K. Hill

Experience of Young Women Diagnosed With Breast Cancer Who Undergo Fertility Preservation Consultation

BACKGROUNDnFertility preservation (FP) is of increasing concern to young patients with breast cancer. The American Society of Clinical Oncology has recommended referral to a reproductive specialist as early as possible before beginning systemic adjuvant therapy.nnnAIMnTo gather information from young patients with breast cancer about their experiences with FP referral, consultation, and decision making.nnnMETHODSnAn anonymous questionnaire was mailed to consecutive patients with breast cancer who were referred, from January 2005 to January 2010, from our center to the CReATe fertility clinic. Topics included demographics; cancer stage and treatment; previous fertility problems; referral source and timing; options presented and chosen; and satisfaction with the referral, consultation, and decision-making processes.nnnRESULTSnOf the 53 women identified, 27 (51%) participated. The mean age was 31 years (range, 24-41 years). Fifteen (56%) women opted for embryo or oocyte cryopreservation, 2 for ovarian suppression, and 10 for no FP. The choice was not affected by disease stage or by already having a child. Of the 22 women who responded, 14 (64%) were satisfied or very satisfied overall. Eighteen out of 23 (78%) respondents felt that the right amount of information was given. Thirty-nine percent had difficulty with decision making, but only 1 (4%) woman indicated that cost was a deciding factor. A common theme among respondents was inadequate time for decision making. A common complaint was the lack of written material before and/or after their consultation. Sixty-three percent expressed an interest in meeting with a psychosocial counselor.nnnCONCLUSIONSn(1) FP referral should be initiated by the surgeon as soon as a diagnosis of invasive cancer is made, (2) women need written materials before and after FP consultation is needed, and (3) a FP counselor who is able to spend additional time after the consultation could help with decision making.

Improvement in DCIS Detection Rates by MRI Over Time in a High‐Risk Breast Screening Study

Abstract:u2002 Although magnetic resonance imaging (MRI) is much more sensitive than mammography for detecting early invasive breast cancer, in many high‐risk screening studies MRI was less sensitive than mammography for detecting ductal carcinoma in situ (DCIS). We reviewed our experience detecting DCIS in our single center study of annual MRI, mammography, ultrasound and clinical breast examination (CBE) for screening very high‐risk women. All cases of DCISu2003±u2003microinvasion and invasive cancer were compared in two time frames: before (period A) and after (period B) July 2001—when we acquired expertise in the detection of DCIS with MRI—with respect to patient demographics, method of detection, and rates of detection of invasive cancer and DCIS. In period A there were 15 cases (3.1% of 486 screens) in 223 women, of which 2 (13%) were DCIS—one with microinvasion—neither detected by MRI. In period B there were 29 cases (3.3% of 877 screens) in 391 women, of which 10 (34%) were DCISu2003±u2003microinvasion (pu2003=u20030.04), all 10 detected by MRI but only one by mammography. No DCIS cases were detected by ultrasound or CBE. Specificity was lower in period B than in period A but acceptable. The ability to detect DCIS with screening MRI improves significantly with experience. MRI‐guided biopsy capability is essential for a high‐risk screening program. In experienced centers the increased sensitivity of MRI relative to mammography is at least as high for DCIS as it is for invasive breast cancer.

Psychological impact of recall on women with BRCA mutations undergoing MRI surveillance

OBJECTIVEnThe addition of magnetic resonance imaging (MRI) to mammography for surveillance of women with BRCA mutations significantly increases sensitivity but lowers specificity. This study aimed to examine whether MRI surveillance, and particularly recall, is associated with increased anxiety, depression, or breast cancer worry/distress.nnnMETHODSnWomen with BRCA mutations in an MRI surveillance study were invited to complete: Hospital Anxiety and Depression Scale (HADS), Lermans Breast Cancer Worry Scale, Breast Cancer Worry Interference Scale, and a quality of life rating at 3 time points: 1-2 weeks before (T1), 4-6 weeks after (T2) and 6 months after their annual surveillance (T3). Repeated measures analyses were performed over the 3 time points for recalled and non-recalled women.nnnRESULTSn55 women (30 BRCA1, 25 BRCA2) completed study instruments at T1 and T2, and 48 at T3. Eighteen women (32%) were recalled for additional imaging. At T1, 27 women (49%) were above HADS threshold for possible cases for anxiety (score≥8). Recalled (but not non-recalled) women had a significant increase of HADS anxiety at T2 which dropped to below baseline by T3. No group differences were observed in terms of change over time in other quantitative psychological measures.nnnCONCLUSIONSnWhile breast MRI surveillance did not have a detrimental psychological impact on women with a BRCA1 or BRCA2 mutation, recalling these very high-risk women for further imaging after a false positive MRI scan temporarily increased their global anxiety.

Can breast MRI computer-aided detection (CAD) improve radiologist accuracy for lesions detected at MRI screening and recommended for biopsy in a high-risk population?

AIMnTo evaluate the sensitivity and specificity of magnetic resonance imaging (MRI) computer-aided detection (CAD) for breast MRI screen-detected lesions recommended for biopsy in a high-risk population.nnnMATERIAL AND METHODSnFifty-six consecutive Breast Imaging Reporting and Data System (BI-RADS) 3-5 lesions with histopathological correlation [nine invasive cancers, 13 ductal carcinoma in situ (DCIS) and 34 benign] were retrospectively evaluated using a breast MRI CAD prototype (CAD-Gaea). CAD evaluation was performed separately and in consensus by two radiologists specializing in breast imaging, blinded to the histopathology. Thresholds of 50, 80, and 100% and delayed enhancement were independently assessed with CAD. Lesions were rated as malignant or benign according to threshold and delayed enhancement only and in combination. Sensitivities, specificities, and negative predictive values (NPV) were determined for CAD assessments versus pathology. Initial MRI BI-RADS interpretation without CAD versus CAD assessments were compared using paired binary diagnostic tests.nnnRESULTSnThreshold levels for lesion enhancement were: 50% to include all malignant (and all benign) lesions; and 100% for all invasive cancer and high-grade DCIS. Combined use of threshold and enhancement patterns for CAD assessment was best (73% sensitivity, 56% specificity and 76% NPV for all cancer). Sensitivities and NPV were better for invasive cancer (100%/100%) than for all malignancies (54%/76%). Radiologists MRI interpretation was more sensitive than CAD (p=0.05), but less specific (p=0.001) for cancer detection.nnnCONCLUSIONnThe breast MRI CAD system used could not improve the radiologists accuracy for distinguishing all malignant from benign lesions, due to the poor sensitivity for DCIS detection.

A Prospective Study of Breast Cancer Incidence and Stage Distribution in Women with a BRCA1 or BRCA2 Mutation under Surveillance with and without Magnetic Resonance Imaging.

Introduction: The sensitivity of MRI for the detection of pre-clinical breast cancer exceeds that of mammography and of other screening tests. If MRI screening leads to reduced mortality in women with a BRCA1 or BRCA2 mutation, then it is expected that the incidence of advanced stage breast cancers should be reduced in a cohort of women undergoing regular MRI screening, compared to conventional screening. Methods: We followed 1275 women with a BRCA1 or BRCA2 mutation for a mean of 3.2 years for incident breast cancers. 445 women were enrolled in an MRI screening trial in Toronto and 830 controls, from elsewhere in Canada and the United States, underwent conventional screening. The cumulative incidences of DCIS, of early-stage and of late-stage breast cancer were estimated at six years in the two cohorts. Results: There were 41 cases of breast cancer diagnosed in the MRI-screened cohort and 76 cases of breast cancer diagnosed in the control cohort. The cumulative incidence of DCIS or stage I breast cancer at six years was 12.7% in the MRI-screened cohort and was 9.5% in the control group (p = 0.02; log rank test). The cumulative incidence of stage II – IV breast cancers at six years was 2.0% in the MRI-screened cohort and was 7.1% in the control group (p = 0.02; log rank test). The adjusted hazard ratio for the development of stage II – IV breast cancer associated with membership in the MRI-screened cohort was 0.30 (95% CI: 0.12 to 0.72; p = 0.008). Conclusion: Annual surveillance with MRI is associated with a significant reduction in the incidence of advanced stage breast cancer in BRCA1 and BRCA2 carriers.Funding for this study is generously provided by the Canadian Breast Cancer Research Alliance. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 26.

Effect of age and temporal patterns over 5 years in a Magnetic Resonance Imaging (MRI)-based breast surveillance study for BRCA mutation carriers

9500 Background: With mammography (M) -based screening for BRCA mutation carriers, interval cancer rates are 44-56% and node +ve rates are 23-56%. (Brekelmans JCO 2001, Scheuer JCO 2002). Breast MRI is more sensitive than M but less specific (Robson ASCO 2002), and a reduction in breast cancer mortality is yet unproven.nnnMETHODSnSince 11/97 BRCA mutation carriers ages 25 to 65 have been enrolled in a 5 year surveillance study of annual M, ultrasound (US), MRI, and semi-annual clinical breast examination (CBE).nnnRESULTSn279 women (57% BRCA1, 39% previously affected) have had at least 1 round of screening, with 30 screen-detected cancers in 29 women and only 1 interval cancer (3%). Overall sensitivity of MRI was 84%, M 32% (p=0.005), US 40%, CBE 7%. These differences in sensitivity were almost identical for the 14 women ≥ age 50 vs. 17 women < age 50 at diagnosis, and for the 10 in-situ (DCIS) vs. 21 invasive cancers, and did not vary significantly over the 5 years. (See table below.) Conclusions: 1. MRI is significantly more sensitive than mammography independent of age. 2. MRI specificity improves more than ultrasound over time and is acceptable after the 1st year. 3. The extremely low interval cancer rate and tumour stage compared to historical controls, and the decrease in cancer detection rate and tumour stage after the first screen, all predict that MRI-based surveillance will likely lower cancer mortality rates in BRCA mutation carriers. [Figure: see text] [Table: see text].