Rossy Sandoval

Breast Cancer Chemoprevention among High‐risk Women and those with Ductal Carcinoma In Situ

Chemoprevention with the anti‐estrogens, tamoxifen, raloxifene, and aromatase inhibitors, reduce breast cancer incidence in high‐risk women; however, uptake has been poor (<5%) in the prevention setting. We assessed use of anti‐estrogens for breast cancer prevention, among high‐risk women seen at an academic breast center, to observe how uptake rates compare in this setting. We collected data on demographics, breast cancer risk factors, and health behaviors via self‐administered questionnaires and medical chart abstraction. Women eligible for chemoprevention with anti‐estrogens had a 5‐year predicted breast cancer risk according to the Gail model of ≥1.67%, history of lobular or ductal carcinoma in situ (LCIS/DCIS), and/or BRCA mutation. We dichotomized anti‐estrogen use as ever or never. Predictors of use were evaluated using multivariable log‐binomial regression. Of 412 high‐risk women enrolled, 316 (77%) were eligible for chemoprevention. Among eligible women, 55% were non‐Hispanic white, 29% Hispanic, 8% non‐Hispanic black, and 7% Asian. Women were grouped based upon their highest category of breast cancer risk (in descending order): BRCA mutation carriers (3%), DCIS (40%), LCIS (22%), and 5‐year Gail risk ≥1.67% (36%). Among those eligible for chemoprevention, 162 (51%) had ever initiated anti‐estrogen therapy (71% tamoxifen, 23% raloxifene, 5% aromatase inhibitor). Anti‐estrogen use was highest among women with DCIS (73%). In multivariable analysis, women with a 5‐year Gail risk ≥1.67% had approximately a 20% lower likelihood of anti‐estrogen use compared to women with DCIS (p = 0.01). In the primary prevention setting, excluding women diagnosed with DCIS, anti‐estrogen use was 37%. Multivariable analysis showed differences in uptake by education and potentially by race/ethnicity. Among high‐risk women seen at a breast center, anti‐estrogen use for chemoprevention was relatively high as compared to the published literature. Clinicians can support high‐risk women by effectively communicating breast cancer risk and enhancing knowledge about the risks and benefits of chemoprevention.

Electronic Communication Channel Use and Health Information Source Preferences Among Latinos in Northern Manhattan.

Understanding key health concepts is crucial to participation in Precision Medicine initiatives. In order to assess methods to develop and disseminate a curriculum to educate community members in Northern Manhattan about Precision Medicine, clients from a local community-based organization were interviewed during 2014–2015. Health literacy, acculturation, use of Internet, email, and text messaging, and health information sources were assessed. Associations between age and outcomes were evaluated; multivariable analysis used to examine the relationship between participant characteristics and sources of health information. Of 497 interviewed, 29.4 % had inadequate health literacy and 53.6 % had access to the Internet, 43.9 % to email, and 45.3 % to text messaging. Having adequate health literacy was associated with seeking information from a healthcare professional (OR 2.59, 95 % CI 1.54–4.35) and from the Internet (OR 3.15, 95 % CI 1.97–5.04); having ≤ grade school education (OR 2.61, 95 % CI 1.32–5.17) also preferred information from their provider; persons >45 years (OR 0.29, 95 % CI 0.18–0.47) were less likely to use the Internet for health information and preferred printed media (OR 1.64, 95 % CI 1.07–2.50). Overall, electronic communication channel use was low and varied significantly by age with those ≤45 years more likely to utilize electronic channels. Preferred sources of health information also varied by age as well as by health literacy and educational level. This study demonstrates that to effectively communicate key Precision Medicine concepts, curriculum development for Latino community members of Northern Manhattan will require attention to health literacy, language preference and acculturation and incorporate more traditional communication channels for older community members.

P4-11-06: Uptake of Selective Estrogen Receptor Modulators and Other Breast Cancer Prevention Strategies among High-Risk Women Seen in a Breast Center.

Background: Selective estrogen receptor modulators (SERMs), tamoxifen and raloxifene, are FDA-approved for breast cancer (BC) risk reduction. However, uptake has been poor in the prevention setting, partly due to a lack of knowledge in the medical community about BC prevention and public misconceptions about the risks of SERMs. We assessed demographic and clinical factors that influence SERM uptake among high-risk women seen in an academic breast center, where specialized risk counseling is provided by a breast surgeon or medical oncologist. Methods: Potential subjects included high-risk women seen for an initial consultation by Breast Surgery or Medical Oncology. Eligibility for SERM use included a 5-year Gail risk ≥1.67%, lobular carcinoma in situ (LCIS), BRCA mutation carrier, or estrogen receptor (ER)-positive and/or progesterone receptor (PR)-positive ductal carcinoma in situ (DCIS). Demographic and BC risk factor data was collected from self-administered questionnaires. Clinical data, including prior/current SERM use, was abstracted from medical chart review. Differences in distribution of risk factors, between women who ever took a SERM and those who did not, were examined using chi-square statistics or Fisher9s exact test. Multivariable logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals using SERM use as the dependent variable. Results: Among 247 high-risk women enrolled between March 2007 and January 2011, median age 51 (17-82); White/Hispanic/Black/Asian (%): 55/32/7/6. 85% of women were undergoing annual mammography, 94% had a breast biopsy, 19% genetic testing, and 71% Medical Oncology referral. Among 181 (73%) women eligible for a SERM, Gail risk ≥1.67%/LCIS/DCIS/BRCA mutation (%): 35/22/39/3; 83 (46%) ever took a SERM, including 62 on tamoxifen and 21 on raloxifene. Early SERM discontinuation was only 7%. In multivariable analysis, significant predictors of SERM uptake included risk category (DCIS vs. Gail risk ≥1.67%/LCIS/BRCA mutation), higher income, higher body mass index (BMI), and referral to Medical Oncology. In terms of this high-risk population meeting American Cancer Society (ACS) behavioral guidelines for cancer prevention, 53% had a BMI Conclusions: Among high-risk women seen at a specialized breast center, application of clinical recommendations such as screening mammography, genetic testing, and SERM uptake were relatively high, suggesting that a comprehensive approach to the management of high-risk women is feasible. However, meeting ACS nutrition and physical activity guidelines for cancer prevention was limited, perhaps due to a lack of reimbursable staff to implement these guidelines. Breast cancer risk assessment and available interventions for prevention among high-risk women are underutilized in the U.S. Future studies should focus on the development and delivery of breast cancer prevention strategies. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-06.

Factors associated with false positive results on screening mammography in a population of predominantly Hispanic women

Background: Potential harms of screening mammography include false positive results, such as recall breast imaging or biopsies. Methods: We recruited women undergoing screening mammography at Columbia University Medical Center in New York, New York. They completed a questionnaire on breast cancer risk factors and permitted access to their medical records. Breast cancer risk status was determined using the Gail model and a family history screener. High risk was defined as a 5-year invasive breast cancer risk of ≥1.67% or eligible for BRCA genetic testing. False positive results were defined as recall breast imaging (BIRADS score of 0, 3, 4, or 5) and/or biopsies that did not yield breast cancer. Results: From November 2014 to October 2015, 2,361 women were enrolled and 2,019 were evaluable, of whom 76% were Hispanic and 10% non-Hispanic white. Fewer Hispanic women met high-risk criteria for breast cancer than non-Hispanic whites (18.0% vs. 68.1%), but Hispanics more frequently engaged in annual screening (71.9% vs. 60.8%). Higher breast density (heterogeneously/extremely dense vs. mostly fat/scattered fibroglandular densities) and more frequent screening (annual vs. biennial) were significantly associated with false positive results [odds ratio (OR), 1.64; 95% confidence interval (CI), 1.32–2.04 and OR, 2.18; 95% CI, 1.70–2.80, respectively]. Conclusions: We observed that women who screened more frequently or had higher breast density were at greater risk for false positive results. In addition, Hispanic women were screening more frequently despite having a lower risk of breast cancer compared with whites. Impact: Our results highlight the need for risk-stratified screening to potentially minimize the harms of screening mammography. Cancer Epidemiol Biomarkers Prev; 27(4); 446–53. ©2018 AACR.

Identifying women at high-risk for breast cancer using data from the electronic health record compared to self-report.

e13044Background: One of the barriers to chemoprevention uptake among high-risk women is the lack of routine breast cancer risk assessment in the primary care setting. We calculated breast cancer risk using the Breast Cancer Surveillance Consortium (BCSC) model, which accounts for age, race/ethnicity, first-degree family history of breast cancer, benign breast disease, and mammographic density, using data collected from the electronic health record (EHR) compared to self-report. Methods: Among women undergoing screening mammography, we collected breast cancer risk information from the EHR and a self-administered survey. Eligibility criteria for calculating 5-year invasive breast cancer risk using the BCSC model included age 35-74, no prior history of breast cancer, mastectomy, or breast augmentation. We extracted data on demographics, structured first-degree family history, breast radiology and pathology reports from the EHR. We assessed agreement in breast cancer risk information between the EHR and self...

Abstract 1790: Factors associated with false positive results on screening mammography in a population of predominantly Hispanic women

Objective - High rates of screening mammography have been reported among Hispanic women in the U.S. However, a potential harm of screening is a false positive result with recall breast imaging or biopsy. Our objective was to identify factors associated with false positive results on screening mammography among a predominantly Hispanic population in New York City. Methods - We enrolled women receiving mammography at Columbia University Medical Center in New York, NY. They completed a questionnaire on breast cancer risk factors and gave consent to access their medical records for breast imaging and biopsy reports for the past 15 years. Breast cancer risk was assessed using the Gail model and eligibility for BRCA genetic testing was determined using a family history screener. High breast density was defined qualitatively as heterogeneously or extremely dense. Recall breast imaging was based upon a BIRADS score of 0, 3, 4, 5, or 6 on the screening mammogram. False positive breast biopsies were any biopsies that did not yield breast cancer. Results - From November 2014 to May 2015, 1325 women were enrolled: median age 58 years (range, 29-89); white/black/Hispanic/other (%): 10/10/76/4; 25% met high-risk criteria for breast cancer; 31% had high breast density; 71% were undergoing annual mammography; 53% had at least one recall breast imaging and 6% had at least one false positive breast biopsy. In multivariable analysis, high breast cancer risk, high breast density, and more frequent screening mammograms were associated with recall breast imaging and biopsy. Conclusions - Based upon our results, a potential strategy to reduce the false positive rates on screening mammography is to target women at high risk for breast cancer or with high breast density for screening with breast tomosynthesis, which has less false positives than digital mammography. Additionally, we may adopt less frequent breast cancer screening in average risk women to further reduce the harms of screening. Citation Format: William Ueng, Julia McGuinness, Katherine Infante, Meghna S. Trivedi, Hae Seung Yi, Raven David, Alejandro Vanegas, Jennifer Vargas, Rossy Sandoval, Rita Kukafka, Katherine D. Crew. Factors associated with false positive results on screening mammography in a population of predominantly Hispanic women. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1790.

Abstract PR01: Knowledge, attitudes, and uptake of breast cancer chemoprevention in a multi-ethnic cohort of high-risk women

Background: Chemoprevention with anti-estrogens, such as tamoxifen, raloxifene, and aromatase inhibitors, has been shown to reduce breast cancer incidence in high-risk women; however, uptake remains low ( Methods: We enrolled high-risk women and those with newly diagnosed ductal carcinoma in situ (DCIS), who were seen for an initial consultation by medical oncology at Columbia University Medical Center. Women eligible for chemoprevention with anti-estrogens had a 5-year breast cancer risk ≥1.67% or lifetime risk ≥20% according to the Gail or Tyrer-Cuzick models, lobular carcinoma in situ (LCIS), DCIS, or BRCA mutation. Patients completed a baseline questionnaire collecting information on health literacy, numeracy, breast cancer knowledge, perceived breast cancer risk, reasons for taking preventive actions, and attitudes toward chemoprevention using validated measures. Demographic and clinical data, including chemoprevention uptake and type of anti-estrogen, were collected from medical chart review. Results: From August 2012 to July 2014, 69 women were enrolled and 45 were evaluable. Among evaluable women, median age was 51.5 years (range, 31.8-76.4); 51% were pre-menopausal; race/ethnicity, white/Hispanic/black/Asian/other (%): 49/24/16/9/2; risk category, elevated breast cancer risk/LCIS/DCIS/BRCA mutation (%): 49/18/29/4. Mean health literacy score was 0.74 (score range 0-4, lower scores indicate higher literacy) and 31% met criteria for low numeracy. At baseline, only 49% demonstrated good breast cancer knowledge and 45% perceived themselves to be at higher risk for breast cancer than the general population. Excluding women with DCIS, median lifetime breast cancer risk according to the Gail or Tyrer-Cuzick models was 29.2% (range, 10.3-92) and 42% had accurate risk perceptions (perceived risk within 10% of estimated lifetime risk). The most common reasons for wanting to take preventive action to lower breast cancer risk included to live longer (98%), to improve health (91%), and to do it for family (87%). Twenty-nine (64%) women had previously heard of a prescription medicine to prevent breast cancer, but only 34% had ever thought about taking an anti-estrogen for prevention. The most common concerns about side effects with tamoxifen were blood clots (47%) and uterine cancer (40%); with raloxifene, blood clots (77%); and with aromatase inhibitors, osteoporosis (59%) and arthritis symptoms (36%). Thirty (68%) women felt like they had enough information following the initial visit with the medical oncologist to decide whether or not to take chemoprevention. Overall, 22 (49%) started an anti-estrogen: 54% tamoxifen, 14% raloxifene, and 32% an aromatase inhibitor. The chemoprevention uptake rate was 69% for DCIS and 41% for the other risk categories combined. Conclusions: In a multi-ethnic cohort of high-risk women, less than half demonstrated sufficient breast cancer knowledge and had accurate breast cancer risk perceptions. After consultation with a medical oncologist, over two-thirds felt they had sufficient information for chemoprevention decision-making. Our chemoprevention uptake rate was relatively high compared to the published literature, which may reflect the highly select women referred to a breast center and the comfort level of medical oncologists in prescribing anti-estrogens. Citation Format: Meghna S. Trivedi, Laura Reimers, Katherine Infante, Dawn L. Hershman, Matthew Maurer, Kevin Kalinsky, Stephanie Aguilar, Rossy Sandoval, Maria C. Alvarez, Rita Kukafka, Katherine D. Crew. Knowledge, attitudes, and uptake of breast cancer chemoprevention in a multi-ethnic cohort of high-risk women. [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 PR01.

Abstract P5-13-01: Uptake of breast cancer chemoprevention among high-risk women and those with ductal carcinoma in situ.

Background: Chemoprevention with antiestrogens, such as tamoxifen, raloxifene, and aromatase inhibitors (AIs), reduces breast cancer incidence in high-risk women. However, uptake has been poor in the prevention setting. We examined demographic and clinical factors that influenced chemoprevention uptake in women with an elevated Gail risk score (≥1.67%), lobular/ductal carcinoma in situ (LCIS/DCIS), and/or BRCA mutation carriers. Methods: We enrolled women prospectively without a diagnosis of invasive breast cancer, who were seen for an initial consultation by breast surgery or medical oncology at Columbia University Medical Center. Eligibility for chemoprevention included a 5-year Gail risk ≥1.67%, LCIS, known BRCA1 or BRCA2 mutation, or hormone receptor (HR)-positive DCIS. Demographic and risk factor data were collected from a self-administered baseline questionnaire and clinical data from medical chart review, including prior/current chemoprevention, type of antiestrogen, duration of use, and toxicities. Differences in distribution of risk factors between women who ever took chemoprevention and those who did not were examined using chi-square statistics or Fisher9s exact test. We used log-binomial regression models to estimate relative risks (RRs) and 95% confidence intervals (95% CI) using chemoprevention uptake as the dependent variable. A subset of high-risk women completed questionnaires assessing their attitudes towards chemoprevention and perceived risks/benefits. Results: Among 412 women enrolled between March 2007 and April 2013, 316 (77%) were eligible for chemoprevention. Main reasons for ineligibility included 5-year Gail risk BRCA mutation (%): 36/22/40/2. Overall, 162 (51%) women started an antiestrogen (72% for DCIS and 37% among high-risk women), including 114 on tamoxifen, 40 on raloxifene, and 11 on an AI. Early discontinuation occurred in 27 (18%) women, but 7 switched to a different antiestrogen. In univariable analysis, postmenopausal status and medical oncology referral were associated with higher chemoprevention uptake. In multivariable analysis, only higher risk was a significant predictor of chemoprevention uptake. Among the subset of women who completed additional questionnaires on attitudes towards chemoprevention, they reported that the most important factors in chemoprevention decision-making included their healthcare provider (50%), results of chemoprevention studies (44%), and knowledge about others’ experience with chemoprevention (44%). The majority (69%) were concerned about side effects, specifically blood clots with tamoxifen and raloxifene and bone fractures with AIs. Conclusions : In high-risk women seen at an academic breast center, chemoprevention uptake was relatively high compared to the published literature. Further research is needed to determine how the risks and benefits of chemoprevention are best communicated to women to enhance informed decision-making and increase uptake of chemoprevention strategies. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-13-01.

Facilitators and barriers to recruitment for an exercise and dietary intervention study in minority breast cancer survivors.

CTRC-AACR San Antonio Breast Cancer Symposium: 2008 Abstracts Abstract #5077 Background: Hispanic and black women with breast cancer (BC) have poorer survival than non-Hispanic whites. Lean body mass, regular physical activity, and high intake of fruits/vegetables may improve survival. However, minority BC survivors are more likely to be obese and sedentary than non-Hispanic whites, which may contribute to poorer survival. We are conducting a randomized waitlist-controlled pilot study to test the effects of 6-months of the Curves® 30-minute circuit-based exercise and high-vegetable/low-fat nutrition program, on weight loss among Hispanic and black women, and now report facilitators and barriers to recruitment. Methods: Eligibility criteria: 21-70 yrs, Hispanic/black, BMI ≥25kg/m2, sedentary, stage 0-IIIa breast cancer, no evidence of recurrent/metastatic disease, radiation/chemotherapy completed ≥6 months prior, no uncontrolled comorbidities, and non-smoker. Participants were identified by physicians and referred for screening. Barriers to study participation were assessed, including work/family responsibilities, transportation, financial resources, and perceived risks/benefits of exercise and dietary change after cancer diagnosis. Results: To date, 96 women have been referred for screening and 50 (52%) completed screening questionnaires. Of those who completed questionnaires, 43/50 (86%) were eligible, and of those who were eligible, 37/43 (86%) chose to participate. Enrolled participants are 70% Hispanic, mean age 51yrs (range:32-69), mean BMI 33.2 (±5.8) kg/m2, 64% diagnosed as AJCC stage II/III, and 70% ≤ high school education. Reasons for ineligibility (n=53) include inability to recontact (46%), uncontrolled comorbidity (21%), too busy/not convenient (15%), still undergoing treatment (11%), currently smoking (4%), and not sedentary (2%). Eligible and ineligible women were not statistically different in terms of race, BMI, or stage at diagnosis. However, ineligible women were older (P<0.01). Of the women who completed the screening questionnaire, women enrolled in the study (n=37), compared to women not enrolled (n=13), believed losing weight after cancer would prolong survival (P=0.01), making dietary changes would prevent recurrence (P=0.01), and that exercising would help them feel better (P=0.01), prevent recurrence (P=0.01), and prolong survival (P=0.046). Women not enrolled were more likely to report that exercising after a cancer diagnosis is dangerous (P=0.04). Conclusions: Recruitment of a multiethnic population to a Curves® based exercise intervention study was feasible. Patients who ultimately enrolled in this study believed that exercise and eating a healthy diet are beneficial to their health. Given that many overweight and sedentary women had pre-existing negative misconceptions about the benefits of exercise and dietary change after a BC diagnosis, and this was a key factor in predicting enrollment, educational efforts promoting healthy lifestyle behaviors should be further targeted towards this high-risk patient population. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5077.

Effects of a Combined Physical Activity and Dietary Change Intervention on Weight Loss in Minority Breast Cancer Survivors.

Background: Hispanic and black women with breast cancer have poorer survival and are more likely to be obese and sedentary than non-Hispanic whites. Regular physical activity, high intake of fruits and vegetables, and lean body mass may improve survival. We report the initial results of a randomized wait-list controlled pilot study to test the effects of 6 months of the community-based Curves® exercise and nutrition program on weight loss among minority BC survivors. Methods: Hispanic/black women with stage 0-IIIa breast cancer who were ≥6 months post-treatment, sedentary and had a BMI≥25kg/m 2 were enrolled. Eligible participants were randomized to the Immediate Arm (IA): 6 months of the Curves® exercise and dietary change weight loss program, followed by 6 months of observation; or the Delayed Arm (DA): 6 months of a waitlist control period, followed by 6 months of the Curves® program. The intervention entailed recommending exercise 5 times/wk using the 30-minute Curves® circuit-based exercise program and attending a series of 6 weekly nutrition sessions that promoted a high-vegetable/low-fat diet. All study materials were available in Spanish and English. Participants underwent clinic visits at baseline, 3, 6, 9, and 12 months and were followed with monthly telephone calls during the intervention. Month 6 results are reported here. Results: Forty-two women enrolled in the study (IA, n=22; DA, n=20). Baseline characteristics: mean (±SD) age, 50.7 (±8.9) years; 78.6% Hispanic/21.4% black; breast cancer stage, stage 0 9.5%, stage I 42.9%, stage II 33.3%, stage III 14.2%; mean body mass index (BMI), 33.2 (±5.9) kg/m 2 ; mean % body fat as measured by DEXA, 41.6 (±4.9) %; and mean VO 2 max, 18.4 (±3.6). Six month data were collected from 39 women; 2 women were removed from the study due to medical conditions (1 recurrent disease, 1 previously undiagnosed cardiac condition) and 1 women dropped from the study due to being too busy. In the IA, the average number of exercise sessions attended over the 6 month period was 1.1(±0.8) per week (range: 0.04 to 2.9/wk), and all participants attended all 6 nutrition classes either in-person or via phone make-up sessions. After 6 months, women in the IA lost an average of 2.7 (±3.2) kg (range: loss of 9.9 kg to gain of 1.7 kg), had a decrease in percent body fat of 1.5 (±1.5)% (range: loss of 5.9% to gain of 0.2%), and a decrease in VO 2 max of 1.0 (±3.4) ml/kg/min (range: decrease of 8.6 ml/kg/min to increase of 2.5 ml/kg/min) (within-subject measures p 0.05). Twelve month data collection will be completed in July 2009 and will be presented at the conference. Conclusions: This 6 month pilot physical activity and dietary change intervention resulted in decreased in body weight and percent body fat among Hispanic and black BC survivors, although this decline was not significantly different than the wait-list control group. Though adherence to the exercise intervention was less than the targeted 5 exercise sessions per week, those that did adhere lost up to 9.9 kg. Further research on barriers to participation, optimal dose, and duration are necessary for future intervention trials. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1038.