiologically placed within 5 mm of the target lesion/node. Time between incision and specimen removal was 17 min (range 6-40 min). All breast and axillary Magseeds were successfully identified and retrieved during surgery. The target lesion was identified in the specimen in all cases. A total of 10% of cases required further surgery for pathologically positive margins. Overall, surgeons reported that Magseed localisation was "easy" or "very easy" in 77% of cases.

CONCLUSION

Magseed is a reliable, safe and accurate surgical technique that provides logistical advantages and flexibility of surgical approach. The method was well-accepted by all users.

Elevated risk thresholds predict endocrine risk-reducing medication use in the Athena screening registry

Risk-reducing endocrine therapy use, though the benefit is validated, is extremely low. The FDA has approved tamoxifen and raloxifene for a 5-year Breast Cancer Risk Assessment Tool (BCRAT) risk ≥ 1.67%. We examined the threshold at which high-risk women are likely to be using endocrine risk-reducing therapies among Athena Breast Health Network participants from 2011-2018. We identified high-risk women by a 5-year BCRAT risk ≥ 1.67% and those in the top 10% and 2.5% risk thresholds by age. We estimated the odds ratio (OR) of current medication use based on these thresholds using logistic regression. One thousand two hundred and one (1.2%) of 104,223 total participants used medication. Of the 33,082 participants with 5-year BCRAT risk ≥ 1.67%, 772 (2.3%) used medication. Of 2445 in the top 2.5% threshold, 209 (8.6%) used medication. Participants whose 5-year risk exceeded 1.67% were more likely to use medication than those whose risk was below this threshold, OR 3.94 (95% CI = 3.50-4.43). The top 2.5% was most strongly associated with medication usage, OR 9.50 (8.13-11.09) compared to the bottom 97.5%. Women exceeding a 5-year BCRAT ≥ 1.67% had modest medication use. We demonstrate that women in the top 2.5% have higher odds of medication use than those in the bottom 97.5% and compared to a risk of 1.67%. The top 2.5% threshold would more effectively target medication use and is being tested prospectively in a randomized control clinical trial.

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.

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 P5-08-01: Breast cancer risk thresholds as a predictor of chemoprevention uptake in the Athena Breast Health Network

Background: Large-scale chemoprevention trials validated endocrine risk reduction strategies to lower breast cancer risk. We sought to understand the risk at which women are likely to adopt chemoprevention. A 5-year Gail risk of 1.67% or above is considered elevated risk, and the FDA indication for prescribing chemoprevention. We examined chemoprevention use in the Athena Breast Health Network (Athena), which includes approximately 100,000 women who are screened by mammography at Sanford Health, UC Davis, UC Irvine, UC Los Angeles, UC San Diego, and UC San Francisco.

Methods: We calculated the Gail risk score for women who had completed an Athena online intake survey distributed before being seen at screening centers; this survey included questions about chemoprevention usage. First, we analyzed 16,518 surveys of 9,318 unique women without breast cancer or DCIS who received breast cancer screening at UCSF from 2011- 2018 and who consented to research. These women also self-reported use of chemoprevention. We stratified Gail risk scores by a threshold of 1.67%, and by percentiles to identify those women in the top 2.5% by age. We compared current chemoprevention use in these different breast cancer risk strata, and factors associated with its use. An analysis including all 100,000 women in the Athena Network will be presented at SABCS.

Results: Overall, at UCSF, 48 of 9,318 women (0.51%) reported current chemoprevention use. The 5-year Gail risk was greater than 1.66% in 3,675 of 9,318 women (39%), of whom 205 (2.2%) were in the top 2.5% of risk by age. Chemoprevention use was reported by 13 of 205 (6.3%) women in the top 2.5% of risk by age (mean Gail risk 5.6%), as compared to 41 of 3,675 (1.1%) who were at Gail above 1.66% (mean Gail = 3.9%). Women in the top 2.5% and those with Gail risk &gt;1.66% were significantly more likely to be using chemoprevention p&lt; 0.01 for each respectively). Chemoprevention uptake was correlated with the joint effect of the top 2.5% of risk by age and increasing Gail score (OR = 10.25; P = 0.009). Preliminary results were consistent among the 100,000 women in the Athena registry (analysis ongoing). In addition, chemoprevention use was more likely in older women (OR = 1.10; P &lt; 0.01, for every year of age) and in those women with Ashkenazi ancestry on both sides of the family compared to none (OR = 2.32; P = 0.02). Race and education were not associated with use of chemoprevention.

Discussion: Women with higher Gail scores in the top 2.5% of risk by age are positively associated with current chemoprevention use (6.34%). Importantly, this analysis presents a risk-stratified, population-level risk reduction strategy, using the top 2.5% risk threshold by age. It provides an opportunity to specifically target chemoprevention to women at highest need to reduce their breast cancer risk. In the WISDOM Study (NCT02620852), we are prospectively testing active outreach based on breast cancer risk in the top 2.5% of risk by age, and have developed a breast health decisions aid to standardize communication of risk-reducing options.

Citation Format: Yash S Huilgol, Holly Keane, Yiwey Shieh, Jeffrey Tice, Elad Ziv, Lisa Madlensky, Leah Sabacan, Irene Acerbi, Mandy Che, Allison Stover Fiscalini, Hoda Anton-Culver, Alexander D Borowsky, Sharon Hunt, Arash Naeim, Barbara Parker, Laura J van 't Veer, Athena Breast Health Network Investigators and Advocate Partners and Laura J Esserman. Breast cancer risk thresholds as a predictor of chemoprevention uptake in the Athena Breast Health Network [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 P5-08-01.

Abstract P5-13-17: Comparing characteristics of patients who fill out online surveys before visits with patients who fill out surveys in-clinic with staff assistance at the UCSF breast screening clinic

Background: At the UCSF breast screening clinic, intake surveys are sent to women with upcoming mammogram appointments to obtain their demographic data, comorbidities, and assess breast cancer risk (family history, biopsy history). Many patients complete surveys online before their visit. For those who do not, a staff member is present to assist with survey completion on a tablet in-clinic.

Methods: Data was collected from 10,755 patients from December 2012–May 2018. To assess if different survey modalities capture different demographic groups, we analyzed these submissions, comparing responses completed by patients online before visits and in-clinic with assistance.

Results:On average, 48% of invited patients complete a survey. Of respondents 76% completed surveys before visits and 24% completed surveys in-clinic. Both methods captured electronic data that was summarized and presented to clinicians for clinical decision support. Compared to the in-clinic group, a before group patient was more likely to be white, married, and have at least a college education. The before group included a smaller proportion of patients who were Black/African American, Hispanic/Latina, and 65 years or older. Furthermore, a greater proportion of the before group reported 2 or more comorbidities. The before population reported more often having fair or poor health over the preceding 30 days. While these differences were statistically significant, it is important to put some of these results into perspective: while only 24% of survey responses were collected in-clinic, 59.1% of all Black/African American responses and 33.5% of all Hispanic/Latina responses were represented in this group.

  Before group (N=7869) In-clinic group (N=2886)P valueWhite64.43%55.79%&lt;0.0001Black/African American3.57%10.91%&lt;0.0001Hispanic/Latina7.96%10.91%&lt;0.0001Aged 65 or older29.84%39.54%&lt;0.0001Married66.40%56.10%&lt;0.0001College educated or more79.93%66.87%&lt;0.00012 or more diagnosed comorbidities38.18%30.32%&lt;0.0001Poor or Fair health over last 30 days10.41%5.45%&lt;0.0001

Conclusions/Future Directions: 1) Online surveys are completed more often by traditionally well-represented groups. Offering staff supported electronic surveys in-clinic improves the total yield and diversity of patients who complete surveys. More research is required to see the impact of income levels. 2) We did not anticipate a greater incidence of fair or poor health over the last 30 days or the higher number of patients reporting 2 or more comorbidities in the before group. This could result from the before group having better access to health care, and more familiarity with health surveys, but more detailed study is needed. 3) We will investigate further issues of health care trust, familiarity, and access to adjust our clinic practices. As more studies move surveys entirely online, we need to identify and address factors that prevent patients from completing surveys before appointments. Alternative survey modalities must be made available in accessible ways and integrated into routine clinical practice.

Citation Format: Shibley WP, Dreher N, van 't Veer L, Acerbi I, Fiscalini AS, Keane H, Esserman LJ, Athena Breast Health Network Investigators and Advocate Partners. Comparing characteristics of patients who fill out online surveys before visits with patients who fill out surveys in-clinic with staff assistance at the UCSF breast screening clinic [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 P5-13-17.

Management of Early Node-Positive Breast Cancer in Australia: A Multicentre Study

To examine practice patterns for breast cancer patients with limited sentinel node (SN) disease in light of the ACOSOG Z0011 results. Retrospective analysis of patients with T1-2 breast cancer and positive sentinel lymph node biopsy (SLNB) admitted between January 2009 and December 2012. Patient demographics, tumor characteristics, and treatments were recorded. Eight hundred positive SLNBs were identified. A total of 452 (56.5%) proceeded to completion axillary lymph node dissection (cALND). cALND rate decreased from 65.1% to 49.7% from 2009-2010 to 2011-2012. cALND was performed for micrometastasis or isolated tumor cells in 39.3% in 2009-2010 and 22.2% in 2011-2012, whereas for macrometastases the rates were 83.1% and 68.6%, respectively. cALND rates diminished for both Z0011-eligible and -ineligible patients. The ACOSOG Z0011 trial presentation and publication coincided with a reduction in cALND for breast cancer with limited nodal disease. There appears equipoise regarding management of macrometastatic SN disease.

Implanon® failure in an HIV-positive woman on antiretroviral therapy resulting in two ectopic pregnancies

Since its introduction in 1999, Implanon® remains one of the preferred contraceptive choices for many women as it offers a highly effective means of long-term contraception for three years that does not rely on adherence. Like all hormonal contraceptives, certain hepatic enzyme-inducing drugs may reduce its efficacy. We present an interesting case of an HIV-positive woman on antiretroviral therapy having tubal pregnancies on two separate occasions with Implanon in place.

Early syphilis in a man with a negative Treponema pallidum enzyme immunoassay-IgM

Most serological tests for syphilis rely on an individual's ability to produce antibodies. A single screening test may be unreliable for screening in those with primary immunodeficiency. We present the first reported case of primary and secondary syphilis with negative Treponema pallidum enzyme immunoassay-IgM and Venereal Disease Research Laboratory tests in a man with common variable immunodeficiency.