Management of Women at High Risk for Breast Cancer.

BACKGROUND: Primary care clinicians screen for breast cancer risk factors and assess the risk level of their patients. Women at high risk for breast cancer (eg, 5-year risk of at least 3% or lifetime risk of ≥20%) are eligible for enhanced screening and/or chemoprophylaxis. However, many clinicians do not identify women at high risk and offer appropriate referrals, screening, or chemoprophylaxis. METHODS: We reviewed a sample of 200 charts of women ages 35 to 50 years old with a family history of breast cancer. We identified factors that contribute to their risk for breast cancer and used the Tyrer-Cuzick Risk Assessment Calculator to determine their personal lifetime risk. We then assessed whether these patients received counseling for chemoprophylaxis, referrals, or screening. We also looked for correlations between combinations of risk factors and increased lifetime risk. RESULTS: Out of 200 charts reviewed, 71 women were identified as high risk for breast cancer (lifetime risk of ≥20%). Of those 71 women, just 17 were referred to a high-risk clinic for enhanced screening and/or chemoprophylaxis. Three risk factors, mammographic breast density of category C or D, first degree relatives with breast cancer, and age first given birth if after 30 years old had a significant impact on lifetime risk for breast cancer. DISCUSSION: Primary care clinicians can use these independent risk factors as cues to pursue a more formal calculation of a woman's lifetime risk for breast cancer and make appropriate referrals for enhanced screening and chemoprophylaxis counseling if indicated.

Team Science Principles Enhance Cancer Care Delivery Quality Improvement: Interdisciplinary Implementation of Breast Cancer Screening Shared Decision Making.

PURPOSE: Implementing shared decision making (SDM), recommended in screening mammography by national guidelines for women age 40-49 years, faces challenges that innovations in quality improvement and team science (TS) are poised to address. We aimed to improve the effectiveness, patient-centeredness, and efficiency of SDM in primary care for breast cancer screening. METHODS: Our interdisciplinary team included primary and specialty care, psychology, epidemiology, communication science, engineering, and stakeholders (patients and clinicians). Over a 6-year period, we executed two iterative cycles of plan-do-study-act (PDSA) to develop, revise, and implement a SDM tool using TS principles. Patient and physician surveys and retrospective analysis of tool performance informed our first PDSA cycle. Patient and physician surveys, toolkit use, and clinical outcomes in the second PDSA cycle supported SDM implementation. We gathered team member assessments on the importance of individual TS activities. RESULTS: Our first PDSA cycle successfully generated a SDM tool called Breast Cancer Risk Estimator, deemed valuable by 87% of patients surveyed. Our second PDSA cycle increased Breast Cancer Risk Estimator utilization, from 2,000 sessions in 2017 to 4,097 sessions in 2019 while maintaining early-stage breast cancer diagnoses. Although TS activities such as culture, trust, and communication needed to be sustained throughout the project, shared goals, research/data infrastructure support, and leadership were more important earlier in the project and persisted in the later stages of the project. CONCLUSION: Combining rigorous quality improvement and TS principles can support the complex, interdependent, and interdisciplinary activities necessary to improve cancer care delivery exemplified by our implementation of a breast cancer screening SDM tool.

An Evidence-Based Review of Vitamin D for Common and High-Mortality Conditions.

BACKGROUND: Vitamin D is a fat-soluble vitamin available from food and sun exposure. Vitamin D receptors are present in cells throughout the body and cause it to act like a hormone. Observational studies document the association of low vitamin D levels with multiple health conditions. This article reviews the evidence for vitamin D in prevention and treatment in primary care. METHODS: We performed a literature review of randomized controlled trials, meta-analyses, systematic reviews, and large prospective trials looking at the role of vitamin D deficiency in the most common conditions seen in primary care and the top 10 causes of mortality since 2010. RESULTS: Vitamin D supplementation in patients with known cardiovascular disease does not reduce risk of stroke or heart attack. Vitamin D supplementation does not seem to have an effect in the treatment of hypertension or in cancer prevention. There is emerging evidence that supplementation reduces COVID-19 severity and risk of mechanical ventilation. Vitamin D at more moderate levels may reduce the risk of falls, but higher doses may cause increased fall risk. There does not seem to be a link between vitamin D supplementation and improved cognition. Vitamin D supplementation may be helpful in patients with major depression. High dose vitamin D may improve pain in people with fibromyalgia. Supplementing patients with prediabetes reduced the risk of progression to type 2 diabetes mellitus. Vitamin D supplementation in addition to standard emollient treatment helped to reduce symptoms in people with atopic dermatitis. CONCLUSION: Prospective studies of vitamin D supplementation demonstrate variable impact on disease specific and patient-oriented outcomes, suggesting a correlation but not a causal relationship between low vitamin D levels and disease pathogenicity. Future research should determine dosing standards and timing of vitamin D in treatment and prevention.

How to better identify and manage women with elevated breast cancer risk.

This case-based review details screening and management strategies that can maximize the care you provide to women at heightened risk.

Adenomyosis: Diagnosis and Management.

Adenomyosis is a clinical condition where endometrial glands are found in the myometrium of the uterus. One in three patients with adenomyosis is asymptomatic, but the rest may present with heavy menstrual bleeding, pelvic pain, or infertility. Heavy menstrual bleeding is the most common symptom. Adenomyosis is distinct from endometriosis (the presence of endometrial glands outside of the uterus), but the two conditions often occur simultaneously. Risk factors for developing adenomyosis include increasing age, parity, and history of uterine procedures. Most patients are diagnosed from 40 to 50 years of age, but younger patients with infertility are increasingly being diagnosed with adenomyosis as imaging modalities improve. Diagnosis of adenomyosis begins with clinical suspicion and is confirmed with transvaginal ultrasonography and pelvic magnetic resonance imaging. Treatment of adenomyosis typically starts with hormonal menstrual suppression. Levonorgestrel-releasing intrauterine systems have shown some effectiveness. Patients with adenomyosis may ultimately have a hysterectomy if symptoms are not controlled with medical therapy.

Patient and Clinician Characteristics That Predict Breast Cancer Screening Behavior in 40-49-Year-Old Women.

Guidelines recommend that clinicians practice shared decision-making (SDM) with women in their 40s to discuss breast cancer screening. Traditionally, SDM includes discussion of values and preferences to help determine a decision that is congruent with what the patient desires. We analyzed 54 women's breast cancer screening decisions after a SDM conversation with their clinician. We looked at both patient and clinician characteristics that predicted whether or not a woman would get a screening mammogram. Women with a family history of breast cancer or who had a previous abnormal mammogram had higher rates of screening. Screening rates also varied widely between clinicians, raising the question of whether clinician attitudes impacted the SDM conversation.

Breast Implants: Common Questions and Answers.

Breast implants are used for a wide range of cosmetic and reconstructive purposes. In addition to breast augmentation, implants can be used for postmastectomy breast reconstruction, correction of congenital breast anomalies, breast or chest wall deformities, and male-to-female top surgery. Breast implants may confer significant benefits to patients, but several factors are important to consider preoperatively, including the impact on mammography, future lactation, and potential long-term implant complications (e.g., infection, capsular contracture, rupture, and the need for revision, replacement, or removal). A fundamental understanding of implant monitoring is also paramount to implant use. Patients with silicone breast implants should undergo routine screening for implant rupture with magnetic resonance imaging or ultrasonography completed five to six years postoperatively and then every two to three years thereafter. With the exception of complications, there are no formal recommendations regarding the timing of breast implant removal or exchange. Women with unilateral breast swelling should be evaluated with ultrasonography for an effusion that might indicate breast implant-associated anaplastic large cell lymphoma. There are no specific breast cancer screening recommendations for patients with breast implants, but special mammographic views are indicated to enhance accuracy. Although these discussions are a routine component of consultation and postoperative follow-up for plastic surgeons performing these procedures, family physicians should have a working knowledge of implant indications, characteristics, and complications to better counsel their patients, to ensure appropriate screening, and to coordinate care after surgery.

Preliminary Evaluation of a Breast Cancer Screening Shared Decision-Making Aid Utilized Within the Primary Care Clinical Encounter.

INTRODUCTION: The US Preventative Services Task Force recommends shared decision-making (SDM) between women aged 40 and 49 years and their physician regarding timing of mammography screening. This preliminary study evaluates women's and physician's satisfaction using Breast Cancer Risk Estimator & Decision Aid (BCARE-DA), a shared decision aid utilized during the clinical encounter, and examines SDM quality for these encounters. METHODS: Fifty-three women and their physician utilized BCARE-DA and completed surveys measuring satisfaction with Likert-type and open-ended items and women completed the Decision Conflict Scale. Clinic visit transcripts were evaluated for SDM quality using Observer OPTION-5 and Breast Cancer Screening Decision Core Components Checklist. RESULTS: Women and physicians positively evaluated BCARE-DA. Women had low decision conflict. Physicians demonstrated moderate effort toward SDM, greatest in offering options, and lowest for team talk. Physicians demonstrated 2/3 of core SDM elements in 80% to 100% of encounters. CONCLUSION: Preliminary findings suggest specific promise for such Decision Aids to facilitate SDM through understanding of personal risks for breast cancer formulated within each screening option, while some SDM elements likely require additional facilitating.

Managing a woman with BRCA mutations? Shared decision-making is key.

A collaborative assessment of options and trade-offs-perhaps using visual decision aids-can help.

Breast Cancer Screening in Older Women: The Importance of Shared Decision Making.

Incidence of breast cancer increases with age up until age 80. Screening mammography has demonstrated efficacy in decreasing mortality from breast cancer among women between 50 and 74 years of age. However, most major organizations do not include women over 74 in their recommendations due to the lack of evidence in this age-group. This article will review current recommendations for breast cancer screening in women over the age of 74. It will also present clear guidelines for primary care clinicians to follow that incorporate shared decision-making techniques, tools for estimating the risks and benefits of screening mammography, and strategies for integrating a patient's life expectancy and comorbidities into the decision-making process. We also emphasize the importance of using thoughtful communication strategies to fully engage older women in the breast cancer screening discussion.

Beyond Birth Control: Noncontraceptive Benefits of Hormonal Methods and Their Key Role in the General Medical Care of Women.

Contraceptives that contain estrogen and/or progestins are used by millions of women around the world to prevent pregnancy. Owing to their unique physiological mechanism of action, many of these medications can also be used to prevent cancer and treat multiple general medical conditions that are common in women. We performed a comprehensive literature search. This article will describe the specific mechanisms of action and summarize the available data documenting how hormonal contraceptives can prevent ovarian and uterine cancer and be used to treat women with a variety of gynecological and nongynecological conditions such as endometriosis, uterine fibroids, heavy menstrual bleeding, polycystic ovary syndrome, acne, and migraines. Contraceptive methods containing estrogen and progestin can be used for a wide variety of medical issues in women.

Core Elements of Shared Decision-making for Women Considering Breast Cancer Screening: Results of a Modified Delphi Survey.

BACKGROUND: The United States Preventive Services Task Force recommends individualized breast cancer screening for average-risk women before age 50, advised by risk assessment and shared decision-making (SDM). However, the foundational principles of this recommendation that would inform decision support tools for patients and primary care physicians at the point of care have not been codified. Determining the core elements of SDM for breast cancer screening as valued by patients and primary care providers (PCPs) is necessary for implementing effective SDM tools. The aim of this study is to affirm core elements of SDM in the context of clinical interactions, through a Delphi consensus process. METHODS: A Delphi was conducted with 30 participants (10 women aged 40-49, 10 PCPs, and 10 healthcare decision scientists), to codify core elements of breast cancer screening SDM. The criterion for establishing consensus was a threshold of 80% agreement. The Delphi concluded with an 83% response rate. RESULTS: Of 48 items fielded, 44 met the threshold on the high-importance end of the response scale and were accepted as core elements. Core elements across three thematic categories-information delivery and patient education, interpersonal clinician-patient communication, and framework of the decision-received panelists' support in nearly equal measure. Panelists unanimously agreed that SDM should include provision of clearly understandable information, including that of personal breast cancer risk factors, and benefits and harms of mammography screening, and that PCPs should convey they are listening, knowledgeable, and demonstrate cultural sensitivity. DISCUSSION: This research codifies the core elements of SDM for mammography in women 40-49, augmenting the evidence to inform discussions between patients and physicians. These core elements of SDM have the potential to operationalize SDM for breast cancer screening in an effort to improve public health outcomes.

Age-based versus Risk-based Mammography Screening in Women 40-49 Years Old: A Cross-sectional Study.

Background Risk-based screening in women 40-49 years old has not been evaluated in routine screening mammography practice. Purpose To use a cross-sectional study design to compare the trade-offs of risk-based and age-based screening for women 45 years of age or older to determine short-term outcomes. Materials and Methods A retrospective cross-sectional study was performed by using a database of 20 539 prospectively interpreted consecutive digital screening mammograms in 10 280 average-risk women aged 40-49 years who were screened at an academic medical center between January 1, 2006, and December 31, 2013. Two hypothetical screening scenarios were compared: an age-based (≥45 years) scenario versus a risk-based (a 5-year risk of breast cancer greater than that of an average 50-year-old) scenario. Risk factors for risk-based screening included family history, race, age, prior breast biopsy, and breast density. Outcomes included breast cancers detected at mammography, false-positive mammograms, and benign biopsy findings. Short-term outcomes were compared by using the χ2 test. Results The screening population included 71 148 screening mammograms in 24 928 women with a mean age of 55.5 years ± 8.9 (standard deviation) (age range, 40-74 years). In women 40-49 years old, usual care included 50 screening-detected cancers, 1787 false-positive mammograms, and 384 benign biopsy results. The age-based (≥45 years) screening strategy revealed more cancers than did the risk-based strategy (34 [68%] vs 13 [26%] of 50; P < .001), while prompting more false-positive mammograms (899 [50.3%] vs 216 [12.1%] of 1787; P < .001) and benign biopsy results (175 [45.6%] vs 49 [12.8%] of 384; P < .001). The risk-based strategy demonstrated low levels of eligibility (few screenings) in the 40-44-year age group. Differences in outcomes in the 45-49-year age group explained the overall hypothetical screening strategy differences. Conclusion Risk-based screening for women 40-49 years old includes few women in the 40-44-year age range. Significant trade-offs in the 45-49-year age group explain the overall difference between hypothetical screening scenarios, both of which reduce the benefits as well as the harms of mammography for women 40-49 years old. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Joe and Hayward in this issue.

BRCA Mutation Carriers: Breast and Ovarian Cancer Screening Guidelines and Imaging Considerations.

Patients who carry the BRCA1 and BRCA2 gene mutations have an underlying genetic predisposition for breast and ovarian cancers. These deleterious genetic mutations are the most common genes implicated in hereditary breast and ovarian cancers. This monograph summarizes the evidence behind current screening recommendations, reviews imaging protocols specific to this patient population, and illustrates some of the imaging nuances of breast and ovarian cancers in this clinical setting.

Breast Cancer Screening in Primary Care: A Call for Development and Validation of Patient-Oriented Shared Decision-Making Tools.

The latest recommendations on breast cancer screening in women from 40 to 49 years charge primary care providers (PCPs) with completing shared decision-making with women about screening mammography. However, there is a lack of supportive materials accompanying this directive. No easy-to-use risk assessment tool is available for PCPs to stratify women's risk. Neither is an evidence-based patient-centered way to assess values surrounding mammography available. To provide the highest quality care for women of 40-49 years, further research should clarify ways to apply risk assessment and values clarification to individual women.

Menopause.

The menopausal transition is a time when many physical and psychological changes are occurring for women. Women may experience irregular menses, vasomotor symptoms, sleep disruption, mood disorders as well as genitourinary symptoms. Despite irregular menstrual cycles, some women can still conceive. It is important to understand what is within normal physiologic changes and what may represent pathologic changes and how to further evaluate this. There are many options available to manage menopausal symptoms when they are impacting quality of life.