Review of Breast Imaging in Transgender and Gender-Diverse Patients: Gender-Affirming Care, Histopathologic Findings, Breast Cancer Risk, and Screening Recommendations

Gender diversity, especially pertaining to transgender and gender-diverse (TGD) populations, is often stigmatized. A small but not insignificant number of adults in the United States identify as TGD, including transgender, nonbinary, and other gender identities than cisgender. Accessing health care remains a significant challenge for TGD individuals because many health care systems adhere to a gender binary model and many TGD individuals experience negative interactions when interfacing with health care. There is also a scarcity of literature addressing their unique health care needs, limiting our current understanding of breast cancer risks and screening recommendations for TGD patients. This article reviews important considerations when providing care to TGD patients. It covers background information on gender identity and sexuality, explores gender-affirming care, discusses histopathologic findings of breast biopsy specimens, examines breast cancer risks, and presents current breast cancer screening recommendations for TGD patients. Education on TGD breast cancer risks and screening and creating a standardized screening protocol for TGD patients who may receive gender-affirming care through hormonal and surgical therapies could help improve their health care equity and access.

Effectiveness of Community Education for Breast Cancer Screening

OBJECTIVE

Screening based on individual risk factors results in detection of earlier, more curable breast cancer. There is expectation that improved public education about the importance of personalized screening will result in earlier diagnoses and reduced breast cancer mortality. The purpose of this study is to evaluate the effectiveness of community education on patient perceptions about risk-based screening.

METHODS

This study is Health Insurance Portability and Accountability Act-compliant and institutional review board exempt. A standardized curriculum was used by radiologists and experts to conduct nine 1-hour patient education sessions between October 2018 and January 2019 about breast cancer risk factors and screening options. Patient participants completed voluntary, anonymous pre-event and post event surveys to determine if the presented educational program led to attitude changes. Survey results were summarized using statistical analysis including mean, median, range, and percentage of participants responding and comparison of pre- and post event fear and anxiety.

RESULTS

Of 336 education session participants, 59.5% (200/336) completed the pre-event and 44.3% (149/336) completed the post event surveys, Respondents reported decreased anxiety and fear regarding breast cancer screening following educational sessions, with 36.1% (64/178) reporting anxiety pre-event compared to 23.3% (31/133) post event, although the difference was not statistically significant (P = .96). Additionally, 64.7% (55/85) of participants stated they were more likely to schedule breast cancer screening based on individual risk factors, and 98.0% (145/148) of participants reported increased knowledge on post event surveys.

CONCLUSION

This study demonstrates the importance and effectiveness of community-based educational programs in increasing knowledge of risk-based screening and potentially reducing anxiety related to screening.

Breast Cancer Screening in the Intermediate-Risk Population: Falling Through the Cracks?

Breast cancer screening guidelines vary for women at intermediate risk (15%-20% lifetime risk) for developing breast cancer across jurisdictions. Currently available risk assessment models have differing strengths and weaknesses, creating difficulty and ambiguity in selecting the most appropriate model to utilize. Clarifying which model to utilize in individual circumstances may help determine the best screening guidelines to use for each individual.

Reducing Barriers and Strategies to Improve Appropriate Screening Mammogram Attendance in Women 75 Years and Older

Although breast cancer death rates have persistently declined over the last 3 decades, older women have not experienced the same degree in mortality reduction as younger women despite having more favorable breast cancer phenotypes. This occurrence can be partially attributed to less robust mammographic screening in older women, the propensity to undertreat with advancing age, and the presence of underlying comorbidities. With recent revisions to breast cancer screening guidelines, there has been a constructive shift toward more agreement in the need for routine mammographic screening to commence at age 40. Unfortunately, this shift in agreement has not occurred for cutoff guidelines, wherein the recommendations are blurred and open to interpretation. With increasing life expectancy and an aging population who is healthier now than any other time in history, it is important to revisit mammographic screening with advanced age and understand why older women who should undergo screening are not being screened as well as offer suggestions on how to improve screening mammogram attendance in this population.

Screening in Women With BRCA Mutations Revisited

Patients with BRCA1 or BRCA2 gene mutations are at high risk for the development of breast cancer. This article reviews the current evidence for breast cancer screening of patients with BRCA1 or BRCA2 pathogenic gene mutations if they have not undergone prophylactic mastectomy. It will review the current evidence-based imaging recommendations for different modalities and ages of screening initiation in screening this patient population at high risk. Special considerations in transgender BRCA1 and BRCA2 mutation carriers are also discussed.

Breast Cancer Screening for Women at Higher-Than-Average Risk: Updated Recommendations From the ACR

Early detection decreases breast cancer death. The ACR recommends annual screening beginning at age 40 for women of average risk and earlier and/or more intensive screening for women at higher-than-average risk. For most women at higher-than-average risk, the supplemental screening method of choice is breast MRI. Women with genetics-based increased risk, those with a calculated lifetime risk of 20% or more, and those exposed to chest radiation at young ages are recommended to undergo MRI surveillance starting at ages 25 to 30 and annual mammography (with a variable starting age between 25 and 40, depending on the type of risk). Mutation carriers can delay mammographic screening until age 40 if annual screening breast MRI is performed as recommended. Women diagnosed with breast cancer before age 50 or with personal histories of breast cancer and dense breasts should undergo annual supplemental breast MRI. Others with personal histories, and those with atypia at biopsy, should strongly consider MRI screening, especially if other risk factors are present. For women with dense breasts who desire supplemental screening, breast MRI is recommended. For those who qualify for but cannot undergo breast MRI, contrast-enhanced mammography or ultrasound could be considered. All women should undergo risk assessment by age 25, especially Black women and women of Ashkenazi Jewish heritage, so that those at higher-than-average risk can be identified and appropriate screening initiated.

Radiomic and deep learning characterization of breast parenchyma on full field digital mammograms and specimen radiographs: a pilot study of a potential cancer field effect

Purpose

In women with biopsy-proven breast cancer, histologically normal areas of the parenchyma have shown molecular similarity to the tumor, supporting a potential cancer field effect. The purpose of this work was to investigate relationships of human-engineered radiomic and deep learning features between regions across the breast in mammographic parenchymal patterns and specimen radiographs.

Approach

This study included mammograms from 74 patients with at least 1 identified malignant tumor, of whom 32 also possessed intraoperative radiographs of mastectomy specimens. Mammograms were acquired with a Hologic system and specimen radiographs were acquired with a Fujifilm imaging system. All images were retrospectively collected under an Institutional Review Board-approved protocol. Regions of interest (ROI) of 128×128  pixels were selected from three regions: within the identified tumor, near to the tumor, and far from the tumor. Radiographic texture analysis was used to extract 45 radiomic features and transfer learning was used to extract 20 deep learning features in each region. Kendall's Tau-b and Pearson correlation tests were performed to assess relationships between features in each region.

Results

Statistically significant correlations in select subgroups of features with tumor, near to the tumor, and far from the tumor ROI regions were identified in both mammograms and specimen radiographs. Intensity-based features were found to show significant correlations with ROI regions across both modalities.

Conclusions

Results support our hypothesis of a potential cancer field effect, accessible radiographically, across tumor and non-tumor regions, thus indicating the potential for computerized analysis of mammographic parenchymal patterns to predict breast cancer risk.

Acceptability of an mHealth breast cancer risk-reduction intervention promoting risk assessment, education, and discussion of risk in the primary care setting

BACKGROUND

Breast cancer risk assessment tools and risk reduction strategies have advanced significantly over the past few decades but are underutilized in practice, due in part to limited acceptability by patients and physicians. We implemented a tablet-based Breast Cancer Risk Education Intervention (BreastCARE) tailored towards increasing patients' knowledge about their individual risk of developing breast cancer, increasing patient-physician discussion of breast cancer risk reduction practices, and increasing participation in recommended screening.

METHODS

We surveyed patients and physicians who received the BreastCARE intervention and analyzed their satisfaction and acceptability of the intervention. We compared patient satisfaction measures by race/ethnicity and used multivariable logistic regression models to examine the effect of race/ethnicity on measures of patient satisfaction with the tablet-based risk assessment and with the breast cancer risk report. We also compared measures of physician satisfaction by resident vs. attending/NP status. Finally, we identified patients' and physicians' suggestions for implementation.

RESULTS

Overall, both patients and physicians were highly satisfied with BreastCARE, with some variation by patient race/ethnicity and breast cancer risk status. The risk assessment tool and accompanying risk report helped transmit complex information in an efficient way.

CONCLUSIONS

Patient self-administered risk assessment with a health education component at the point of care is acceptable for both patients and physicians, and represents a novel approach to facilitating health promotion. This risk assessment tool should be made routine in primary care accompanied by results that are easy for the patient to understand and actionable for the clinician.

Approach to Managing a Postmenopausal Patient

The case of a symptomatic, postmenopausal woman is presented and a full discussion of the approach to her management is discussed. Pertinent guidelines and scientific evidence are emphasized as support for the recommendations.

Screening Strategy Modification Based on Personalized Breast Cancer Risk Stratification and its Implementation in the National Guidelines - Pilot Study

Background

One of the most consistent models for estimating personalized breast cancer (BC) risk is the Tyrer-Cuzick algorithm that is incorporated into the International Breast Cancer Intervention Study (IBIS) software. Our main objective was to provide criteria for the classification of the Slovenian population, which has BC incidence below the European average, into risk groups, and to evaluate the integration of the criteria in Slovenian guidelines. Our main focus was on women age <50 with higher BC risk, since no organized BC screening is available for these women.

Methods

Slovenian age-specific BC risks were incorporated into IBIS software and threshold values of risk categories were determined. Risk categories were assigned according to the individual’s ten-year risk for women aged 40 and older, and lifetime risk for women between 20 and 39. To test the software, we compared screening strategies with the use vs. no use of IBIS.

Results

Of the 197 women included in the study IBIS assigned 75.1% to the BC risk group, and the rest to the moderately increased risk. Without IBIS 80 women were offered mammographic and 33 ultrasound screening. In contrast, 28 instead of 80 would have been offered mammographic screening and there would have been no referrals for ultrasound if IBIS had been used.

Conclusions

The Slovenian IBIS has been developed, tested and suggested for personalized breast cancer risk assessment. The implementation of the software with the consideration of Slovenian risk thresholds enables a more accurate and nationally unified assessment.

A Quality Improvement Initiative: Improving Mammogram Screening Rates Among Low-income Hispanic Women in Primary Care

BACKGROUND

Low-income women of predominantly Hispanic ethnicity between the ages of 50-74 who receive primary care services in a South Texas region experienced a 12% disparity gap for women completing a screening mammogram in the last 2 years when compared to Hispanic women nationally.

OBJECTIVE

The purpose of this quality improvement (QI) initiative is to design and implement interdisciplinary evidence-based interventions to improve the screening mammogram completion rates in a primary care clinical setting.

METHODS

Following a systematic review and selection of two evidence-based breast cancer risk screening tools, a pre-post intervention was conducted. The Knowledge-to-Action (KTA) framework was used to train staff and providers to implement the screening tools. The Breast Cancer Risk Assessment Tool (BCRAT) and the National Health Interview Survey (NHIS) provided triggers for initiating a screening mammogram.

RESULTS

Evidence-based screenings triggered mammogram initiation resulting in a 7.21% improvement in screening mammogram completion rates over a 3-month time period.

CONCLUSION/IMPLICATIONS FOR NURSING

The outcomes discussed in this report provide guidance for new policy considerations and clinical protocol initiatives along with processes to improve mammogram completion rates.

An Intervention Tool to Increase Patient-Physician Discussion of Lifestyle Risk Factors for Breast Cancer

Background: Risk assessment and discussion of lifestyle in primary care are crucial elements of breast cancer prevention and risk reduction. Our objective was to evaluate the impact of a breast cancer risk assessment and education tool on patient-physician discussion of behaviors and breast cancer risk. Materials and Methods: We conducted a randomized controlled trial with an ethnically and linguistically diverse sample of women, ages 40-74, from two primary care practices. Intervention participants completed a tablet computer-based Breast Cancer Risk Assessment and Education (BreastCARE) intervention in the waiting room before a scheduled visit. Both patients and physicians received an individualized risk report to discuss during the visit. Control patients underwent usual care. Telephone surveys assessed patient-physician discussion of weight, exercise, and alcohol use 1 week following the visit. Results: Among the 1235 participants, 27.7% (161/580) intervention and 22.3% (146/655) usual-care patients were high risk for breast cancer. Adjusting for clustering by physician, the intervention increased discussions of regular exercise (odds ratios [OR] = 1.94, 1.50-2.51) and weight (OR = 1.56, 1.23-1.96). There was no effect of the intervention on discussion of alcohol. Women with some college education were more likely to discuss their weight than those with high school education or less (OR = 1.75, 1.03-2.96). Similarly, non-English speakers were more likely to discuss their weight compared with English speakers (OR = 2.33, 1.04-5.22). Conclusions: BreastCARE is a feasible risk assessment tool that can successfully promote discussions about modifiable breast cancer risk factors between patients and primary care physicians.

Breast Cancer Chemoprevention: A Practical Guide for the Primary Care Provider

Several organizations, including the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the United States Preventive Services Task Force, recommend incorporation of breast cancer risk-based counseling and chemoprevention into routine well-woman care. However, primary care providers report both discomfort with and a lack of medical knowledge on this topic. In this review we present a practical, evidence-based guide for incorporating breast cancer risk assessment and chemoprevention into routine care. We advocate a stepwise approach consisting of: (1) risk assessment and communication, (2) selection of appropriate chemoprevention based on risk-benefit analysis, (3) shared decision-making regarding chemoprevention, and (4) management of chemoprevention side effects. We encourage providers to identify high-risk women and refer them to genetic counseling or a high-risk breast cancer clinic. For women who are not considered high risk, we suggest using the Gail model to estimate a woman's 5-year risk of invasive breast cancer. Usually, the benefits of chemoprevention outweigh the risks of chemoprevention once a woman's 5-year risk of invasive breast cancer reaches 3%. For these women there are several factors that need to be considered when selecting a chemoprevention agent, including patient preference, thrombotic history, menopausal status, absence or presence of a uterus, and bone mineral density. We advocate an evidence-based shared decision-making approach that reflects the woman's individual preferences when communicating risk and counseling about chemoprevention. After starting a chemoprevention agent, close follow-up is important as side effects of chemoprevention are common, including vasomotor symptoms and arthralgias. We also review evidence-based management of chemoprevention side effects.

Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR

Early detection decreases breast cancer mortality. The ACR recommends annual mammographic screening beginning at age 40 for women of average risk. Higher-risk women should start mammographic screening earlier and may benefit from supplemental screening modalities. For women with genetics-based increased risk (and their untested first-degree relatives), with a calculated lifetime risk of 20% or more or a history of chest or mantle radiation therapy at a young age, supplemental screening with contrast-enhanced breast MRI is recommended. Breast MRI is also recommended for women with personal histories of breast cancer and dense tissue, or those diagnosed by age 50. Others with histories of breast cancer and those with atypia at biopsy should consider additional surveillance with MRI, especially if other risk factors are present. Ultrasound can be considered for those who qualify for but cannot undergo MRI. All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk no later than age 30, so that those at higher risk can be identified and can benefit from supplemental screening.

Deep learning in breast cancer risk assessment: evaluation of convolutional neural networks on a clinical dataset of full-field digital mammograms

To evaluate deep learning in the assessment of breast cancer risk in which convolutional neural networks (CNNs) with transfer learning are used to extract parenchymal characteristics directly from full-field digital mammographic (FFDM) images instead of using computerized radiographic texture analysis (RTA), 456 clinical FFDM cases were included: a "high-risk" BRCA1/2 gene-mutation carriers dataset (53 cases), a "high-risk" unilateral cancer patients dataset (75 cases), and a "low-risk dataset" (328 cases). Deep learning was compared to the use of features from RTA, as well as to a combination of both in the task of distinguishing between high- and low-risk subjects. Similar classification performances were obtained using CNN [area under the curve [Formula: see text]; standard error [Formula: see text]] and RTA ([Formula: see text]; [Formula: see text]) in distinguishing BRCA1/2 carriers and low-risk women. However, in distinguishing unilateral cancer patients and low-risk women, performance was significantly greater with CNN ([Formula: see text]; [Formula: see text]) compared to RTA ([Formula: see text]; [Formula: see text]). Fusion classifiers performed significantly better than the RTA-alone classifiers with AUC values of 0.86 and 0.84 in differentiating BRCA1/2 carriers from low-risk women and unilateral cancer patients from low-risk women, respectively. In conclusion, deep learning extracted parenchymal characteristics from FFDMs performed as well as, or better than, conventional texture analysis in the task of distinguishing between cancer risk populations.

Association between Breast Parenchymal Complexity and False-Positive Recall From Digital Mammography Versus Breast Tomosynthesis: Preliminary Investigation in the ACRIN PA 4006 Trial

RATIONALE AND OBJECTIVES

We investigate associations between measures of mammographic parenchymal complexity and false-positive (FP) recall from screening with digital mammography (DM) versus digital breast tomosynthesis (DBT).

MATERIALS AND METHODS

We retrospectively analyzed data from 541 women recruited by the American College of Radiology Imaging Network 4006 trial, designed to evaluate callback and detection rates from screening with DM versus combined DM and DBT. Of these, 68 and 56 were FPs based on DM alone versus the combined DM/DBT readings, respectively. Mammographic complexity was quantified with computerized texture analysis and percent density. Logistic regression was performed to evaluate associations between extracted features and FP recall, after adjusting for age and number of previous benign biopsies. Odds ratios and area under the curve (AUC) of the receiver operating characteristic were used to assess association strength.

RESULTS

For DM, age, previous benign biopsies and texture features of correlation, inverse difference moment, sum average, and sum variance were deemed as significant predictors (P <.05) of FP recall, with an AUC = 0.77. For DBT, age was the only significant predictor of FP recall with AUC = 0.64. Using exploratory receiver operating characteristic thresholds for which no true-positives would be missed, a potential FP reduction of 23.5% and 8.9% was demonstrated, respectively, for DM alone versus DM/DBT.

CONCLUSION

Measures of breast complexity measured on 2D digital mammograms are indicative of the likelihood for FP recall from screening with DM, and could help identify women who could benefit from supplemental screening, including DBT.

Comparative analysis of image-based phenotypes of mammographic density and parenchymal patterns in distinguishing between BRCA1/2 cases, unilateral cancer cases, and controls

We statistically compare the contributions of parenchymal phenotypes to mammographic density in distinguishing between high-risk cases and low-risk controls. The age-matched evaluation included computerized mammographic assessment of breast percent density (PD) and parenchymal patterns (phenotypes of coarseness and contrast) from radiographic texture analysis (RTA) of the full-field digital mammograms from 456 cases: 53 women with BRCA1/2 gene mutations, 75 with unilateral cancer, and 328 at low risk of developing breast cancer. Image-based phenotypes of parenchymal pattern coarseness and contrast were each found to significantly discriminate between the groups; however, PD did not. From ROC analysis, PD alone yielded area under the fitted ROC curve (AUC) values of 0.53 ([Formula: see text]) and 0.57 ([Formula: see text]) in the classification task between BRCA1/2 gene-mutation carriers and low-risk women, and between unilateral cancer and low-risk women, respectively. In a round-robin evaluation with Bayesian artificial neural network (BANN) analysis, RTA yielded AUC values of 0.81 (95% confidence interval [0.71, 0.89]) and 0.70 (95% confidence interval [0.63, 0.77]) between the BRCA1/2 gene-mutation carriers and low-risk women, and between unilateral cancer and low-risk women, respectively. These results show that high-risk and low-risk women have different mammographic parenchymal patterns with significantly higher discrimination resulting from characteristics of the parenchymal patterns than just the breast PD.

Risk assessment, genetic counseling, and clinical care for hereditary breast cancer

During the last 30 years, key advances in the field of cancer genetics have improved identification of high-risk families in which cancer risk can be linked to mutations in cancer susceptible genes. Identification of individuals with heritable cancer risk may influence short- and long-term medical management issues. Heightened screening and risk reducing options can offer lifesaving interventions for the woman and family members who are at risk.

An alternative approach to selecting patients for high-risk screening with breast MRI

Current guidelines for adding breast MRI to annual screening mammography are based entirely upon stratification of risk, with a heavy focus on lifetime calculations. This approach is fraught with difficulty due to the reliance on mathematical models that vary widely in their calculations, the inherent age discrimination of using lifetime risks rather than short-term incidence, and the failure to incorporate mammographic density, the latter being an independent risk as well as the greatest predictor of mammographic failure. By utilizing a system of patient selection similar to what was used in the American College of Radiology Imaging Network (ACRIN) 6666 trial for multi-modality imaging, 33 women without a prior diagnosis of breast cancer were found to harbor mammographically occult carcinoma through MRI screening. These 33 patients represent a 2% yield, closely approximating the yields seen in prospective MRI screening trials of women at very high risk of breast cancer. Using the "~20-25%" minimum established by the American Cancer Society and later the National Comprehensive Cancer Network, the Gail model would have prompted the use of MRI in only 9 of 33 (27.3%) patients, the Claus model 1 of 33 (3%), and the Tyrer-Cuzick model 12 of 33 (36.4%). Using all three models and opting for the highest calculated risk, then including BRCA-positivity, still would have identified only 16 of 33 (48.5%) patients with occult breast cancer discovered by MRI. Only one patient was BRCA-positive, and none had lobular carcinoma in situ, while 6 of 33 patients (18.2%) had atypical ductal hyperplasia (ADH). Measures are proposed to refine patient selection for MRI screening through the use of short-term or categorical risks, mammographic density, while maintaining cost-effectiveness through longer MRI screening intervals.

Can mHealth Improve Risk Assessment in Underserved Populations? Acceptability of a Breast Health Questionnaire App in Ethnically Diverse, Older, Low-Income Women

BACKGROUND

Use of mobile health (mHealth) tools has expanded rapidly but little research has been done on its acceptability by low-income, diverse, older patient populations.

OBJECTIVE

To assess the attitudes of a diverse group of underserved women on the acceptability and usability of mHealth tools in a clinical setting using a breast health questionnaire application (app) at a public hospital mammography clinic.

METHODS

Semi-structured interviews were conducted in a breast-imaging center of an urban safety net institution from July-August 2012. Interviews included pre- and post-questions. Women completed the Athena breast health questionnaire app on an iPad and were asked about their experience and ways to improve the tool.

RESULTS

Fifteen women age 45-79 years from diverse ethnic and educational backgrounds were interviewed. The majority of women, 11 of 15, preferred the Athena app over a paper version and all the women thought the app was easy to use. Two Spanish-speaking Latinas preferred paper; and two women, with limited mobile phone use, did not have a preference. Many women indicated that it would be necessary to have staff available for instruction and assistance if the app were to be implemented.

CONCLUSIONS

mHealth tools are an acceptable, if not preferred, method of collecting health information for diverse, older, low-income women. Further studies are required to evaluate the reliability and accuracy of data collection using mHealth tools in underserved populations. mHealth tools should be explored as a novel way to engage diverse populations to improve clinical care and bridge gaps in health disparities.

'Suspect molecular signature' in blood as the indicator of undiagnosed breast cancer, cancer risk and targeted prevention

BACKGROUND

Breast cancer is a multifactorial disease with the highest incidence rates amongst all cancer types. Further, high levels of circulating tumour cells are a characteristic of breast cancer patients demonstrating a particular predisposition to the development of breast cancer metastatic disease. Actual diagnostic approaches are frequently unable to recognise early stages of tumour development which impairs individual outcomes. In contrast, predictive and preventive risk assessment and early diagnosis may lead to full recovery after surgical resection. Recently, the authors have reported about the construction of diagnostic windows, which could influence the molecular diagnostics of breast cancer.

MATERIAL AND METHODS

In a previous study, diagnostic windows for breast cancer risk assessment were analysed. Women with non-malignant breast diseases demonstrating molecular profiles similar to those of breast cancer patients were enrolled into this follow-up study. In the interviews, for patients identified as predisposed to cancer, a specialised questionnaire has been set up to characterise individual risk factors and estimate their potential impacts on cancer onset and progression.

RESULTS AND CONCLUSIONS

By utilising the technological tool of diagnostic windows, 13 individuals have been identified demonstrating molecular profiles typical for patients diagnosed with breast cancer. The current paper summarises the analytical results and makes statements to the application of the pathology-specific molecular profiles recognised as the technological tool for improved diagnostic approach, breast cancer risk assessment and preventive health care management. The necessity to create individual patient profiles and analyse the evolution of the molecular signature is justified for advanced medical services. Expert recommendations are provided to promote further developments in the field of advanced breast cancer management.