Assessing Biomarkers of Breast Cancer Risk in Underserved Women in a Midwestern County

Objective:

The primary aim of this study was to evaluate the feasibility of collecting risk factor information and accessing digitized mammographic data in a medically marginalized population. A secondary aim was to examine the association between vitamin D status and mammographic density.

Methods:

Breast-screening examinations were provided for age-appropriate patients, and a referral for no-cost screening mammography was offered. Study participants were asked to undergo 25-hydroxyvitamin D testing at mammography and 1-year follow-up.

Results:

Of 62 women approached, 35 (56%) consented to participate. Of 32 participants who had baseline mammography, the median mammographic density measured by VolparaDensity (Volpara Solutions Limited) was 5.7%. After 1 year, 9 women obtained follow-up mammograms, with a median density of 5.7%. Vitamin D status was measured for 31 participants at baseline and 13 participants in the following year. Insufficient vitamin D status (<30 ng/mL) was noted in 77% at each time point. Mammographic density was not significantly correlated with vitamin D status (P = .06).

Conclusions:

On the basis of this small pilot study, vitamin D insufficiency is common in this study population. Owing to the small sample size, an association between vitamin D insufficiency and breast density was not clear. Additional unexpected findings included substantial barriers in initial access to care and longitudinal follow-up in this population. Further study of these issues is needed.

Impact of Personalized Genetic Breast Cancer Risk Estimation With Polygenic Risk Scores on Preventive Endocrine Therapy Intention and Uptake

Endocrine therapy is underutilized to reduce breast cancer incidence among women at increased risk. Polygenic risk scores (PRSs) assessing 77 breast cancer genetic susceptibility loci personalizes risk estimates. We examined effect of personalized PRS breast cancer risk prediction on intention to take and endocrine therapy uptake among women at increased risk. Eligible participants had a 10-year breast cancer risk ≥5% by Tyrer-Cuzick model [International Breast Cancer Intervention Study (IBIS)] or ≥3.0 % 5-year Gail Model risk with no breast cancer history or hereditary breast cancer syndrome. Breast cancer risk was estimated, endocrine therapy options were discussed, and endocrine therapy intent was assessed at baseline. After genotyping, PRS-updated breast cancer risk estimates, endocrine therapy options, and intent to take endocrine therapy were reassessed; endocrine therapy uptake was assessed during follow-up. From March 2016 to October 2017, 151 patients were enrolled [median (range) age, 56.1 (36.0-76.4 years)]. Median 10-year and lifetime IBIS risks were 7.9% and 25.3%. Inclusion of PRS increased lifetime IBIS breast cancer risk estimates for 81 patients (53.6%) and reduced risk for 70 (46.4%). Of participants with increased breast cancer risk by PRS, 39 (41.9%) had greater intent to take endocrine therapy; of those with decreased breast cancer risk by PRS, 28 (46.7%) had less intent to take endocrine therapy (P < 0.001). On multivariable regression, increased breast cancer risk by PRS was associated with greater intent to take endocrine therapy (P < 0.001). Endocrine therapy uptake was greater among participants with increased breast cancer risk by PRS (53.4%) than with decreased risk (20.9%; P < 0.001). PRS testing influenced intent to take and endocrine therapy uptake. Assessing PRS effect on endocrine therapy adherence is needed.Prevention Relevance: Counseling women at increased breast cancer risk using polygenic risk score (PRS) risk estimates can significantly impact preventive endocrine therapy uptake. Further development of PRS testing to personalize breast cancer risk assessments and endocrine therapy counselling may serve to potentially reduce the incidence of breast cancer in the future.

Evaluation of Germline Genetic Testing Criteria in a Hospital-Based Series of Women With Breast Cancer

PURPOSE

To determine the sensitivity and specificity of genetic testing criteria for the detection of germline pathogenic variants in women with breast cancer.

MATERIALS AND METHODS

Women with breast cancer enrolled in a breast cancer registry at a tertiary cancer center between 2000 and 2016 were evaluated for germline pathogenic variants in 9 breast cancer predisposition genes (ATM, BRCA1, BRCA2, CDH1, CHEK2, NF1, PALB2, PTEN, and TP53). The performance of the National Comprehensive Cancer Network (NCCN) hereditary cancer testing criteria was evaluated relative to testing of all women as recommended by the American Society of Breast Surgeons.

RESULTS

Of 3,907 women, 1,872 (47.9%) meeting NCCN criteria were more likely to carry a pathogenic variant in 9 predisposition genes compared with women not meeting criteria (9.0% v 3.5%; P < .001). Of those not meeting criteria (n = 2,035), 14 (0.7%) had pathogenic variants in BRCA1 or BRCA2. The sensitivity of NCCN criteria was 70% for 9 predisposition genes and 87% for BRCA1 and BRCA2, with a specificity of 53%. Expansion of the NCCN criteria to include all women diagnosed with breast cancer at ≤ 65 years of age achieved > 90% sensitivity for the 9 predisposition genes and > 98% sensitivity for BRCA1 and BRCA2.

CONCLUSION

A substantial proportion of women with breast cancer carrying germline pathogenic variants in predisposition genes do not qualify for testing by NCCN criteria. Expansion of NCCN criteria to include all women diagnosed at ≤ 65 years of age improves the sensitivity of the selection criteria without requiring testing of all women with breast cancer.

Micro-spectrometer for fusion plasma boundary measurements

In situ probes are being developed to make direct, spatially resolved measurements of the ion energy spectra in the edge of tokamak plasmas while being easily replaced and requiring minimal resources. The ion spectrometers will consist of a combined collimator and energy analyzer fabricated from silicon and mated to a detector to yield a form factor of approximately 2.0 cm × 1.5 cm × 0.2 cm. Results of fabrication and testing of the combined collimator and energy analyzer element are presented.

Military psychiatry: a unique national resource

The aim of the defence medical services (DMS) is to maintain the health of those individuals who volunteer for service in HM Armed Forces, in order that they may efficiently discharge their duties.

Medical factors influencing decision making regarding radiation therapy for breast cancer

Radiation therapy is an important and effective adjuvant therapy for breast cancer. Numerous health conditions may affect medical decisions regarding tolerance of breast radiation therapy. These factors must be considered during the decision-making process after breast-conserving surgery or mastectomy for breast cancer. Here, we review currently available evidence focusing on medical conditions that may affect the patient-provider decision-making process regarding the use of radiation therapy.

Diagnosis and management of benign, atypical, and indeterminate breast lesions detected on core needle biopsy

Imaging abnormalities detected by mammographic screening often lead to diagnostic evaluations, with suspicious abnormalities subjected to image-guided core needle biopsy (CNB) to exclude malignancy. Most CNBs reveal benign pathological alterations, termed benign breast disease (BBD). Adoption of CNB presents challenges with pathologic classification of breast abnormalities and management of patients with benign or atypical histological findings. Patient management and counseling after CNB diagnosis of BBD depends on postbiopsy determination of radiologic-pathologic concordancy. Communication between radiologists and pathologists is crucial in patient management. Management is dependent on the histological type of BBD. Patients with concordant pathologic imaging results can be reassured of benign biopsy findings and advised about the future risk of developing breast cancer. Surgical consultation is advised for patients with discordant findings, symptomatic patients, and high-risk lesions. This review highlights benign breast lesions that are encountered on CNB and summarizes management strategies. For this review, we conducted a search of PubMed, with no date limitations, and used the following search terms (or a combination of terms): atypical ductal hyperplasia, atypical hyperplasia, atypical lobular hyperplasia, benign breast disease, cellular fibroepithelial lesions, columnar cell lesions, complex sclerosing lesion, core needle biopsy, fibroadenomas, flat epithelial atypia, lobular carcinoma in situ, lobular neoplasia, mucocele-like lesions, phyllodes tumor, pseudoangiomatous stromal hyperplasia, radial scar, and vascular lesions. The selection of references included in this review was based on study relevance and quality. We used additional articles culled from the bibliographies of retrieved articles to examine the published evidence for risk factors of BBD.

Factors associated with surgical decision making in women with early-stage breast cancer: a literature review

BACKGROUND

Current recommendations for surgical management of early-stage breast cancer include breast-conserving surgery with postoperative irradiation. However, studies show that mastectomy is still being used by women with early-stage breast cancer.

METHODS

Review of the medical literature published between 2000 and 2010 to determine the factors associated with the decision of patients for surgical treatment in early-stage breast cancer.

RESULTS

The following patient characteristics affect the surgical decision-making process in early-stage breast cancer: age, socioeconomic factors, geographic area in which the patient lives, proximity to a radiation therapy center, testing for BRCA gene, breast imaging, and decision aids.

CONCLUSIONS

Of increasing importance in the decision making about treatment of women with early-stage breast cancer are the woman's perception of having a surgical choice and the influence of that choice on postoperative quality of life.

Breast manifestations of systemic diseases

Although much emphasis has been placed on the primary presentations of breast cancer, little focus has been placed on how systemic illnesses may affect the breast. In this article, we discuss systemic illnesses that can manifest in the breast. We summarize the clinical features, imaging, histopathology, and treatment recommendations for endocrine, vascular, systemic inflammatory, infectious, and hematologic diseases, as well as for the extramammary malignancies that can present in the breast. Despite the rarity of these manifestations of systemic disease, knowledge of these conditions is critical to the appropriate evaluation and treatment of patients presenting with breast symptoms.

Clinician's guide to imaging and pathologic findings in benign breast disease

The discussion of abnormal results of breast imaging and abnormal pathologic findings can be challenging for health care professionals and often is stressful for patients. Although most imaging findings and biopsy results are negative and do not infer a substantial increase in breast cancer risk, the subsequent conversation between the patient and her practitioner is more effective and informative with a thorough review of the pathologic results and an appreciation of the importance of radiologic-histologic concordance. This article provides insight into and understanding of breast imaging and biopsy techniques and of histologic findings as a means to timely and appropriate decision making and action by the patient and her health care professional.

Promoting a breast cancer screening clinic for underserved women: a community collaboration

OBJECTIVE

To increase breast cancer (BC) awareness, screening services, and education for local underserved women.

DESIGN

Mayo Clinic launched a twice-monthly, half-day outreach breast clinic composed of 3 women physicians, a nurse and medical interpreters.

SETTING

Community Adult Literacy Learning Center in Rochester, Minnesota.

PATIENTS

Underserved women from immigrant and minority backgrounds in Rochester.

INTERVENTIONS

The clinic offered clinical breast examinations, breast imaging, follow-up appointments, assistance in accessing government paid health coverage programs, educational classes, transportation vouchers, and follow-up surveys.

MAIN OUTCOME MEASURES

We assessed the number of patients seen, number of mammograms, breast sonograms, number of patients diagnosed with BC, number of interpreters, quantity of transportation vouchers and results of follow-up surveys.

RESULTS

Between December 1, 2005 and July 31, 2009 there were 177 patient visits (including 46 follow-up visits) provided to 131 women on 58 days spent in the clinic. One hundred thirteen women (86.3%) had mammograms, sonograms, or both. Screening identified one woman with a diagnosis of breast cancer, 5 with symptomatic breast cysts and 3 women who underwent breast biopsy after a suspicious lesion was identified with breast imaging. One hundred and twenty women required an interpreter for the initial examination and mammogram visit. Transportation vouchers were used by 51 women. All follow-up surveys indicated overall satisfaction with the breast clinic, services and screening procedures.

CONCLUSIONS

For effective breast screening of underserved in a community setting, it is important to address racial/ethnic background, socioeconomic status, English language proficiency, and access to health care in general.

Frequency format diagram and probability chart for breast cancer risk communication: a prospective, randomized trial

Background

Breast cancer risk education enables women make informed decisions regarding their options for screening and risk reduction. We aimed to determine whether patient education regarding breast cancer risk using a bar graph, with or without a frequency format diagram, improved the accuracy of risk perception.

Methods

We conducted a prospective, randomized trial among women at increased risk for breast cancer. The main outcome measurement was patients' estimation of their breast cancer risk before and after education with a bar graph (BG group) or bar graph plus a frequency format diagram (BG+FF group), which was assessed by previsit and postvisit questionnaires.

Results

Of 150 women in the study, 74 were assigned to the BG group and 76 to the BG+FF group. Overall, 72% of women overestimated their risk of breast cancer. The improvement in accuracy of risk perception from the previsit to the postvisit questionnaire (BG group, 19% to 61%; BG+FF group, 13% to 67%) was not significantly different between the 2 groups (P = .10). Among women who inaccurately perceived very high risk (≥ 50% risk), inaccurate risk perception decreased significantly in the BG+FF group (22% to 3%) compared with the BG group (28% to 19%) (P = .004).

Conclusion

Breast cancer risk communication using a bar graph plus a frequency format diagram can improve the short-term accuracy of risk perception among women perceiving inaccurately high risk.

Pathophysiology of chronic progressive renal disease in the African American patient with hypertension

Chronic renal failure and ESRD are major causes of morbidity, mortality, and chronic disability in patients in the United States. Hypertension is a major underlying cause of chronic progressive renal disease and continues to be a leading reason for the heavy burden of ESRD observed in African Americans. Hypertension is actually a syndrome of vascular pathology manifesting itself in patients by a constellation of common findings and attributes. These pathophysiologic alterations include dysregulation of arterial compliance, endothelial dysfunction, obesity and insulin resistance, abnormal sympathetic nervous system activation, accelerated atherosclerosis, left ventricular hypertrophy, and a propensity for increased vascular thrombogenesis among others. This review will focus on some of the important mechanisms possibly involved in the progression of renal disease in the setting of chronic hypertension.

Effects of the alpha-glucosidase inhibitor acarbose on postprandial serum glucose and insulin concentrations in healthy dogs

OBJECTIVE

To determine effects of acarbose on baseline and postprandial serum glucose and insulin concentrations in healthy dogs, if effects of acarbose were dosage related, and if acarbose caused any short-term adverse effects.

ANIMALS

5 healthy dogs fed a high-fiber diet.

PROCEDURE

A Latin-square design was used. During each 1-week treatment period, dogs were given a placebo or 25, 50, 100, or 200 mg of acarbose, PO, twice daily immediately prior to feeding. There was a 1-week interval between periods. At the end of each treatment period, serum glucose and insulin concentrations were measured prior to feeding and at 30- to 60-minute intervals for 6 hours after feeding.

RESULTS

Baseline serum glucose and insulin concentrations, insulin peak response, and total glucose absorption were not significantly different following treatment with placebo and treatment with acarbose; however, total insulin secretion was significantly decreased when dogs were treated with 100 or 200 mg of acarbose. Four dogs developed soft to watery stools when treated with 200 mg of acarbose, and 2 dogs lost weight during the study. Results of CBC and serum biochemical analyses were within reference ranges throughout the study.

CONCLUSIONS

Acarbose did not induce any serious adverse effects and was effective in healthy dogs in reducing total postprandial insulin secretion when administered immediately prior to meals.

CLINICAL RELEVANCE

Results suggest that acarbose may help control hyperglycemia in dogs with insulin-dependent diabetes mellitus. Additional studies designed to evaluate the effect of acarbose on postprandial blood glucose concentrations in dogs with diabetes mellitus are indicated.

Effect of dietary insoluble fiber on control of glycemia in dogs with naturally acquired diabetes mellitus

OBJECTIVE

To evaluate the effect of a high insoluble-fiber (HF) diet containing 12% cellulose in dry matter and a low insoluble-fiber (LF) diet on control of glycemia in dogs with naturally acquired insulin-dependent diabetes mellitus.

DESIGN

Prospective randomized crossover controlled trial.

ANIMALS

11 dogs with naturally acquired diabetes mellitus.

PROCEDURE

Dogs were fed HF and LF diets for 8 months each in 1 of 2 randomly assigned diet sequences. Caloric intake and insulin treatment were adjusted as needed to maintain stable body weight and control of glycemia, respectively. After a 2-month adaptation period, control of glycemia was evaluated every 6 weeks for 6 months. Variables assessed included serum glucose concentration measured during the preprandial state, blood glycosylated hemoglobin concentration, serum glucose concentration measured every 2 hours for 24 hours beginning at the time of the morning insulin injection, 24-hour mean serum glucose concentration, mean serum glucose concentration fluctuation from the 24-hour mean serum glucose concentration, and 24-hour urinary excretion of glucose.

RESULTS

Significant differences in mean daily caloric intake, body weight, or daily insulin dosage among dogs fed HF and LF diets were not found. Mean preprandial serum glucose concentration, most postprandial serum glucose concentrations, 24-hour mean serum glucose concentration, and 24-hour urinary excretion of glucose were significantly lower in dogs fed the HF diet, compared with the LF diet.

CLINICAL IMPLICATIONS

Results of this study support feeding of commercially available insoluble fiber diets to dogs with naturally acquired diabetes mellitus.

Basic musculoskeletal assessment: tips for the home health nurse

Home care clients typically present with functional deficits that are frequently attributable to musculoskeletal abnormalities. This article teaches the home care nurse how to conduct a basic musculoskeletal assessment and how to use the findings to develop a thorough plan of care for the home care client.

Prospective trial using Virtual Vision as distraction technique in patients undergoing gastric laboratory procedures

To determine whether distraction techniques using Virtual Vision, an audiovisual system integrated into a modified pair of glasses, improves tolerance to routine gastric laboratory procedures, a prospective study of 50 patients was done. Patients were allowed to view/hear a travelogue tape during testing. Patients and registered nurses, who performed the procedure, were asked their interpretation of Virtual Vision as a device that improved patient tolerance, impaired the patient's ability to follow directions, or impaired the nurse's ability to perform the procedure. Patients graded the procedure from 1 (unbearable) to 5 (reasonably comfortable) and were asked whether they would use the device for a repeat procedure. For those who had undergone previous procedures, patients were queried regarding their preference for routine testing or Virtual Vision. Improved tolerance to procedures was noted in 82% of the patients as perceived by nurses and patients. Eighteen percent of the nurses and 8% of the patients thought that the auditory insert and glasses impaired the patient's ability to cooperate with the test, whereas 88% and 86%, respectively, thought that Virtual Vision was a valuable distraction technique. Using an ordinal scale for testing tolerance, patients graded their test at a mean of 3.8 (SD 1.25) and 82% expressed a desire to use the system in conjunction with future testing. Twenty-six of 33 patients (79%) who had undergone previous gastric laboratory testing preferred distraction techniques using Virtual Vision to conventional testing. Distraction techniques using a system such as Virtual Vision have the potential to improve patient tolerance to routine gastric laboratory studies.

Cognitive processing in post-traumatic stress disorder

Recent research has suggested an abnormal attentional bias to threat in anxiety disorders. We have assessed the processing of thoughts of trauma, panic attacks, general fear and positive affect in a cohort of 15 war veterans with post-traumatic stress disorder (PTSD) and an age- and sex-matched normal control group. Subjects with PTSD showed delayed processing of self-referential sentences when the themes of the sentences were traumatic experiences or positive affect, compared with controls. However, they were more efficient than control subjects in the processing of sentences describing situations of panic attacks and general fear. It would therefore appear that in patients with PTSD, cognitive processing is hindered by personally relevant themes of past traumatic experiences, whereas it may be facilitated by information related to general threat or internal body sensations of panic.

Effects of the anatomical region used for insulin injections on glycemia in type I diabetes subjects

OBJECTIVE

Subcutaneous insulin is absorbed at different rates from different anatomical regions, but it is not clear how much the varying rates of absorption affect plasma glucose concentrations in diabetic subjects. To address this issue, subcutaneous injections of insulin in the abdomen were compared with subcutaneous injections of insulin in the thigh.

RESEARCH DESIGN AND METHODS

In a crossover trial, 22 type I diabetic subjects received, in random order, a test dose of regular insulin injected subcutaneously in the abdomen on one morning and in a thigh on another morning. The subjects also received, in random order, usual morning doses of NPH and regular insulins injected subcutaneously in the abdomen on one morning and in a thigh on another morning. The study was performed in the University of Minnesota General Clinical Research Center. Main outcome measures were plasma glucose and serum free insulin.

RESULTS

After injections of regular insulin in the abdomen, the peak postprandial increment in plasma glucose was 3.1 mM or 29% lower (P < 0.001), the peak increment in serum free insulin was 54 pM or 38% higher (P = 0.017), and the length of time required to achieve peak serum free insulin was significantly shorter than after injections of regular insulin in the thigh. After injections of NPH and regular insulins in the abdomen, the morning peak increment in plasma glucose was 2.5 mM or 18% lower (P = 0.008) than after injections of NPH and regular insulins in a thigh. However, no significant difference was observed in the afternoon peak increment in plasma glucose.

CONCLUSIONS

A subcutaneous injection of regular insulin in the abdomen produced a substantially greater reduction in plasma glucose than an injection of regular insulin in the thigh. Changing the injection site of regular insulin from the abdomen to the thigh had an effect equivalent to reducing the dose administered. With injections of NPH and regular insulin in combination, the influence of the region used for injection was less but still potentially important.

Serial thyroid hormone concentrations in healthy euthyroid dogs, dogs with hypothyroidism, and euthyroid dogs with atopic dermatitis

Serum thyroxine (T4) and 3,5,3'-triiodothyronine (T3) concentrations were determined every 3 h for 12 h beginning at 8 a.m. in 20 healthy euthyroid dogs, 19 dogs with hypothyroidism, and 18 euthyroid dogs with atopic dermatitis. Status of thyroid function was based on history, physical findings, results of thyrotropin response testing, and requirement for thyroid hormone replacement therapy. Mean serum T4 and T3 concentrations did not vary significantly between blood samplings within each of the three groups of dogs. Between groups of dogs, mean serum T4 concentration was significantly (P less than 0.05) higher at each blood sampling time in healthy euthyroid dogs and euthyroid dogs with atopic dermatitis when compared to dogs with hypothyroidism. There was no significant difference in mean serum T4 concentration at any blood sampling time between healthy euthyroid dogs and euthyroid dogs with atopic dermatitis or in mean serum T3 concentrations at any blood sampling time between any of the three groups of dogs. Random fluctuation in serum T4 and T3 concentrations was found in dogs in all three groups. Random fluctuations were more common with serum T3 versus T4 concentrations. Consequently, sensitivity (0.88 versus 0.52), specificity (0.73 versus 0.45), predictive value for a positive test (0.75 versus 0.32), predictive value for a negative test (0.87 versus 0.65), and accuracy (0.80 versus 0.47) were better for serum T4 concentration than serum T3 concentration, respectively, when all blood samples were analysed. Measurement of serum T4 concentration was more accurate than serum T3 concentration in assessing the status of thyroid gland function.

Effect of glipizide on serum insulin and glucose concentrations in healthy cats

With the recent identification of non-insulin-dependent diabetes mellitus (NIDDM) in cats, new possibilities arise for the use of oral hypoglycaemic agents in the treatment of feline NIDDM, similar to their use in humans. To identify the future applicability of the oral hypoglycaemic agent, glipizide, in the treatment of feline NIDDM, its effects on serum insulin and glucose concentrations in healthy cats was examined. In addition, adverse effects seen clinically or on bloodwork following short-term use of the drug were looked for. Serum insulin and glucose concentrations were evaluated after the oral administration of 2.5, 5.0 and 10.0 mg glipizide and placebo in 10 healthy cats. For each drug trial, blood was obtained five minutes before, immediately before, and 7.5, 15, 30, 45, 60, 90 and 120 minutes after glipizide or placebo administration. Mean serum insulin concentration increased after glipizide administration, with peak mean serum insulin concentration occurring 15 minutes after administration and declining to baseline by 60 minutes. There was no significant difference in peak mean serum insulin concentration, mean serum insulin concentration at 60 minutes after glipizide administration, or mean total insulin secretion between the three glipizide dosages. Mean serum glucose concentration decreased within 15 minutes of glipizide administration, with the glucose nadir occurring 60 minutes after glipizide administration. Placebo trials showed no significant change in mean serum insulin or glucose concentrations from baseline concentrations.

Microvascular architecture of the elastase emphysemic hamster lung

Vascular corrosion casts of normal and elastase-induced emphysemic hamster lungs, prepared with a low viscosity resin mixture consisting of Mercox and Sevriton, were observed by scanning electron microscopy. Casts were quantitated by measuring vascular volume or determining non-alveolar air space using confocal laser scanning microscopy. Normal lung casts were characterized by well-organized fields of alveoli (about 70 microns in diameter) connected by distinct alveolar ducts. Emphysemic lung casts exhibited numerous bullae (often as large as 0.5 mm in diameter). The vasculature of the bullae indicated that they were formed by destruction of alveolar walls and subsequent coalescence of numerous alveolae. Remnants of alveolar walls, consisting of shallow ridges of capillaries, lined the bases of the bullae. Vascular volumes expressed as cast volume/total tissue volume were calculated at 20% and 12% for uninflated and inflated lungs, respectively, for both control and emphysemic lungs. Four months after elastase instillation, nonalveolar air space of the emphysemic lungs was increased by 73% over controls. These observations indicate that elastase emphysema results, initially, in remodeling of the alveolar structure (bullae formation) and loss of surface area for gas exchange, rather than from extensive loss of vasculature. Vascular corrosion casting is a useful technique for monitoring emphysema both morphologically and quantitatively.

Per capita income in breast cancer patients

The Wisconsin Department of Health and Human Services has identified breast cancer as the most common malignant neoplasm among women in Wisconsin. To determine the potential effectiveness of a program of low-cost screening mammography in reducing cancer morbidity and mortality in individuals of low socioeconomic status, the authors conducted a retrospective analysis of data from tumor registries. Using the tumor registries of two hospitals in Milwaukee, Wisconsin, the records of 323 patients with breast cancer were identified and analyzed for size of tumor at first presentation. These data were correlated with per capita income taken from census block information for the residence of each patient. The data indicate that mean income was lower for patients with more advanced disease. Other variables such as race did not influence tumor classification at initial presentation. Economically disadvantaged women present with more advanced breast cancers than affluent patients. This adverse circumstance may be the result of lack of financial resources and poor dissemination of information. Programs that recognize these problems are likely to be more successful in achieving earlier breast cancer detection.