Shira Schwartz

The relationship of breast density in mammography and magnetic resonance imaging in high-risk women and women with breast cancer

PURPOSE To evaluate the relationship between mammographic breast density (MBD), background parenchymal enhancement (BPE), and fibroglandular tissue (FGT) in women with breast cancer (BC) and at high risk for developing BC. METHODS Our institutional database was queried for patients who underwent mammography and MRI. RESULTS Four hundred three (85%) had BC and 72 (15%) were at high risk. MBD (P=.0005), BPE (P<.0001), and FGT (P=.02) were all higher in high-risk women compared to the BC group. CONCLUSIONS Higher levels of MBD, BPE and FGT are seen in women at higher risk for developing BC when compared to women with BC.

Screening prior to Breast Cancer Diagnosis: The More Things Change, the More They Stay the Same

Purpose. In November 2009, the U.S. Preventative Service Task Force (USPSTF) revised their breast cancer screening guidelines. We evaluated the pattern of screening subsequent to the altered guidelines in a cohort of women. Methods. Our database was queried for the following variables: age, race, method of diagnosis, mass palpability, screening frequency, histology, and stage. Statistical analyses were performed using Pearsons chi-square and Fishers exact tests. Results. 1112 women were diagnosed with breast cancer from January 2010 to 2012. The median age at diagnosis was 60 years. Most cancers were detected on mammography (61%). The majority of patients had invasive ductal carcinoma (59%), stage 0 (23%), and stage 1 (50%) cancers. The frequency of screening did not change significantly over time (P = 0.30). However, nonregular screeners had an increased risk of being diagnosed with later stage breast cancer (P < 0.001) and were more likely to present with a palpable mass compared to regular screeners (56% versus 21%; P < 0.001). Conclusions. In our study, screening behavior did not significantly change in the years following the USPSTF guidelines. These results suggest that women who are not screened annually are at increased risk of a delay in breast cancer diagnosis, which may impact treatment options and outcomes.

Assessing breast cancer risk in a primary care setting.

Individuals who are given a preventive exam by a primary care provider are more likely to agree to cancer screening. The provider recommendation has been identified as the strongest factor associated with screening utilization. This article provides a framework for breast cancer risk assessment for an advanced practice registered nurse working in primary care practice.

The Relationship of Race, Oncotype DX, and Ki67 in a Population Highly Screened For Breast Cancer

Oncotype DX recurrence score (ODX) can predict risk of invasive breast cancer recurrence and benefit of chemotherapy. Literature is limited on the relationship of ODX and race in women with hormone receptor positive and node negative/positive disease. Our study examines the relationship between race and clinical characteristics within a population of highly screened women with newly diagnosed breast cancer. The institutional Breast Cancer Database was queried for patients with newly diagnosed breast cancer between January2010 and March2015. We analyzed clinical and tumor characteristics including ODX. Statistical analyses included Pearsons Chi‐Square and Fishers Exact Tests. There were 2,092 women in our study cohort. The majority had college‐level education (84%), regular screening (78%), and clinical breast exams (88%). The majority had invasive ductal carcinoma (IDC) (62%), early stage (0, I, II) tumors (93%), ER+ (84%), PR+ (71%), Her2 negative (86%), and node negative disease (83%). There was a significantly higher proportion of later stage disease among African‐Americans (p = 0.001) and Asians (p = 0.006) and more triple negative breast cancers among African‐Americans (p < 0.0001). A majority of patients had a low ODX (56%). While ODX was not different among the race categories (p = 0.97), there were significant racial differences in Ki‐67 (p < 0.0001). In a population of highly screened women, differences were found between races regarding tumor histology. No statistical difference between race and ODX was noted, but there were racial differences in Ki67. Therefore we recommend that further research be focused on refining management algorithms by ethnicity.

Clinical Characteristics in Patients with Triple Negative Breast Cancer

Purpose The purpose of this study was to compare and contrast the clinical characteristics of the triple negative breast cancer (TNBC) and non-TNBC patients, with a particular focus on genetic susceptibility and risk factors prior to diagnosis. Methods Our institutional database was queried for all patients diagnosed with invasive breast cancer between January 2010 and May 2016. Results Out of a total of 1964 patients, 190 (10%) patients had TNBC. The median age for both TNBC and non-TNBC was 59 years. There was a significantly higher proportion of African American and Asian patients with TNBC (p = 0.0003) compared to patients with non-TNBC. BRCA1 and BRCA2 were significantly associated with TNBC (p < 0.0001, p = 0.0007). A prior history of breast cancer was significantly associated with TNBC (p = 0.0003). There was no relationship observed between TNBC and a history of chemoprevention or patients who had a history of AH or LCIS. Conclusions We found that having Asian ancestry, a prior history of breast cancer, and a BRCA1 or BRCA2 mutation all appear to be positively associated with TNBC. In order to develop more effective treatments, better surveillance, and improved prevention strategies, it is necessary to improve our understanding of the population at risk for TNBC.

Breast Cancer Risk Assessment and Screening in Transgender Patients

Cases of breast cancer have been reported in transgender patients; however, because this occurrence is so rare, no evidence-based screening guidelines exist for this complicated patient population, and there are no formal recommendations for surgery selection in this population. We present the case of a 36-year-old female-to-male transgender patient with a strong family history of BRCA-negative premenopausal breast cancer. Because of the patient’s high-risk status, the patient underwent bilateral total mastectomy with reconstruction to produce a male-appearing chest. Breast cancer risk assessment should be performed in all transgender patients; if the patient desires top surgery, a full risk assessment is essential in selecting appropriate surgical intervention. Postsurgical surveillance should be performed, as appropriate, given risk factors and choice of surgery. Given the dearth of large population series and the small number of cases of cancer in the transgender population, a registry should be produced among providers of care to the transgender population to allow evidence-based guidelines to be formulated.

The relationship of obesity, mammographic breast density, and magnetic resonance imaging in patients with breast cancer

PURPOSE The purpose was to evaluate the relationship between body mass index (BMI), mammographic breast density, magnetic resonance (MR) background parenchymal enhancement (BPE), and MR fibroglandular tissue (FGT) in women with breast cancer. METHODS Our institutional database was queried for patients with preoperative mammography and breast MR imaging. RESULTS There were 573 women eligible for analysis. Elevated BMI was associated with advanced stage of disease (P=.01), lower mammographic density (P<.0001), lower FGT (P<.0001), higher BPE (P=.005), and nonpalpable lesions (P=.04). CONCLUSIONS Higher BMI was associated with decreased breast density and FGT. Higher BMI was also associated with advanced stage disease and nonpalpable tumors on clinical exam.

Race, Oncotype DX, and other characteristics in a highly screened population.

32 Background: Oncotype DX breast cancer 21 gene assay recurrence score (RS) is used to predict disease recurrence and response to chemotherapy in order to offer patients the highest treatment benefit to risk ratio. There is a dearth of literature on the relationship of Oncotype RS and race in women with hormone receptor positive and node negative/positive disease. The purpose of this study was to investigate the relationship of race and clinical characteristics (including Oncotype RS) in an insured population of highly screened women with newly diagnosed breast cancer. METHODS The Breast Cancer Database of our institution was queried for patients who were newly diagnosed with breast cancer. We looked at demographics, risk factors, tumor characteristics, and Oncotype RS. Statistical analyses included Pearsons Chi-Square and Fishers Exact Tests. RESULTS A total of 1,767 women were diagnosed with breast cancer from 1/2010 to 4/2014. The median age was 59 years. There was a total of 1327 (75%) Whites, 162 (9%) Blacks, 163 (9%) Asians, and 108 (6%) Hispanics. Majority of patients had a college-level education (83%), had annual/biannual screening mammography (78%), and clinical breast exams (89%). Majority of patients had invasive ductal carcinoma (61%), early stage (0, I, II) tumors (94%), ER+ (85%), PR+ (72%), Her2-negative (86%), and node-negative disease (80%). Compared to Whites, there was a significantly higher proportion of later stage disease among Blacks (p = 0.001) and Asians (p = 0.003), more triple negative breast cancers among Blacks (p < 0.0001) and higher Ki-67 scores among Blacks (p < 0.001) and Asians (p < 0.001). Oncotype RS was not significantly different among the race categories and a majority of patients had a low Oncotype RS (57%). These results did not change after stratifying for nodal status. CONCLUSIONS In a population of women who had health insurance and were highly screened, we found clinical differences among races with respect to tumor histology. However, we did not find a statistically significant difference among race and Oncotype RS, even after stratifying for nodal status. Further studies are warranted to determine which tumor proliferation markers are contributing to ethnic differences in breast cancer mortality.

Tumor characteristics in obese women with breast cancer.

179 Background: Obesity is an established risk factor for postmenopausal breast cancer. Though women with high BMI tend to develop less aggressive molecular subtypes, previous studies have shown that they still have a higher risk of recurrence and worse prognosis. The biological mechanisms for this difference in outcome have yet to be identified. The purpose of this study is to determine the correlation between obesity and tumor characteristics, including Ki67, and Oncotype DX scores in both pre- and post-menopausal women. METHODS The Breast Cancer Database of NYU Langone Medical Center was queried for patients who were newly diagnosed with invasive breast cancer. We looked at the following variables: menopausal status, body mass index (BMI), histology, stage, ER/PR/Her2-neu status, Ki67, and Oncotype DX scores. Obesity was defined as having a BMI (kg/m2) ≥30. We looked at Ki67 as a continuous variable. Oncotype scores were categorized as low (<18), intermediate (18-30), and high (>31). Statistical analyses were performed using Spearman Correlation Coefficients. RESULTS Out of a total of 648 patients with a median age of 59 years, 153 (24%) women had a BMI≥30. The majority of the obese women had stage I and II (88%) cancers that were ER positive (84%), PR positive (74%), Her2-neu negative (86%), with mean Ki67 of 22%, and low to intermediate Oncotype DX scores (85%). However, when compared with women of BMI <30, there was no correlation between BMI and tumor characteristics, even when stratified by menopausal status. CONCLUSIONS In our cohort, obesity was not correlated with tumor stage, histology, Ki67 and Oncotype DX scores, even after adjusting for menopausal status. There are other factors that may explain the higher risk of recurrence and worse prognosis of breast cancer in obese women, such as insulin resistance, and obesity-related inflammatory cytokines that are independent of breast cancer subtypes and genomics. Treatment-related factors, such as non-compliance and inadequate dosing of chemotherapeutic agents, may also play a role in the worse outcome seen in this population. Further studies are necessary to identify measurable molecular characteristics of breast cancer in obese women that would allow us to predict more aggressive disease.

Ductal carcinoma in situ on core needle biopsy only with no residual disease at surgery

The treatment of ductal carcinoma in situ (DCIS) remains controversial and may be particularly difficult for patients with minimal disease. There is a dearth of information regarding patients who have been diagnosed with DCIS on core needle biopsy (CNB), who have no residual disease in the lumpectomy specimen. The purpose of this study was to explore the frequency of this presentation and short‐term outcomes in these patients.