Average Risk For Breast Cancer Research Articles

Abbreviated Breast MRI for Supplemental Screening in Patients With Dense Breasts: Comparison of Baseline Versus Subsequent-Round Examinations.

Background: Abbreviated breast MRI (AB-MR) achieves a higher cancer detection rate (CDR) versus digital breast tomosynthesis when applied for baseline (i.e. first-round) supplemental screening in individuals with dense breasts. Limited literature has evaluated subsequent (i.e., sequential) AB-MR screening rounds. Objectives: This study aimed to compare outcomes between baseline and subsequent rounds of screening AB-MR in individuals with dense breasts at otherwise average risk of breast cancer. Methods: This retrospective study included patients with dense breasts and at otherwise average breast-cancer risk who underwent AB-MR for supplemental screening between December 20, 2016 and May 10, 2023. Clinical interpretations and results of recommended biopsies for AB-MR examinations were extracted from the EMR. Baseline and subsequent-round AB-MR examinations were compared. Results: The final sample included 2585 AB-MR examinations (2007 baseline, 578 subsequent-round) performed for supplemental screening in 2007 women (mean age, 57.1 years) with dense breasts. Among baseline examinations, 1658 (82.6%) were assessed as BI-RADS category 1 or 2, 171 (8.5%) as category 3, and 178 (8.9%) as category 4 or 5. Among subsequent-round examinations, 533 (92.2%) were assessed as BI-RADS category 1 or 2, 20 (3.5%) as category 3, and 25 (4.3%) as category 4 or 5 (p<.001). Abnormal interpretation rate (AIR) was 17.4% (349/2007) among baseline examinations, versus 7.8% (45/578) among subsequent-round examinations (p<.001). Among baseline examinations, PPV2 was 21.3% (38/178), PPV3 was 26.6% (38/143), and CDR was 18.9 per 1000 (38/2007). Among subsequent-round examinations PPV2 was 28.0% (7/25) (p=.45), PPV3 was 29.2% (7/24) (p=.81), and CDR was 12.1 per 1000 (7/578) (p=.37). All 45 cancers diagnosed by baseline or subsequent-round AB-MR were stage 0 or 1. Seven cancers diagnosed by subsequent-round AB-MR had a mean interval since prior AB-MR of 872 days, size of 0.3-1.2 cm, and node-negative status at surgical axillary evaluation. Conclusion: Subsequent rounds of AB-MR screening in individuals with dense breasts had lower AIR compared to baseline examinations while maintaining high CDR. All cancers detected by subsequent-round examinations were early-stage node-negative cancers. Clinical Impact: The findings support sequential AB-MR for supplemental screening in individuals with dense breasts. Further investigations are warranted to optimize the screening interval.

Decision support for breast cancer screening decisions: A single case pre-/post-test study.

Canadian guidelines recommend shared decision making for women less than 50 years old who are considering breast cancer screening. Nurses can support women in making these decisions. This single case pre-/post-test study measured change in decisional conflict after decision support for a woman less than 50 years old considering whether or not to initiate mammography screening. At baseline, a 44-year-old female at average risk of breast cancer was experiencing decisional conflict. She scored 1 out of 4 on the SURE test indicating feeling uninformed, unclear values, and inadequate support. After receiving decision coaching with a breast cancer screening decision aid by a nurse trained in decision coaching, she scored 4 on the SURE test indicating no decisional conflict. She reached an informed decision consistent with her values about mammography screening. Providing decisional support improved her knowledge, reduced her decisional conflict, and enhanced her confidence in making an informed decision that was consistent with her values.

Mammography followed by ultrasonography compared to mammography alone for breast cancer screening in women at average risk of breast cancer (Russian translation of the Plain Language Summary (PLS) of the Cochrane Systematic Review)

Mammography followed by ultrasonography compared to mammography alone for breast cancer screening in women at average risk of breast cancer (Russian translation of the Plain Language Summary (PLS) of the Cochrane Systematic Review)

Breast cancer risk factors and mammographic density among 12518 average-risk women in rural China

BackgroundMammographic density (MD) is a strong risk factor for breast cancer. We aimed to evaluate the association between MD and breast cancer related risk factors among average-risk women in rural China.MethodsThis is a population-based screening study. 12518 women aged 45–64 years with complete MD data from three maternal and childcare hospitals in China were included in the final analysis. ORs and 95%CIs were estimated using generalized logit model by comparing each higher MD (BI-RADS b, c, d) to the lowest group (BI-RADS a). The cumulative logistic regression model was used to estimate the ORtrend (95%CI) and Ptrend by treating MD as an ordinal variable.ResultsOlder age (ORtrend = 0.81, 95%CI: 0.79–0.81, per 2-year increase), higher BMI (ORtrend = 0.73, 95%CI: 0.71–0.75, per 2 kg/m2), more births (ORtrend = 0.47, 95%CI: 0.41–0.54, 3 + vs. 0–1), postmenopausal status (ORtrend = 0.42, 95%CI: 0.38–0.46) were associated with lower MD. For parous women, longer duration of breastfeeding was found to be associated with higher MD when adjusting for study site, age, BMI, and age of first full-term birth (ORtrend = 1.53, 95%CI: 1.27–1.85, 25 + months vs. no breastfeeding; ORtrend = 1.45, 95%CI: 1.20–1.75, 19–24 months vs. no breastfeeding), however, the association became non-significant when adjusting all covariates. Associations between examined risk factors and MD were similar in premenopausal and postmenopausal women except for level of education and oral hormone drug usage. Higher education was only found to be associated with an increased proportion of dense breasts in postmenopausal women (ORtrend = 1.08, 95%CI: 1.02–1.15). Premenopausal women who ever used oral hormone drug were less likely to have dense breasts, though the difference was marginally significant (OR = 0.54, P = 0.045). In postmenopausal women, we also found the proportion of dense breasts increased with age at menopause (ORtrend = 1.31, 95%CI: 1.21–1.43).ConclusionsIn Chinese women with average risk for breast cancer, we found MD was associated with age, BMI, menopausal status, lactation, and age at menopausal. This finding may help to understand the etiology of breast cancer and have implications for breast cancer prevention in China.

Trends in breast cancer screening during the COVID-19 pandemic within a universally insured health system in theUnited States, 2017-2022.

In the United States, breast cancer is the most commonly diagnosed cancer and second leading cause of cancer death in women. Early detection through mammogram screening is instrumental in reducing mortality and incidence of disease. The COVID-19 pandemic posed unprecedented challenges to the provision of care, including delays in preventive screenings. We examined trends in breast cancer screening during the COVID-19 pandemic in a universally insured national population and evaluated rates across racial groups and socioeconomic strata. In this retrospective open cohort study, we used the Military Health System Data Repository to identify female TRICARE beneficiaries ages 40-64 at average risk for breast cancer between FY2018 and FY2022, broken down into prepandemic (September 1, 2018-February 28, 2020), early pandemic (March 1, 2020-September 30, 2020), and late pandemic periods (October 1, 2020-September 30, 2022). The primary outcome was receipt of breast cancer screening. Screening dropped 74% in the early pandemic period and 22% in the late pandemic period, compared with the prepandemic period. Compared with White women, Asian/Pacific Islander women were less likely to receive mammograms during the late pandemic period (0.92RR; 0.90-0.93 95%CI). American Indian/Alaska Native women remained less likely to receive screenings compared with White women during the early (0.87RR; 0.80-0.94 95% CI) and late pandemic (0.94RR, 0.91-0.98 95% CI). Black women had a higher likelihood of screenings during both the early pandemic (1.10RR; 1.08-1.12 95% CI) and late pandemic (1.12RR, 1.11-1.13 95% CI) periods compared with White women. During the early and late pandemic periods, disparities by rank persisted from prepandemic levels, with a decrease in likelihood of screenings across all sponsor ranks. Our results indicate the influence of race and socioeconomics on mammography screening during COVID-19. Targeted outreach and further evaluation of factors underpinning lower utilization in these populations are necessary to improve access to preventative services across the population.

Providers Respond to USPSTF Report on Screening for Breast Cancer

Providers Respond to USPSTF Report on Screening for Breast Cancer

Testing Theory-Based Messages to Encourage Women at Average Risk for Breast Cancer to Consider Biennial Mammography Screening.

The US Preventive Services Task Force does not recommend routine annual mammography screening for women aged 40-49 at average risk. Little research has been done to develop theory-based communication interventions to facilitate informed decision-making about reducing potentially low-value mammography screening. Evaluate the effects of theory-based persuasive messages on women's willingness to consider delaying screening mammography until age 50 or have mammograms biennially. We conducted a randomized controlled communication experiment online with a population-based sample of U.S. women aged 40-49 (N = 383) who screened to be at average risk for breast cancer. Women were randomly assigned to the following messaging summaries: annual mammography risks in 40s (Arm 1, n = 124), mammography risks plus family history-based genetic risk (Arm 2, n = 120), and mammography risks, genetic risk, and behavioral alternatives (Arm 3, n = 139). Willingness to delay screening or reduce screening frequency was assessed post-experiment by a set of 5-point Likert scale items. Women in Arm 3 reported significantly greater willingness to delay screening mammography until age 50 (mean = 0.23, SD = 1.26) compared with those in Arm 1 (mean = -0.17, SD = 1.20; p = .04). There were no significant arm differences in willingness to reduce screening frequency. Exposure to the communication messages significantly shifted women's breast cancer-related risk perceptions without increasing unwarranted cancer worry across all three arms. Providing women with screening information and options may help initiate challenging discussions with providers about potentially low-value screening.

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk.

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk.

Abstract P1-05-32: Outcomes of diagnostic breast imaging in young women (less than 50 years old)

Abstract INTRODUCTION The incidence of breast cancer is on the rise in the younger population, with 23 percent of all breast cancer diagnoses occurring in those under the age of 50. In Canada, screening mammography in women at average risk of breast cancer is recommended after the age of 50. Breast cancer in younger women is biologically more aggressive with greater rates of recurrence and metastatic disease. The sensitivity of mammograms to detect clinical breast abnormalities may be reduced due to increased breast density in this age group, leading to potential delayed diagnosis and poor outcomes. The frequency of false-negative diagnostic mammograms in young women is unknown. The purpose of this study is to describe the outcomes of diagnostic breast imaging in young women undergoing investigations for abnormal clinical breast findings and the frequency of delayed breast cancer diagnosis (more than 6 months after initial diagnostic mammography). METHODS We conducted a retrospective electronic chart review in women at average risk of breast cancer, aged between 30 and 50, who underwent diagnostic mammograms and/or breast ultrasounds (US) at our institution between 2018 to 2019 for symptomatic clinical presentations (breast pain, palpable mass, nipple discharge or breast skin changes). Patients undergoing routine screening mammograms were excluded. We collected demographics, findings of initial and follow-up breast imaging (using the Breast Imaging Reporting and Data System (BI-RADS) &amp; breast density), and breast cancer diagnosis timelines where applicable. The primary outcome measure was the frequency of delayed breast cancer diagnosis defined as &amp;gt; 6 months from initial diagnostic imaging. Secondary outcomes included completion of recommended follow-up investigations and their outcomes, total number of breast cancer diagnoses and stage. The study was approved by the local research ethics board and the results were summarized using descriptive analysis. RESULTS We reviewed 400 electronic charts and identified 171 eligible patients. Mean age was 38 years; initial breast imaging included both diagnostic mammogram and US in 168 (87%), US alone in 20 (12%) and mammogram alone in 3 (2%) patients. Breast density was not routinely reported during this time frame. Ninety patients (53%) had benign findings (BIRADS 1 and 2), 41 (24%) had probable benign findings requiring short-term follow-up (BIRADS 3) while 30 (18%) patients had findings suspicious of malignancy (BIRADS 4&amp;5) with biopsy recommended for diagnosis. In the BIRADS 3 group, 93% had recommended follow-up at a median of 7.6 months. Breast US alone was the most common subsequent investigation of which 15 % were benign lesions (BIRADS 1 &amp; 2) and 68% remained in the BIRADS 3 category, while none were scored BIRADS 4 or 5. Among patients with BIRADS 4 &amp; 5 scores, 83% underwent recommended biopsy at a median time of 3 weeks. Ten (6%) out of all 171 patients were diagnosed with breast cancer, all of which had BIRADS 4 or 5 on initial diagnostic imaging. Stage distribution was as follows: stage 0 - 2 patients, stage 1- 7 patients and stage 2 - 1 patients with no locally advanced or metastatic disease. The mean time from initial imaging to breast cancer diagnosis was 1.5 weeks (range 1 to 22 weeks). None of the patients had delayed breast cancer diagnosis in our cohort. CONCLUSION More than half of patients with clinical breast findings in our cohort had benign findings on diagnostic mammogram and/or US (BIRADS 1&amp;2) with no subsequent breast diagnosis. Majority of patients requiring further investigations (BIRADS 0, 3, 4 and 5) underwent recommended follow-up (imaging or biopsy). Ultimately, a total of 10 patients were diagnosed with breast cancer at a median time of 1.5 weeks from original diagnostic imaging with no delayed breast cancer diagnosis. We, therefore, conclude that diagnostic mammograms and US are appropriate diagnostic investigations for clinical breast concerns in women between 30-50 years. Citation Format: Navdeep Dehar, Joseph N. Samuel, Doris Jabs, Wilma Hopman, Mihaela Mates. Outcomes of diagnostic breast imaging in young women (less than 50 years old) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-05-32.

Abstract P2-05-03: Perceived Guideline Clarity &amp; Deferral to Patient Preferences impact guideline concordant care for breast cancer screening in women age 40-49

Abstract Background: Canadian and US Task Forces recommend against routine mammography screening for women age 40-49 at average breast cancer risk on the basis that harms outweigh the benefits. Both cite the importance of supporting women’s individualized decisions based on the relative value placed on potential benefits and harms of screening (2, 4). Population-based data reveal that screening rates in this age group are influenced by the woman’s primary care provider (PCP), suggesting some providers refer more often than others. This highlights the need to explore PCP perspectives on screening and how this informs clinical behaviour. Methods: Qualitative semi-structured interviews were performed by phone with PCPs in Ontario, Canada. Interviews were structured using the Theoretical Domains Framework (TDF) to explore determinants (barriers/facilitators) of three screening-related behaviours: 1) conducting a risk assessment; 2) discussion regarding benefits and harms; and 3) making a decision regarding referral for mammographic screening. Analysis: Interviews were transcribed and analyzed iteratively until saturation was reached. Two independent researchers coded all transcripts deductively both by behaviour and according to TDF domain. Findings that did not fit within a TDF code were coded inductively. Data were then grouped by screening behaviour and the associated codes were used to generate descriptive narratives of the determinants influencing PCP behaviour. Results: Eighteen physicians (mean age 48, 72% identified female) were interviewed. Table 1 outlines the determinants of the three screening behaviours. Analysis of inductive codes revealed two key contextual themes that influenced behaviours and moderated TDF codes: perceived guideline clarity (a lack of clarity on which behaviours (if any) were guideline-concordant) and deferral to patient preference (patient decision regarding screening without a complete discussion of benefits and harms). PCPs who perceived that the guidelines stated definitively that screening was not recommended had improved knowledge of harms and stronger beliefs about capabilities to educate patients about why screening was not recommended routinely. Deferral to patient preference seemed to occur when PCP’s knowledge was low and/or if they were impacted by experience of a younger woman diagnosed with breast cancer, which often led to anticipated regret (TDF domain: emotion). Discussion/Conclusion: Low knowledge related to formal breast cancer risk assessment, combined with a tendency to over-estimate benefits of screening relative to harms could explain some inappropriate variation in practice. All 3 PCP screening behaviours appeared to be affected by both perceived guideline clarity and deferral to patient preferences. These may all be effective targets for future interventions to address variation in care. Table 1: Unique Barriers and Facilitators of Three Screening Behaviours Citation Format: Michelle Nadler, Ann Marie Corrado, Brooke E. Wilson, Alexandra Desnoyers, Eitan Amir, Noah Ivers, Laura Desveaux. Perceived Guideline Clarity &amp; Deferral to Patient Preferences impact guideline concordant care for breast cancer screening in women age 40-49 [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-05-03.

Abstract P5-04-05: Predictors of guideline-incongruent breast cancer screening in an urban comprehensive cancer center

Abstract Background: Guideline-congruent breast cancer (BC) screening is imperative to systematically curb BC mortality. This study was conducted to identify predictors of BC screening behaviors congruent with guidelines from various nationally recognized organizations (e.g, American Cancer Society, National Comprehensive Cancer Network, American College of Radiology) among high- and average-risk women, and to elucidate the alternative screening behaviors of women who were incongruently screened. Methods: Medical records of 6,090 women who received at least two screening mammograms from January 2016 to March 2018 at the Karmanos Cancer Institute were reviewed to determine breast cancer risk status (classified by the Tyrer-Cuzick model) and breast density status to determine whether breast cancer screening was concordant with risk-driven screening guidelines. Breast density was determined by BI-RADS density scoring, with non-dense breasts defined by a score of A or B, and dense breasts as C or D. For women at average-risk of breast cancer, incongruent screening was defined as receiving supplemental imaging in the interval between screening mammograms. For high-risk women, incongruent screening was defined as not having a recommended supplemental image in the interval between screening mammograms. Further, we examined BC risk, breast density, age, and race as predictors for guideline-concordant screening. Results: The screening cohort included 73.3% Black and 26.7% White women of whom 86.5% were classified as average-risk, 7.7% intermediate risk and 5.8% high risk. Further analyses focused on women with average and high-risk of breast cancer. Among both average- and high-risk women, 390 (6.9%) were incongruently screened, however the rate of incongruent screening was much higher among high-risk vs. average risk women (97.7 vs. 0.9%, p&amp;lt; 0.01). Among average-risk women, incongruent screening was more likely among women with dense vs. non-dense breasts (2.0% vs 0.1%, p&amp;lt; .01). High-risk women were more likely to be incongruently screened if they had non-dense compared to dense breasts (99.5% vs 95.2%, p &amp;lt; .01). Younger women more likely to be incongruently screened among average-risk women (55.11 [SD = 10.24] vs 62.20 [SD = 9.73]; t5267 = 4.87, p &amp;lt; .01, d = 0.73), whereas older women were more likely to be incongruently screened among high-risk women, although this difference was not statistically significant (52.38 [SD = 7.27] vs 47.50 [SD = 8.57]; t351 = 1.87, p = .06, d = 0.67).There was no significant impact of race and incongruent screening for individual risk-level categories. With the exception of rendering the age effect non-significant, preliminary multivariable analyses did not significantly change the results. Further analyses will be conducted to assess the relationship between predictive factors and incongruent screening. Conclusions: An apparent lack of adherence to evidence-based screening guidelines for BC has led to underutilization of supplementary breast imaging for women at high-risk for BC. Further interventions are needed to promote increased supplemental imaging for this group of women. Citation Format: Alexandra Wehbe, Madeleine Gonte, Suzanne O’Neill, Alit Amit-Yousif, Kristen Purrington, Mark Manning, Michael Simon. Predictors of guideline-incongruent breast cancer screening in an urban comprehensive cancer center [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-04-05.

Perceived guideline clarity impacts guideline-concordant care for breast cancer screening in women age 40–49

BackgroundCanadian and US Task Forces recommend against routine mammography screening for women age 40–49 at average breast cancer risk as harms outweigh benefits. Both suggest individualized decisions based on the relative value women place on potential screening benefits and harms. Population-based data reveal variation in primary care professionals (PCPs) mammography rates in this age group after adjusting for sociodemographic factors, highlighting the need to explore PCP screening perspectives and how this informs clinical behaviours. Results from this study will inform interventions that can improve guideline concordant breast screening for this age group.MethodsQualitative semi-structured interviews were performed with PCPs in Ontario, Canada. Interviews were structured using the theoretical domains framework (TDF) to explore determinants of breast cancer screening best-practice behaviours: (1) risk assessment; (2) discussion regarding benefits and harms; and (3) referral for screening.AnalysisInterviews were transcribed and analyzed iteratively until saturation. Transcripts were coded deductively by behaviour and TDF domain. Data that did not fit within a TDF code were coded inductively. The research team met repeatedly to identify potential themes that influenced or were important consequences of the screening behaviours. The themes were tested against further data, disconfirming cases, and different PCP demographics.ResultsEighteen physicians were interviewed. The theme of perceived guideline clarity (a lack of clarity on guideline-concordant practices) influenced all behaviours and moderated the extent to which the risk assessment and discussion occurred. Many were unaware of how risk-assessment factored into the guidelines and/or did not perceive that a shared-care discussion was guideline-concordant. Deferral to patient preference (screening referral without a complete discussion of benefits and harms) occurred when the PCPs had low knowledge regarding harms and/or if they experienced regret (TDF domain: emotion) resulting from prior clinical experiences. Older providers described patient’s influence impacting their decisions and physicians trained outside Canada, practicing in higher-resourced areas, and female physicians described being influenced by beliefs about consequences of benefits of screening.ConclusionPerceived guideline clarity is an important driver of physician behaviour. Improving guideline concordant care should start by clarifying the guideline itself. Thereafter, targeted strategies include building skills in identifying and overcoming emotional factors and communication skills important for evidence-based screening discussions.

Changes in mammography screening in Ontario and Alberta following national guideline dissemination: an interrupted time series analysis.

Background:In November 2011, the Canadian Task Force on Preventive Health Care released guidelines for screening women at average breast cancer risk. Weak recommendations (framed using GRADE methodology) were made for screening women aged 50 to 74 years every two to three years, and for not screening women aged 40 to 49 years. Methods:We conducted an interrupted time series analysis using administrative data to examine bilateral mammography use before and after a release of a national breast screening guideline. Women aged 40 to 74 years living in Ontario or Alberta from 30th November 2008 to 30th November 2014 were included. Strata included age, region of residence, neighbourhood income quintile, immigration status, and education level. Results:In both provinces, mammography use rates were lower in the post-intervention period (527 vs. 556 and 428 vs. 465/1000 women in Ontario and Alberta, respectively). In Ontario, mammography trends decreased following guideline release to align with recommendations for women aged 40 to 74 (decrease of 2.21/1000 women, SE 0.26/1000, p<0.0001). In Alberta, mammography trends decreased for women aged 40 to 49 years (3/1000 women, SE 0.32, p<0.001) and 50 to 69 (2.9/1000 women, SE 0.79, p<0.001), but did not change for women aged 70 to 74 (0.7/1000 women, SE 1.23, p=0.553). In both provinces, trends in mammography use rates were sustained for up to three years after guideline release. Conclusions:We observed a decrease in screening for women aged 40-49. Additional research to explore whether shared decision making was used to optimize guideline-concordant screening for women aged 50-74 is needed.

Association of disability with long-term noncompliance of breast cancer screening.

118 Background: Although the U.S. Preventive Services Task Force (USPSTF) recommends a biennial screening mammography for women aged 50 to 74 years at average risk for breast cancer, 24.6% of screening-eligible women do not follow the recommendation. Very little is known regarding the association between various types of disabilities and subsequent breast cancer screening behaviors following the initiation of screening mammography. This study examines the association of disability with short-term vs. long-term noncompliance of having a mammogram. Methods: Using data from 2016, 2018, and 2020 Behavioral Risk Factor Surveillance System annual surveys, we constructed the study cohort of women aged 55 to 74 years who did not have a cancer history and who received a mammogram at least once in the past. Outcomes are short-term (2 years) and long-term (5 years) noncompliance of USPSTF recommendations. Key independent variables are six binary variables of standard functional disability conditions (hearing, vision, cognition, ambulation, self-care, and independent living) in the first model and a categorized total number of disabilities (0, 1, 2, ≥3) in the second model. We employed a multivariable logistic regression model, adjusting individuals’ socio-demographics, general health status, chronic conditions, health risk factors, and metropolitan statistical areas (MSA), and accounting for complex survey design. Results: Among the study cohort (n = 232,143; weighted n = 29,358,431), 18.1% and 7.1% of women reported not having mammography in the past two and five years, respectively, representing short- vs. long-term noncompliance. Of the study cohort, 32.8% had any type of disability (ambulation 22.7%, cognition 11.0%, independent living 8.8%). Notably, the long-term noncompliance rate was highest among women with a disability and residing in non-MSA (10.2%). In multivariable analysis, while only disability in independent living was associated with short-term noncompliance (odds ratio [OR] 1.28; 95% confidence interval [CI] 1.15-1.42), disability in independent living (OR 1.34; 95% CI 1.18-1.52), vision (OR 1.15; 95% CI 1.01-1.32) and ambulation (OR 1.12; 95% CI 1.01-1.24) were all significantly associated with long-term noncompliance. Women with ≥3 disabilities were 1.64 times more likely to be non-compliant in the long term, and the association of disability with noncompliance was more pronounced in non-MSA. Conclusions: This study provides the first empirical evidence on the positive association between disability and screening noncompliance, especially in the long term. It suggests disability could aggravate disparities in timely access to cancer screening, particularly in non-MSA. Understanding how various types of disabilities affect screening behavior is a critical step for public health efforts in cancer prevention and control through identifying vulnerable subgroups for targeted interventions.

Operating on Anxiety: Negative Affect toward Breast Cancer and Choosing Contralateral Prophylactic Mastectomy.

Rates of contralateral prophylactic mastectomy (CPM)-removal of the healthy breast following breast cancer diagnosis-have increased, particularly among women for whom CPM provides no survival benefit. Affective (i.e., emotional) decision making is often blamed for this increase. We studied whether greater negative breast cancer affect could motivate uptake of CPM through increased cancer risk perceptions and biased treatment evaluations. We randomly assigned healthy women with average breast-cancer risk (N = 1030; Mage = 44.14, SD = 9.23 y) to 1 of 3 affect conditions (negative v. neutral v. positive narrative manipulation) in a hypothetical online experiment in which they were asked to imagine being diagnosed with cancer in one breast. We assessed 1) treatment choice, 2) affect toward CPM, and 3) perceived risk of future breast cancer in each breast (cancer affected and healthy) following lumpectomy, single mastectomy, and CPM. The manipulation caused women in the negative and neutral narrative conditions (26.9% and 26.4%, respectively) to choose CPM more compared with the positive narrative condition (19.1%). Across conditions, women's CPM affect did not differ. However, exploratory analyses addressing a possible association of affect toward cancer-related targets suggested that women in the negative narrative condition may have felt more positively toward CPM than women in the positive narrative condition. The manipulation did not have significant effects on breast cancer risk perceptions. The manipulation of affect had a small effect size, possibly due to the hypothetical nature of this study and/or strong a priori knowledge and attitudes about breast cancer and its treatment options. Increased negative affect toward breast cancer increased choice of CPM over other surgical options and might have motivated more positive affective evaluations of CPM. This study used narratives to elicit different levels of negative integral affect toward breast cancer to investigate the effects of affect on breast cancer treatment choices.Increased negative affect toward breast cancer increased the choice of double mastectomy over lumpectomy and single mastectomy to treat a hypothetical, early-stage cancer.The narrative manipulation of negative affect toward breast cancer did not change the perceived risks of future cancer following any of the surgical interventions.Negative affect toward breast cancer may have biased affective evaluations of double mastectomy.

Breast cancer screening in average and high-risk women.

Breast cancer is the most common cancer among females worldwide with rising incidence. In the United States, screening mammography and advances in therapy have lowered mortality by 41% since 1990. Screening mammography is supported by randomized control trials (RCT), observational studies, and computer model data. Digital breast tomosynthesis is a new technology that addresses limitations in mammography resulting from overlapping breast tissue, improving its sensitivity and specificity. Patients at high risk for breast cancer include those with a ≥20% lifetime risk, high-risk germline mutation, or history of thoracic radiation treatment between 10-30 years of age. Such patients are recommended to undergo annual screening mammography and adjunctive annual screening breast MRI. Patients unable to undergo MRI may undergo whole breast ultrasound or contrast-enhanced mammography. Pregnant and lactating patients at average risk for breast cancer are recommended to undergo age-appropriate screening mammography.

Racial disparities in the screening mammography continuum within a diverse healthcare system.

e18580 Background: Racial disparities in breast cancer have been extensively characterized in the literature. Access to screening mammography is a significant contributor to breast cancer disparities. Decreased access to mammography translates into disparities in breast cancer through delayed presentation to care. The USPSTF recommends biannual screening mammography of women 50-74 with average risk for breast cancer. Methods: We conducted a cross-sectional analysis of encounter-level data for Black and white female primary care patients aged 50-74 in the University of Washington Medicine system who were due for mammogram in 2019. Completion of steps of the mammography continuum (referral, scheduling, and completion of mammogram) were compared among Black and white women. Multivariable logistic regression was used to explore race and mammogram completion, adjusting for age, language, referral, insurance, clinical site, wellness visit utilization, and history of prior mammogram. Results: The study population comprised 18,156 women of whom 2,059 (11.3%) were Black and 16,097 (88.7%) were white. Among Black women, 26.8% were referred to screening mammogram, 12.9% self-referred, 39.3% were scheduled, and 21.4% completed their mammogram, compared to 21.1%, 20.6%, 41.4%, and 26.9% among white women respectively. The greatest attrition among Black women was in the step of completing a mammogram after it was scheduled, which was higher seen in white women at the same step. Adjusted analyses demonstrated an association between Black race and lower rates of screening mammography completion (OR 0.85, [95% CI 0.78-0.98], p = 0.02). Conclusions: Our analysis assessed racial disparities in steps of the screening mammography continuum in a large, diverse health system. Black race was associated with lower screening mammography completion after adjustment for several covariates. Provider-initiated referral was higher for Black women, while self-referral was higher for white women. Both Black and white women experienced highest attrition from no-show rates for scheduled mammograms, though attrition was greater for Black women. These findings have systems implications for future interventions, such as patient navigators or system-driven nudges, to mitigate disparities in breast cancer screening. [Table: see text]

Inclusion of the US Preventive Services Task Force Recommendation for Mammography in State Comprehensive Cancer Control Plans in the US

The recommendations for the age and frequency that women at average risk for breast cancer should undergo breast cancer mammography screening have been a matter of emotional, political, and scientific debate over the past decades. Multiple national organizations provide recommendations for breast cancer screening age and frequency. US Centers for Disease Control and Prevention (CDC) funding for state comprehensive cancer control (CCC) planning requires compliance with stated objectives for attaining goals. US Preventive Services Task Force (USPSTF) recommendations on cancer prevention and control are currently used to require coverage of prevention services. To evaluate the consistency of state CCC plan objectives compared with the most current (2016) USPSTF recommendations for the age and frequency that individuals should undergo mammography screening and to make recommendations for improvement of state CCC plans. This cross-sectional study used a descriptive, point-in-time evaluation and was conducted from November 1, 2019, to June 30, 2021. In November 2019, the most recent CCC plans from 50 US states and the District of Columbia were downloaded from the CDC website. The recommended ages at which to begin and end mammography examinations and the frequency of mammography examinations were extracted from plan objectives. The recommendations found in CCC plan objectives regarding the ages at which to begin and end mammography examinations and the frequency of mammography examinations for women with average risk for breast cancer were compared with USPSTF recommendations. Of the 51 CCC plans, 16 (31%) were consistent with all USPSTF recommendations for age and frequency that women at average risk should undergo mammography. Twenty-six plans (51%) were partially consistent with recommendations, and 9 plans (18%) were not consistent with any of the 3 guideline components. Compared with the USPSTF recommendation, state CCC plans are not homogenous regarding the age and frequency that women at average risk for breast cancer should undergo mammography. This variation is partially due to differences in state-specific planning considerations and discretion, variations in recommendations among national organizations, and publication of plans prior to the most current USPSTF recommendation (2016). Specifying the concept that high-risk populations need different age and frequency of screening recommendations than the general population may reduce heterogeneity among plans.

Downstream Mammary and Extramammary Cascade Services and Spending Following Screening Breast Magnetic Resonance Imaging vs Mammography Among Commercially Insured Women

Increasing use of screening breast magnetic resonance imaging (MRI), including among women at low or average risk of breast cancer, raises concerns about resulting mammary and extramammary cascades (downstream services and new diagnoses) of uncertain value. To estimate rates of cascade events (ie, laboratory tests, imaging tests, procedures, visits, hospitalizations, and new diagnoses) and associated spending following screening breast MRI vs mammography among commercially insured US women. This cohort study used 2016 to 2018 data from the MarketScan research database (IBM Corporation), which includes claims and administrative data from large US employers and commercial payers. Participants included commercially insured women aged 40 to 64 years without prior breast cancer who received an index bilateral screening breast MRI or mammogram between January 1, 2017, and June 30, 2018. We used propensity scores based on sociodemographic, clinical, and utilization variables to match MRI recipients to mammogram recipients in each month of index service use. Data were analyzed from October 8, 2020, to October 28, 2021. Breast MRI vs mammography. Mammary and extramammary cascade event rates and associated total and patient out-of-pocket spending in the 6 months following the index test. In this study, 9208 women receiving breast MRI were matched with 9208 women receiving mammography (mean [SD] age, 51.4 [6.7] years). Compared with mammogram recipients, breast MRI recipients had 39.0 additional mammary cascade events per 100 women (95% CI, 33.7-44.2), including 5.0 additional imaging tests (95% CI, 3.8-6.2), 17.3 additional procedures (95% CI, 15.5-19.0), 13.0 additional visits (95% CI, 9.4-17.2), 0.34 additional hospitalizations (95% CI, 0.18-0.50), and 3.0 additional new diagnoses (95% CI, 2.5-3.6). For extramammary cascades, breast MRI recipients had 19.6 additional events per 100 women (95% CI, 8.6-30.7) including 15.8 additional visits (95% CI, 10.2-21.4) and no statistically significant differences in other events. Breast MRI recipients had higher total spending for mammary events ($564 more per woman; 95% CI, $532-$596), extramammary events ($42 more per woman; 95% CI, $16-$69), and overall ($1404 more per woman; 95% CI, $1172-$1636). They also had higher overall out-of-pocket spending ($31 more per woman; 95% CI, $6-$55). In this cohort study of commercially insured women, breast MRI was associated with more mammary and extramammary cascade events and spending relative to mammography. These findings can inform cost-benefit assessments and coverage policies to ensure breast MRI is reserved for patients for whom benefits outweigh harms.

Novel Interactive Tool for Breast and Ovarian Cancer Risk Assessment (Bright Pink Assess Your Risk): Development and Usability Study.

BackgroundThe lifetime risk of breast and ovarian cancer is significantly higher among women with genetic susceptibility or a strong family history. However, current risk assessment tools and clinical practices may identify only 10% of asymptomatic carriers of susceptibility genes. Bright Pink developed the Assess Your Risk (AYR) tool to estimate breast and ovarian cancer risk through a user-friendly, informative web-based quiz for risk assessment at the population level.ObjectiveThis study aims to present the AYR tool, describe AYR users, and present evidence that AYR works as expected by comparing classification using the AYR tool with gold standard genetic testing guidelines.MethodsThe AYR is a recently developed population-level risk assessment tool that includes 26 questions based on the National Comprehensive Cancer Network (NCCN) guidelines and factors from other commonly used risk assessment tools. We included all women who completed the AYR between November 2018 and January 2019, with the exception of self-reported cancer or no knowledge of family history. We compared AYR classifications with those that were independently created using NCCN criteria using measures of validity and the McNemar test.ResultsThere were 143,657 AYR completions, and most participants were either at increased or average risk for breast cancer or ovarian cancer (137,315/143,657, 95.59%). Using our estimates of increased and average risk as the gold standard, based on the NCCN guidelines, we estimated the sensitivity and specificity for the AYR algorithm–generated risk categories as 100% and 89.9%, respectively (P<.001). The specificity improved when we considered the additional questions asked by the AYR to define increased risk, which were not examined by the NCCN criteria. By race, ethnicity, and age group; we found that the lowest observed specificity was for the Asian race (85.9%) and the 30 to 39 years age group (87.6%) for the AYR-generated categories compared with the NCCN criteria.ConclusionsThese results demonstrate that Bright Pink’s AYR is an accurate tool for use by the general population to identify women at increased risk of breast and ovarian cancer. We plan to validate the tool longitudinally in future studies, including the impact of race, ethnicity, and age on breast and ovarian cancer risk assessment.