Mammography Program Research Articles

Abstract PO5-09-05: Characteristics of newly diagnosed breast cancer patients at a large safety-net system: Implications for health equity and care delivery

Abstract Introduction: Despite the increased awareness and advocacy for health equity, racial and socioeconomic disparities remain prevalent among breast cancer patients. Since lack of access to care is a major barrier, safety-net systems that provide services for the uninsured/underinsured play a significant role in promoting health equity and eliminating disparities. Understanding the patient population treated within these systems, which are often resource-limited, can help develop strategies to improve care delivery and outcomes. Here, we describe characteristics of breast cancer patients treated at a large safety-net system. Methods: Parkland Health (PH) is the safety-net system for Dallas County, and is affiliated with the University of Texas Southwestern Harold C. Simmons Comprehensive Cancer Center (NCI-CCC). Electronic medical records of patients with a new invasive breast cancer diagnosis between 2018 to 2020 at PH were reviewed and data on demographics and clinical presentation were collected. Categorical data was summarized with counts and percentages and continuous data was summarized with median and interquartile range. Statistical comparisons used Chi-square test for categorical data and rank sum test for continuous data with a significance level of 0.05. Data from the National Cancer Database (NCDB) for the same period was used for comparison. Results: A total of 657 patients at PH were included in the analysis (50.2% Hispanic; 32.3% Black). Median age at diagnosis was 53 years (range 46-61), with 39.1% of patients < 50 (12.3% < 40). The majority of patients were uninsured at the time of diagnosis (67.0%). Hispanic patients were younger than others (median age 49 years (range 43-57) vs 57 (range 48-63), p < 0.01), with 51.2% < 50. Late-stage diagnosis was observed in 30.6% of patients (stage III 16.4%, stage IV 14.2%), and triple negative breast cancer (TNBC) accounted for 22.8% of cases. While the stage distribution was not statistically different between racial and ethnic subgroups (p=0.66), black patients were diagnosed with TNBC at a significantly higher rate compared to others (30.2% vs 19.3%, p < 0.01). Although a trend towards higher rate of HER2(+) disease was noted among Hispanics, this difference did not reach the level of statistical significance (22.7% vs 16.5%, p=0.06). One hundred eighty-nine patients (28.8%) were diagnosed outside PH. Compared to Black patients, Hispanic patients were more often diagnosed in the community (22.2% vs 32.4%, p=0.01). Of the 564 patients with stage I-III, 340 (60.3%) had T2-4 and 203 (36.0%) had node positive disease at diagnosis. Median time to treatment initiation (TTI) was 51 days (range 35-76) and was significantly longer in patients who were diagnosed in the community compared to those diagnosed at PH, median 63 days (range 44-96) vs 48 (range 34-70), p < 0.01. Compared to the NCDB, PH patients were younger (39.1% vs 18.4% < 50 years, p < 0.01), presented at a higher rate with late-stage disease (30.6% vs 13.2%, p < 0.01) and TNBC (22.8% vs 10.7%, p < 0.01), and had a longer median time from diagnosis to treatment initiation - 51 days (range 35-76) vs 33 (range 21-49), p < 0.01. Conclusion: Breast cancer patients at PH were significantly different from the national average, with over a third below the USPSTF recommended breast cancer screening age. The rate of late-stage diagnosis at PH was more than two-fold the national average. Lowering the screening age to 40, expansion of outreach mammography programs, improving patient navigation, and simplifying access to indigent care programs are among strategies to promote health equity. Considering the high disease burden among safety-net patients, a systematic effort to increase resources at safety-net health systems is warranted. Citation Format: Sarah Kashanian, Shifa Kanjwal, L. Steven Brown, Andrea Semlow, Mary Hodges, Robyn Cobb, Brad Walsh, Umber Dickerson, Navid Sadeghi. Characteristics of newly diagnosed breast cancer patients at a large safety-net system: Implications for health equity and care delivery [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-05.

Automated 3D Ultrasound as an Adjunct to Screening Mammography Programs in Dense Breast: Literature Review and Metanalysis.

Purpose: The purpose of this meta-analysis is to investigate the effectiveness of supplementing screening mammography with three-dimensional automated breast ultrasonography (3D ABUS) in improving breast cancer detection rates in asymptomatic women with dense breasts. Materials and Methods: We conducted a thorough review of scientific publications comparing 3D ABUS and mammography. Articles for inclusion were sourced from peer-reviewed journal databases, namely MEDLINE (PubMed) and Scopus, based on an initial screening of their titles and abstracts. To ensure a sufficient sample size for meaningful analysis, only studies evaluating a minimum of 20 patients were retained. Eligibility for evaluation was further limited to articles written in English. Additionally, selected studies were required to have participants aged 18 or above at the time of the study. We analyzed 25 studies published between 2000 and 2021, which included a total of 31,549 women with dense breasts. Among these women, 229 underwent mammography alone, while 347 underwent mammography in combination with 3D ABUS. The average age of the women was 50.86 years (±10 years standard deviation), with a range of 40-56 years. In our efforts to address and reduce bias, we applied a range of statistical analyses. These included assessing study variation through heterogeneity assessment, accounting for potential study variability using a random-effects model, exploring sources of bias via meta-regression analysis, and checking for publication bias through funnel plots and the Egger test. These methods ensured the reliability of our study findings. Results: According to the 25 studies included in this metanalysis, out of the total number of women, 27,495 were diagnosed with breast cancer. Of these, 211 were diagnosed through mammography alone, while an additional 329 women were diagnosed through the combination of full-field digital mammography (FFDSM) and 3D ABUS. This represents an increase of 51.5%. The rate of cancers detected per 1000 women screened was 23.25‱ (95% confidence interval [CI]: 21.20, 25.60; p < 0.001) with mammography alone. In contrast, the addition of 3D ABUS to mammography increased the number of tumors detected to 20.95‱ (95% confidence interval [CI]: 18.50, 23; p < 0.001) per 1000 women screened. Discussion: Even though variability in study results, lack of long-term outcomes, and selection bias may be present, this systematic review and meta-analysis confirms that supplementing mammography with 3D ABUS increases the accuracy of breast cancer detection in women with ACR3 to ACR4 breasts. Our findings suggest that the combination of mammography and 3D ABUS should be considered for screening women with dense breasts. Conclusions: Our research confirms that adding 3D automated breast ultrasound to mammography-only screening in patients with dense breasts (ACR3 and ACR4) significantly (p < 0.05) increases the cancer detection rate.

Abstract C134: Efficacy of mobile mammography and state-funded cancer services in reducing disparities in follow-up adherence: A retrospective analysis

Abstract Objective: Mobile mammography programs, such as the one at Stony Brook Cancer Center (SBCC), play an important role in providing breast cancer screening services to underserved communities. Follow-up to abnormal mammogram screenings is critical for early cancer detection, but patients often encounter barriers that prevent timely diagnostic procedures. We aim to evaluate the role of New York State’s Cancer Services Program (CSP) in facilitating follow-up care among underserved patients who participated in SBCC’s mobile mammography initiative. Methods: We conducted a retrospective analysis of 817 mobile mammography patients who required additional testing following an abnormal mammogram over a five-year period. Of these, 68% were beneficiaries of the CSP, while 32% were insured. Results: Our findings revealed that among CSP beneficiaries, only 3.5% were lost to follow-up, compared to a significant 16.5% of insured patients who did not adhere to recommended follow-up care. This suggests that the CSP’s supportive role is critical in ensuring follow-up care among underserved communities. Conclusions: The CSP’s substantial impact on follow-up care adherence highlights the program's effectiveness in reducing healthcare disparities. However, more work is needed to enhance follow-up care adherence among insured patients. Solutions may include identifying and addressing barriers to care and implementing targeted interventions to improve patient outcomes. Implications for Policy or Practice: Mobile mammography programs, such as SBCC’s initiative, demonstrate a potential strategy for reducing health disparities in breast cancer screening and detection. Securing access to follow-up care is crucial for improving patient outcomes. Addressing barriers to care, strengthening patient education, and enhancing outreach efforts can increase participation in screening initiatives, thus advancing health equity and reducing disparities in breast cancer outcomes. Citation Format: Patrick J. Dineen, Mollie M. Williams. Efficacy of mobile mammography and state-funded cancer services in reducing disparities in follow-up adherence: A retrospective analysis [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C134.

A multicentre review of the direct-access mammography programme in Ireland for women with breast pain

To assess the current use of the direct access mammography pathway for breast pain and the rate of breast cancer detection in this patient cohort. A retrospective review of general practitioner (GP)-referred mammograms performed during a 12-month period from January to December 2022 across four tertiary referral centres. With the use of medical records and GP referrals, patient demographics, presenting symptoms, family history, and clinical outcomes were recorded. The present study comprised 2,046 patients of which 21.6% did not report breast pain at the time of referral. Thirty-five per cent had a positive family history with 40% of these patients having no breast pain. Twelve per cent were recalled with 30% of these patients requiring biopsy. An overall cancer detection rate (CDR) of 7 per 1000 was determined for women with mastalgia. A CDR of 0 per 1,000 was determined for women <50 years with mastalgia alone and no additional risk factors for malignancy. Fisher's exact test showed no statistically significant association between breast pain and breast cancer. There was no statistically significant relationship found between breast pain and breast cancer. This review suggests a low cancer detection rate in women <50 years. In women <50 years with mastalgia without additional symptoms or family history, breast imaging is not required.

Overcoming the limitations of screening mammography in Japan and Korea: a paradigm shift to personalized breast cancer screening based on ultrasonography.

Screening mammography programs have been implemented in numerous Western countries with the aim of reducing breast cancer mortality. However, despite over 20 years of population-based screening mammography, the mortality rates in Japan and Korea continue to rise. This may be due to the fact that screening mammography is not as effective for Japanese and Korean women, who often have dense breasts. This density decreases the sensitivity of mammography due to a masking effect. Therefore, the early detection of small invasive cancers requires more than just mammography, particularly for women in their 40s. This review discusses the limitations and challenges of screening mammography, as well as the keys to successful population-based breast cancer screening in Japan and Korea. This includes a focus on breast ultrasonography techniques, which are based on histopathologic anatomical knowledge, and personalized screening strategies that are based on risk assessments measured by glandular tissue components.

Breast Cancer Champions: a peer-to-peer education and mobile mammography program improving breast cancer screening rates for women of African heritage.

Nationally, women of African heritage die at higher rates from breast cancer than women of other races or ethnicities. We developed Breast Cancer Champions (BCC) a peer-to-peer education program, which recruited 12 women and deployed them into the community in August 2020 during the height of the COVID pandemic. BCC aims to improve breast cancer screening rates for women of African heritage through peer-to-peer education, which has proven successful for addressing cancer-related health disparities. BCC community experts, or "Champions," are peer-to-peer educators that conduct awareness and screening events in their communities. Champion's education activities were tracked by bi-weekly check-in calls, which recorded the activity type, location, and the number of participants for each event. We used spatial and statistical analyses to determine the efficacy of the program at increasing screening rates for women within the area of Champion activity versus women outside of their activity area. Over 15months, Champions conducted 245 in-person or online events to engage women in their community for screening. More women of African heritage were screened in areas Champions were active during the intervention compared to historical data comparing areas outside of the Champion activity in the prior 15months (X 2 = 3.0845, p = 0.079). BCC successes could be attributed to pivoting to online community building when in-person events were restricted and enabling Champions to design and conduct their own events, which increased outreach possibilities. We demonstrate improved screening outcomes associated with an updated peer-to-peer education program.

Impact of Different Mammography Systems on Artificial Intelligence Performance in Breast Cancer Screening.

Artificial intelligence (AI) tools may assist breast screening mammography programs, but limited evidence supports their generalizability to new settings. This retrospective study used a 3-year dataset (April 1, 2016-March 31, 2019) from a U.K. regional screening program. The performance of a commercially available breast screening AI algorithm was assessed with a prespecified and site-specific decision threshold to evaluate whether its performance was transferable to a new clinical site. The dataset consisted of women (aged approximately 50-70 years) who attended routine screening, excluding self-referrals, those with complex physical requirements, those who had undergone a previous mastectomy, and those who underwent screening that had technical recalls or did not have the four standard image views. In total, 55 916 screening attendees (mean age, 60 years ± 6 [SD]) met the inclusion criteria. The prespecified threshold resulted in high recall rates (48.3%, 21 929 of 45 444), which reduced to 13.0% (5896 of 45 444) following threshold calibration, closer to the observed service level (5.0%, 2774 of 55 916). Recall rates also increased approximately threefold following a software upgrade on the mammography equipment, requiring per-software version thresholds. Using software-specific thresholds, the AI algorithm would have recalled 277 of 303 (91.4%) screen-detected cancers and 47 of 138 (34.1%) interval cancers. AI performance and thresholds should be validated for new clinical settings before deployment, while quality assurance systems should monitor AI performance for consistency. Keywords: Breast, Screening, Mammography, Computer Applications-Detection/Diagnosis, Neoplasms-Primary, Technology Assessment Supplemental material is available for this article. © RSNA, 2023.

21 (PB-021) Poster Spotlight - Breast Cancer Whole Blood Screening: Analytical and Clinical Performance from Early Analysis of the International Identify Breast Cancer (IDBC) Study

Background: Breast cancer is detected after stage I for many women, particularly women with dense breast tissue and those under 50, due to screening mammography performance and program participation. This report provides data for a new CE-marked blood test currently available in Canada. The test uses a non-fractionated blood sample and involves analysis of a gene expression panel (12 targets) using custom reagents and machine-learning informed software for identification of an active breast cancer signature that has been validated through a retrospective clinical study.

140 (PB-053) Poster - Contribution and performance of subsidized mammography and breast cancer detection rate in underserved populations of rural and urban areas of Sindh, Pakistan

Background: In Pakistan, breast cancer is an enormous public health concern as its mortality is the highest in any Asian population. It can be effectively detected in its early stage with screening mammography, offered to all eligible asymptomatic women. However, in Pakistan, there is no organized screening mammography program at the national level & screening practices are very low. That is why advanced-stage presentation is common in our population. It is important to assess the utility of subsidized screening mammography services in the early detection of breast cancer and reduction of mortality rates in Pakistan.

Breast Cancer in Asia: Incidence, Mortality, Early Detection, Mammography Programs, and Risk-Based Screening Initiatives.

Simple SummaryNearly all breast cancer patients survive for more than five years when the tumor is found early and in the localized stage. Regular clinical breast examinations, mammograms, and monthly self-exams of the breasts all contribute to early detection. However, late-stage breast cancers are common in many Asian countries. Low-income countries suffer from a lack of resources for breast cancer screening. High-income countries, on the other hand, are not benefiting fully from national breast screening programs due to an underutilization of the preventive healthcare services available. Existing reviews on Asian breast cancers are heavily focused on risk factors. The question of whether we should adopt or adapt the knowledge generated from non-Asian breast cancers would benefit from an extension into screening guidelines. In addition, several Asian countries are piloting studies that move away from the age-based screening paradigm.Close to half (45.4%) of the 2.3 million breast cancers (BC) diagnosed in 2020 were from Asia. While the burden of breast cancer has been examined at the level of broad geographic regions, literature on more in-depth coverage of the individual countries and subregions of the Asian continent is lacking. This narrative review examines the breast cancer burden in 47 Asian countries. Breast cancer screening guidelines and risk-based screening initiatives are discussed.

Breast cancer risk predictions by birth cohort and ethnicity in a population-based screening mammography program.

To examine whether birth cohorts affect the risk of breast cancer for East Asian, First Nations, African, South Asian and Caucasian ethnicities in British Columbia (BC). We used Cox PH models adjusted for well-known risk factors, such as age, breast density, mammographic features on false positives, and family history, to examine risk of breast cancer among East Asian, First Nations, African and South Asian ethnicities, relative to Caucasian, across three birth cohorts. There were 813,280 participants and 11,166 in situ and invasive breast cancer diagnoses. East Asians screened in BC were found to have a lower risk of breast cancer in the birth cohort born pre-1946 compared to Caucasian, but there was no statistically significant decrease for East Asians born after 1946. First Nations had an increased risk of breast cancer compared with Caucasian for all birth cohorts ranging from 1.1 to 2.0x the risk, which was statistically significant for those born after 1965. South Asians showed a statistically significant decrease in risk ranging from 0.58 to 0.81x lower compared with Caucasians for all birth cohorts. Risk of breast cancer for South Asians living in BC was found to be lower than Caucasians for each birth cohort examined, while East Asians had a comparable risk of breast cancer, First Nations had a consistently higher risk than Caucasians. When accounting for birth cohort, compared to Caucasians, South Asians have a decreased risk, First Nations have an increased risk, and East Asians have a similar risk of breast cancer.

Time to biopsy of screening mammography-detected abnormalities: Evaluating the impact of same-day services implemented during the COVID-19 pandemic.

1511 Background: Screening mammography programs often require patients undergo multiple visits (screening exam, diagnostic exam, and biopsy) before tissue diagnoisis of screen-detected abnormalities. During the COVID-19 pandemic, same-day breast imaging services were leveraged to decrease the number of visits following abnormal screening exams. Specifically, in May 2020, we implemented an immediate-read screening mammography program to synergize with our pre-existing same-day breast biopsy program, such that every effort was made to perform diagnostic imaging during the same visit after an abnormal screening mammogram. This study aims to evaluate the impact of these same-day breast imaging services on time and number of patient visits to undergo breast biopsy after an abnormal screening mammogram. Methods: Consecutive screening mammograms performed during normal business hours pre- (6/1/16 to 5/30/17) and post-implementation (6/1/20 to 5/30/21) of same-day services were identified. Patient demographics, imaging and biopsy results, and visit dates were extracted from the medical record. Multivariable logistic, linear, and ordinal regression models estimated with generalized estimating equations were fit to assess the association of period (pre- versus post-implementation), patient age, and race and ethnicity (White versus races other than White) with having a same-day biopsy (biopsy on the same day as the abnormal screening exam), number of days to biopsy, and number of visits. Adjusted odds ratios (aOR) and beta estimates (aBeta) of each covariate and corresponding 95% confidence intervals (CI) were estimated. Results: A total of 409/25,922 (1.6%) of patients (median age 61, IQR 50-70) pre-implementation and 221/20,452 (1.1%) patients (median age 62, IQR 49-71) post-implementation had screen-detected abnormalities leading to diagnostic breast imaging and biopsy. Median number of days from screening to biopsy decreased from 16 days pre-implementation to 5 days post-implementation (p &lt; 0.001). Pre-implementation, 86.8% of patients required 3 visits between screening and biopsy, while post-implementation only 23.1% required 3 visits (p &lt; 0.001). Compared to pre-implementation, the post-implementation period was associated with increased odds of undergoing same-day biopsy (aOR 20.7, 95% CI 8.3-51.7), p &lt; 0.001), fewer days from abnormal screening mammogram to biopsy (aBeta -13.3, 95% CI -15.7 to -10.9, p &lt; 0.001), and fewer visits (aOR 0.05, 95% CI 0.02-0.09), p &lt; 0.001), controlling for age and race and ethnicity. Conclusions: Same-day breast imaging services decreased time and patient visits between abnormal screening mammogram and breast biopsy. Same-day services implemented out of necessity during the COVID-19 pandemic should be continued after the pandemic has subsided to improve timeliness of care.

Socio-Economic Status and Clinical Breast Examination Screening Uptake: Findings from the First Cohort Study among Iranian Kurdish Women.

Clinical Breast Examination (CBE) is utilized as a screening modality in many low income countries without widespread mammography capability. The aim of the current study was to evaluate the impact of socio-economic status (SES) on CBE screening rates in Iranian Kurdish women. A cross-sectional study was conducted in the western region of Iran. A sample of 5,289 Iranian Kurdish women aged 35-65 years old was analyzed. Data were collected from July 2014 to September 2018. The Concentration Index-CI and Concentration Curve were used to estimate the socioeconomic inequalities in CBE rate. The analysis of data was done by STATA software (Version 14). 12.3% of the women had received CBE at least once. CBE rates in the 46-50 age group were higher than in other age groups (OR = 2.06; 95% CI = 1.56-2.71). Women with 6-9 years of education had higher odds ratio of receiving CBE (OR = 1.41; 95% CI = 1.02-1.94). Women living in rural areas were less likely to have received CBE compared to those living in urban areas (OR=0.54; 95% CI = 0.42-0.61). The overall concentration index for receipt of CBE was 0.188. In countries without widespread mammography programs, strategies for the promotion of CBE should focus on the lower SES population.

The Fundamental Flaws of the CNBSS Trials: A Scientific Review.

Although the two Canadian National Breast Screening Study (CNBSS) trials were performed 40 years ago, their negative findings continue to heavily influence screening policies around the world. These policies, based on underestimates of the mortality reduction attributable to mammography particularly for women in the 40-49-year age range, contribute to increased mortality and morbidity from breast cancer. This review summarizes principles of a randomized controlled trial (RCT) and evaluates the compliance of the CNBSS1 and CNBSS2 RCTs in the context of these principles. We describe the fundamental flaws of the CNBSS trials, which failed to demonstrate mortality benefit of screening mammography and contribute to their being the only two outlier studies of eight screening mammography RCTs. The most significant flaws of the trials are (1) inadequate power to detect significant differences in breast cancer mortality; (2) very poor quality mammography with low sensitivity and cancer detection rates; (3) inclusion of women with symptoms of breast cancer; and (4) study design that allowed for violation of the randomization of the allocation process. Finally, we demonstrate that the conditions of the screening intervention in the CNBSS do not reflect the environment of modern population-based screening mammography programs.

Abstract P2-11-08: Impact of COVID-19 on patients undergoing neoadjuvant therapy: A pre/post pandemic analysis and assessment of quality of care delivered

Abstract Background: When the first wave of COVID-19 hit globally in early 2020, concerns were raised about access to surgical interventions for cancer patients. It was considered that neoadjuvant therapy (NAT) although conventionally given to locally advanced breast cancer may need to also be provided to earlier-stage disease. In addition, due to the temporary closure of breast cancer screening programs during the pandemic, concerns were raised about patients presenting with later-stage disease at initial diagnosis. This project aims to assess the impact of COVID-19 on the volume of neoadjuvant referrals at a large cancer centre, as well as any stage migration, impact on treatment timelines and impact on outcomes for breast cancer patients compared to the pre-pandemic population. Methods: The BC Cancer Vancouver centre has a neoadjuvant breast cancer program to ensure high quality of care is maintained. This program’s prospective database of breast cancer patients referred for and treated with NAT between the years 2012-2021 was queried to assess data on neoadjuvant referrals, clinical stage, receptor status, treatment timelines, and outcomes between January 1, 2019 - December 31, 2020. Data from the years 2019 and 2020 were compared to evaluate the impact of COVID-19 on NAT. Summary data available from earlier years were also utilized as reference. Results: The COVID-19 pandemic resulted in a 51% increase in the number of patients referred to the neoadjuvant program, with 102 patients referred for NAT in 2019, whereas 154 patients were referred in 2020. This proportional increase in referrals is higher than any other year since the database inception. Of note, during 2020 there were no COVID related closures for cancer surgeries in the province. The proportion of patients referred who received NAT remained similar between 2019 and 2020 (69.1% vs 70.8% in 2020). The trend in referrals by month varied between the two years. In 2019, the majority of patients were referred between April to July with the lowest proportion of referrals in October to December. In 2020, the opposite occurred with the lowest proportion of referrals transpiring between January - June, and the greatest proportion in October to December. The proportion of patients who presented with de-novo metastatic disease was consistent between the two years (7.8% in 2019 vs 9.7% in 2020). Despite the closure of all screening mammography programs between March-June of 2020, the clinical stage and receptor status are equivalent between 2019 and 2020. With regards to treatment timelines, there was a 3 day increase in the median time between referral date and medical oncology consultation in 2020 compared to 2019. No other treatment timeline delays were found between 2019 and 2020. With regards to outcomes, 34.9% of patients achieved pCR in 2019, but only 24.1% achieved pCR in 2020, despite similar stage and receptor subtypes. Conclusion: During the COVID-19 pandemic in 2020, a higher volume of patients were referred for NAT than had ever before been referred, despite the fact that there were no closures of operating rooms in our province for COVID-19. From a quality of care perspective there was a delay in referral to consultation for medical oncology, but no delay on referral to treatment, treatment to surgery, or surgery to radiation. However, and a significantly lower pCR rates was seen in 2020 compared to 2019. The 10% decrease in pCR rates may have resulted from increased complexity in breast cancer cases. This trend may continue, as the impact of COVID-19 on breast cancer outcomes will likely take many years to fully appreciate. Attention should be paid to encouraging women to return to regular breast screening programs to decrease the number of patients needing neoadjuvant therapy. Citation Format: Lauren Corke, Omar Hajjaj, Kaylie Willemsma, Stephen Chia, Christine Simmons. Impact of COVID-19 on patients undergoing neoadjuvant therapy: A pre/post pandemic analysis and assessment of quality of care delivered [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 P2-11-08.

Revisiting the Effects of Organized Mammography Programs on Inequalities in Breast Screening Uptake: A Multilevel Analysis of Nationwide Data From 1997 to 2017.

This study revisits the effects of mammography screening programs on inequalities in breast screening uptake in Switzerland. The progressive introduction of regional mammography programs by 12 out of the 26 Swiss cantons (regions) since 1999 offers an opportunity to perform an ecological quasi-experimental study. We examine absolute income and marital status inequalities in mammography uptake, and whether the cantons' implementation of mammography programs moderate these inequalities, as previous research has devoted little attention to this. We use five waves of the Swiss Health Interview Survey covering the 1997–2017 period and comprising data on 14,267 women aged 50–70. Both up-to-date and ever-screening outcomes are analyzed with multilevel models which assess the mammography programs' within-canton effect. Findings show that higher income women and married women (compared to unmarried women) had significantly higher mammography uptake probabilities. Mammography programs did not moderate absolute income differences in up-to-date screening; however, they were associated with smaller absolute income differences in ever-screening uptake. Mammography programs related to higher screening uptake for married women, more than for unmarried women. In conclusion, we showed absolute income inequalities in mammography uptake which were not revealed by previous studies using relative inequality measures. Mammography programs may have contributed to reducing income inequalities in ever-screening, yet this was not observed for up-to-date screening. This study has implication for preventive health interventions—e.g., cancer screening promotion should pay attention to women's marital status since screening programs may widen the screening gap between married and unmarried women.

Ductal Carcinoma in Situ: State-of-the-Art Review.

Ductal carcinoma in situ (DCIS) is a nonobligate precursor of invasive cancer, and its detection, diagnosis, and management are controversial. DCIS incidence grew with the expansion of screening mammography programs in the 1980s and 1990s, and DCIS is viewed as a major driver of overdiagnosis and overtreatment. For pathologists, the diagnosis and classification of DCIS is challenging due to undersampling and interobserver variability. Understanding the progression from normal breast tissue to DCIS and, ultimately, to invasive cancer is limited by a paucity of natural history data with multiple proposed evolutionary models of DCIS initiation and progression. Although radiologists are familiar with the classic presentation of DCIS as asymptomatic calcifications at mammography, the expanded pool of modalities, advanced imaging techniques, and image analytics have identified multiple potential biomarkers of histopathologic characteristics and prognosis. Finally, there is growing interest in the nonsurgical management of DCIS, including active surveillance, to reduce overtreatment and provide patients with more personalized management options. However, current biomarkers are not adept at enabling identification of occult invasive disease at biopsy or accurately predicting the risk of progression to invasive disease. Several active surveillance trials are ongoing and are expected to better identify women with low-risk DCIS who may avoid surgery.

Disparities in Same-Day Diagnostic Imaging in Breast Cancer Screening: Impact of an Immediate-Read Screening Mammography Program Implemented During the COVID-19 Pandemic.

BACKGROUND. The need for second visits between screening mammography and diagnostic imaging contributes to disparities in the time to breast cancer diagnosis. During the COVID-19 pandemic, an immediate-read screening mammography program was implemented to reduce patient visits and decrease time to diagnostic imaging. OBJECTIVE. The purpose of this study was to measure the impact of an immediate-read screening program with focus on disparities in same-day diagnostic imaging after abnormal findings are made at screening mammography. METHODS. In May 2020, an immediate-read screening program was implemented whereby a dedicated breast imaging radiologist interpreted all screening mammograms in real time; patients received results before discharge; and efforts were made to perform any recommended diagnostic imaging during the visit (performed by different radiologists). Screening mammographic examinations performed from June 1, 2019, through October 31, 2019 (preimplementation period), and from June 1, 2020, through October 31, 2020 (postimplementation period), were retrospectively identified. Patient characteristics were recorded from the electronic medical record. Multivariable logistic regression models incorporating patient age, race and ethnicity, language, and insurance type were estimated to identify factors associated with same-day diagnostic imaging. Screening metrics were compared between periods. RESULTS. A total of 8222 preimplementation and 7235 postimplementation screening examinations were included; 521 patients had abnormal screening findings before implementation, and 359 after implementation. Before implementation, 14.8% of patients underwent same-day diagnostic imaging after abnormal screening mammograms. This percentage increased to 60.7% after implementation. Before implementation, patients who identified their race as other than White had significantly lower odds than patients who identified their race as White of undergoing same-day diagnostic imaging after receiving abnormal screening results (adjusted odds ratio, 0.30; 95% CI, 0.10-0.86; p = .03). After implementation, the odds of same-day diagnostic imaging were not significantly different between patients of other races and White patients (adjusted odds ratio, 0.92; 95% CI, 0.50-1.71; p = .80). After implementation, there was no significant difference in race and ethnicity between patients who underwent and those who did not undergo same-day diagnostic imaging after receiving abnormal results of screening mammography (p > .05). The rate of abnormal interpretation was significantly lower after than it was before implementation (5.0% vs 6.3%; p < .001). Cancer detection rate and PPV1 (PPV based on positive findings at screening examination) were not significantly different before and after implementation (p > .05). CONCLUSION. Implementation of the immediate-read screening mammography program reduced prior racial and ethnic disparities in same-day diagnostic imaging after abnormal screening mammograms. CLINICAL IMPACT. An immediate-read screening program provides a new paradigm for improved screening mammography workflow that allows more rapid diagnostic workup with reduced disparities in care.

Breast Density and Risk of Interval Cancers: The Effect of Annual Versus Biennial Screening Mammography Policies in Canada

Regular screening mammography reduces breast cancer mortality. However, in women with dense breasts, the performance of screening mammography is reduced, which is reflected in higher interval cancer rates (ICR). In Canada, population-based screening mammography programs generally screen women biennially; however, some provinces and territories offer annual mammography for women with dense breast tissue routinely and/or on recommendation of the radiologist. This study compared the ICRs in those breast screening programs with a policy of annual vs. those with biennial screening for women with dense breasts. Among 148,575 women with dense breasts screened between 2008 to 2010, there were 288 invasive interval breast cancers; screening programs with policies offering annual screening for women with dense breasts had fewer interval cancers 63/70,814 (ICR 0.89/1000, 95% CI: 0.67-1.11) compared with those with policies of usual biennial screening 225/77,761 (ICR 1.45 /1000 (annualized), 95% CI: 1.19-1.72) i.e. 63% higher (p = 0.0016). In screening programs where radiologists’ screening recommendations were able to be analyzed, a total of 76,103 women were screened, with 87 interval cancers; the ICR was lower for recommended annual (65/69,650, ICR 0.93/1000, 95% CI: 0.71, 1.16) versus recommended biennial screening (22/6,453, ICR 1.70/1000 (annualized), 95%CI: 0.70, 2.71)(p = 0.0605). Screening program policies of annual as compared with biennial screening in women with dense breasts had the greatest impact on reducing interval cancer rates. We review our results in the context of current dense breast notification in Canada.

Encouraging Mammograms Using Behavioral Economics: A Randomized Controlled Trial in Chile

ObjectivesThis article illustrates the effect of a direct mail campaign that used insights from behavioral economics and psychology to increase the number of free mammograms in Chilean women aged 50 years or older. MethodsWe hypothesized 4 barriers in obtaining a mammogram based on previous literature and focus group analysis. A behavioral economic approach providing incentives was used to help overcome these barriers. We accessed a unique data set, which comprised 12 000 women 50 years old or older, with private health insurance who have not had a mammogram for 24 or more months. We conducted a randomized controlled trial with 8 treatments, each involving a specific combination of messages. ResultsThe intervention overall led to a 167% increase in the use of free mammograms, a 1.13% to 3.03% average increase from the control to treatment groups, respectively. Regarding barriers, we found that all messages were effective, with a slightly larger and persistent effect for the less complex ones in terms of information. This finding illustrates the benefits of keeping the message simple. ConclusionsFinally, these results suggest a successful public policy for increasing use of free mammography programs. Moreover, they are potentially transferable because the study considered decision-making heuristics that are not specific to one culture or social context.