Chemoprevention acceptance and adherence in women with high-risk breast lesions.

Patients with atypical hyperplasia and lobular carcinoma in situ (LCIS) (atypical breast lesions) are at high risk of developing breast cancer, and chemoprevention has been shown to confer a substantial reduction in that risk. Despite this, the overall rate of chemoprevention utilization in this group is low. This study evaluates the efficacy of a formal individualized education and counseling session on patient acceptance and adherence to chemoprevention. Patients with atypical breast lesions having an individualized education and counseling session in a single surgical oncology practice were prospectively entered into a database from 2001 to 2016, and with IRB approval, their data were analyzed. Chemoprevention recommendations, acceptance, duration of treatment, and side effects were recorded. A total of 536 patients were included in this study. Mean age at diagnosis was 52 years (range: 19-86 years). Chemoprevention was recommended for 386 (72%) of whom 199 (52%) elected to take medication or participate in a chemoprevention clinical trial. At the time of this writing, 72 patients had completed therapy, 69 were still in treatment, and 58 had stopped chemoprevention prematurely. Approximately 55% of the women who accepted chemoprevention in this study will complete 5 years of therapy. A formal individualized education and counseling session can improve chemoprevention acceptance and achieve a reasonable completion rate, thus reducing cancer incidence in women with atypical breast lesions.

Breast Cancer Risk and Follow-up Recommendations for Young Women Diagnosed with Atypical Hyperplasia and Lobular Carcinoma In Situ (LCIS).

BACKGROUND: The risk of breast cancer in young women diagnosed with atypical hyperplasia and (LCIS) is not well defined. The objectives were to evaluate outcomes and to help determine guidelines for follow-up in this population. METHODS: A retrospective review of women under age 35 diagnosed with ADH, ALH, LCIS, and severe ADH from 1987 to 2010 was performed. Patient characteristics, pathology and follow-up were determined from chart review. RESULTS: We identified 58 young women with atypical breast lesions. Median age at diagnosis was 31 years (range 19-34). 34 patients had ADH, 11 had ALH, 8 had LCIS, and 5 had severe ADH. 7 (12%) patients developed breast cancer. The median follow-up was 86 months (range 1-298). Median time to cancer diagnosis was 90 months (range 37-231). 4 cancers were on the same side, 3 were contralateral. 4 were IDC, 1 was ILC, and 2 were DCIS. Cancer was detected by screening mammogram in 4 patients, 2 by clinical exam, and 1 unknown. In the entire cohort, 26 (45%) patients had screening mammograms as part of their follow up, 12 patients had only clinical follow up, and 20 had no additional follow up. 13 patients required subsequent biopsies. CONCLUSION: Young women with atypical breast lesions are at a markedly increased risk for developing breast cancer and should be followed closely. Based on our findings, we recommend close clinical follow-up, MRI starting at age 25 through age 29, and screening mammograms for those over 30 in this high-risk group of patients.

The role of chemoprevention in modifying the risk of breast cancer in women with atypical breast lesions.

Women with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), and severe ADH are at increased risk of breast cancer, but a systematic quantification of this risk and the efficacy of chemoprevention in the clinical setting is still lacking. The objective of this study is to evaluate a woman's risk of breast cancer based on atypia type and to determine the effect of chemoprevention in decreasing this risk. Review of 76,333 breast pathology reports from three institutions within Partners Healthcare System, Boston, from 1987 to 2010 using natural language processing was carried out. This approach identified 2,938 women diagnosed with atypical breast lesions. The main outcome of this study is breast cancer occurrence. Of the 2,938 patients with atypical breast lesions, 1,658 were documented to have received no chemoprevention, and 184/1,658 (11.1 %) developed breast cancer at a mean follow-up of 68 months. Estimated 10-year cancer risks were 17.3 % with ADH, 20.7 % with ALH, 23.7 % with LCIS, and 26.0 % with severe ADH. In a subset of patients treated from 1999 on (the chemoprevention era), those who received no chemoprevention had an estimated 10-year breast cancer risk of 21.3 %, whereas those treated with chemoprevention had a 10-year risk of 7.5 % (p < 0.001). Chemoprevention use significantly reduced breast cancer risk for all atypia types (p < 0.05). The risk of breast cancer with atypical breast lesions is substantial. Physicians should counsel patients with ADH, ALH, LCIS, and severe ADH about the benefit of chemoprevention in decreasing their breast cancer risk.

Hereditary breast and ovarian cancer and other hereditary syndromes: using technology to identify carriers.

PURPOSE AND METHODS: Most patients who harbor a genetic mutation for hereditary breast cancer have not been identified, despite the availability of genetic testing. Developing an effective approach to the identification of high-risk individuals is the key to preventing and/or providing early diagnosis of cancer in this patient population. This educational review addresses these issues. RESULTS AND DISCUSSION: Using data available on the internet, and making assumptions regarding the types and results of genetic testing, we have estimated the number of mutation carriers in the country and the number who have been tested and identified as such. Overall, our ability to fund and more effectively manage carriers is weak. A technological solution is discussed.

Support needs and acceptability of psychological and peer consultation: attitudes of 108 women who had undergone or were considering prophylactic mastectomy.

OBJECTIVE: Prophylactic mastectomy (PM) offers 90% or greater reduction in risk of breast cancer to women at increased hereditary risk. Nonetheless, acceptance in North America is low (0-27%) and 25-50% of women electing surgery report psychological distress and/or difficulty adapting following PM. Most women also report reduced cancer worry postoperatively. Psychological consultation to aid decision-making and post-surgical coping is not routinely offered. This retrospective, cross-sectional study explored interest in and acceptability of psychological consultation for issues related to PM among 108 women who had undergone or were considering surgery. METHOD: Qualitative interviews were conducted with 26 healthy women who had undergone prophylactic mastectomy of both (bilateral) breasts (BPM), 45 women who had undergone prophylactic mastectomy of one breast (unilateral contralateral) (UPM) after diagnosis of invasive breast cancer in the other breast or ductal carcinoma in situ (DCIS), and 37 women who were considering having PM surgery. RESULTS: Of the women who had undergone PM, more than half felt pre-surgical psychological consultation was advisable; nearly 2/3 thought post-surgical psychological consultation would be helpful. All women currently considering PM believed psychological consultation would aid decision-making and preparation for surgery. Strong support was reported in all groups for the emotional and informational value of speaking with a woman who had previously undergone PM. CONCLUSIONS: Narratives illustrate the nature and intensity of the need for psychological support and describe preferences for the role of the psychologist. Suggestions are offered for integration of psychological services for women deciding about or adapting to PM.

Evaluation of hereditary risk in a mammography population.

PURPOSE: BRCA1 and BRCA2 mutations significantly increase a women's lifetime risk of breast and ovarian cancer. Because several management options have shown promise in decreasing morbidity and mortality for these women, identifying potential mutation carriers is increasingly important. We have developed a large-scale method to collect family histories in a population of unaffected women presenting for mammography. We then applied current risk-assessment models to determine the prevalence of women at risk for hereditary breast and ovarian cancer. MATERIALS AND METHODS: We performed a retrospective review of family histories using data collected on all unaffected women presenting for mammography over a 14-week period. The Claus, Myriad II, and Hartmann models for hereditary risk assessment were applied to the survey results. RESULTS: The questionnaire was completed by 5736 women, 695 of whom were excluded because of a personal history of breast or ovarian cancer. Family histories of the remaining 5041 women were evaluated. Totals of 5.9%, 5.2%, and 3.3% of patients, respectively, met criteria for increased risk according to the Hartmann, Myriad II, and Claus models, corresponding to 3.5, 3.1, and 1.9 patients per day. Although 9.2% of patients met criteria for >/=1 model, only 1.4% met criteria for all 3. CONCLUSIONS: Application of available models to a screening population classifies a larger than expected number of women at high risk for a BRCA1 or BRCA2 mutation. New approaches to risk assessment and counseling are needed to apply our knowledge of hereditary risk to a broad population in a practical manner.

The feasibility of using natural language processing to extract clinical information from breast pathology reports.

OBJECTIVE: The opportunity to integrate clinical decision support systems into clinical practice is limited due to the lack of structured, machine readable data in the current format of the electronic health record. Natural language processing has been designed to convert free text into machine readable data. The aim of the current study was to ascertain the feasibility of using natural language processing to extract clinical information from >76,000 breast pathology reports. APPROACH AND PROCEDURE: Breast pathology reports from three institutions were analyzed using natural language processing software (Clearforest, Waltham, MA) to extract information on a variety of pathologic diagnoses of interest. Data tables were created from the extracted information according to date of surgery, side of surgery, and medical record number. The variety of ways in which each diagnosis could be represented was recorded, as a means of demonstrating the complexity of machine interpretation of free text. RESULTS: There was widespread variation in how pathologists reported common pathologic diagnoses. We report, for example, 124 ways of saying invasive ductal carcinoma and 95 ways of saying invasive lobular carcinoma. There were >4000 ways of saying invasive ductal carcinoma was not present. Natural language processor sensitivity and specificity were 99.1% and 96.5% when compared to expert human coders. CONCLUSION: We have demonstrated how a large body of free text medical information such as seen in breast pathology reports, can be converted to a machine readable format using natural language processing, and described the inherent complexities of the task.

Accuracy of self-reported personal history of cancer in an outpatient breast center.

The self-reporting of cancer history is becoming increasingly important, as it frequently guides medical decision-making. We studied the accuracy of personal cancer history using a self-administered questionnaire, comparing the results with the Tumor Registry at our institution. Among 39,662 records, we identified 3614 women with a single cancer in the Tumor Registry who reported none or one cancer on their questionnaire. The sensitivity in self-reporting cancers was 85.7%, ranging from 92.1% for breast cancer to 42.9% for leukemia. The accuracy for breast cancer and Hodgkin's Lymphoma was significantly better than other cancers (p=0.00027, CI: 1.4-3.88). Analysis of patient's characteristics showed that Caucasians reported breast cancer more accurately than Asian/Pacific Islanders (p=0.008), and those with Jewish ancestry more accurately than non-Jewish (p=0.0435). These results will help us to improve data collection and thus improve medical decision-making.