History Of Early-stage Breast Cancer Research Articles

Evaluation of a mobile behavior change program for weight loss in breast cancer survivors: A prospective single-arm pilot study.

12070 Background: Post-diagnosis weight gain is common among women with early-stage breast cancer and is associated with increased risk of recurrence, breast cancer death, and all-cause mortality. Intentional weight loss following diagnosis is difficult to maintain. Targeted lifestyle interventions focusing on behavioral changes and education that can be implemented long-term are needed. Methods: This was a prospective single-arm pilot study in patients with history of early-stage breast cancer (NCT04753268). Key eligibility criteria included body mass index (BMI) ≥27.5 kg/m2, stage I-III breast cancer, and completion of active cancer treatment ≥6 months prior to study enrollment. Patients were recruited at the Dempsey Center in Lewiston, ME and via social media. Participants were given access to the Noom mobile application, which utilizes cognitive behavioral therapy, motivational interviewing, and self-determination theory to induce behavior change using an educational curriculum of daily articles, virtual health coaching, social networking, food records, and physical activity logs. The primary endpoint was change in self-reported weight from baseline to 26 weeks. Secondary endpoints included change in physical activity measured using step count and the Global Physical Activity Questionnaire (GPAQ), change in diet patterns analyzed using the Nutrition Data System for Research, patient-reported outcome (PRO) measures, and metrics for engagement with the mobile application. Results: 31 patients were enrolled; 24 at the Dempsey Center and 7 via social media. Mean age was 56.8 and mean baseline BMI was 33.5 kg/m2. Mean weight change was -4.8 kg (range +0.6 to -19.9 kg, p < 0.001) and mean percent weight change was -5.6%; 11/31 patients (35.5%) lost ≥5% of their initial weight. Average daily step count increased by 54.7% (p = 0.004). Mean GPAQ score for physical activity increased from 990 to 1773 (p = 0.01), and the proportion of patients who met physical activity guidelines increased from 45.1% to 74.2%. Mean energy intake did not change significantly over 26 weeks (p = 0.779). Improvements were observed in PROMIS-Physical Functioning T-scores and Body Image Scale scores (p = 0.04, p < 0.001 respectively). Metrics of engagement with Noom that were predictive of weight loss ≥5% included total articles read (p = 0.012), total weights logged (p = 0.006), total food records logged (p = 0.001), messages sent to coach (p = 0.001), and number of times the application was opened (p = 0.014). Conclusions: In this pilot study, breast cancer survivors lost weight and became more physically active using a commercially-available mobile application. This digital weight loss program is a scalable intervention, and these findings support future studies investigating impact on breast cancer outcomes. Clinical trial information: NCT04753268 .

Abstract P1-05-04: Physician Practice Patterns of Breast Imaging After Treatment: Survey of Real-World Practice

Abstract Introduction: Mammography is the cornerstone of breast cancer screening, diagnosis, and surveillance. After definitive treatment for breast cancer, mammograms are continued for surveillance. The current recommendations regarding surveillance after definitive treatment (surgery and radiation) lack consensus amongst various societies. There are no clear guidelines in regards to the type of mammogram recommended: diagnostic or screening mammogram or if a diagnostic mammogram is used, when to return to routine screening protocols. Current practice patterns are driven by physician’s preference. We conducted a survey to evaluate physicians’ preferences in ordering breast imaging post- breast cancer diagnosis and treatment. Methods: This survey was approved by University of Arizona institutional review board. This survey was conducted through American Society of Clinical Oncology (ASCO) voluntary opt-in Research Survey Pool (RSP). ASCO sent out this survey to 1000 randomly selected members between 10/19/2021-11/22/2021. Weekly reminders to participate were sent through the ASCO RSP for 5 weeks. Participants clicked the link to the survey platform where upon consent they completed the survey. Results: The survey was completed by 244 healthcare professionals through the ASCO RSP. Most respondents were physicians (n=228), primarily medical oncologists (n=174) and practiced in an academic environment in the United States (n=132). After definitive treatment, majority (58%) ordered first imaging at 6 months post-surgery/radiation, and it was primarily a diagnostic mammogram (68%). Interestingly, for patients at age 80 or above, screening mammogram was used for surveillance after definitive treatment by most respondents (59%). After first post-surgery/radiation mammogram there is an almost even spilt (50%) on continuing with diagnostic versus screening mammograms for follow up. Of those who order diagnostic mammograms, majority (38%) do it for 3-5 years with an additional 30% continuing it beyond 5 years. Almost 65% of respondents reported they do not stop screening mammograms at any age for patients with a history of early-stage breast cancer as long as they are healthy. Conclusions: The practice patterns of healthcare professionals as it relates to the type and frequency of breast imaging varies significantly. Despite having the same imaging quality there is a significant difference in the cost of screening and diagnostic mammograms. In addition, in clinical practice, most routine screening care is covered by insurances without co-pays or out of pocket costs for patients. Diagnostic imaging does not fall under routine screening care and frequently requires out of pocket expenses for patients. As insurance companies start to decline certain imaging modalities used for cancer detection due to lack of data supporting the use of these expensive studies, specific imaging guidelines for follow up in post-treatment setting for patients with breast cancer are needed. Citation Format: Meredith Whittaker, Kiah Farr, Preethika Potluri, Nova Foster, Jennifer Erdrich, Jennifer Segar, Sima Ehsani, Sao Jiralerspong, Denise Roe, Pavani Chalasani. Physician Practice Patterns of Breast Imaging After Treatment: Survey of Real-World Practice [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 P1-05-04.

A digital health intervention to improve nutrition and physical activity in breast cancer survivors: Rationale and design of the Cook and Move for Your Life pilot and feasibility randomized controlled trial

BackgroundThe design of a randomized pilot trial evaluating the feasibility of two doses of a digital health intervention promoting changes in nutrition and physical activity in breast cancer (BC) survivors is described. MethodsEligible women were adults with history of early-stage breast cancer and > 60 days post-treatment, consumed <5 servings/day of fruits/vegetables and/or engaged in <150 min/week of aerobic moderate-to-vigorous physical activity, and had internet access. Participants were randomized to 6 months of either a “low” (1 session) or “high” (12 sessions) dose digital health intervention. Zoom-delivered sessions focused on improving diet and physical activity through didactic and experiential classes delivered by a registered dietitian, chef, exercise physiologist, and culinary educator. All study participants received weekly motivational texts, a Fitbit, and study website access. Diet, accelerometry, anthropometric, psychosocial, and biospecimen data were collected remotely at baseline and six months. Primary outcome was feasibility measured via accrual rate, adherence, retention, and acceptability. ResultsRecruitment began in December 2019, was suspended in March 2020 due to the COVID-19 pandemic, resumed September 2020, and concluded in January 2021. Women were identified from the local BC registry and flyers posted in the oncology clinic. Of 929 women recruited, 321 completed the screening assessment, and of these, 138 were eligible. A total of 74 women were enrolled and randomized to the study. ConclusionBC survivors were successfully enrolled in a digital health nutrition and physical activity intervention. If feasible, this intervention will be tested in larger and more diverse populations of cancer survivors.Trial registration:ClinicalTrials.govNCT04200482

Abstract P3-01-12: The impact of COVID-19 on diagnosis of recurrent breast cancer

Abstract Background - Physical distancing for COVID-19 led to decreased in-person patient follow up assessments and delayed imaging appointments. Herein we describe for the first time the impact of delays in diagnostic investigations of patients with an history of early-stage breast cancer (BC) in the largest public cancer center of Lombardy, the Italian region most affected by the pandemic. Methods - This single-institution retrospective study included three observational periods. The first pandemic peak period (March-April 2020) corresponding to the interruption of follow up imaging; the post-peak period (May-December 2020); the pre-pandemic period represented by the five previous years (January 2015- December 2019) as control. The flow of diagnostic activities was compared among the different years. Moreover, the number and characteristics of recurrent BC cases (rBC) diagnosed in the post-peak period were compared to the figures observed in pre-pandemic years, when imaging was regularly carried out, using descriptive statistics. A further comparison was performed between the characteristics of scheduled and delayed rBC diagnosed after the first peak. Results - During the first pandemic peak, diagnostic investigations declined by 81.2% (from 1032 in January-February to 194 in March-April), a drop which was not identified in the same period of the pre-pandemic years, before rebounding to 1065 in May-June, 832 July-August (reflecting the summer physiological drop), 1334 September-October, and 879 November-December. The average number of rBC cases of 16 (range 12-25) in March-April of the pre-pandemic period declined to a value as low as 4 during the first pandemic peak. Thereafter, the number of rBC cases began a steady increase, until reaching a total of 27 in September-October 2020, almost doubling the mean of 14.8 (range 11-21) achieved in the corresponding months of 2015-2019. As a result, the absolute number of rBC cases was 76 in 2020 and on average 78.4 (range 70 - 95) in pre-pandemic years, and the rBC proportion of 1.42% (76/5336; 95% exact confidence interval, CI: 1.12-1.78%) in 2020 was slightly higher than the average proportion of 1.26% of the five previous years, though the latter being well included in the CI of the 2020 proportion. No difference in primary tumor presentation and age at initial diagnosis was found among recurrent patients before and after the pandemic. Of the rBC cases reported during 2020, 10 were from 513 patients with postponed follow up who were finally diagnosed between September-December. As compared to patients on schedule, delayed rBC cases did not present with ductal carcinoma in situ, and reported a median tumor size of 18 mm (range 4.3-90 mm), which was 20% higher than the median of 15 mm (3.1-34) observed for scheduled patients. Distribution of luminal-like, triple negative and HER2-overexpressing BC subtypes among evaluable rBC cases was 75%, 12.5%, 12.5% in scheduled and 66%, 11% and 22% in delayed cases, respectively. Conclusions - Our data showed a slight decrease in the absolute number of rBC during 2020 despite a rebound of examinations, and an increased size of invasive recurrence following the 2-month stop of the first pandemic peak. The full impact of the COVID-19 pandemic on recurrent cancer diagnosis will be known when national population-based data become available in the coming years. Citation Format: Serena Di Cosimo, Catherine Depretto, Rosalba Miceli, Paolo Baili, Silva Ljevar, Milena Sant, Claudio Ferranti, Secondo Folli, Massimiliano Gennaro, Filippo G de Braud, Claudio Vernieri, Maria Carmen De Santis, Laura Lozza, Andrea Vingiani, Giancarlo Pruneri, Giovanni Apolone, Alfonso Marchianò, Gianfranco P Scaperrotta. The impact of COVID-19 on diagnosis of recurrent breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-01-12.

Patient preferences for cancer survivorship care: Results of an online survey.

12064 Background: Nearly 17 million cancer survivors live in the United States. Workforce shortages are projected to diminish the number of available medical oncologists (MOs) to care for newly diagnosed patients with cancer and for the growing number of cancer survivors. Models of survivorship care include oncologist-led, primary care-led, and shared care approaches. Recent proposals recommend a risk-stratified approach to care, guided by individual and cancer-specific factors, but there is little evidence regarding patient preferences for non-oncologist survivorship care. Methods: We developed a survey in partnership with patient advocates. The primary endpoints were patient-reported comfort with survivorship care by a primary care provider (PCP) or in a dedicated survivorship clinic. We distributed the survey to online, cancer-specific patient communities from June to August 2020. Logistic regression analyses were adjusted for patient age, race and ethnicity, insurance, and cancer type and stage. Results: Of 1166 responses, 975 surveys were complete and available for analysis. Respondents were primarily women (91%), white (92%), and US residents (73%); 78% had a college or graduate degree. Two-thirds had private insurance. Thirty-six different cancer types were reported; 61% of respondents had breast cancer, and 25% were treated for more than one type of cancer. Most respondents (83%) had nonmetastatic disease, 74% reported experiencing late effects of cancer therapy, and almost all (93%) had a PCP. Only 21% of respondents were comfortable seeing a PCP (versus MO) for survivorship care, including cancer follow-up, side effect management, and monitoring for recurrence or progression. About half (55%) were comfortable with follow-up in a survivorship clinic instead of with their MO. Multivariable analyses showed no significant associations between age, race or ethnicity, insurance, cancer type, or stage at diagnosis and comfort with follow-up care from a PCP or in a survivorship clinic. In analyses restricted to the 439 respondents with a history of early-stage breast cancer, the 239 (54%) who were within 1 to 5 years of diagnosis were less comfortable with PCP versus MO follow-up, compared with the 52 (12%) who were &gt; 15 years from diagnosis (OR 0.40; 95% CI 0.20–0.75; p= 0.004). In this sub-analysis, time from diagnosis was not associated with comfort being seen in a survivorship clinic. Conclusions: In our study, most patients with a history of cancer were not comfortable receiving follow-up care from their PCP. It is often recommended that survivors of early-stage breast cancer transition to primary care for follow-up and surveillance, but our study revealed comfort with this approach only many years after diagnosis. While both PCP survivorship training and patient confidence in PCP follow up is needed, preferences of cancer survivors should be considered in designing new models of survivorship care.

Effect of mammography screening frequency on false-positive biopsy rates and detection of local recurrence among breast cancer survivors.

7016 Background: Current guidelines recommend that women with a history of early-stage breast cancer treated with breast-conserving therapy (BCT) continue screening mammography after treatment. One strategy is semi-annual ipsilateral mammography for the first 3 years after diagnosis, when risk of local recurrence is highest. However, a potential harm of more frequent screening is false-positive breast biopsy. We examined the association between screening frequency and rates of false-positive biopsy and local recurrence among breast cancer survivors. Methods: We conducted a retrospective cohort study at Columbia University Irving Medical Center (CUIMC) in New York, NY, of women diagnosed with stage 0-III breast cancer from 2007 to 2017, who were treated with BCT and had at least 2 screening mammograms at CUIMC within the first 3 years after diagnosis. Demographic and clinical information were collected from the electronic health record. Frequency of mammography screening was defined as the median interval between two consecutive mammograms (every 6 months vs. yearly). False-positive biopsy and local recurrence were identified by review of breast pathology reports. A false-positive biopsy was defined as a breast biopsy without evidence of invasive or non-invasive cancer. Descriptive statistics and logistic regression models were conducted to examine relationships between covariates and either false-positive biopsy or local recurrence. Results: In our study cohort (n = 1404), the median age at breast cancer diagnosis was 61 years (range, 24-94), including 45% white, 14% black, 32% Hispanic, and 8% Asian. Eighty percent of women had screening mammography of the ipsilateral breast every 6 months during the first 3 years after diagnosis. Comparing women who screened every 6 months vs. yearly, there was no difference in local recurrence rates (4.0% vs. 4.1%), including screen-detected and invasive recurrences, but a higher rate of false-positive biopsy (13.5% vs. 7.5%). In multivariable analysis, women who screened every 6 months had about a 2-fold increased risk of having a false-positive biopsy (OR 1.93; 95% CI 1.17-3.19); no other factors were significantly associated with false-positive biopsy. Conclusions: We observed that women with early-stage breast cancer treated with BCT who underwent more frequent screening mammography had more false-positive breast biopsies, but no difference in local recurrence rates. Future studies are needed to determine optimal screening strategies for breast cancer survivors.

Screening mammography for second breast cancers in women with history of early-stage breast cancer: factors and causes associated with non-detection

BackgroundThe aim of our study was to identify the factors and causes associated with non-detection for second breast cancers on screening mammography in women with a personal history of early-stage breast cancer.MethodsBetween January 2000 and December 2008, 7976 women with early-stage breast cancer underwent breast surgery in our institution. The inclusion criteria of our study were patients who had: (a) subsequent in-breast recurrence, (b) surveillance mammography within 1 year before recurrence. Retrospective analysis of mammography was performed. Non-detection was defined as second breast cancers that were not visible on screening mammography. Imaging features, demographics, primary breast cancer (PBC) characteristics, and clinical features were evaluated to determine its association with non-detection. Univariate and multivariate logistic regression analyses were also performed to identify the factors related to non-detection.ResultsWe identified 188 patients that met the criteria. Among them, 39% of patients showed non-detection (n = 74). Of the 74 patients with non-detection, 53 (72%) were classified as having no detectable mammographic abnormality (i.e., true negative) due to overlapping dense breast tissue (n = 32), obscured by postoperative scar (n = 12) or difficult anatomic location / poor positioning (n = 9). The remaining 21 patients were categorized as having subtle findings (n = 11) or missed cancer (n = 10). Non-detection for second breast cancers were significantly associated with mammographic breast density (p = 0.001, OR = 2.959) and detectability of PBC on mammography (p = 0.011, OR = 3.013).ConclusionNon-detection of second breast cancer in women with a personal history of early-stage breast cancer were associated with mammographic dense breast and lower detectability of PBC on mammography.

Development and pilot testing of a Decision Aid (DA) for women with early-stage breast cancer considering contralateral prophylactic mastectomy

ObjectiveDescribe the development, acceptability and feasibility of a Decision Aid (DA) for women with early-stage breast cancer (BC) at average contralateral breast cancer (CBC) risk considering contralateral prophylactic mastectomy (CPM). MethodsThe DA was developed using the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. It provides evidence-based information about CPM in a booklet format combining text, graphs and images of surgical options. Twenty-three women with a history of early-stage breast cancer were interviewed in person or over the phone using a ‘think aloud approach’. Framework analysis was used to code and analyse data. ResultsTwenty-three women participated in the study. Mean age of participants was 58.6 years and time since diagnosis ranged from 14 months to 21 years. Five women had CPM and eighteen had not. Women strongly endorsed the DA. Many felt validated by a section on appearance and found information on average risk of recurrence and metastases helpful, however, noted the importance of discussing personal risk with their surgeon. Many requested more information on surgery details (time taken, recovery) and costs of the different options. ConclusionThe DA was acceptable to women, including the format, content and proposed implementation strategies. Practical and financial issues are important to women in considering treatment options. Practice implicationsWomen appreciate information about CPM at diagnosis and emphasised the importance of discussing potential downsides of the procedure in addition to benefits. The DA was considered acceptable to facilitate such discussions.

GR and ER Coactivation Alters the Expression of Differentiation Genes and Associates with Improved ER+ Breast Cancer Outcome.

In estrogen receptor (ER)-negative breast cancer, high tumor glucocorticoid receptor (GR) expression has been associated with a relatively poor outcome. In contrast, using a meta-analysis of several genomic datasets, here we find that tumor GR mRNA expression is associated with improved ER(+) relapse-free survival (RFS; independently of progesterone receptor expression). To understand the mechanism by which GR expression is associated with a better ER(+) breast cancer outcome, the global effect of GR-mediated transcriptional activation in ER(+) breast cancer cells was studied. Analysis of GR chromatin immunoprecipitation followed by high-throughput sequencing in ER(+)/GR(+) MCF-7 cells revealed that upon coactivation of GR and ER, GR chromatin association became enriched at proximal promoter regions. Furthermore, following ER activation, increased GR chromatin association was observed at ER, FOXO, and AP1 response elements. In addition, ER associated with GR response elements, suggesting that ER and GR interact in a complex. Coactivation of GR and ER resulted in increased expression (relative to ER activation alone) of transcripts that encode proteins promoting cellular differentiation (e.g., KDM4B, VDR) and inhibiting the Wnt signaling pathway (IGFBP4). Finally, expression of these individual prodifferentiation genes was associated with significantly improved RFS in ER(+) breast cancer patients. Together, these data suggest that the coexpression and subsequent activity of tumor cell GR and ER contribute to the less aggressive natural history of early-stage breast cancer by coordinating the altered expression of genes favoring differentiation. The interaction between ER and GR activity highlights the importance of context-dependent nuclear receptor function in cancer. Mol Cancer Res; 14(8); 707-19. ©2016 AACR.

Patients’ beliefs about the aims of breast cancer follow-up: A qualitative study

ObjectiveTo explore patients’ beliefs about the aims of breast cancer follow-up, and to compare these with the current literature on best practice for survivor care. Study designWe reviewed the literature on breast cancer and interviewed 61 women with a history of early-stage breast cancer. By means of descriptive content analysis with qualitative and quantitative elements, the patients’ verbatim responses were thematically and independently analysed by two researchers. Results were compared with current literature and breast cancer guidelines. ResultsWhen patients were asked to comment on what they thought the aims of breast cancer follow-up were, they most frequently mentioned ‘detection of recurrence’ and ‘receiving reassurance’, followed by ‘receiving psychological support’, and ‘collecting data to evaluate care’. Some patients explicitly mentioned ‘surveillance for metastatic disease’ as an aim of follow-up. However, some patients believed that breast cancer could not recur after 2–5 years of follow-up, and that recurrences could not develop directly after or between follow-up appointments. In relation to follow-up appointments, some patients experienced anxiety, while others felt it made them confront their breast cancer history. ConclusionsPatients’ beliefs are often not in line with guidelines. Educating patients about the aims of follow-up, and the evidence underlying it, might be important, in part to make patients’ expectations more realistic.

Doxorubicin-induced cardiac dysfunction in unselected patients with a history of early-stage breast cancer.

Cardiomyopathy is a known complication of anthracycline-based adjuvant chemotherapy and is more commonly reported in population-based studies of breast cancer survivors than in clinical trials. This study prospectively evaluated the prevalence of elevated cardiac biomarkers in unselected patients who had been treated with doxorubicin for early-stage breast cancer and the prevalence of reduced LVEF in patients with an elevated biomarker. All participants underwent an examination, symptom inventory, medical record review, and biomarker analysis for BNP, troponin, and plasma and urine NT-proBNP. Patients who had one or more elevated biomarkers were referred for echocardiogram; systolic dysfunction was defined as LVEF less than 55 %. Multivariable logistic regression was used to determine the associations between age, BMI, cumulative dose of doxorubicin, diabetes, hypertension, and left-sided radiation therapy and the risk of reduced LVEF. Among the 269 patients who underwent lab testing (mean age 56 years, mean time since completion of doxorubicin-based chemotherapy 6 years), 192 (72 %) had one or more elevated biomarker. Among the 166 patients who completed an echocardiogram, 11.5 % had a LVEF < 55 %. After adjusting for covariates known to affect cardiac function, multivariable logistic regression revealed plasma NT-proBNP to be the only measured cardiac biomarker associated with systolic dysfunction. There is a relationship between NT-proBNP and the frequency of reduced LVEF in women treated with doxorubicin for curative intent; further study of NT-proBNP as a potential biomarker for subclinical cardiac dysfunction after exposure to anthracyclines is warranted.

Doxorubicin-induced cardiac dysfunction in unselected patients with a history of early-stage breast cancer.

e17653 Background: Cardiomyopathy is a serious but rare side effect seen in patients participating in clinical trials investigating anthracyclines for the treatment of breast cancer, but is far mor...

Patients' preferences for post‐treatment breast cancer follow‐up in primary care vs. secondary care: a qualitative study

To explore patients' preferences for follow-up in primary care vs. secondary care. A cross-sectional design was employed, involving semi-structured interviews with 70 female patients with a history of early-stage breast cancer. Using descriptive content analysis, interview transcripts were analysed independently and thematically by two researchers. Patients expressed the strongest preference for annual visits (31/68), a schedule with a decreasing frequency over time (27/68), and follow-up > 10 years, including lifelong follow-up (20/64). The majority (56/61) preferred to receive follow-up care from the same care provider over time, for reasons related to a personal doctor-patient relationship and the physician's knowledge of the patient's history. About 75% (43/56) preferred specialist follow-up to other follow-up models. However, primary care-based follow-up would be accepted by 57% (39/68) provided that there is good communication between GPs and specialists, and sufficient knowledge among GPs about follow-up. Perceived benefits of primary care-based follow-up referred to the personal nature of the GP-patient relationship and the easy access to primary care. Perceived barriers included limited oncology knowledge and skills, time available, motivation among GPs to provide follow-up care and patients' confidence with the present specialist follow-up. More than half of the patients were open to primary care-based follow-up. Patients' confidence with this follow-up model may increase by using survivorship care plans to facilitate communication across the primary/secondary interface and with patients. Training GPs to improve their oncology knowledge and skills might also increase patients' confidence.

Risk Factors for Second Screen-Detected or Interval Breast Cancers in Women with a Personal History of Breast Cancer Participating in Mammography Screening

Women with a personal history of breast cancer (PHBC) have increased risk of an interval cancer. We aimed to identify risk factors for second (ipsilateral or contralateral) screen-detected or interval breast cancer within 1 year of screening in PHBC women. Screening mammograms from women with history of early-stage breast cancer at Breast Cancer Surveillance Consortium-affiliated facilities (1996-2008) were examined. Associations between woman-level, screen-level, and first cancer variables and the probability of a second breast cancer were modeled using multinomial logistic regression for three outcomes [screen-detected invasive breast cancer, interval invasive breast cancer, or ductal carcinoma in situ (DCIS)] relative to no second breast cancer. There were 697 second breast cancers, of these 240 were interval cancers, among 67,819 screens in 20,941 women. In separate models for women with DCIS or invasive first cancer, first breast cancer surgery predicted all three second breast cancer outcomes (P < 0.001), and high ORs for second breast cancers (between 1.95 and 4.82) were estimated for breast conservation without radiation (relative to mastectomy). In women with invasive first breast cancer, additional variables predicted risk (P < 0.05) for at least one of the three outcomes: first-degree family history, dense breasts, longer time between mammograms, young age at first breast cancer, first breast cancer stage, and adjuvant systemic therapy for first breast cancer; and risk of interval invasive breast cancer was highest in women <40 years at first breast cancer (OR, 3.41; 1.34-8.70), those with extremely dense breasts (OR, 2.55; 1.4-4.67), and those treated with breast conservation without radiation (OR, 2.67; 1.53-4.65). Although the risk of a second breast cancer is modest, our models identify risk factors for interval second breast cancer in PHBC women. Our findings may guide discussion and evaluations of tailored breast screening in PHBC women, and incorporating this information into clinical decision-making warrants further research.

Increased primary healthcare utilisation among women with a history of breast cancer

Little is known about the current role of the general practitioner (GP) in breast cancer follow-up care. This study explores primary healthcare use in the period after completion of primary breast cancer treatment. A total of 336 women with a history of early-stage breast cancer treated with curative intent were identified in the primary care database of the Registration Network Groningen (RNG) (1998-2007) and matched with a reference population of 983 women without breast cancer on birth year and GP. Over the entire follow-up period (starting 1 year post-diagnosis), the median numbers of face-to-face contacts, drug prescriptions, and referrals in the patient group were significantly higher than those in the reference group: 4.0 vs. 3.2/year, 12.3 vs. 8.4/year, and 0.4 vs. 0.3/year, Mann-Whitney (M-W) test p < 0.001 for all differences. At least one annual face-to-face contact was observed for 96.7 % of patients and 92.9 % of women from the reference population (Chi-square test p = 0.011). More patients than women from the reference population had face-to-face contacts for reasons related to breast cancer or were prescribed hormone antagonists and aromatase inhibitors to treat breast cancer. The main predictor of higher rates of face-to-face contacts and drug prescriptions was a higher age at diagnosis. This study shows increased primary healthcare utilisation among women with a history of breast cancer, especially among the elderly. When follow-up is transferred to the primary care setting, new responsibilities of GPs might be incorporated into existing primary healthcare delivery.

Fear of cancer recurrence in young women with a history of early-stage breast cancer: a cross-sectional study of prevalence and association with health behaviours

Fear of cancer recurrence (FCR) is common and associated with younger age. This study aimed to explore the prevalence and correlates of FCR amongst younger survivors of early breast cancer. A total of 218 women aged 18-45 were diagnosed with stage 0-2 breast cancer at least 1 year earlier. The participants completed a web-based survey including a validated measure of FCR and items exploring medical surveillance practices and health care use. A total of 70% of participants reported clinical levels of FCR. Higher FCR was associated with higher frequency of unscheduled visits to the GP, higher frequency of breast self-examination and other forms of self-examination for cancer, not having mammograms or ultrasounds or other forms of cancer screening in the past year, more complementary therapy use and the use of counselling and support groups. Young women with breast cancer are particularly vulnerable to FCR. The present study provides preliminary evidence that FCR is associated with higher health costs and lower surveillance rates which may compromise health outcomes. Routine screening for FCR in follow-up care is recommended.

Accuracy and Outcomes of Screening Mammography in Women With a Personal History of Early-Stage Breast Cancer

Women with a personal history of breast cancer (PHBC) are at risk of developing another breast cancer and are recommended for screening mammography. Few high-quality data exist on screening performance in PHBC women. To examine the accuracy and outcomes of mammography screening in PHBC women relative to screening of similar women without PHBC. Cohort of PHBC women, mammogram matched to non-PHBC women, screened through facilities (1996-2007) affiliated with the Breast Cancer Surveillance Consortium. There were 58,870 screening mammograms in 19,078 women with a history of early-stage (in situ or stage I-II invasive) breast cancer and 58,870 matched (breast density, age group, mammography year, and registry) screening mammograms in 55,315 non-PHBC women. Mammography accuracy based on final assessment, cancer detection rate, interval cancer rate, and stage at diagnosis. Within 1 year after screening, 655 cancers were observed in PHBC women (499 invasive, 156 in situ) and 342 cancers (285 invasive, 57 in situ) in non-PHBC women. Screening accuracy and outcomes in PHBC relative to non-PHBC women were cancer rates of 10.5 per 1000 screens (95% CI, 9.7-11.3) vs 5.8 per 1000 screens (95% CI, 5.2-6.4), cancer detection rate of 6.8 per 1000 screens (95% CI, 6.2-7.5) vs 4.4 per 1000 screens (95% CI, 3.9-5.0), interval cancer rate of 3.6 per 1000 screens (95% CI, 3.2-4.1) vs 1.4 per 1000 screens (95% CI, 1.1-1.7), sensitivity 65.4% (95% CI, 61.5%-69.0%) vs 76.5% (95% CI, 71.7%-80.7%), specificity 98.3% (95% CI, 98.2%-98.4%) vs 99.0% (95% CI, 98.9%-99.1%), abnormal mammogram results in 2.3% (95% CI, 2.2%-2.5%) vs 1.4% (95% CI, 1.3%-1.5%) (all comparisons P < .001). Screening sensitivity in PHBC women was higher for detection of in situ cancer (78.7%; 95% CI, 71.4%-84.5%) than invasive cancer (61.1%; 95% CI, 56.6%-65.4%), P < .001; lower in the initial 5 years (60.2%; 95% CI, 54.7%-65.5%) than after 5 years from first cancer (70.8%; 95% CI, 65.4%-75.6%), P = .006; and was similar for detection of ipsilateral cancer (66.3%; 95% CI, 60.3%-71.8%) and contralateral cancer (66.1%; 95% CI, 60.9%-70.9%), P = .96. Screen-detected and interval cancers in women with and without PHBC were predominantly early stage. Mammography screening in PHBC women detects early-stage second breast cancers but has lower sensitivity and higher interval cancer rate, despite more evaluation and higher underlying cancer rate, relative to that in non-PHBC women.

Accuracy and Outcomes of Screening Mammography in Women With a Personal History of Early-Stage Breast Cancer

Accuracy and Outcomes of Screening Mammography in Women With a Personal History of Early-Stage Breast Cancer

Using Lifetime Risk Estimates to Recommend Magnetic Resonance Imaging Screening for Breast Cancer Survivors

There are millions of breast cancer survivors in the United States currently, and expectations are that the number will continue to increase in the years to come. Survivors of early-stage breast cancer are at increased risk for developing second primary breast cancers. Data regarding the effectiveness of surveillance mammography among survivors of early-stage breast cancer are limited, but suggest that mammography may reduce breast cancer mortality for this cohort as it does when used to screen the general population. Although national guidelines recommend annual mammographic surveillance for survivors of early-stage breast cancer, studies suggest surveillance mammography is underutilized. Mammography is not a perfect test. In fact, it may be particularly insensitive at detecting breast cancer among selected high-risk populations, such as BRCA carriers, young women, and women with dense breast tissue. Magnetic resonance imaging (MRI) has consistently demonstratedgreatersensitivityversusmammographyinthesepopulations. However, MRI screening is more costly and time consuming, requires the injection of intravenous contrast, generates more false-positive results, and has not been shown to impact breast cancer mortality. Debate regarding the role of MRI as a screening test led the American Cancer Society to convene an expert panel to develop guidelines in 2007. The panel recommended breast MRI screening as an adjunct to mammography for: BRCA mutation carriers and their first-degree relatives; women with a lifetime breast cancer risk 20% to 25%; women with a history of chest radiation between ages of 10 and 30 years; and women with predisposing genetic syndromes (eg, Li-Fraumeni, Cowden). The group felt there was insufficient evidence to recommend for or against MRI screening among women with a personal history of invasive breast cancer or ductal carcinoma in situ. On one hand, MRI surveillance may seem appropriate for breast cancer survivors. Compared to women with a higher than 20% lifetime risk of primary breast cancer as defined by BRCAPRO or other family history–based models, many survivors of early-stage breast cancer could experience an even greater risk of second primary breast cancer. In addition, the sensitivity of mammography among survivors could be impaired by changes in the breast caused by previous treatments. In contrast, no studies have explored the utility of surveillance MRI among survivors. Moreover, this cohort also faces a competing risk of mortality from the primary breast cancer diagnosis. Based on personal observations, use of surveillance MRI among women with a personal history of early-stage breast cancer appears to be increasing. These issues raise serious questions regarding the appropriate use of surveillance breast MRI among survivors of early-stage breast cancer. To explore the implications of applying the American Cancer Society risk threshold to women with a personal history of breast cancer who are not BRCA carriers, we constructed an analytic model to calculate lifetime risk of developing a second breast cancer after diagnosis of an initial breast cancer. Specifically, we sought to determine which subsets of breast cancer survivors met a 20% or 25% lifetime risk threshold of having a new cancer, taking into account the competing risk of cancer mortality from the first diagnosis and agedependent noncancer mortality. The model was designed to provide customized values for lifetime risk of developing breast cancer for each year after diagnosis, as a function of the initial cancer (hormone receptor–positive v –negative, mortality risk), its treatment (breastconserving surgery v mastectomy, and tamoxifen v not for hormone receptor–positive cancers), and age at initial diagnosis. Our model assumed the risk of developing a second breast cancer was constant over time, not related to a patient’s age, and the same for the ipsilateral versus contralateral breast—as demonstrated in multiple prospective and retrospective studies. Adjuvant tamoxifen therapy was associated with a 47% reduction in the risk of developing a new breast cancer over the 10-year period after the primary cancer diagnosis. Therefore, the risk of developing a second breast cancer was only a function of the number of intact breasts and use of tamoxifen. No assumptions were made regarding the sensitivity or specificity of MRI screening in women with a personal history of breast cancer. Mortality risk from the initial diagnosis was assumed to be constant and completed within 7 years for hormone receptor–negative cancers and 15 years for hormone receptor–positive cancers. Patients with an initial diagnosis of ductal carcinoma in situ were assumed to have no mortality risk associated with their primary breast cancer diagnosis. Nonbreast cancer mortality was determined using 2004 United States female life-tables. The annual likelihood of a survivor developing a second breast cancer was determined by multiplying the per year probability of developing a new breast cancer with the per year probability of being alive (ie, not dying from the primary breast cancer or a nonbreast cancer cause). The lifetime risk of developing a JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES VOLUME 28 NUMBER 27 SEPTEMBER 2

Pain in Long-Term Breast Cancer Survivors: Frequency, Severity, and Impact

To better understand the severity and impact of pain in women who are breast cancer survivors.Cross-sectional survey.Cancer wellness clinic.Two hundred fifty-three women with a history of early-stage breast cancer who had completed therapy and were without evidence of disease. Interventions. None.A survey that included questions about cancer history, pain, sleep problems, and physical and psychological functioning.About half of the participants (117 or 46%) reported some pain, although most rated its intensity as mild. Both average and worst pain ratings showed significant associations with physical functioning (rs, -0.48 and -0.43, respectively), severity of sleep problems (rs, 0.31 and 0.30), and psychological functioning (rs, -0.27 and -0.24). Age (with younger participants slightly more likely to report pain) and history of antiestrogen therapy showed nonsignificant trends to predict the presence of pain.The study findings provide new and important knowledge regarding the severity and impact of pain in female breast cancer survivors. The results indicate that clinicians should assess pain regularly in breast cancer survivors and treat this pain when indicated. The findings also support the need for research to determine whether improved pain management would result in improved quality of life for women with a history of breast cancer.