Undergoing Screening Mammography Research Articles

Preliminary study of standardized semiquantitative method for ultrasonographic breast composition assessment.

To develop a classification tree via semiquantitative analysis for ultrasonographic breast composition assessment using routine breast ultrasonography examination images. This study retrospectively enrolled 100 consecutive normal women who underwent screening mammography and supplemental ultrasonography. Based on sonographic breast composition, the patients' breasts were classified as nondense or dense, which were correlated with mammographic breast composition. Ultrasonographic breast composition was classified based on the fibroglandular tissue (FGT) thickness-to-subcutaneous fat and retromammary fat (FAT) thickness ratio. In addition, the presence of a high glandular tissue component (GTC) in FGT or the presence of evident fat lobules in FGT was investigated. The cutoff point between the nondense and dense breasts was calculated from the area under the curve (AUC). All cases with a high GTC were dense breasts, and all cases with evident fat lobules in the FGT were nondense breasts. The AUC of the FGT thickness-to-FAT ratio of all cases, the group without a high GTC, the group without evident fat lobules in the FGT, and the group without a high GTC or evident fat lobules in the FGT were 0.93, 0.94, 0.99, and 1, respectively. The presence of a high GTC indicated dense breasts, and the presence of evident fat lobules in the FGT represented nondense breasts. For the remaining cases, the cutoff point of the FGT thickness-to-FAT thickness ratio was 0.93 for ultrasonographic two-grade scale breast composition assessment with 100% accuracy.

Abstract PO4-09-10: A successful method for treatment of an uninsured underprivileged breast cancer population

Abstract Background Improvements in breast cancer treatment and care have resulted in improved outcomes and decreased mortality. These improvements, however, come with great expense. Despite efforts from health care systems, a significant proportion of the population remains uninsured. The uninsured population is often underprivileged, undereducated and more likely to come from racial/ethnic minority groups. This combination of factors results in a delay in diagnosis, presentation at later stage, and decreased access and compliance with treatment. The goal of the current study is to describe a method for treating an uninsured, underprivileged breast cancer population and the resulting outcomes. Methods Retrospective review was performed of all breast cancer patients seen at Maricopa Medical Center, the safety net hospital in Phoenix, AZ. All breast cancer patients seen from January 1, 2000 to December 31, 2020 were included. Baseline data for every patient was compiled prospectively, supplemented by retrospective chart review. The data included sociodemographic information, health literacy assessment, and diagnostic tests. Health literacy was assessed using the Newest Vital Sign (NVS). Breast cancer treatment, follow up, and mortality were documented. Beginning on July 1, 2006 a new process was implemented to facilitate care of uninsured patients. More details will be included in the poster presentation. Briefly, however, core needle biopsies were performed in the Breast Clinic by the Breast surgeon or Physician assistant during the initial consultation. Rather than requiring full payment of the planned operation upfront, instead a down payment was made with a plan for payment in installments of the remainder of the cost. For chemotherapy and targeted therapy, a process was implemented to apply for discounted medications for appropriate regimens. There are no radiation therapy facilities at Maricopa Medical Center. An agreement was therefore made with a Radiation oncology group in Phoenix to provide discounted radiation therapy. The treatment was paid through treatment grants as well as fundraising activities by the Health Foundation of the hospital. In 2011, the Breast surgeon underwent training for genetic counseling at City of Hope Medical Center to provide genetic counseling for these patients. Results A total of 1,797 patients were included. Among them, 661 patients were seen before the process (BP) was started, while 1,136 patients were seen after the new process (NP) was implemented. Overall, the mean age of the patients was 52 years with most patients being Hispanic (56%). On average the patients had 10 yrs of education and 18% had adequate health literacy. The majority of patients were not employed (70%) and completely uninsured (56%) or underinsured (31%). Only 18% of patients underwent screening mammography and as a result 67% of patients presented at stage II or later. Despite the barriers mentioned above, the NP group underwent a higher percentage of breast conservation procedures (75% versus 47%, p < 0.001). A higher percentage of the NP group received adjuvant therapy: Chemotherapy (91% vs 70%, p < 0.001), Radiation therapy (91% versus 70%, p < 0.001), and initiated endocrine therapy (87% versus 67%, p < 0.001). At a mean follow up of 8 years, these improvements in adjuvant therapy resulted in a lower incidence of both ipsilateral breast tumor recurrence and chest wall recurrence (2% vs 16%, p < 0.001 and 5% versus 8%, p = 0.21, respectively) and improvement in overall survival (90% vs 81%, p < 0.001). Conclusions Despite treatment of a population with many barriers to breast cancer management, implementation of a treatment process improved access to diagnosis and surgical therapy as well as recommended adjuvant therapy. These improvements resulted in lower local recurrence rates and improved survival in an uninsured population. Citation Format: Ian Komenaka, Trevin Reyes, Jacqueline Gilbert, Chiu-Hsieh Hsu, Waqas Arslan, Gilbert Ramos, John Dover, Herbert Hitchon, Jesse Nodora, Elena Martinez. A successful method for treatment of an uninsured underprivileged breast cancer population [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 PO4-09-10.

Abstract PO2-20-10: Exceptional long-term disease control on pembrolizumab monotherapy in a patient with TMB-high PMS2-mutated MMR-deficient triple negative breast cancer brain metastasis

Abstract Introduction The brain is among the most common sites of breast cancer (BC) spread. Prognosis of BC brain metastasis (BCBM) differs by receptor subtype, with poorest median overall survival (OS) for triple-negative (TN) BCBM at under 5 months. Though treatment guidelines have evolved in recent years, most strategies have focused on local therapies including surgery and stereotactic radiotherapy (SRT), rather than on systemic agents. The 2020 FDA approval of pembrolizumab (pembro) for patients (pts) with metastatic high-tumor mutational burden (TMB-h, ≥ 10 mutations/megabase) solid tumors, agnostic of primary site, combined with clinical trials in melanoma reporting efficacy of immune checkpoint inhibitors (ICI) against BM, suggest a potential use of ICI for pts with TMB-h BCBM. Results of the TAPUR study supported modest therapeutic benefit of pembro for 28 pts with metastatic BC selected for TMB-h, with median OS of 30.6 weeks, but did not include pts with active BCBM. TMB-h is uncommon in BC, and further genomic signatures remain to be elucidated to identify pts with BCBM responsive to ICI. We present a remarkable case of a pt with Lynch Syndrome (LS) due to a germline PMS2 mutation, who developed TMB-h, mismatch repair (MMR)-deficient TN BCBM, and has maintained stable disease for over 6 years on pembro monotherapy. Case description A 62-y.o. woman underwent screening mammography that identified a right breast mass. Pt has a family history of a mother with uterine and pancreatic cancer, and father with bladder cancer. Biopsy confirmed invasive ductal carcinoma (IDC), grade 1 (G1), ER/PR-positive, HER2 score 0. She underwent partial mastectomy, axillary dissection, radiation, and received adjuvant anastrozole. Three years later, while still on anastrozole, she presented with a 6 cm right breast mass. Mastectomy disclosed G3, ER/PR-negative, HER2-positive (3+, Her2:CEP17 ratio 5.6) IDC. She received adjuvant chemotherapy (AC-T) and 1 year of trastuzumab. Seven years later, pt presented with headaches and word finding difficulties. MRI identified a 3.6 cm frontal mass, which biopsy revealed as TN BCBM. Systemic imaging ruled out distant metastases. Pt proceeded with SRT and exemestane (despite receptor staining ER- in case of a possible false negative result). Despite radiotherapy, pt had BCBM progression within the same year with the largest mass diameter grown to 4.8 cm. Resection (followed by SRT) identified the dominant histology as G3 TNBC. Following transition of care to our institution, germline testing revealed a pathogenic mutation in PMS2 (c943C >T). Tumor sequencing of the resected brain metastasis showed TMB of 48 and MMR deficiency. Therefore, systemic therapy with pembro monotherapy was initiated and maintained with good tolerability. Two years later, concern for progression from rising tumor markers led to addition of concurrent carboplatin/gemcitabine for 5 cycles. Imaging and tumor markers stabilized, and pt returned to pembro monotherapy. Today, 3 years later, and over 6.5 years after initial TN BCBM diagnosis, pt continues to have stable disease on pembro with an excellent performance status (ECOG 0) and no evidence of intracranial or extracranial progression. Discussion We document an exceptional case of prolonged benefit to pembro in a pt with TMB-h PMS2-mutated MMR-deficient TN BCBM. This case highlights two major pragmatic points to clinical practice; (i) the significance of germline testing in all pts with metastatic BC, and (ii) the impact of molecular testing of tumor tissue to identify rare alterations which may have dramatic effects on pt outcomes. Altogether, this case is a remarkable addition to growing evidence that TMB could be a biomarker for predicting response to ICI therapy and provides an example of ICI efficacy in the setting of BCBM. Further research on additional genomic, clinical, and pathologic features associated with ICI responsiveness is warranted for greater precision in BCBM management. Citation Format: Jaeyoon Cha, Albert Grinshpun, Lauren Buckley, Brian Alexander, Sara Tolaney, Nancy Lin. Exceptional long-term disease control on pembrolizumab monotherapy in a patient with TMB-high PMS2-mutated MMR-deficient triple negative breast cancer brain metastasis [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 PO2-20-10.

Abstract PO5-07-12: Feasibility of organized population-based mass-level mammography screening (0.2 million women) –Report from LMIC-Uzbekistan

Abstract Background. Breast cancer is one of the leading diseases worldwide. The early detection of breast cancer is the best way to improve survival. Mammography is included in the standard guidelines of all the leading organizations. The procedure is technically demanding and cost sensitive. Despite being a standard, it is not practical in many countries, and more so in LMIC. The state of Uzbekistan embarked on a massive, unique, organized population-based program of mass-level mammography screening, starting from one region of the country and expanding to others. Here, we report the process of such establishment and the feasibility of this innovative model. Methods. Realizing the importance of breast cancer screening, the Republic of Uzbekistan initiated a pilot project in the Bukhara Region. The area is divided into 12 districts. Every district was equipped with a stationary mammography machine in a regional polyclinic and one mobile van. The personnel were appropriately trained and a selection process was established to invite women for screening. The invitation was sent using the local area's existing municipality residential directory, which contains the complete demographic details of every individual living in the area. The state has 100 % coverage in the registry. The study targeted every woman aged 45-65 starting May 2021. All mammographs were digitally recorded and sent in real time to a centralized server at the National Republican Cancer Center in Tashkent, Uzbekistan. Reporting is performed at a centralized reading center on the information system platform. The program envisages a complete care pathway, from screening to diagnosis and treatment. Results. Over a period of two years, 140506 women in the age range–45-65 underwent mammography screening. Depending on the size of the target group of the district, an average of 30-60 mammograms were performed per day. A reported preliminary analysis shows the presence of BIRADS 0 in 4495, BIRADS 1 IN 78634, BIRADS 2 in 64345, BIRADS 4 in 4998, BIRADS 5 in 893. All women with BIRADS 4 and 5 were referred to the regional comprehensive cancer center for further evaluation. A total of 7570 patients underwent cytology and 408 underwent core biopsy. Depending on the reports, the patients were appropriately managed. A total of 1885 patients were recalled for additional screening owing to their inappropriate quality. After a year of function, the project was expanded with “Mobile Vans” to other regions of the country. An additional 13 mobile mammography vans were added after 1.5 years. From January 2023, approximately 50000 mammograms were additionally performed, taking the total number of screened women to 190506. Conclusion. Thus, it is feasible to plan and successfully implement state-owned mass-level mammography screenings. This project has the potential for duplication in any part of the world, and other organizations can learn from this extensive, wide program. Citation Format: Mirzagaleb Tillyashaykhov, Aysulu Seytmuratova, Alexander Ososkov, Saide Djanklich, Yakhyo Ziyaev, Dinesh Pendharlkar. Feasibility of organized population-based mass-level mammography screening (0.2 million women) –Report from LMIC-Uzbekistan [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 PO5-07-12.

Use of an AI Score Combining Cancer Signs, Masking, and Risk to Select Patients for Supplemental Breast Cancer Screening.

Background Mammographic density measurements are used to identify patients who should undergo supplemental imaging for breast cancer detection, but artificial intelligence (AI) image analysis may be more effective. Purpose To assess whether AISmartDensity-an AI-based score integrating cancer signs, masking, and risk-surpasses measurements of mammographic density in identifying patients for supplemental breast imaging after a negative screening mammogram. Materials and Methods This retrospective study included randomly selected individuals who underwent screening mammography at Karolinska University Hospital between January 2008 and December 2015. The models in AISmartDensity were trained and validated using nonoverlapping data. The ability of AISmartDensity to identify future cancer in patients with a negative screening mammogram was evaluated and compared with that of mammographic density models. Sensitivity and positive predictive value (PPV) were calculated for the top 8% of scores, mimicking the proportion of patients in the Breast Imaging Reporting and Data System "extremely dense" category. Model performance was evaluated using area under the receiver operating characteristic curve (AUC) and was compared using the DeLong test. Results The study population included 65 325 examinations (median patient age, 53 years [IQR, 47-62 years])-64 870 examinations in healthy patients and 455 examinations in patients with breast cancer diagnosed within 3 years of a negative screening mammogram. The AUC for detecting subsequent cancers was 0.72 and 0.61 (P < .001) for AISmartDensity and the best-performing density model (age-adjusted dense area), respectively. For examinations with scores in the top 8%, AISmartDensity identified 152 of 455 (33%) future cancers with a PPV of 2.91%, whereas the best-performing density model (age-adjusted dense area) identified 57 of 455 (13%) future cancers with a PPV of 1.09% (P < .001). AISmartDensity identified 32% (41 of 130) and 34% (111 of 325) of interval and next-round screen-detected cancers, whereas the best-performing density model (dense area) identified 16% (21 of 130) and 9% (30 of 325), respectively. Conclusion AISmartDensity, integrating cancer signs, masking, and risk, outperformed traditional density models in identifying patients for supplemental imaging after a negative screening mammogram. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Kim and Chang in this issue.

Assessing breast arterial calcification in mammograms and its implications for atherosclerotic cardiovascular disease risk

PurposeBreast arterial calcifications (BAC) are incidentally observed on mammograms, yet their implications remain unclear. We investigated lifestyle, reproductive, and cardiovascular determinants of BAC in women undergoing mammography screening. Further, we investigated the relationship between BAC, coronary arterial calcifications (CAC) and estimated 10-year atherosclerotic cardiovascular (ASCVD) risk. MethodsIn this cross-sectional study, we obtained reproductive history and CVD risk factors from 215 women aged 18 or older who underwent mammography and cardiac computed tomographic angiography (CCTA) within a 2-year period between 2007 and 2017 at hospital. BAC was categorized as binary (present/absent) and semi-quantitatively (mild, moderate, severe). CAC was determined using the Agatston method and recorded as binary (present/absent). Adjusted odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated, accounting for age as a confounding factor. ASCVD risk over a 10-year period was calculated using the Pooled Cohort Risk Equations. ResultsOlder age, systolic and diastolic blood pressures, higher parity, and younger age at first birth (≤28 years) were significantly associated with greater odds of BAC. Women with both BAC and CAC had the highest estimated 10-year risk of ASCVD (13.30 %). Those with only BAC (8.80 %), only CAC (5.80 %), and no BAC or CAC (4.40 %) had lower estimated 10-year risks of ASCVD. No association was detected between presence of BAC and CAC. ConclusionsThese findings support the hypothesis that BAC on a screening mammogram may help to identify women at potentially increased risk of future cardiovascular disease without additional cost and radiation exposure.

Incidence, Timing, and Long-Term Outcomes of COVID-19 Vaccine-Related Lymphadenopathy on Screening Mammography

ObjectiveTo determine the incidence, timing, and long-term outcomes of unilateral axillary lymphadenopathy ipsilateral to vaccine site (UIAL) on screening mammography after COVID-19 vaccination. MethodsThis retrospective, multisite study included consecutive patients undergoing screening mammography February 8, 2021, to January 31, 2022, with at least 1 year of follow-up. UIAL was typically considered benign (BI-RADS 1 or 2) in the setting of recent (≤6 weeks) vaccination or BI-RADS 0 (ultrasound recommended) when accompanied by a breast finding or identified >6 weeks postvaccination. Vaccination status and manufacturer were obtained from regional registries. Lymphadenopathy rates in vaccinated patients with and without UIAL were compared using Pearson’s χ2 test. ResultsThere were 44,473 female patients (mean age 60.4 ± 11.4 years) who underwent screening mammography at five sites, and 40,029 (90.0%) received at least one vaccine dose. Ninety-four (0.2%) presented with UIAL, 1 to 191 days postvaccination (median 13.5 [interquartile range: 5.0-31.0]). Incidence declined from 2.1% to 0.9% to ≤0.5% after 1, 2, and 3 weeks and persisted up to 36 weeks (P < .001). UIAL did not vary across manufacturer (P = .15). Of 94, 77 (81.9%) were BI-RADS 1 or 2 at screening. None were diagnosed with malignancy at 1-year follow-up. Seventeen (18.1%) were BI-RADS 0 at screening. At diagnostic workup, 13 (76.5%) were BI-RADS 1 or 2, 2 (11.8%) were BI-RADS 3, and 2 (11.8%) were BI-RADS 4. Both BI-RADS 4 patients had malignant status and ipsilateral breast malignancies. Of BI-RADS 3 patients, at follow-up, one was biopsied yielding benign etiology, and one was downgraded to BI-RADS 2. DiscussionIsolated UIAL on screening mammography performed within 6 months of COVID-19 vaccination can be safely assessed as benign.

Overcoming obstacles to mammography screening: Examining the role of offline healthcare barriers and online patient-provider communication.

Barriers to accessing offline healthcare may discourage patients from undergoing mammography screening. Online patient-provider communication (OPPC) offers a supplementary health resource that can complement traditional medical encounters and facilitate mammography screening. This study examines how offline healthcare barriers influence mammography screening, taking into account OPPC as an independent variable and cancer fatalism and patient activation as two mediators. Data from the 2017, 2018, and 2020 iterations of the Health Information National Trends Survey were used for this study. Results showed that OPPC was positively linked to mammography screening. Offline healthcare barriers had a negative association with patient activation and subsequent mammography behaviors. Moreover, offline healthcare barriers and OPPC were associated with mammography screening through serial mediation of cancer fatalism and patient activation. This study has important implications for encouraging mammography screening.

Top 5 Research Studies of the month for Italian Primary Care Physicians: January 2024.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) A recent high-quality systematic review (SR) of 76 SRs found that, compared to all other lipid-lowering medications, for overall, primary, and secondary prevention the best balance of benefits, harms, and costs is provided by statins. 2) To our surprise, a network meta-analysis of 12 randomized controlled trials (RCTs) concluded that acetaminophen and ketorolac were more effective than morphine in alleviating pain from renal colic and were less likely than morphine to cause adverse effects and the need for rescue analgesia. 3) Proton pump inbibitors (PPI) use in children is associated with an increased risk of developing serious infections as compared with the use other acid-suppressing therapy. It seems prudent to use antacids and histamine 2 receptor antagonists first and reserve PPIs for nonresponders. 4) Overdiagnosis - the identification of, in this case, breast cancer, that would not have caused symptoms in a person's lifetime - seems to increase with age. In a study including more than 50.000 women aged above 70 who underwent mammography screening, the overdiagnosis rate was 31%, 47% and 51% for women aged 70 to 74 years, 75 to 84 years and over age 85, respectively. 5) An RCT among community-dwelling adults conducted in the US found that using a regular cuff on larger-than-average arms can falsely raise blood pressure readings by almost 5 mmHg, and a regular cuff on an especially thin arm can lower readings by 3.6 mmHg.

Predictors of Breast Cancer Outcome in a Cohort of Women Seeking Care at a Safety Net Hospital

ObjectiveThis study aimed to identify predictors associated with lower mortality in a population of women diagnosed and treated for breast cancer at a safety net hospital. MethodsFrom 2008-2014, 1,115 patients were treated for breast cancer at our academic safety net hospital. 208 were excluded due to diagnosis at an outside facility, and the remaining 907 (81%) formed the study cohort. Retrospective charts and imaging reviews looked at race, ethnicity, insurance status, social determinants of health, screening utilization, treatment regimen, and 7-13-year follow-up care, including the cause of death. Multivariable logistic regression modeling assessed mortality, and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were computed. ResultsOf the 907 women, the mean age was 59 years (inter-quartile range 50-68 years), with 40% White, 46% Black, 4% Asian, and 10% Other. Increasing age (aOR=1.03, p=0.001) and more advanced stage at diagnosis (aOR=6.37, p<0.0001) were associated with increased mortality. There was no significant difference in mortality based on race or ethnicity (p>0.05). Of 494 with screening prior to diagnosis, longer screening time was observed for patients with advanced stage (median 521 days) vs. early stage (median 404 days), p=0.0004. Patients with Medicaid, insurance not specified, and no insurance were less likely to undergo screening before diagnosis than privately insured (all p<0.05). Shorter screening time was associated with lower all-cause mortality (aOR=0.57, 95% CI=0.36-0.89, p=0.013). DiscussionIn a safety net population, a more advanced stage at diagnosis was associated with higher mortality and lower odds of undergoing screening mammography in the two years prior to a breast cancer diagnosis. Early screening was associated with lower mortality. Finally, given no racial or ethnic differences in mortality, the safety net infrastructure at our institution effectively provides equitable cancer care once a cancer is confirmed.

Abstract C112: Improving breast cancer screening disparities through A3 problem solving: Design of a quality improvement initiative

Abstract Introduction: Extensive research studies on breast cancer disparities have had limited impact on reducing breast cancer disparities. Quality improvement initiatives use data-driven, rigorous approaches to plan, execute, and study the delivery of healthcare services. There have been limited studies using quality improvement methods to address health disparities. The purpose of our study was to describe the design of a quality improvement initiative to address breast cancer disparities using the A3 problem solving method. Methods: A3 problem solving method was used to reduce breast cancer screening disparities. The A3 method is a quality improvement tool used to identify problems, organize and synthesize data, and propose solutions to achieve goals (summarized on one side of a sheet of paper). A3 methods are outlined by the FOCUS-PDCA acronym: F - Find process to improve, O - Organize team of stakeholders, C - Clarify current state, U - Understand sources of variation that contribute to the problem, S - Select change ideas, P - Plan and do the improvement, C - Check the results, A - Act. Quantitative data was derived from the electronic medical record. Qualitative data was derived from divergent thinking exercises asking participants from diverse standing urban stakeholder groups about barriers to cancer screening. Results: Design of the A3 problem solving process was conducted between November 2022 until May 2023 yielding the following FOCUS-PDCA design and initial results. F - Increase the percentage of patients who have undergone mammography screening within the last two years. O - Team includes representative leaders from primary care, community health, ambulatory operations, diversity, equity, and inclusion, radiology, breast center, population health, information services, and federally qualified health centers. C and U - Quantitative data collection revealed that 74% of 37,509 eligible patients (women between 50-74 years old) received a mammogram within the last two years (75% White, 58% Black, 67% Asian, 60% American Indian, 64% Hispanic). Divergent thinking exercises revealed the following root causes for mammography screening disparities: patients don’t know they are due, transportation issues, barriers to scheduling, access to mammography facilities, financial concerns, and fears about returning to clinics during COVID-19. S - Process improvements included multilingual and modality reminders, marketing campaigns, transportation vouchers, co-location of screening centers with federally qualified health centers, expanded access to mammography screening facilities, educational activities for primary care physicians, participation in community events, equity-focused review of screening guidelines. PDCA - Based on selected improvements, changes in breast cancer screening percentages will be displayed using run charts until December 2024, stratified by race and ethnicity. Conclusion: A3 problem solving tools represent structured, scientifically rigorous approaches that cancer centers can use to reduce screening disparities. Citation Format: Nia Foster, Arissa J. Milton, Mai A. Elezaby, Roberta M. Strigel, Meeghan A. Lautner, Ryan W. Woods, Nicci O. Brackett, Noelle K. LoConte, Anand K. Narayan. Improving breast cancer screening disparities through A3 problem solving: Design of a quality improvement initiative [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 C112.

Mammographic breast density and cardiovascular disease risk in women

AimsWe aimed to determine the predictive role of mammographic breast density in addition to the Framingham Risk Score (FRS) on subsequent CVD events in women. Methods and ResultsThis cohort study included 4,268,579 women aged ≥40 years who underwent mammography screening between 2009 and 2010 with follow-up until 2020. Breast density was reported following the Breast Imaging Reporting and Data System. Primary outcomes included coronary heart disease, cerebrovascular disease, peripheral arterial disease, and heart failure. The incremental predictive ability of breast density added to the FRS model was assessed using the ROC and net reclassification index (NRI) among all women and strata based on FRS risk categories (<5% as low-risk, 5%–10% as moderate-risk, and ≥10% as high-risk). In total, 135,475 CVD events were recorded after a median follow-up of 10.9 years. A lower category of breast density was associated with a higher risk of CVD. Compared to the extremely dense breast group, the hazard ratios (95% CI) for CVDs were 1.12 (1.09–1.14), 1.19 (1.17–1.22), and 1.29 (1.26–1.32) in women with heterogeneously dense, scattered fibroglandular densities, and almost entirely fat breast density, respectively. Adding breast density to the FRS showed a slight improvement in AUROC but a modest improvement in NRI; the C-statistic difference was 0.083% (95% CI 0.069–0.096) with a 7.15% (6.85–7.69) increase in NRI, with the strongest improvement observed in the low-risk group. ConclusionsMammographic breast density is an independent predictor of incident CVD among women. The addition of mammographic breast density to FRS improves the prediction of CVDs, especially in low-risk individuals.

Factors Influencing Patient Confidence in Screening Mammography.

We aimed to assess factors associated with patients' confidence in the ability of screening mammography to detect breast cancer. Data were analyzed from a cross-sectional, prospective survey conducted in 2017 of women without a breast cancer history who were undergoing screening mammography at our institution. In total, 390 women completed the survey questions relevant to this study. Most respondents were 46 years or older (89.7%), White (87.6%), and college-educated (66.1%). Approximately 80% of respondents reported having confidence in the ability of screening mammography to detect breast cancer. Factors significantly associated with lower confidence in screening mammography were higher education (P = .01) and dense breast tissue (P < .001). Age (P = .12), race (P = .64), family history of breast cancer (P = .17), prior abnormal mammogram (P = .07), and mammogram frequency (P = .42) were nonsignificant. Women with a college education or higher were less likely to report confidence in routine mammography than women with less education (odds ratio [OR]= 0.43; 95% CI, 0.20-0.84; P = .02). Compared with women who reported their breast tissue as not dense, women who were aware they had increased breast density (OR = 0.16; 95% CI, 0.04-0.49; P = .004) or were unaware whether they had increased breast density (OR = 0.17; 95% CI, 0.04-0.51; P = .005) reported less confidence in screening mammography. Most respondents were confident in the ability of screening mammography to detect breast cancer. Confidence was inversely associated with education level and self-reported increased breast density. These findings highlight the importance of continued patient education about the effectiveness of screening mammography for patients with dense breast tissue.

Trends in the pre-operative diagnosis and surgical management of axillary lymph node metastases in women with screen-detected breast cancer

AimThe aim of the current study was to investigate time-trends in pre-operative diagnosis and surgical treatment of axillary lymph node metastases in breast cancers detected at screening mammography. MethodsWe included all women who underwent screening mammography in the South of the Netherlands between 2005 and 2020. During a follow-up period of at least two years, data on clinical radiological examinations, biopsy procedures and surgical interventions were obtained. The 15 years of inclusion were divided into five cohorts of three years each. ResultsOf the 4049 women with invasive breast cancer, 22.1 % (896/4049) had axillary lymph node metastasis at pathology (ALN+). Percutaneous axillary biopsy was performed in 39.6 % (355/896) of these women, with the proportions of fine needle aspiration biopsy (FNAB) decreasing from 97.6 % (40/41) in 2005–2007 to 41.6 % (37/89) in 2017–2019 and core needle biopsy (CNB) rising from 2.4 % (1/41) in 2005–2007 to 58.4 % (52/89) in 2017–2019 (P < 0.001). Sensitivity of FNAB and CNB was comparable (77.4 % (188/243, 95%CI = 71%–82 %) versus 82.4 % (103/125), 95%CI = 74%–88 %) (P = 0.26). Pre-operative confirmation of ALN + by percutaneous biopsy ranged from 27.3 % (56/205) in 2011–2013 to 39.0 % (80/205) in 2017–2019, with no significant trend changes over time (P = 0.103). The proportion of ALN + women who underwent axillary lymph node dissection (ALND) decreased from 96.0 % (97/101) in 2005–2007 to 16.6 % (34/205) in 2017–2019 (P < 0.001). ConclusionPre-operative confirmation of axillary lymph node metastasis by ultrasound-guided biopsy did not rise despite the increased use of CNB at the expense of less invasive FNAB. A significant reduction in ALND was observed through the years.

Patient Notification About Breast Arterial Calcification on Mammography: Empowering Women With Information About Cardiovascular Risk.

To assess the impact of informing women about the presence of breast arterial calcification (BAC) on mammography by determining whether those notified about the presence of BAC would seek cardiovascular evaluation. This IRB-approved prospective study included 494 patients who underwent screening mammography between June 8, 2021, and April 22, 2022. Mammograms were reviewed by a radiologist, and patients were notified via e-mail about the presence or absence of BAC. Patients with BAC were advised to discuss the results with their physicians and were surveyed 3 months later. Frequencies and proportions were calculated for study participation, presence of BAC, survey participation, health actions, and perceptions. Confidence intervals were calculated for proportions of health actions and perceptions. Of 494 study participants, 68/494 (13.8%; 95% CI: 10.9%-17.1%) had BAC detected on mammography and 42/68 (61.8%; 95% CI: 61.1%-62.1%) with BAC completed the follow-up survey at 3 months. Of these 42 survey respondents, 24/42 (57.1%; 95% CI: 41.1%-72.3%) reported discussing results with their primary care physician (PCP) or a cardiologist. In addition, 34/42 (81.0%; 95% CI: 65.9%-91.4%) reported finding it helpful to receive information about BAC and 32/42 (76.2%; 95% CI: 60.6%-88.0%) believed all women should be informed about BAC after mammography. After notification about the presence of BAC on screening mammography, the majority (57.1%) of survey respondents reported discussing the results with a PCP or cardiologist. These results suggest that providing mammography patients with information about BAC may promote preventive cardiovascular health.

Non–timely referral of women aged 40 to 69 to preventive medicine for breast cancer detection and its association with the BI-RADS classification

PurposeIn the first level of health care, the timely detection of breast cancer is essential to prevent the progression of the disease, obtain optimal treatment and improve the prognosis and survival of patients. The objective of this study was to analyze the opportunity in referral to the Preventive Medicine Modules offered to women aged 40 to 69 years of the Family Medicine Unit 1, of the Mexican Social Security Institute, Decentralized Administrative Operation Body, Aguascalientes, Mexico, by their family physician, and its impact in the findings of mammographic screening according to the BI-RADS classification. Methods This was a cross-sectional comparative study of 412 mammograms performed on women aged 40 to 69, who were treated in the preventive medicine modules from January 2019 to June 2021. Data collection was carried out by simple random sampling using a checklist. Multiple logistic regression models adjusted for age were applied. ResultsA total of 90.29% of the patients who underwent screening mammography were not referred in a timely manner to the preventive medicine modules by the family physician, this delay in diagnosis and treatment increased by 3.01 times the probability of having a classification BI-RADS suspected of malignancy compared to those women whose referral was timely (OR adj = 3.01, 95% CI 1.04–8.72, p = 0.041). ConclusionThe untimely referral of women aged 40–69 to preventive medicine modules for the detection of breast cancer increases the risk of finding a malignant lesión.

Comparing the performance of full-field digital mammography and digital breast tomosynthesis in the post-treatment surveillance of patients with a history of breast cancer: A retrospective study

IntroductionThe purpose of our study was to compare the performance of 2D (FFDM) against 3D (FFDM plus DBT) examinations in the post-treatment surveillance of asymptomatic breast cancer survivors. MethodsA list of women with a history of breast cancer who underwent screening mammography (2D or 3D) from 5/2017 to 5/2020 was retrieved. A total of 20,210 examinations were identified and performance metrics were compared. ResultsThere were no statistically significant difference in cancer detection rate (CDR) (p = 0.38), recall rate (RR) (p = 0.087), or positive predictive value (PPV) (p = 0.74) between 2D vs. 3D examinations. Stratification by breast tissue identified no statistically significant difference in CDR (p = 0.581 and p = 0.428), RR (p = 0.230 and p = 0.205), or PPV (p = 0.908 and p = 0.721) between fatty/scattered and heterogeneous/extremely dense breast tissue when comparing 2D vs 3D examinations. Stratification by age did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased with 2D vs. 3D examinations in the 60–69 years group (p = 0.021). Stratification by race did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased with 3D vs. 2D examinations in white women (p = 0.036). Stratification by laterality (bilateral vs. unilateral post mastectomy) did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased in 2D vs. 3D examinations in unilateral studies (p = 0.009). ConclusionFor asymptomatic women with a history of breast cancer, there is no evidence that the addition of DBT to FFDM improves CDR, RR, or PPV. Implications for practiceMore studies are needed concerning screening methodologies supplementing FFDM in the screening regimens of breast cancer survivors.

Survey of knowledge and awareness of breast density amongst Maltese Women undergoing mammography screening

IntroductionThe ratio of breast glandular tissue to fatty tissue is known as breast density. This study assessed the knowledge and awareness of breast density of Maltese women undergoing mammography screening at the National Screening Unit. Increased breast density knowledge may lead to an increase in supplementary imaging attendance. In Europe, there are very limited studies assessing the knowledge and awareness of breast density, providing a solid rationale for this study to be done locally. MethodsWomen aged 50 to 69 who were eligible for breast cancer screening at the National Screening Unit were given a validated closed-ended questionnaire as part of a quantitative, prospective, cross-sectional, and descriptive study. The questionnaire was designed to achieve the aims of the study. Using IBM-SPSS (v28) software, the data was analysed using the Friedman and Kruskal Wallis tests. ResultsA total of 127 surveys were gathered, with a maximum margin of error of 8.66% based on a 95% confidence range. Breast density and the risks associated with it were not well known or understood (average scores ranging from 2.80 to 3.34 out of 5), but supplemental screening was more widely known (3.65). Participants' knowledge and awareness were correlated with their age, profession, and degree of education. Leaflets (40%) and medical experts (40%) were respondents' favourite sources of information. ConclusionThe population under study lacks knowledge and awareness of breast density and the risks it entails. It's important to provide women more details about breast density. With this information, women will be empowered to seek the finest care. Implications for practiceAlthough some socio-demographic parameters were linked to women's knowledge and awareness, it is advised that more research be done using a bigger sample size through interviews and other studies. Moreover, more information regarding breast density must be provided to women undergoing breast cancer screening in Malta to increase their knowledge and awareness.

Breast cancer risk characteristics of women undergoing whole-breast ultrasound screening versus mammography alone.

There are no consensus guidelines for supplemental breast cancer screening with whole-breast ultrasound. However, criteria for women at high risk of mammography screening failures (interval invasive cancer or advanced cancer) have been identified. Mammography screening failure risk was evaluated among women undergoing supplemental ultrasound screening in clinical practice compared with women undergoing mammography alone. A total of 38,166 screening ultrasounds and 825,360 screening mammograms without supplemental screening were identified during 2014-2020 within three Breast Cancer Surveillance Consortium (BCSC) registries. Risk of interval invasive cancer and advanced cancer were determined using BCSC prediction models. High interval invasive breast cancer risk was defined as heterogeneously dense breasts and BCSC 5-year breast cancer risk ≥2.5% or extremely dense breasts and BCSC 5-year breast cancer risk ≥1.67%. Intermediate/high advanced cancer risk was defined as BCSC 6-year advanced breast cancer risk ≥0.38%. A total of 95.3% of 38,166 ultrasounds were among women with heterogeneously or extremely dense breasts, compared with 41.8% of 825,360 screening mammograms without supplemental screening (p<.0001). Among women with dense breasts, high interval invasive breast cancer risk was prevalent in 23.7% of screening ultrasounds compared with 18.5% of screening mammograms without supplemental imaging (adjusted odds ratio,1.35; 95% CI, 1.30-1.39); intermediate/high advanced cancer risk was prevalent in 32.0% of screening ultrasounds versus 30.5% of screening mammograms without supplemental screening (adjusted odds ratio,0.91; 95% CI, 0.89-0.94). Ultrasound screening was highly targeted to women with dense breasts, but only a modest proportion were at high mammography screening failure risk. A clinically significant proportion of women undergoing mammography screening alone were at high mammography screening failure risk.

A scalable approach to democratizing cancer risk stratification: One healthcare system’s approach using a patient-facing digital platform.

10622 Background: Access to genetic testing and risk stratification is primarily gated by referrals from non-genetics providers for patients who meet testing criteria. The majority of Americans seek care at community hospitals that are closer to home; community hospitals are faced with the challenge of how to democratize access to precision oncology and cancer prevention. Research has shown that the establishment of such protocols is challenging, requiring organizational buy-in, capital, resources, and the involvement of multiple levels of clinical and nonclinical stakeholders. Here we highlight Sarah Cannon, the Cancer Institute of HCA Healthcare, and their programmatic approach to risk stratification using a digital platform offered universally to all patients undergoing screening mammography. Methods: From February to November in 2022, fourteen sites were assessed to have appropriate provider and facility capabilities to support the implement the CARE program. The web-based risk-stratification tool is sent to individuals before standard ambulatory appointments to assess their lifetime risk for breast cancer based on the Tyrer-Cuzick (version 8.0) risk algorithm and National Comprehensive Cancer Network (NCCN) genetic testing criteria. Testing criteria included hereditary breast, ovarian, pancreatic, and prostate cancers, Lynch syndrome, and familial adenomatous polyposis (FAP). Retrospective data was pulled from patients seen between February 2022 through January 2023. The outcome measures included percentage of individuals who completed the risk-assessment, met genetic testing criteria, pursued germline genetic testing, received a positive germline result, and/or had a breast cancer risk ≥20%. Results: During the 10 months at the 14 community hospitals a total of 25,671 individuals were invited for risk assessment through the CARE program; 19,277 (75.1%) individuals completed assessment. Overall, 5,070 (26.3%) met genetic testing criteria and 1,536 individuals had a ≥20% lifetime risk of breast cancer, for a total of 34% of patients identified as elevated risk. 23.4% (1,187) of those meeting criteria opted to proceed with germline genetic testing. An additional 126 individuals who did not meet criteria pursued genetic testing. Of the 1,313 completed genetic tests, 96 (7%) had positive genetic test results. Fifty-four of 96 (56%) positive results had an impact on medical management and cancer prevention. Conclusions: Sarah Cannon and HCA Healthcare have successfully begun implementing a comprehensive, digital risk stratification program in the community hospital setting to provide standardized access to genomic testing and risk stratification. By identifying patients with an elevated risk for cancer, the potential for increased early cancer detection and precision oncology can be observed in a scalable and sustainable program.