Use Of Screening Mammography Research Articles

Comparison of Local Recurrence After Simple and Skin-Sparing Mastectomy Performed in Patients with Ductal Carcinoma In Situ

BackgroundThe incidence of ductal carcinoma in situ (DCIS) is increasing with the use of screening mammography, and approximately 30% of all women diagnosed with DCIS are treated by mastectomy. There is increasing use of a skin-sparing mastectomy (SSM) approach to surgically excise DCIS as this facilitates immediate breast reconstruction. The rates of locoregional recurrence (LRR) after simple mastectomy performed for pure DCIS are historically reported as 1%; however, international data suggest that LRR after SSM may be higher.MethodsTo determine our rates of LRR and compare the effect of the type of mastectomy performed, we undertook a retrospective review of all patients who underwent a mastectomy for pure DCIS at our institution between 2000 and 2010. ResultsIn total, 199 patients underwent a mastectomy for pure DCIS (with eight local recurrences), all of which were invasive ductal carcinoma. The recurrences all occurred after SSM, which was associated with a higher 5-year LRR of 5.9% (5/102) compared with 0% in the simple mastectomy group (0/97; p = 0.012), log-rank. Univariate analysis showed the two factors that predicted the risk of recurrence were a young age at mastectomy and close or involved margins.ConclusionsThese data highlight the importance of achieving clear margins, especially in young women with estrogen receptor-negative DCIS who have a higher risk of invasive recurrence. Women undergoing a mastectomy for DCIS should be counseled as to the importance of achieving clear margins and the potential increased need for further excision, post-mastectomy radiotherapy and post-reconstruction mammography in order to prevent LRR after SSM.

The Effect of the Controversial US Preventive Services Task Force Recommendations on the Use of Screening Mammography

PurposeThe 2009 release of updated US Preventive Services Task Force (USPSTF) recommendations on screening mammography differed sharply from those of the American Cancer Society, the ACR, and the American College of Obstetricians and Gynecologists. The aim of this study was to ascertain the effect of these recommendations on the utilization of screening mammography in the Medicare population. MethodsThe Medicare Part B Physician/Supplier Procedure Summary Master Files from 2005 through 2010 were used to determine the annual utilization rate of screening mammography from 2005 to 2010. A utilization trend line was plotted for those years. ResultsThe utilization rate of screening mammography per 1,000 women in the Medicare population was 311.6 in 2005 and increased gradually each year to 322.9 in 2009 (a compound annual growth rate of 0.9%). However, after the USPSTF recommendations were issued in late 2009, this rate decreased abruptly to 309.1 (−4.3%) in 2010. ConclusionsThe abrupt decrease in the utilization of screening mammography in 2010 was in sharp contrast to the previous slow annual increases in its utilization from 2005 to 2009. Because there are no other factors to explain a decrease of this magnitude, it would seem that the USPSTF recommendations and the ensuing publicity resulted in a decrease in the utilization of screening mammography in the Medicare population in the first year after issuance of the new recommendations.

Screening Breast Cancer: the Mammography War

There is an established consensus in the breast health community that mammography is the mainstay imaging examination for screening breast cancer. However, there are varied national recommendations among stakeholders and major institutions in the topic of breast cancer screening. Lack of consensus in screening criteria includes risk stratification, age to initiate screening, and the interval of screening. The differences in practice guidelines are mainly due to variation in design and interpretation of screening trials over the past decades. As debates for and against the use of screening mammography continue to escalate, both providers and patients are often confused and wrongly perceive the recommendations as directives. The purpose of this article is to review the current guidelines, analyze the reason for the controversies in screening mammography, and shine light on the upcoming trends of future screening guidelines.

Impact of Medicare Shared Savings Program Accountable Care Organizations at Screening Mammography: A Retrospective Cohort Study.

Materials and Methods Institutional review board approval was waived, as the study used publicly available unidentifiable data. Medicare data were retrospectively obtained for participating ACOs from 2012 to 2014. Baseline information and the ACO-20 measure (percentage of women aged 40-69 years who underwent screening mammography within 24 months) were obtained. Negative binomial regression models were used to evaluate baseline and longitudinal mammography use, with stratified analyses performed for year of entry into the ACO, number of beneficiaries, and geographic region. Results A total of 333 ACOs with 5 329 831 Medicare beneficiaries (mean size, 16 006 beneficiaries) participated in the MSSP. Screening use varied across ACOs (median, 63.0%; range, 8.8%-90.3%), with differences found across regions (use was highest in the Midwest [66.6%] and lowest in the South [58.2%], P = .038). A total of 208 ACOs reported longitudinal outcomes, with mean change in screening mammography use of +2.6% (range, -33.2% to +42.2%), with 128 (61.6%) ACOs reporting improvements (incidence rate ratio, 1.04; 95% confidence interval: 1.02, 1.07) (P = .002). No longitudinal differences in use were seen across regions (P = .078), year of entry (P = .902), number of beneficiaries (P = .814), or total composite quality score (P = .324), nor was there a difference between ACOs that saved money and those that did not (P = .391). Conclusion ACOs in the MSSP have produced small significant improvements in screening mammography use. © RSNA, 2016.

A prospective study of endometriosis and risk of benign breast disease.

Given the altered hormonal and inflammatory environment of women with endometriosis, several studies have suggested a positive association between endometriosis and breast cancer, although findings have been mixed. This study investigates the relationship between endometriosis and benign breast disease (BBD), benign lesions that are associated with an increased risk of breast cancer. Among women in the Nurses' Health Study II followed from 1991-2003 (n=76,393), we investigated the association between laparoscopically confirmed endometriosis and biopsy-confirmed BBD. Cox proportional hazard models, adjusted for a priori potential confounding factors, were used to calculate hazard ratios (HR) and 95% confidence intervals (CI). Across follow-up, 2011 BBD biopsies were collected and centrally reviewed by study pathologists (nonproliferative=675, proliferative=1336). Effect modification by infertility history and use of screening mammography was investigated. Endometriosis was associated with a modest increased risk of biopsy-confirmed BBD in crude and multivariable adjusted models (HR 1.20, 95% CI 1.00-1.43). When evaluating subtypes of BBD, we did not see different associations for nonproliferative or proliferative BBD lesions, as endometriosis was associated with a modest increased risk for both (HR nonproliferative 1.15, 95% CI 0.84-1.57; HR proliferative 1.22, 95% CI 0.98-1.52). The association between endometriosis and proliferative BBD appeared strongest among women who had ever experienced infertility (HR 1.50, 95% CI 1.12-2.03; P value, test for heterogeneity=0.05). Sensitivity analyses investigating screening behaviors between those with and without endometriosis did not significantly alter results. Endometriosis was associated with a modest increased risk of both proliferative and nonproliferative BBD, although future work should replicate this novel finding.

Screening Mammography Use Among Older Women Before and After the 2009 U.S. Preventive Services Task Force Recommendations.

It is uncertain how changes in the U.S. Preventive Services Task Force breast cancer screening recommendations (from annual to biennial mammography screening in women aged 50-74 and grading the evidence as insufficient for screening in women aged 75 and older) have affected mammography use among Medicare beneficiaries. Cohort study of 12 million Medicare fee-for-service women aged 65-74 and 75 and older to measure changes in 3-year screening use, 2007-2009 (before) and 2010-2012 (after), defined by two measures-proportion screened and frequency of screening by age, race/ethnicity, and hospital referral region. Fewer women were screened, but with similar frequency after 2009 for both age groups (after vs. before: age 65-74: 60.1% vs. 60.8% screened, 2.1 vs. 2.1 mammograms per screened woman; age 75 and older: 31.7% vs. 33.6% screened, 1.9 vs. 1.9 mammograms per screened woman; all p < 0.05). Black women were the only subgroup with an increase in screening use, and for both age groups (after vs. before: age 65-74: 55.4% vs. 54.0% screened and 2.0 vs. 1.9 mammograms per screened woman; age 75 and older: 28.5% vs. 27.9% screened and 1.8 vs. 1.8 mammograms per screened woman; all p < 0.05). Regional change patterns in screening were more similar between age groups (Pearson correlation r = 0.781 for proportion screened; r = 0.840 for frequency of screening) than between black versus nonblack women (Pearson correlation r = 0.221 for proportion screened; r = 0.212 for frequency of screening). Changes in screening mammography use for Medicare women are not fully aligned with the 2009 recommendations.

Abstract P6-12-07: The benefit of preoperative chemotherapy in an underinsured Hispanic population with poor use of screening mammography

Abstract Background: Despite prospective clinical trials demonstrating the safety and effectiveness of preoperative chemotherapy for nearly 2 decades, it may still be underutilized in underserved, uninsured populations most likely to present with advanced cancers. The current study was performed to evaluate the effect of preoperative chemotherapy (PC) in a Hispanic safety net population. Methods: A retrospective review of Hispanic breast cancer patients who presented at clinical stage 2 or higher and were treated from July 2001 to February May 2015 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. Surgical outcomes were evaluated. Margin status was determined for those who underwent breast conservation. Results: The average age of the 266 patients was 45 years. 93% of the patients were insured with Medicaid or uninsured (70%). Only 24% of patients underwent screening mammography. 133 underwent PC and 133 had primary operations. Patients who underwent PC presented with larger cancers (5cm vs 3.5cm, p &amp;lt; 0.001). 96% of patients in PC group were not candidates for lumpectomy at presentation. However, lumpectomy was performed more often in those who underwent PC (75% vs. 57%, p = 0.01). Re-excision for margins were necessary less often in those who underwent PC (10.3% vs 27%, p = 0.01). Patients who underwent PC were also less likely to require an ALND (33% vs 47%, p = 0.04). Despite presentation at higher average clinical stage in patients who underwent PC, at average follow up of 52 months, risk of IBTR and risk of regional recurrence were similar in the PC and no-PC groups (IBTR: 4.4% vs 3%, p = 0.99 and Regional: 1.5% vs. 1.5%, p = 0.99). Breast cancer specific survival was 86.5% in the PC group compared to 84% in the no-PC group (p = 0.68). Patients in the no-PC group were less likely to comply with recommended chemotherapy.Conclusions: In this underinsured, Hispanic population who did not use screening mammography, preoperative chemotherapy allowed many women to undergo breast conservation, undergo fewer operations, and were less likely to require ALND. Risk of local and regional recurrence is low in these patients and comparable to those who underwent primary operation. Citation Format: Komenaka IK, Djenic B, Walters J, Hsu C-H, Nodora JN, Martinez ME, Bouton M, Mehta D. The benefit of preoperative chemotherapy in an underinsured Hispanic population with poor use of screening mammography. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-07.

Abstract P6-02-01: Screening mammography in women over age 75: Is it beneficial?

Abstract Background: In 2015 the U.S. Preventive Services Task Force (USPSTF) stated that there was insufficient evidence for the use of screening mammography in women aged 75 and older. This statement was based on the lack of randomized controlled trials demonstrating survival benefit in this population. As per the American College of Radiology, the acceptable cancer detection rate via screening mammography is at least 2.5 cases per 1000 examinations for an institution, with reported rates as high as 4.7 cases per 1000. Aim: In this study, we sought to examine our institution's practice of screening mammography for women 75 years and older. We aimed to determine the incidence of cancer detection in this age group through screening mammography. Methods: A search was performed to identify women aged 75 and above who underwent screening mammography at Mount Sinai Beth Israel Medical Center between January 1, 2013 and December 31, 2014. Patients classified as BIRADS 0 on initial screening were reclassified based on their subsequent diagnostic imaging, if performed. A chart review was performed for those patients who underwent breast biopsies to obtain their pathology results. Results: In this two year period, 2057 patients aged 75 and older underwent screening mammography. The majority of women in this age group had non-actionable results of their screening mammography, and were classified as BIRADS 1 or 2 (96%). There were a total of 49 patients who had BIRADS 3 final results (2.4%). Twenty-two patients had screening mammograms that were classified as BIRADS 4 (1.1%). Biopsies revealed 6 invasive ductal carcinomas, 4 cases of in situ carcinoma, 2 cases of duct ectasia, 2 intraductal papillomas, 3 fibrocystic biopsies, and 3 fibroadenomas. In total, 10 of 2057 patients were diagnosed with breast cancer (0.5%). Mammography results from 2013-2014Final radiologic classificationNumber of patientsPercent of populationBIRADS 182940.3%BIRADS 2114755.7%BIRADS 3492.4%BIRADS 4221.1%BIRADS 500%BIRADS 0100.5%Total screening mammograms2057 Conclusions: In our institution, 98.4% of women aged 75 and older had screening mammography with benign results. Ten women in this group were found to have breast cancer. The breast cancer detection rate in this cohort was 4.9 per 1000 screening examinations, which is nearly double the cited recommendation put forth by the American College of Radiology. These results are certainly relevant when considering appropriateness of annual screening mammography in this age group. Citation Format: Cate SP, Kohli MK, Gillego A, Chadha M, Fulop T, Boolbol SK. Screening mammography in women over age 75: Is it beneficial?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-01.

Content Validity of a Screening Instrument for Breast Cancer Early Detection Among Asian American Women: The Cultural Health and Screening Mammography Belief Scale.

Asian American women have the lowest mammography screening rate in the United States. There is no standardized instrument available to measure their cultural beliefs regarding screening mammography. The purpose of this study is to evaluate the content validity of the Cultural Health and Screening Mammography Belief Scale (CHSMBS) developed for this population. Procedures for Instrument Development: The content validity was examined using content validity index (CVI). Both item-level (I-CVI) and scale-level CVIs (S-CVI) were evaluated. The instrument's I-CVIs ranged from 0.75 to 1.00, and the S-CVI was 1.00, reflecting excellent inter-rater agreement. The study has established the scale's content validity to evaluate Asian American women's use of screening mammography. Further examination of the reliability and construct validity will add further support of the scale's utility in health research and practice.

Predictors of Non-Adherence to Breast Cancer Screening among Hospitalized Women.

ObjectiveDisparities in screening mammography use persists among low income women, even those who are insured, despite the proven mortality benefit. A recent study reported that more than a third of hospitalized women were non-adherent with breast cancer screening. The current study explores prevalence of socio-demographic and clinical variables associated with non-adherence to screening mammography recommendations among hospitalized women.Patients and MethodsA cross sectional bedside survey was conducted to collect socio-demographic and clinical comorbidity data thought to effect breast cancer screening adherence of hospitalized women aged 50–75 years. Logistic regression models were used to assess the association between these factors and non-adherence to screening mammography.ResultsOf 250 enrolled women, 61% were of low income, and 42% reported non-adherence to screening guidelines. After adjustment for socio-demographic and clinical predictors, three variables were found to be independently associated with non-adherence to breast cancer screening: low income (OR = 3.81, 95%CI; 1.84–7.89), current or ex-smoker (OR = 2.29, 95%CI; 1.12–4.67), and history of stroke (OR = 2.83, 95%CI; 1.21–6.60). By contrast, hospitalized women with diabetes were more likely to be compliant with breast cancer screening (OR = 2.70, 95%CI 1.35–5.34).ConclusionBecause hospitalization creates the scenario wherein patients are in close proximity to healthcare resources, at a time when they may be reflecting upon their health status, strategies could be employed to counsel, educate, and motivate these patients towards health maintenance. Capitalizing on this opportunity would involve offering screening during hospitalization for those who are overdue, particularly for those who are at higher risk of disease.

Factors associated with surgical management in an underinsured, safety net population

Few studies include significant numbers of racial and ethnic minority patients. The current study was performed to examine factors that affect breast cancer operations in an underinsured population. We performed a retrospective review of all breast cancer patients from January 2010 to May 2012. Patients with American Joint Committee on Cancer clinical stage 0-IIIA breast cancer underwent evaluation for type of operation: breast conservation, mastectomy alone, and reconstruction after mastectomy. The population included 403 patients with mean age 53years. Twelve of the 50 patients (24%) diagnosed at stage IIIB presented with synchronous metastatic disease. Of the remaining patients, only 2 presented with metastatic disease (0.6%). The initial operation was 65% breast conservation, 26% mastectomy alone, and 10% reconstruction after mastectomy. Multivariate analysis revealed that Hispanic ethnicity (odds ratio [OR], 0.38; 95% CI, 0.19-0.73; P=.004), presentation with palpable mass (OR, 0.34; 95% CI, 0.13-0.90; P=.03), preoperative chemotherapy (OR, 0.25; 95% CI, 0.10-0.62; P=.003) were associated with a lesser likelihood of mastectomy. Multivariate analysis of factors associated with reconstruction after mastectomy showed that operation with Breast surgical oncologist (OR, 18.4; 95% CI, 2.18-155.14; P<.001) and adequate health literacy (OR, 3.13; 95% CI, 0.95-10.30; P=.06) were associated with reconstruction. The majority of safety net patients can undergo breast conservation despite delayed presentation and poor use of screening mammography. Preoperative chemotherapy increased the likelihood of breast conservation. Routine systemic workup in patients with operable breast cancer is not indicated.

Abstract CN03-03: Improving decision making for ductal carcinoma in situ

Abstract With greater use of screening mammography, the incidence of pre-invasive breast carcinoma or ductal carcinoma in situ (DCIS) has increased by 560% over the past 35 years. By the year 2020, more than 1 million women will be living with a DCIS diagnosis. Despite the large number of women affected, the optimal treatment strategy for DCIS is not known. DCIS does not spread to the lymph nodes or other sites in the body, but left untreated, can progress to invasive breast cancer. Mastectomy, or removal of the breast, had been the standard of care for treatment of DCIS and is curative in almost all patients; however, it is an extreme surgery for a diagnosis that may not progress to invasive breast cancer. Currently over 70% of women with DCIS receive breast-conserving surgery, but they then have a risk of being diagnosed with a second cancer in the same breast. To reduce this risk some women receive radiation therapy or tamoxifen therapy. Radiation therapy delivered to the breast after breast-conserving surgery to decrease the risk of another diagnosis in the affected breast. But if a woman undergoes radiation for DCIS and then has a 2nd diagnosis in the same breast, she will need a mastectomy since radiation can only be given once due to limits of normal tissue tolerance. Therefore, radiation therapy may also reduce the long-term likelihood of breast conservation. The important outcome of lifetime breast conservation with or without radiation has not been studied, resulting in patients and physicians choosing treatment without complete information about expected treatment outcomes. Across the United States, treatment patterns (type of surgery, use of radiation therapy or tamoxifen) for DCIS vary widely by region of the country. Instead, the choice of treatment should vary according to the values and preferences of each DCIS patient. To enable informed decision-making by DCIS patients, we seek to provide individualized data about outcomes– in terms of recurrence, disease-free and overall survival, and likelihood of long-term breast conservation. To present these data, we developed an online decision aid, www.onlineDeCISion.org through support from the Agency for Health Care Research and Quality (AHRQ). This web-based decision aid is informed by a disease simulation model and projects customized 10-year and lifetime outcomes following six different treatment strategies for DCIS: lumpectomy alone, lumpectomy with radiation, lumpectomy with radiation and tamoxifen, lumpectomy with tamoxifen, and mastectomy with and without breast reconstruction (Soeteman et al., JNCI 2013). Presented results are tailored to a patient's age at diagnosis. Default risks of recurrence are taken from randomized trials, however the tool allows for flexibility in terms of presenting outcomes for personalized risks of recurrence. The development of the decision tool used semi-structured interviews and incorporated results from usability testing with key stakeholders, including a diverse group of multidisciplinary clinicians and patient advocates. After further testing, we hope that our tool will help patients and clinicians choose treatment that is most aligned with a patient's preferences for the tailored outcomes. Citation Format: Rinaa Punglia. Improving decision making for ductal carcinoma in situ. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr CN03-03.

Ductal Carcinoma In Situ of the Breast: Evaluating the Role of Radiation Therapy in the Management and Attempts to Identify Low-risk Patients.

Ductal carcinoma in situ of the breast has rapidly increased in incidence over the past several decades secondary to an increased use of screening mammography. Local treatment options for women diagnosed with ductal carcinoma in situ include mastectomy or breast-conserving therapy. Although several randomized trials have confirmed a >50% reduction in the risk of local recurrence with the administration of radiation therapy (RT) compared with breast-conserving surgery alone, controversy persists regarding whether or not RT is needed in selected "low-risk" patients. Over the past two decades, two prospective single-arm studies and one randomized trial have been performed and confirm that the omission of RT after surgery is associated with higher rates of local recurrence even after selecting patients with optimal clinical and pathologic features. Importantly, these trials have failed to consistently and reproducibly identify a low-risk cohort of patients (based on clinical and pathologic features) that does not benefit from RT. As a result, adjuvant RT is still advocated in the majority of patients, even in low-risk cases. Future research is moving beyond traditional clinical and pathologic risk factors and instead focusing on approaches such as multigene assays and biomarkers with the hopes of identifying truly low-risk patients who may not require RT. However, recent studies confirm that even low-risk patients identified from multigene assays have higher rates of local recurrence with local excision alone than would be expected with the addition of RT.

Comment on “A Prospective Study of the Use and Effects of Screening Mammography in Women Aged 70 and Older”

The article by Vacek and Skelly focuses on the study of older women and whether breast cancer screening is necessary or beneficial.1 Being a young woman and having numerous female relatives, the topic of mammogram use and breast cancer awareness is of importance to me. There has been a great deal of debate in the medical community and among health insurance companies about how often and to what age screening should occur and how frequent screening should be. Some doctors recommend mammograms begin at the age of 40, but if there is history of breast cancer in the family, they may recommend screenings at an earlier age. Other doctors recommend that women have their first mammogram at age 50. Because there are conflicting views, there needs to be more research on this topic so that women and healthcare providers can make more evidence-based decisions. Before reading this article, I had assumed, like many others, that mammogram screening really was not necessary once a woman reached the age of 75. This study has opened my eyes and caused me to reflect on my thinking. If a woman at the age of 76 is screened and determined to have breast cancer, she is likely to live longer than if she had not had the screening. Also, life expectancy today is much higher than it was, so people in their 70s could live into their 90s if they undergo screenings and treatments. This is so relevant to current health care because women need to know that getting screened for mammograms is important throughout their whole lives no matter what age they are. I have strong feelings about breast cancer screening, which will affect decisions I make with my healthcare provider. Evidence-based practice is based on the use of quantitative studies. This study used evidence-based practice but for a narrow population of women. All the research that was conducted and the conclusions that were drawn were relevant to white women aged 70–85 who did not previously have any type of breast cancer. More than 75% of the women who participated in the study were aged 70–79. When the study was conducted, specific quantitative measures were used and taken into consideration when drawing conclusions. Vacek and Skelly's article showed that older women tend not to continue having breast cancer screening mammograms done. According to Pegg,2 women should continue to have screenings throughout their life, even when they are in their late 70s and 80s. In the 1940s, only one in 20 women had a risk of developing breast cancer, yet today the risk is greater than one in eight women. “There will be almost 233,000 new cases of breast cancer and roughly 40,000 deaths from the disease” in 2014.3 Women who have frequent breast-screening mammograms performed will be less likely to die from cancer. The American Cancer Society and other-health related groups are making efforts to educate women about the importance of breast examinations and screening, but more needs to be done. More studies need to be conducted to determine exactly when women should be screened for breast cancer. There is a debate among healthcare providers. Some experts say women should begin annual screening at the age of 40, whereas others believe screening should begin at the age of 50. The decision ultimately comes down to the woman and her doctor. Women could make more-informed decisions if more-specific conclusive research had been done.3 Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: SS is the sole author of this paper. Sponsor's Role: None.

No Surgery for Low-Grade Ductal Carcinoma In Situ?

Since the more widespread use of routine screening mammography, the incidenceofductal carcinoma in situ (DCIS)has increased dramatically and accounts for about 20% to 30%of all newly diagnosed breast cancers.1 Deaths from breast cancer among women with DCISmayoccur fromunidentified invasive disease at the time of diagnosis, progression of inadequately excised DCIS, or the development of an independent recurrent invasive breast cancer.2 Our current inability to accurately predict which women with DCIS are at the greatest risk for developing invasive disease generally necessitates thatallpatientsdiagnosedashavingDCISundergo treatment. Despite the relatively benign course of DCIS, most women undergo aggressive surgical and radiation treatment. The risk of overtreatment has been recognized.2 Sagaraetal3usedapropensityscoreanalysis toevaluate the survivaloutcomesofpatientswithDCIS intheSurveillance,Epidemiology, andEndResultsdatabaseandconcluded that there wasnosurvival benefit for surgical excisionof low-gradeDCIS. Therewasasurvivalbenefit forsurgicalexcisioninpatientswith intermediate-orhigh-gradeDCIS.Therefore,Sagaraetal3questiontheneedandbenefit forsurgicalexcisionof low-gradeDCIS. We urge physicians to exercise cautionwhen generalizing this population-basedcohort analysis to currentpractice.Thereare inherent limitationstopopulation-basedcancerdatawithregard to specificpatient and tumorcharacteristics. For example, 14% of the nonoperative group received radiation therapywithout undergoingsurgicalexcision.This isnotastandardapproachfor DCISandthedetailssurroundingthesediscrepanciesarenotclear withintheSurveillance,Epidemiology,andEndResultsdatabase. Inaddition, it is impossible todeterminehowmanywomenmay havehadan initial diagnosis ofDCISbasedon their coreneedle biopsy but who then had an upgrade to invasion on final excision.Thosepatientswouldhavebeenexcludedfromthisanalysis. Most importantly, we argue that DCIS grade is not an appropriate surrogate for genomic profile and biologic outcomes. Molecular markers that provide prognostic and predictive informationhold themostpromise for tailoring therapy on an individual level. The 21-gene recurrence score for estrogen receptor–positive invasive breast cancer was used as a benchmark for the development of a 12-gene subset that has been used to develop and validate a DCIS score that divides patients into low risk, intermediate risk, and high risk for 10year local in-breast recurrence.4 Multivariable models of risk for ipsilateral breast events both excluding and including the DCIS scorehavebeenperformed.Tumor size,menopausal status, andDCIS scorewere the only factors significantly associatedwith risk for an ipsilateral breast event. Tumor grade and thepresenceof comedonecrosiswerenot associatedwith risk for ipsilateral breast events.4 The ability to profile entire tumor genomes relatively quickly and affordablywill aid our understanding of the relationship between DCIS and invasive disease so that targeted approaches can be taken. We advocate for less treatment in those patients who have a low risk for invasive recurrence and/or progression. That knowledge is unlikely to come from our standard clinicopathologic characteristics. For now, surgeons should hold onto their scalpels.

Breast hamartoma: ultrasound, elastosonographic, and mammographic features. Mini pictorial essay.

Hamartomas, also known as fibroadenolipomas, are rare, benign formations that can develop in various organs, including the breast. They present clinically as a soft, mobile nodular lesions and are generally asymptomatic. They may be discovered incidentally during imaging studies performed for other reasons. Owing to the increasingly widespread use of mammographic screening, the diagnosis of breast hamartomas is on the rise. The masses are associated with specific mammographic and sonographic features that reflect their diverse tissue components. They also appear to present reproducible features on elastography. This article reviews the typical features of breast hamartomas seen on these three imaging modalities.

Shared Decision Making and the Use of Screening Mammography in Women Younger Than 50 Years of Age

Current breast cancer screening guidelines promote the use of shared decision making for women younger than 50 years of age, yet their effect on mammography utilization is largely unknown. This study aimed to examine the effect of two elements of shared decision making on the use of mammogram screening: patient-perceived choice and patient–provider communication. Data were obtained from HINTS 4, a nationally representative survey of the U.S. population, administered from 2011 to 2013. Choice was measured with the question “Has a doctor ever told you that you could choose whether or not to have a mammogram?” Communication was measured using a 7-item scale (range: 7–28; higher scores denote better communication). Binary logistic regression models assessed the effect of patient choice and communication on ever having a mammogram using weighted sample data. The sample included 1,085 women younger than 50 years of age: 31% of women perceived having a choice to undergo mammography. The mean patient–provider communication score was 22.8. Those who thought they were given a choice regarding mammography were more likely to have a mammogram relative to those who did not think a choice was given by the provider. Patient–provider communication had no significant association with mammography utilization. Patient perceived choice, but not patient-provider communication, is positively associated with mammography utilization in women younger than 50 years of age.

Neglected breast cancers in an inner city hospital.

e11540 Background: Breast cancer is the most commonly diagnosed malignancy in women. Due to widespread use of mammographic screening and awareness campaigns, under 10% present with metastatic disea...

Is Wide Excision Alone an Appropriate Therapy for DCIS?

With the widespread use of screening mammography, the number of ductal carcinoma in situ (DCIS) cases has increased dramatically. Current treatment includes wide local excision (WLE) and adjuvant radiation therapy (RT). The benefit of RT in decreasing local recurrence was established based on the results of four randomized trials and a subsequent meta-analysis. However, RT has a number of side effects and no demonstrated survival benefit in women with in situ breast cancer. This review explores the current literature on the management of DCIS with WLE alone. Although there is insufficient evidence to identify truly low-risk DCIS based on histopathological and immunohistochemical factors, emerging data appear promising in understanding the biological behavior of DCIS. In particular, the Oncotype DX DCIS Score, a multigene assay, predicts local recurrence in women treated with WLE. Risk stratification of DCIS to guide treatment decisions remains elusive, but one of great importance in tailoring therapies to the biology of this heterogeneous disease.

Abstract P1-11-05: Womens' opinion on when to start screening mammography and reasons for not undergoing screening

Abstract Background: In late 2009 significant controversy arose when some screening recommendations were changed to advocate screening mammography starting at age 50 rather than the long standing recommendation of starting at age 40 years. More recently some studies have called into question the benefit of screening mammography. The current study was performed to evaluate patients’ opinion on when women should start screening mammography and reasons for not undergoing screening. Methods: Maricopa Medical Center is the safety net hospital in Phoenix, Arizona. 1,157 consecutive patients were seen at the Breast Clinic from May 2013 to May 2014. Sociodemographic variables were collected including health literacy assessment using the Newest Vital Sign (NVS) validated screening instrument. Patients were asked when they felt women should start screening mammography. In addition, in women at least 40 years of age, if they did not undergo screening mammography, they were asked for the primary reason for not undergoing screening. Differences in patient characteristics were evaluated based on a Fisher’s exact test for categorical variables and one-way ANOVA for continuous variables. Results: Thirteen of the 1,157 consecutive patients were male and excluded. The average age of the 1,144 consecutive female patients was 45 years. Most patients were Hispanic, underinsured, and had limited health literacy. Overall use of screening mammography was poor at only 24%. 402 women (35%) felt that age 40 years was the most appropriate time to start screening. Only 30 women (3%) felt that age 50 years was the most appropriate age. More women, 470 (41%), chose an age younger than age 40 to start screening. More than half (55%) of these women who chose an age 50 years or younger, however, did not undergo screening because they felt they had "no problems" or "didn’t know" they should get a mammogram despite choosing an age to start that was below their current age. Only 187 women (32%) cited cost as the reason for not undergoing screening. Other reasons for not undergoing screening were: physician did not recommend and other medical problems/forgot/too busy. Few patients (4%) cited problems with mammograms for not undergoing screening and none cited concerns about false positives. Multivariate analysis showed that patients with adequate health literacy and insurance were more likely to use screening mammography than patients who were uninsured or had limited health literacy. Family history of breast cancer was not associated with use of screening mammography. Conclusions: Use of screening mammography was poor in this underinsured population. Most women felt that screening mammography should start at age 40 years or younger. More than half of women who did not undergo screening did not do so because they had "no problems" or "didn't know" they should. Although many women feel that screening should start at age 40, most women in this population do not understand the concepts of screening and early detection. Interventions to increase use of screening mammography should focus of the concept of screening as well as the age. Citation Format: Ian K Komenaka, Meredith Heberer, Jesse Nodora, Chiu-Hsieh Hsu, Lisa Winton, Marcia Bouton, Maria Elena Martinez. Womens' opinion on when to start screening mammography and reasons for not undergoing screening [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-05.