Breast Cancer Screening in the Intermediate-Risk Population: Falling Through the Cracks?

Socioeconomic inequalities in breast and thyroid cancer screening in Korea: A nationwide cross-sectional study

Towards consensus on managing high mammographic density in population breast screening?

Screening mammography reduces breast cancer mortality in average-risk women. However, adverse consequences include false-positive findings possibly leading to benign breast biopsies and patient anxiety. There is also potential for overdiagnosis and overtreatment. Differences in how to balance benefits and harms have led to varying recommendations by the U.S. Preventive Services Task Force, the American Cancer Society, the National Comprehensive Cancer Network and the American College of Radiology/Society of Breast Imaging. These recommendations differ with respect to what age to start, what age to stop, and frequency of screening in average-risk women. Most recently, the American College of Obstetricians and Gynecologists have issued updated clinical management guidelines for breast cancer risk assessment and screening in average-risk women that aim to maximize the benefits of screening while keeping in mind the potential harms of false-positive results. This commentary summarizes the clinical management guidelines of the American College of Obstetricians and Gynecologists Practice Bulletin July 2017 for breast cancer risk assessment and screening in average-risk women. We review evidence of the benefits and adverse consequences of screening mammography and briefly discuss new advances in breast cancer screening with recent technologies such digital breast tomosynthesis and risk-adapted screening.

There is a paucity of literature describing breast cancer prevention and screening guidelines in transgender patients. As more patients undergo gender-affirming care, breast cancer screening guidelines must be solidified for transgender patients. While there are no published incidence rates of breast cancer in the transgender population, case reports continue to underscore the prevalence of breast cancer in transgender females. A 27-year-old transgender woman with a family history of breast cancer and personal gender-affirming hormone therapy for 9 years was diagnosed with stage 3 invasive ductal carcinoma. The patient presented with a palpable breast lump and had never undergone breast imaging. Breast cancer risk in transgender patients with long-term hormone therapy use is not well understood. Individuals, both male and female, with a family history of breast cancer; increased cumulative lifetime estrogen and progesterone use; or mutations in BRCA1, BRCA2, CHEK2, PTEN, or PALB2 genes have an increased risk for breast cancer. Hormonal treatment is often used alongside gender-affirming surgeries for development of female secondary sex characteristics in male-to-female patients. Although hormone therapy can have gender-affirming benefits, the increased lifetime exposure to estrogen and progesterone can increase the risk of breast cancer. Mammography guidelines for transgender patients vary by age, familial and genetic risk, as well as duration of hormone therapy. Three current organizations have published mammographic screening guidelines for transgender patients: the University of California San Francisco, the World Professional Association for Transgender Health, and the American College of Radiology. Future research should focus on substantiating these guidelines with greater data to produce evidence-based recommendations to guide the care of transgender patients.

The Women's Preventive Services Initiative (WPSI) expanded its previous breast cancer screening recommendation-initiate annual or biennial mammography screening for women at average risk of breast cancer between the ages of 40 and 50 years-by including additional imaging and pathology evaluation as part of the screening process if needed. Consistent with the previous recommendation, screening should continue through at least age 74 years, and age alone should not be the basis for discontinuing screening. To increase utilization of screening recommendations, the WPSI also issued a new recommendation to provide patient navigation services for breast and cervical cancer screening. To update its 2016 breast cancer screening recommendation, the WPSI found no new evidence of benefits and harms of screening. However, additional studies reported that gaps in insurance coverage contributed to incomplete follow-up after an initial abnormal mammogram for many women. For its new patient navigation recommendation, the WPSI evaluated 42 randomized controlled trials of patient navigation services for breast and cervical cancer screening and follow-up that showed increased rates compared with usual care. Patient navigation services involve person-to-person contact and are individualized to the patient's specific needs. Services include but are not limited to person-centered assessment and planning, health care access and health system navigation, referrals to support services, and patient education. The new recommendations are intended to expand breast cancer screening follow-up and to improve access and equity for cancer screening. Beginning in 2026, under the Affordable Care Act, these services will be covered without copay or deductible charges for most eligible women.

1539 Background: Clinical practice guidelines (CPGs) for cervical, breast, colorectal and prostate cancer screening are well- established. The purpose of this study was to determine how adherence to CPGs has changed over the past five years. Methods: The National Health Interview Survey is a population-based survey, designed to be representative of the entire civilian non-institutionalized population in the US. To determine trends in adherence to CPGs, data from the 2000 and 2005 surveys were analyzed using SAS and SAS-callable SUDAAN software. Results: There was a significant decline in women over the age of 21 reporting having had a PAP smear within the preceding three years and women over the age of 40 reporting having had a mammogram within the preceding two years over the period of 2000 to 2005. However, the rate of men over the age of 50 reporting having had a PSA did not significantly change over this period. The rate of colorectal cancer (CRC) screening with either proctoscopy, sigmoidoscopy or colonoscopy increased between 2000 and 2005. While an increase in CRC screening between 2000 and 2005 was observed in both women (32.3% to 39.9%, p<0.0001) and men (37.2% to 42.7%, p<0.0001), men were significantly more likely to report having had endoscopic screening than women, independent of survey year (p<0.0001). On multivariate analysis, controlling for insurance status, educational level and family income, the trends in colorectal, cervical and breast cancer between 2000 and 2005 remained significant. Conclusions: There has been a significant decline in adherence to breast and cervical cancer screening CPGs over the past five years, while CRC screening has improved over the same time period. Although rates of PAP smears and mammography are high compared with lower GI endoscopy and PSA testing, the decline in breast and cervical cancer screening is concerning. Number of people (%) P value 2000 2005 Univariate Multivariate PAP smear within past 3 yrs 13,538 (78.7) 12,215 (74.1) P<0.0001 P<0.0001 Mammogram within past 2 yrs 7,289 (68.5) 7,061 (65.5) P=0.0005 P=0.0003 Endoscopy within past 10 yrs 4,260 (34.5) 5,337 (41.2) P<0.0001 P<0.0001 PSA within the past yr 2,104 (46.0) 2,350 (54.0) P=0.7649 P=0.8681 No significant financial relationships to disclose.

Breast cancer screening among ethnically diverse low-income women in a general hospital psychiatry clinic

Mammography screening: A major issue in medicine

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Breast cancer screening in the high-risk population

ABSTRACTBreast and cervical cancer screening are associated with dramatically reduced cancer mortality. Mental illnesses have been demonstrated to influence preventative behaviours. This study aims to explore whether anxiety or depressive symptoms is associated with breast and cervical cancer screening. We analyzed data (n = 3104) from the 2013 Brazos Valley Community Health Assessment. The GAD-7 Scale was used to assess the anxiety level, and PHQ-2 was used to assess the depressive symptoms. Stata 15.0 statistical software was used to perform descriptive and logistic regression analysis. Overall, 80.61% of women in each sample met breast cancer or cervical cancer screening guidelines, respectfully. Anxiety was associated with missing breast and cervical cancer screening, but the association was only significant for cervical cancer (OR = 1.430, CI = 1.009, 2.026), not for breast cancer (OR = 1.406, CI = .952, 2.078). Depressive symptom was significantly associated with missing breast (OR = 1.502, CI = 1.051, 2.149) and cervical (OR = 1.689, CI = 1.208, 2.362) cancer screening after controlling for demographics. Women with depressive symptoms and anxiety had higher odds of missing breast and cervical cancer screening. Health promotion programs should consider targeting individuals with anxiety and depression to improve cancer-screening rates..

Breast cancer screening guidelines differ between organizations, and significant variations in practice patterns exist. Previous evidence suggests that provider-level factors are the greatest contributors to risk assessment and screening practice variability. This study aimed to characterize provider factors associated with breast cancer risk assessment and screening practice patterns, and to assess perceived barriers to providing risk assessment. An online survey was distributed to providers at a single academic institution and to providers publicly via social media (January to August 2022). Respondents in the United States who care for adult women at risk for the development of breast cancer were included. Most of the respondents in the 143 completed surveys were white/Caucasian (79%) females (90%) age 50 years or younger (79%), and whereas 97% discuss breast cancer screening with their patients, only 90% order screening mammograms. Risk factor assessment was common (93%), typically performed at the first visit (51%). Additional training in genetics or risk assessment was uncommon (17%), although the majority were interested but did not have the time or resources (55%). Although most (64%) did not perceive barriers to providing risk assessment or appropriate screening, the most common barriers were time (77%) and education (55%). Barriers were more common among family practice or obstetrics and gynecology (OB/GYN) providers and those who worked in an academic setting (all p < 0.05). Breast cancer risk assessment and screening practices are highly variable. Although time is the major barrier to providing risk assessment, providers also need education. Primary care organizations could partner with breast cancer-focused societies for additional resources.

Evaluation of multiple community-based approaches to improve Latinas' breast cancer (BC) screening utilization has resulted in inconsistent findings. Factors contributing to this variation include heterogeneity in approaches (e.g., types of conceptual frameworks) and study quality (e.g., lack of measurement of spillover effects). This pilot study sought to clarify which approach may be most effective by evaluating the relative efficacy of two conceptual approaches using an area-level design with 145 Latinas nonadherent to U.S. Preventive Services Taskforce (USPSTF) BC screening guidelines. Each study arm included identical intervention format and duration (e.g., three group-based sessions, logistic assistance (LA) via five monthly calls and referral to free/low-cost screening programs). However, study content differed. While educate+LA addressed participants' BC prevention and screening behavior, empower+LA addressed participants' and their social networks' BC screening. After adjusting for age, insurance status, and baseline mammography intention, when compared with educate+LA participants, empower+LA participants were more likely to report obtaining mammograms, engaging more individuals about BC, initiating BC conversations in public settings, and discussing mammography specifically. Our study has important implications regarding the utility of evaluating behavioral interventions overall in terms of behavioral and spillover network effects.

Background: Disparities in rates of cancer screening are observed in racial and ethnic minority, immigrant, low-income, and low-education populations. One of the means by which these vulnerable populations may not receive screening is due to lack of stable health insurance. The goal of the present study is to examine the association between current insurance status, insurance stability, and up-to-date cancer screening in underserved populations. Methods: As part of the Cancer Disparities Research Network pilot cohort, the study recruited participants across four sites: Boston Chinatown, African American communities in Philadelphia, Hispanic communities in Columbus, and rural white communities in Appalachia, Ohio. Enrolled participants were eligible if they were 40-74 years old, did not live in a nursing home or other facility, and had no prior invasive cancer diagnosis. Additionally, each participant met at least one of the following criteria indicating being medically underserved: living in a medically underserved area, having low literacy, low income (defined as 100% of the 2015 Federal Poverty Level) or being uninsured, having gaps in insurance, or receiving subsidized health insurance coverage. Participants completed a baseline survey of demographic data, health insurance status, primary care physician (PCP) status, and most recent breast, cervical, and colorectal cancer screenings. Using the USPSTF guidelines, breast cancer screening was considered up to date if women ages 40–74 had a mammogram within the past 2 years. Cervical cancer screenings were up to date if women had a Pap test within the last 3 years or both a Pap test and an HPV test within the last 5 years. Colorectal cancer screening was current if participants had either a colonoscopy within the last 10 years, a flexible sigmoidoscopy within the last 5 years, or a fecal occult blood test (FOBT) within the last year. To assess participants' consistency of coverage, we defined stable insurance coverage as continuous coverage over the prior 12 months, and unstable insurance coverage as being uninsured, losing insurance, or having switches across major insurance categories at any point in the prior 12 months. Results: Of the 333 participants enrolled in the study, 65.5% were women, 14.1% were 40-50 years of age, 59.8% were 51-64 years, and 26.1% were 65-74. The cohort was racially and ethnically diverse: 8.4% participants identified as Hispanic, 30.3% as non-Hispanic White, 31.2% as non-Hispanic Black, 29.4% as non-Hispanic Asian, and 0.6% as Other. 62.2% spoke English, 8.1% Spanish, and 29.7% Chinese as their primary language. Low incomes were common: 33.6% reported incomes $15,000 or less, and 25.8% reported incomes between $15,000 and $24,999. Overall self-reported screening rates were 77.9% for breast cancer, 71.1% for cervical cancer, and 67.7% for colorectal cancer. 90.7% of participants reported being currently insured at the time of the interview, and 70% reported stable insurance coverage. Being currently insured was associated with colorectal cancer screenings [69.5% among insured vs. 30.8% among uninsured (p= 0.0059)] but not with breast or cervical cancer screenings. Stable insurance coverage was not statistically associated with up-to-date screenings. Conclusion: Overall screening rates meet Healthy People 2020 targets for breast cancer, but fall short for cervical and colorectal cancer screening. Rates of insurance are high at 90%, reflecting adoption of Medicaid expansion in all three states. In spite of low income, this population reported being up to date on colorectal cancer screenings if they had current health insurance. The low overall rates of colorectal cancer screening might be related to the lower prevalence of free or low-cost colon cancer screening programs. Citation Format: Karen M. Freund, Sarah A. Reisinger, Amy LeClair, Sarah Al-Najar, Gregory S. Young, Jill Oliveri, Evelyn Gonzalez, Electra Paskett. Impact of insurance and primary care stability on cancer screening behaviors [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C77.

Background: Perceived discrimination among the US population has been associated with lower utilization of cancer screening tests. Data from the Hispanic Community Health Study / Study of Latinos (HCHS/SOL) Socio-cultural Ancillary Study were analyzed to determine if perceived discrimination was associated with adherence to breast, cervical and colorectal cancer screening tests. Methods: Respondents included 5,313 participants from Bronx NY, Chicago IL, Miami FL, and San Diego CA recruited using a 2-stage area household probability design. Of these, 3,083 women aged 18-74 and 840 men aged 50-74 were included in the analysis. Cancer screening behaviors, income, health insurance status, and having a usual source of healthcare were assessed via self-report. Perceived discrimination was measured using the Perceived Ethnic Discrimination Questionnaire (PEDQ). Acculturation was measured using the Short Acculturation Scale for Hispanics. Adherence to cervical and breast cancer screening tests was defined as receipt of a Pap smear within the last 2 years (in women 18-74) and receipt of a mammogram within the last 2 years (in women 40-74), respectively. In all participants 50-74, adherence to fecal occult blood testing (FOBT) was defined as having FOBT within the 1 year; adherence to colonscopy/sigmoidoscopy was defined as having had either test in the last 5 years. Chi-square tests were used to test for differences between groups. Multivariate polytomous logistic regression models were fit to assess the association between perceived discrimination and cancer screening adherence. Models were adjusted for income, health insurance status, having a usual source of care, location, and acculturation. Results: Among women, 72.1% were adherent to cervical cancer screening and 54.2% were adherent to breast cancer screening. In participants aged 50-74, 23.5% of women and 27.2% of men were adherent to FOBT; 36.9% of women and 30.0% of men were adherent to colonscopy/sigmoidoscopy. After adjustment for covariates, men in the highest quartiles of perceived discrimination were more likely be non-adherent to FOBT compared to men in the lowest quartile of perceived discrimination (Q3 vs. Q1, OR: 2.3 [1.1-4.7]; Q4 vs. Q1, OR: 4.4 [2.0-9.7]). We observed no association between perceived discrimination, and breast or cervical cancer screening, or colonoscopy/sigmoidoscopy. Not having health insurance was a significant independent predictor of non-adherence to breast, cervical, and colorectal cancer screening (breast cancer, OR: 2.5 [1.7-3.5]; cervical cancer, OR: 1.7 [1.2-2.4]; FOBT in women, OR: 2.6 [1.3-4.9]; colonoscopy/sigmoidoscopy in women, OR: 5.5[2.7-11.3]; in men, OR: 3.4 [1.5-7.4]). Greater degree of acculturation to the dominant US culture was associated with non-adherence to cervical and colorectal cancer screening in women (cervcal cancer, OR: 1.4 [1.1-1.8]; FOBT, OR: 2.0 [1.3-3.2]; colonscopy/sigmoidoscopy, OR: 1.7 [1.1-2.8]). Conclusions: For breast, cervical and colorectal cancer screening behaviors, not having health insurance and being more acculturated to US culture were significant predictors of lower rates of cancer screening; perceived discrimination was not significantly related. The finding that higher levels of discrimination are associated to non-adherence to FOBT among men warrants further research. Citation Format: Cristina Valdovinos, Carmen Isasi, Molly Jung, Heather Greenlee, Robert Kaplan, Frank J. Penedo, Rebeca A. Espinoza, Patricia Gonzalez, Vanessa L. Malcarne, Krista Perreira, Hugo Salgado, Melissa A. Simon, Lisa M. Wruck. Perceived discrimination and cancer screening behaviors in U.S. Hispanics: Preliminary results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A88.