Average-risk Women Research Articles

Ovarian cancer incidence and death in average-risk women undergoing bilateral oophorectomy at benign hysterectomy

Objectives: Opportunistic bilateral oophorectomy (BO) is often considered in patients undergoing benign hysterectomy, but the degree to which BO reduces the incidence of ovarian cancer in this population remains unclear and is important for patient decision-making. Methods: We performed a population-based cohort study of all women (≥20 years) undergoing hysterectomy for benign indications from 1996-2015 in Ontario, Canada, followed to December 2019. Patients with ovarian pathology at hysterectomy, previous breast or gynecologic cancer, or evidence of genetic susceptibility to malignancy were excluded. Ovarian cancers and deaths were ascertained from the Ontario Cancer Registry. Inverse probability of treatment weighted Fine & Gray subdistribution hazard models were used to examine the effect of BO on ovarian cancer incidence and death, while accounting for competing risks and adjusting for demographic factors, gynecologic conditions, and comorbidities. Results: We identified 249,924 patients (BO 61,203 [25%]; ovarian conservation 188,721 [75%]) with median age 45 years (interquartile range [IQR] 40-52). Over median follow-up of 14 years (IQR 9-19), 584 women developed ovarian cancer (0.2%) and 17,052 died (6.8%) from any cause. Baseline characteristics were balanced after IPT weighting (standardized differences Conclusions: BO results in a small absolute reduction in incident ovarian cancer among women undergoing benign hysterectomy. Population-average risk estimates derived in this study are generalizable, directly address the limitations of previous work, and should be used to counsel patients preoperatively.

BARD1 Autoantibody Blood Test for Early Detection of Ovarian Cancer.

Background: Ovarian cancer (OC) is the most lethal gynaecological cancer. It is often diagnosed at an advanced stage with poor chances for successful treatment. An accurate blood test for the early detection of OC could reduce the mortality of this disease. Methods: Autoantibody reactivity to 20 epitopes of BARD1 and concentration of cancer antigen 125 (CA125) were assessed in 480 serum samples of OC patients and healthy controls. Autoantibody reactivity and CA125 were also tested for 261 plasma samples of OC with or without mutations in BRCA1/2, BARD1, or other predisposing genes, and healthy controls. Lasso statistic regression was applied to measurements to develop an algorithm for discrimination between OC and controls. Findings and interpretation: Measurement of autoantibody binding to a number of BARD1 epitopes combined with CA125 could distinguish OC from healthy controls with high accuracy. This BARD1-CA125 test was more accurate than measurements of BARD1 autoantibody or CA125 alone for all OC stages and menopausal status. A BARD1-CA125-based test is expected to work equally well for average-risk women and high-risk women with hereditary breast and ovarian cancer syndrome (HBOC). Although these results are promising, further data on well-characterised clinical samples shall be used to confirm the potential of the BARD1-CA125 test for ovarian cancer screening.

Breast-Specific Molecular Clocks Comprised of ELF5 Expression and Promoter Methylation Identify Individuals Susceptible to Cancer Initiation.

A robust breast cancer prevention strategy requires risk assessment biomarkers for early detection. We show that expression of ELF5, a transcription factor critical for normal mammary development, is downregulated in mammary luminal epithelia with age. DNA methylation of the ELF5 promoter is negatively correlated with expression in an age-dependent manner. Both ELF5 methylation and gene expression were used to build biological clocks to estimate chronological ages of mammary epithelia. ELF5 clock-based estimates of biological age in luminal epithelia from average-risk women were within three years of chronological age. Biological ages of breast epithelia from BRCA1 or BRCA2 mutation carriers, who were high risk for developing breast cancer, suggested they were accelerated by two decades relative to chronological age. The ELF5 DNA methylation clock had better performance at predicting biological age in luminal epithelial cells as compared with two other epigenetic clocks based on whole tissues. We propose that the changes in ELF5 expression or ELF5-proximal DNA methylation in luminal epithelia are emergent properties of at-risk breast tissue and constitute breast-specific biological clocks. PREVENTION RELEVANCE: ELF5 expression or DNA methylation level at the ELF5 promoter region can be used as breast-specific biological clocks to identify women at higher than average risk of breast cancer.

Gene methylation and cytological atypia in random fine needle aspirates for assessment of breast cancer risk: 10-year follow up in average risk women.

10520 Background: Alterations in DNA methylation occur early in tumorigenesis, and are a potential breast cancer risk biomarker. We previously reported a study where healthy volunteers underwent random fine needle aspiration (rFNA) of the breasts; cumulative methylation index of eight preselected tumor suppressor genes (CMI) was associated with the presence of cytological atypia in rFNA samples. We now report 10-year follow-up of this population, to evaluate whether increased CMI is associated with subsequent breast cancer development. Methods: 380 women, unselected by breast cancer risk, were enrolled. Demographics, breast cancer risk factors, lifetime Gail model risk estimates (Gail-LR), and %breast density were obtained at baseline. rFNA samples were assessed for cytopathology (Masood Score, MS) and CMI. Patients were contacted annually for 10 years to ascertain development of invasive or non-invasive breast cancer. In univariate analysis, log-rank test was used to compare breast cancer incidence rates between individuals with high and low baseline measures (separated by median). Area under the ROC curve was used to evaluate the cancer prediction accuracy. In multivariate analysis, the effect of CMI (after log-transformation to reduce skewness) was further studied using Cox regression model adjusting for confounding baseline variables. Results: 362 women participated in follow up. At a median follow up time of 9.5 years after rFNA sampling, 16 women developed invasive or non-invasive breast cancer. There were no significant differences between women who developed cancer and those that did not in regard to demographic factors, %breast density, MS, or Gail-LR. On univariate analysis, Gail-LR was higher in women who developed cancer (13.0 vs. 16.5, p=0.08). The largest hazard ratios were observed from high breast density (2.30, 95% CI 0.8, 6.6) and high CMI (2.26, 95% CI 0.8, 6.6, p=0.07). In breast cancer prediction, the AUC for CMI was 0.64 (95% CI 0.51, 0.77). In separate bivariable models that adjusted for age, Gail-LR, MS, and %breast density, the HR for log CMI was consistently above unity, with a p value consistently below 0.1, except for the model that included MS (see Table). Conclusions: Elevated CMI has potential as a robust predictor of future breast cancer occurrence in average risk women, even when adjusted for breast density or cytologic atypia. Our prior analysis established that CMI is not susceptible to variation with menstrual cycle phase and menopausal status. These features support its further evaluation in larger trials. Clinical trial information: NCT00896636 .[Table: see text]

Cancer Progress and Priorities: Breast Cancer.

Breast cancer is the most commonly diagnosed invasive cancer among women both globally and within the United States and the number one cause of cancer-related deaths among women globally ([1, 2][1]). Less than 1% of diagnosed breast cancers occur in men ([2][2]) and, therefore, male breast cancer is

Detection at All Costs: Is Cancer Screening Always Better?

Cancer treatment and prevention is a continuously evolving field. Canadian guidelines suggest that women of average breast cancer risk receive mammography screening regularly. Screening seems an intuitive approach to diagnosing cancer in its early and curable stages. However, repeat cancer screening is not without drawbacks; as the intensity and frequency of cancer screening increases, so do the consequences of overdiagnosis, including avoidable testing and treatment, pain, stress, unwillingness to participate in future testing, and healthcare spending. Therefore, achieving optimal screening outcomes requires an accurate understanding of the costs and benefits associated with this procedure. By empowering patients to make informed decisions regarding cancer screening, one potential strategy to improve patient care is to improve communication and decision-making between physicians and patients. Other strategies to achieve better screening include targeted screening programs for high-risk patients that rely on different screening modalities.

Decreasing contralateral prophylactic mastectomy rates in average-risk women with unilateral breast cancer

BackgroundContralateral prophylactic mastectomy (CPM) is not recommended for average-risk women with breast cancer due to lack of evidence for survival benefit, yet recent studies demonstrate increasing CPM rates. MethodsWe identified patients with breast cancer treated with unilateral mastectomy (UM) with or without CPM. Rates of malignancy in CPM specimens and factors in CPM rates were assessed. ResultsFrom 2013 to 2017, 1353 patients had UM and 355 had CPM. Our institution’s occult malignancy detection rate was 5.04%. CPM rates decreased from 31.6% to 17.3% (p < 0.001) over 5 years. Compared to patients receiving UM only, patients receiving CPMs had significantly higher reconstruction rates (p < 0.001), which did not significantly change over time (p = 0.551) and tended to be younger (p < 0.001). ConclusionsPatients having UM have low risk of contralateral malignancy. CPM is associated with younger age and breast reconstruction, suggesting factors to identify for patient and provider education.

Abstract IA-21: AI in an imaging center: Challenges and opportunities

Abstract There is significant and well-founded enthusiasm for the promise of AI to improve healthcare outcomes across diverse clinical applications in oncology. However, careful analyses of the impact of AI tools in actual “real world” clinical settings are sparse in this relatively early phase of scientific discovery. The rigor applied to deep learning model development (training, testing, external validation) must be matched with equal rigor in assessing patient outcomes after implementation of deep learning tools in actual clinical settings. We can learn from our past endeavors in computer-assisted image interpretation. Tools for computer aided detection were approved by the FDA in 1998 to help radiologists find breast cancers on mammograms. However, after widespread clinical implementation (based on promising results in reader studies and reimbursement approvals), clinical trials to assess the impact of CAD on diagnostic accuracy of mammography revealed the tools did not improve human performance in findings cancers, and in many cases increased false positive readings by humans using CAD assistance. Due to severely limited healthcare resources during pandemics, and to protect patients and healthcare workers, state governments and the COVID-19 Pandemic Breast Cancer Consortium urged providers to focus cancer screening efforts on those patients at higher risk. These mandates were and continue to be necessary responses to support fair allocation of scarce resources to maximize benefits for all patients across the full spectrum of healthcare needs and acknowledge the shift in risk-benefit ratios for screening in average risk women. After screening mammography programs were closed due to the COVID-19 pandemic, we implemented an AI image-only risk model strategy at MGH to invite women at higher risk to return to screening for breast cancer. The AI model identified the top 60% of patients at risk, who were diagnosed with 90% of cancers, while the top 60% of at-risk patients based on traditional models harbored less than 50% of cancers. Our AI image-only risk model performed best in identifying women with current breast cancer, followed by strategies which used five-year traditional risk models and included all women with a personal history of breast cancer in invitations to screen. Lifetime risk models performed extremely poorly. Operating at the traditional “high risk” threshold of &amp;gt;20% lifetime risk, these models identified fewer than 10% of patients with cancer in the total population screened. AI-based risk models may support accurate and equitable risk-based screening. It may be possible with early intervention to reduce the widening disparities and later stage breast cancer diagnoses we are experiencing with COVID and mitigate the risk of delayed diagnoses and increased mortality from breast cancer during and after pandemics. Strategies for careful and rigorous assessment of clinical implementation are essential for AI to have the impact in health desired by all. Citation Format: Constance Lehman. AI in an imaging center: Challenges and opportunities [abstract]. In: Proceedings of the AACR Virtual Special Conference on Artificial Intelligence, Diagnosis, and Imaging; 2021 Jan 13-14. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(5_Suppl):Abstract nr IA-21.

Performance Characteristics of the Ultrasound Strategy during Incidence Screening in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).

Simple SummaryThe United Kingdom Collaborative Trial of Ovarian Cancer Screening was undertaken to assess whether screening postmenopausal women from the general population might result in detection of ovarian/tubal cancers at an earlier stage and thus save lives. One of the screening strategies tested was a yearly transvaginal ultrasound scan of the ovaries (USS). Following the initial screen, 44,799 of the 50,639 women in the USS group went on to have a further 280,534 annual scans during April 2002–December 2011. Abnormalities leading to surgery were detected in 960 women of whom 113 (80 invasive epithelial) had ovarian/tubal cancer. Ovarian/tubal cancer was missed in 52 (50 invasive epithelial) women. Of the screen-detected cancers, 37.5% and missed cancers 6% were early stage(I/II). The number (detection rate 61.5%; 80/130) and advanced stage of the missed invasive cancers suggests that a yearly ultrasound scan may not be suitable for screening average risk women for ovarian cancer.Randomised controlled trials of ovarian cancer (OC) screening have not yet demonstrated an impact on disease mortality. Meanwhile, the screening data from clinical trials represents a rich resource to understand the performance of modalities used. We report here on incidence screening in the ultrasound arm of UKCTOCS. 44,799 of the 50,639 women who were randomised to annual screening with transvaginal ultrasound attended annual incidence screening between 28 April 2002 and 31 December 2011. Transvaginal ultrasound was used both as the first and the second line test. Participants were followed up through electronic health record linkage and postal questionnaires. Out of 280,534 annual incidence screens, 960 women underwent screen-positive surgery. 113 had ovarian/tubal cancer (80 invasive epithelial). Of the screen-detected invasive epithelial cancers, 37.5% (95% CI: 26.9–49.0) were Stage I/II. An additional 52 (50 invasive epithelial) were diagnosed within one year of their last screen. Of the 50 interval epithelial cancers, 6.0% (95% CI: 1.3–16.5) were Stage I/II. For detection of all ovarian/tubal cancers diagnosed within one year of screen, the sensitivity, specificity, and positive predictive values were 68.5% (95% CI: 60.8–75.5), 99.7% (95% CI: 99.7–99.7), and 11.8% (95% CI: 9.8–14) respectively. When the analysis was restricted to invasive epithelial cancers, sensitivity, specificity and positive predictive values were 61.5% (95% CI: 52.6–69.9); 99.7% (95% CI: 99.7–99.7) and 8.3% (95% CI: 6.7–10.3), with 12 surgeries per screen positive. The low sensitivity coupled with the advanced stage of interval cancers suggests that ultrasound scanning as the first line test might not be suitable for population screening for ovarian cancer. Trial registration: ISRCTN22488978. Registered on 6 April 2000.

Does diagnostic mammography need to be a routine component of the initial evaluation of a breast symptom in women 30‐39 years of age?

Diagnostic mammography is routinely ordered, along with targeted breast ultrasound, to evaluate breast symptoms in women 30-39years of age. However, in this age group, mammography is often limited by breast density and the probability of detecting an occult malignancy is low. We sought to evaluate whether diagnostic mammography detected any new incidental malignancies in women aged 30-39years presenting with focal breast symptoms. This retrospective study included women 30-39years of age who had a diagnostic mammogram performed for focal breast symptoms at a single institution from 2002 to 2017. Descriptive analyses were performed to determine the rate of incidental mammographic findings outside of the region of the presenting symptom that 1) led to additional imaging and/or biopsies and 2) were found to be malignant. During the 16-year study period, 1770 evaluations were performed, of which 249 (14.1%) were found to have an additional incidental mammographic abnormality. Further diagnostic imaging was required in 211 (11.3%), core biopsy in 67 (3.8%), and excisional biopsy in 8 (0.5%). None of the mammographically detected incidental findings resulted in a new diagnosis of breast cancer. In the evaluation of focal benign breast symptoms in women 30-39years of age, diagnostic mammography did not detect any new incidental malignancies outside of the area of interest, but instead led to additional unavailing imaging and biopsy procedures. The mammography component of the diagnostic evaluation of younger average-risk women may potentially be omitted if the presenting symptom is determined to be benign with ultrasound alone.

Trends in Contralateral Prophylactic Mastectomy Utilization for Small Unilateral Breast Cancer

BackgroundFor average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and patient harm. Despite recommendations from professional societies against CPM, utilization of this service is increasing, partly due to patients’ desire for breast symmetry when undergoing mastectomy. Most women with small tumors are candidates for breast-conserving surgery (BCS) and could avoid CPM. We describe CPM utilization in women with small, unilateral tumors, and identify determinants of possible overuse. MethodsUsing the National Cancer Database, we identified women with unilateral, T1 breast cancer. We evaluated utilization of BCS, unilateral mastectomy, and CPM and assessed patient, tumor, and facility factors associated with CPM. ResultsOf 765,487 women with small, unilateral breast cancer, 69% underwent BCS and 31% chose mastectomy. Of 176,673 women ≥70 y, 75% underwent BCS and 25% chose mastectomy. CPM rates in both cohorts have increased since 2006. Decreased adjuvant radiotherapy in older women was associated with increased BCS rates. Patient factors (younger age, white race, private insurance, and breast reconstruction), tumor factors (lobular histology, higher grade, and human epidermal growth factor receptor 2 positive/estrogen receptor negative status), and facility factors (type and geographic location) were associated with increased CPM rates compared with unilateral mastectomy in multivariable models. ConclusionsMost women with small unilateral breast cancer are candidates for BCS, yet one-third elects to undergo a mastectomy, of which a rising percentage opts for CPM. Tailoring deimplementation strategies to factors influencing treatment may help reduce CPM utilization and associated financial toxicity, pain, and disability.

Routine Breast Cancer Screening in Average-Risk Women Younger Than 50 Years: Current Paradigms Based on National Guidelines.

Breast cancer poses a large health care burden. More than 270,000 women are diagnosed with breast cancer every year in the United States alone, and more than 40,000 women will die from the disease over the same period. Advances in routine screening and curative treatment options have led to mean 5-year survival rates for localized and regional disease of 98.9% and 85.7%, respectively. Diagnosis at an early stage, often due to routine screening, represents one of the most important prognostic factors for survival. Routine mammography screening in average-risk women 50 years and older has reduced the age-adjusted mortality rate from breast cancer by 34% just over the past 20 years.2,3 While there is consensus among national health organizations regarding the benefits of routine mammographic screening in women 50 years and older, screening recommendations for average-risk women aged between 40 and 49 years vary. Differences in screening recommendations among national organizations largely reflect variations in assessment of the benefit-to-harm ratio of screening women aged between 40 and 49 years who are less likely to develop breast cancer, compared with older women. Women who do develop breast cancer in this age group, however, are more likely to develop more aggressive disease.4,5 Over the past decade, this has become an increasingly important topic of discussion as breast cancer shifts to a younger age of onset.1 In this review, we examine the risks and benefits of routine breast cancer screening starting at age 40 at the individual level, followed by an evaluation of the role of advanced imaging techniques in screening women on a population level.

CA125 and Ovarian Cancer: A Comprehensive Review.

Simple SummaryCA125 has been the most promising biomarker for screening ovarian cancer; however, it still does not have an acceptable accuracy in population-based screening for ovarian cancer. In this review article, we have discussed the role of CA125 in diagnosis, evaluating response to treatment and prognosis of ovarian cancer and provided some suggestions in improving the clinical utility of this biomarker in the early diagnosis of aggressive ovarian cancers. These include using CA125 to screen individuals with symptoms who seek medical care rather than screening the general population, increasing the cutoff point for the CA125 level in the plasma and performing the test at point-of-care rather than laboratory testing. By these strategies, we would detect more aggressive ovarian cancer patients in stages that the tumour can be completely removed by surgery, which is the most important factor in redusing recurrence rate and improving the survival of the patients with ovarian cancer.Ovarian cancer is the second most lethal gynecological malignancy. The tumour biomarker CA125 has been used as the primary ovarian cancer marker for the past four decades. The focus on diagnosing ovarian cancer in stages I and II using CA125 as a diagnostic biomarker has not improved patients’ survival. Therefore, screening average-risk asymptomatic women with CA125 is not recommended by any professional society. The dualistic model of ovarian cancer carcinogenesis suggests that type II tumours are responsible for the majority of ovarian cancer mortality. However, type II tumours are rarely diagnosed in stages I and II. The recent shift of focus to the diagnosis of low volume type II ovarian cancer in its early stages of evolution provides a new and valuable target for screening. Type II ovarian cancers are usually diagnosed in advanced stages and have significantly higher CA125 levels than type I tumours. The detection of low volume type II carcinomas in stage IIIa/b is associated with a higher likelihood for optimal cytoreduction, the most robust prognostic indicator for ovarian cancer patients. The diagnosis of type II ovarian cancer in the early substages of stage III with CA125 may be possible using a higher cutoff point rather than the traditionally used 35 U/mL through the use of point-of-care CA125 assays in primary care facilities. Rapid point-of-care testing also has the potential for effective longitudinal screening and quick monitoring of ovarian cancer patients during and after treatment. This review covers the role of CA125 in the diagnosis and management of ovarian cancer and explores novel and more effective screening strategies with CA125.

Abstract PO-248: Breast cancer risk factors, prevalence, and screening rates in uninsured women seen at free clinics

Abstract Introduction: Uninsured women face increased barriers to obtaining age appropriate breast cancer screening. Despite the National Breast and Cervical Cancer Early Detection Program which provides breast cancer screening services to uninsured women below the federal poverty level, a majority of uninsured women still do not receive screenings. As a result, uninsured women are at risk of presenting with more advanced cancer. The purpose of this study is to identify risk factors, prevalence, and screening rates for breast cancer among uninsured women seen at free clinics. Methods: A retrospective chart review was conducted to collect demographics, risk factors, breast cancer prevalence, and screening rates from medical records at ten free clinics in the Tampa Bay area of Florida from January 1st 2016-December 31st 2018. Uninsured women above the age of 45 were included in the study, in accordance with the American Cancer Society’s recommendation to begin screening women of average breast cancer risk by that age. Results: A total of 3721 women over the age of 45 were seen at free clinics during the study period. The mean age was 56.0 (SD=7.8). This sample was largely composed of Hispanic (n=1466, 47.6%) and unemployed (n=845, 46.2%) women. The mean (SD) BMI of patients was 30.5 (7.8). Of those with a recorded substance use history, 433 (18.7%) were current smokers and 454 (24.3%) were current alcohol consumers. Mammograms were documented for 838 (22.5%) of patients above the age of 45 years. The prevalence of breast cancer was 2.0% (n=73). Conclusions: Our study identifies a population of uninsured women who are at risk for breast cancer based on specific risk factors including age, BMI, smoking history, and alcohol use. Uninsured women seen at free clinics have suboptimal breast cancer screening rates. Our study population is largely comprised of Hispanic, unemployed, and low-income women who face additional healthcare barriers putting them at risk of advanced stage breast cancer. Our study increases awareness of an at-risk population, and increased efforts need to be made to provide uninsured women with age appropriate breast cancer screening in order to reduce morbidity and mortality. Citation Format: Madeline MacDonald, Justin Swanson, Shreni Shah, Jhulianna Vivar, Ethan Song, Tanzila Ahsan, Rahul Mhaskar, Abu-Sayeef Mirza. Breast cancer risk factors, prevalence, and screening rates in uninsured women seen at free clinics [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-248.

Physician Perspectives on Mammography Screening for Average-Risk Women: "Like a Double-Edged Sword".

On balance, the benefits and harms of mammography screening put systematic screening for average-risk women into question. Since screening decisions frequently occur in primary care, it is important to understand what family physicians think of the evidence on mammography screening, and how they intend to use this information in practice. Using a cross-sectional design, we obtained data from a group of physician participants who rated the daily Patient-Oriented Evidence that Matters (POEM), which is a short, research-based synopsis. Physicians responded to closed and open-ended questions, based on the validated Information Assessment Method. Quantitative data were assessed with descriptive statistics. The qualitative data were subjected to inductive and deductive iterative thematic analysis. These data were organized into subthemes, and then grouped into major themes. Four relevant POEMs were identified. Each of these POEMs was rated by 1243 to 1351 physicians, and these ratings provided 310 comments. Three major themes emerged across all 4 POEMs: 1) perspectives on information presented in POEMs, 2) applying this information in practice, and 3) confronting clinical and cultural realities. Our findings highlight important differences in the ways physicians value research-based information on mammography screening and use this information in their practice. Although POEMs about mammography screening raise awareness of harms and benefits, deeply rooted ideas illustrate how any change process is complex. In sum, rethinking breast cancer screening for average-risk women is challenging.

Age at initiation of screening mammography by family history of breast cancer in the breast cancer surveillance consortium.

Women with a first-degree family history of breast cancer (FHBC) are sometimes advised to initiate screening mammography when they are 10 years younger than the age at which their youngest relative was diagnosed, despite a lack of unambiguous evidence that this is an effective strategy. It is unknown how often this results in women initiating screening earlier (< 40 years) than screening guidelines recommend for average-risk women. We examined screening initiation age by FHBC and age at diagnosis of the youngest relative using data collected by the Breast Cancer Surveillance Consortium on 74,838 first screening mammograms performed between 1996 and 2016. Of the 74,838 women included in the study, nearly 9% reported a FHBC. Approximately 16.8% of women who initiated mammography before 40 years reported a FHBC. More women with a FHBC than without initiated screening < 40 years (48% vs. 23%, respectively). Among women with a FHBC who initiated screening < 40 years, 65% were 10 years younger than the age at which their relative was diagnosed. Women with a first-degree relative diagnosed with breast cancer were more likely to start screening before 40 years than women reporting no FHBC, especially if their relative was diagnosed before 50 years.

It’s not time to abandon routine screening mammography in average-risk women in their 40s

It’s not time to abandon routine screening mammography in average-risk women in their 40s

Development and pilot testing of an adaptable protocol to address postpartum depression in pediatric practices serving lower-income and racial/ethnic minority families: contextual considerations

BackgroundPostpartum depression (PPD) affects approximately 25% of women in lower-income and racial/ethnic minority populations in the USA. Evidence-based interventions for PPD screening and treatment exist, but many women with PPD are not identified or are inadequately treated. To address this gap, the American Academy of Pediatrics recommends screening for PPD at routine preventive visits in the first 6 months of postpartum, but less than half of pediatricians do so. Small PPD screening studies have been conducted in pediatric practices serving average-risk women, but less is known about practices serving families with lower-income and/or racial/ethnic minority status (safety-net practices). Study objectives were (1) to develop and pilot test an adaptable PPD screening protocol in safety-net practices and (2) to test strategies for implementing the protocol.MethodsThe Consolidated Framework for Implementation Research was used for this two-phase pilot study. Phase I focus groups with pediatric providers and staff in four safety-net practices informed phase II development and implementation of a PPD screening and referral protocol. Feasibility measures included the percentage of eligible women screened and documentation of follow-up plans in the electronic health record at 1-, 2-, 4-, and 6-month preventive visits over 3 months. Implementation strategies were assessed for acceptability, appropriateness, and feasibility.ResultsFocus group participants felt that (1) addressing PPD in the pediatric setting is important, (2) all clinical team members should be engaged in screening, (3) workflows and competing interests may present barriers, and (4) commonly used screening tools/approaches may not adequately detect depression in the population studied. During protocol implementation, screening rates increased from 75 to 85% for 324 eligible preventive visits and documentation of follow-up plans increased from 66 to 87%. Only 6.5% of women screened positive (EPDS ≥ 10). Minor adaptations to implementation strategies were recommended to improve acceptability, appropriateness, and feasibility.ConclusionsAlthough developing and implementing an adaptable protocol for PPD screening in safety-net pediatric practices using external facilitation and a bundle of implementation strategies appear feasible, low positive screen rates suggest adaptations to account for intersecting patient, practice, and external policy contexts are needed to improve PPD screening effectiveness in these practices.

Organization Communication Factors and Abnormal Mammogram Follow-up: a Qualitative Study Among Ethnically Diverse Women Across Three Healthcare Systems.

Regular mammogram screening for eligible average risk women has been associated with early detection and reduction of cancer morbidity and mortality. Delayed follow-up and resolution of abnormal mammograms limit early detection efforts and can cause psychological distress and anxiety. The goal of this study was to gain insight from women's narratives into how organizational factors related to communication and coordination of care facilitate or hinder timely follow-up for abnormal mammogram results. We conducted 61 qualitative in-person interviews with women from four race-ethnic groups (African American, Chinese, Latina, and White) in three different healthcare settings (academic, community, and safety-net). Eligible participants had an abnormal mammogram result requiring breast biopsy documented in the San Francisco Mammography Registry in the previous year. Interview narratives included reflections on experience and suggested improvements to communication and follow-up processes. A grounded theory approach was used to identify themes across interviews. Participants' experiences of follow-up and diagnosis depended largely on communication processes. Twenty-one participants experienced a follow-up delay (> 30days between index mammogram and biopsy). Organizational factors, which varied across different institutions, played key roles in effective communication which included (a) direct verbal communication with the ability to ask questions, (b) explanation of medical processes and terminology avoiding jargon, and (c) use of interpretation services for women with limited English proficiency. Health organizations varied in their processes for abnormal results communication and availability of support staff and interpretation services. Women who received care from institutions with more robust support staff, such as bilingual navigators, more often than not reported understanding their results and timely abnormal mammogram follow-up. These reports were consistent across women from diverse ethnic groups and suggest the value of organizational support services between an abnormal mammogram and resolution for improving follow-up times and minimizing patient distress.

Comparative Study of Ovarian Function in Patients Undergoing Hysterectomy With or Without Bilateral Complete Salpingectomy

Hysterectomy is one of the most common gynaecological procedures performed in clinical practice. Over the past decade, there is increasing evidence that the majority of high-grade serous ovarian cancers arise in the fallopian tube and not primarily in the ovary. This new theory has led to an opportunity to prevent epithelial ovarian cancer by the addition of the prophylactic bilateral salpingectomy in all surgical procedures for average-risk women, not carrying BRCA mutations, who completed their reproductive goal (American Cancer Society and the American College of Obstetricians and gynaecologists). The rising trend in salpingectomy has been associated with a rising concern over its potentially damaging effect on ovarian reserve due to possible concomitant damage of ovarian blood supply given the close proximity of tubal and ovarian arteries. In view of the above arguments the present study was planned to compare the effect on ovarian function in patients undergoing hysterectomy with or without bilateral complete salpingectomy. 50 premenopausal women planned for hysterectomy for benign indications were randomized to undergo hysterectomy with bilateral complete salpingectomy (group A) or hysterectomy alone (group B). Blood sample was collected on pre-operative period for baseline FSH, LH and Serum oestradiol (E2) level estimation. Group A (n = 25) patients underwent total hysterectomy with complete excision of the fallopian tubes bilaterally and in group B (n = 25) patients’ classical approach was done and ovaries and fallopian tubes were left in situ. Duration of surgery, change in haemoglobin on third post-operative day, post-op complications, and total duration of hospital stay was noted. The follow up of these patients was done 3 months after surgery and again blood sample was taken for serum FSH, LH and oestradiol (E2) level estimation. Baseline demographic and clinical characteristics were similar between the two groups. There was also no difference in operative outcomes such as operative time, intra-operative blood loss or complications between the two groups. Mean FSH, LH, and oestradiol values were unchanged after both the techniques. Bilateral complete opportunistic salpingectomy at the time of hysterectomy does not appear to have any short-term deleterious effects on ovarian function or increased surgical risk.