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Women with a first-degree family history of breast cancer are often advised to begin screening when they are 10 years younger than the age at which their relative was diagnosed. Evidence is lacking to determine how much earlier they should begin.Using Breast Cancer Surveillance Consortium data on screening mammograms from 1996 to 2016, the authors constructed a cohort of 306,147 women 30-59 years of age with information on first-degree family history of breast cancer and relative's age at diagnosis. The authors compared cumulative 5-year breast cancer incidence among women with and without a first-degree family history of breast by relative's age at diagnosis and by screening age.Among 306,147 women included in the study, approximately 11% reported a first-degree family history of breast cancer with 3885 breast cancer cases identified. Women reporting a relative diagnosed between 40 and 49 years and undergoing screening between ages 30 and 39 or 40 and 49 had similar 5-year cumulative incidences of breast cancer (respectively, 18.6/1000; 95% confidence interval [CI], 12.1, 25.7; 18.4/1000; 95% CI, 13.7, 23.5) as women without a family history undergoing screening between 50-59 years of age (18.0/1000; 95% CI, 17.0, 19.1). For relative's diagnosis age from 35 to 45 years of age, initiating screening 5-8 years before diagnosis age resulted in a 5-year cumulative incidence of breast cancer of 15.2/1000, that of an average 50-year-old woman.Women with a relative diagnosed at or before age 45 may wish to consider, in consultation with their provider, initiating screening 5-8 years earlier than their relative's diagnosis age.

Use of surveillance mammography and magnetic resonance imaging (MRI) has been understudied among women with variant of uncertain significance (VUS) compared to pathogenic and likely pathogenic variants (P/LP).Using data from two cancer settings, we calculated use of risk-reducing mastectomy (RRM) and surveillance during each 13-month span after genetic testing up to 6 years afterwards for a cohort of genetically elevated risk women.Of 889 women, VUS carriers were less likely to undergo RRM compared to those with P/LP (hazard ratio [HR], 0.17; p = .001) and high-risk women were more likely to undergo RRM than average-risk women (HR, 3.91; p = .005). Longitudinally, surveillance use among unaffected women decreased from 49.8% in the first year to 31.2% in the sixth year after genetic testing. In comparison, a greater proportion of women with a personal history of breast cancer underwent surveillance, which increased from 59.3% in the first year to 63.6% in the sixth year after genetic testing. Mammography rates did not differ between women with P/LP and VUS within the first 13 months after genetic testing and up to 4 years afterward. Over the first 4 years after genetic testing, women with VUS were less likely to undergo annual MRIs compared to P/LP.The authors found that VUS, whether in high or moderate penetrance breast cancer susceptibility genes, was associated with lower use of annual breast MRI compared to P/LP variants and equivalent use of annual mammography. These results add important evidence regarding VUS-related breast surveillance.

Background Genetic evaluation and testing for hereditary breast and ovarian cancer (HBOC) remain suboptimal. The authors evaluated the feasibility of using a screening tool at a breast imaging center to increase HBOC assessment referrals. Methods A brief questionnaire based on the National Comprehensive Cancer Network HBOC genetic counseling referral guidelines was developed and added to the standard intake forms of patients undergoing mammography at a community breast imaging center from 2012 through 2015. Patients who met the criteria in the guidelines were referred for genetic counseling. Results A total of 34,851 patients were screened during the study period, and 1246 (4%) patients were found to be eligible for referral; 245 of these patients made a genetic counseling appointment, and 142 patients received genetic counseling. Forty patients (28%) had a personal history of breast cancer but were not previously tested. Following counseling, 105 patients were tested for BRCA1/2. Eight patients (8%) tested positive for a pathogenic mutation and nine (9%) had a variant of unknown significance. Although they tested negative, many patients met the criteria to add breast magnetic resonance imaging to their screening due to greater than 20% lifetime breast cancer risk based on their family cancer history. This study led to improved clinical risk management in 67% of the patients who underwent genetic counseling. Conclusions This study shows that large-scale screening of patients for HBOC syndromes at time of breast imaging is practical and highly feasible. The screening tool identified women with actionable BRCA1/2 mutations and mutation-negative but high-risk women, leading to significant changes in their risk management; these women would otherwise have been missed. Lay summary Hereditary breast and ovarian cancer (HBOC) caused by pathogenic mutations in breast cancer genes (BRCA1/BRCA2) increase an individual's lifetime risk of getting HBOC. Identifying these high-risk individuals and using proven preventive clinical risk management strategies can significantly reduce their lifetime risk of HBOC. Using an innovative family cancer history questionnaire, 34,000 women were screened at a community breast imaging center, and genetic counseling and testing were provided to eligible women from the screening. Several women at high risk for HBOC were identified and this led to positive clinical risk management changes. These women would have been missed if not for intervention.

BACKGROUND Identifying women at risk for advanced interval cancers would allow better targeting of mammography and supplemental screening. The authors assessed risk factors for advanced breast cancer within 2 years of a negative mammogram. METHODS The authors included 293,520 negative mammograms performed from 2006 to 2015 among 74,736 women. Breast cancers were defined as advanced if they were >2 cm, were >1 cm and triple-negative or human epidermal growth factor receptor 2-positive, had positive lymph nodes, or were metastatic. Cox proportional hazards modeling was used to evaluate associations of age, breast density, menopause, mammogram type, prior breast biopsy, body mass index (BMI), and a family history of breast cancer with a cancer diagnosis within 2 years of a negative mammogram. Models were stratified by year since a negative mammogram. RESULTS Among 1345 breast cancers, 357 were advanced (26.5%), and 988 (73.5%) were at an early stage. Breast density, prior biopsy, and family history were associated with an increased risk of both advanced and early-stage cancers. Overweight and obese women had a 40% higher risk of early-stage cancer only in year 2 (overweight hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.19-1.67; P < .001; obese HR, 1.41; 95% CI, 1.17-1.70; P < .001). Obese women had a 90% increased risk of advanced cancer in year 1 (HR, 1.90; 95% CI, 1.14-3.18; P = .014), and both overweight and obese women had a 40% or greater increased risk in year 2 (overweight HR, 1.55; 95% CI, 1.14-2.07; P = .005; obese HR, 1.42; 95% CI, 1.00-2.01; P = .051). CONCLUSIONS A higher BMI was associated with an advanced breast cancer diagnosis within 2 years of a negative mammogram. These results have important implications for risk assessment, screening intervals, and use of supplemental screening.

Background Differences in utilization of screening mammography partly explain the increased breast cancer mortality observed in African American (AA) women compared with non-Hispanic White women. However, the contribution of noncompliance from women who do not come for their scheduled screening mammography appointment (ie, no-shows) is unknown. The purpose of this study was to investigate racial differences in no-show rates for screening mammography. Methods Women scheduled for routine screening mammograms between January 2018 and March 2018 were identified from the Joanne Knight Breast Health Center at Siteman Cancer Center in St. Louis, Missouri. Using a case-control design, this study retrospectively identified patients who no-showed for their mammograms (cases) and randomly sampled an equal number of patients who completed their mammograms (controls). These participants were compared by race. The main outcome measure was whether AA race was associated with no-shows for screening mammography. Results During the study period, 5060 women were scheduled for screening mammography, and 316 (6.2%) did not keep their appointment (ie, they no-showed). Women who no-showed were more likely to be AA than women who kept their appointment (odds ratio, 2.64; 95% confidence interval, 1.90-3.67). Even after adjustments for marital status, insurance type, and place of residence, AA race was still significantly associated with no-shows for screening mammography. Conclusions This study identified a no-show rate of 6.2% for screening mammography at the authors' institution. Women who no-showed were more likely to be AA than women who completed their mammogram even after adjustments for multiple factors. These data can be leveraged for future studies aimed at improving mammography attendance rates among AA women.

BACKGROUND To understand how health care delays may affect breast cancer detection, the authors quantified changes in breast‐related preventive and diagnostic care during the coronavirus disease 2019 (COVID‐19) pandemic. METHODS Eligible women (N = 39,444) were aged ≥18 years and received a screening mammogram, diagnostic mammogram, or breast biopsy between January 1, 2019 and September 30, 2020, at 7 academic and community breast imaging facilities in North Carolina. Changes in the number of mammography or breast biopsy examinations after March 3, 2020 (the first COVID‐19 diagnosis in North Carolina) were evaluated and compared with the expected numbers based on trends between January 1, 2019 and March 2, 2020. Changes in the predicted mean monthly number of examinations were estimated using interrupted time series models. Differences in patient characteristics were tested using least squares means regression. RESULTS Fewer examinations than expected were received after the pandemic's onset. Maximum reductions occurred in March 2020 for screening mammography (−85.1%; 95% CI, −100.0%, −70.0%) and diagnostic mammography (−48.9%; 95% CI, −71.7%, −26.2%) and in May 2020 for biopsies (−40.9%; 95% CI, −57.6%, −24.3%). The deficit decreased gradually, with no significant difference between observed and expected numbers by July 2020 (diagnostic mammography) and August 2020 (screening mammography and biopsy). Several months after the pandemic's onset, women who were receiving care had higher predicted breast cancer risk (screening mammography, P < .001) and more commonly lacked insurance (diagnostic mammography, P < .001; biopsy, P < .001) compared with the prepandemic population. CONCLUSIONS Pandemic‐associated deficits in the number of breast examinations decreased over time. Utilization differed by breast cancer risk and insurance status, but not by age or race/ethnicity. Long‐term studies are needed to clarify the contribution of these trends to breast cancer disparities., In this observational study, the use of screening mammography, diagnostic mammography, and breast biopsy is significantly lower than expected after the onset of the COVID‐19 pandemic in North Carolina, but the deficits decrease over time. Health insurance status and predicted breast cancer risk are identified as predictors of mammography and biopsy receipt during the pandemic.

During the period from 1942 to 1962, treatment attempts with single-agent chemotherapy such as nitrogen mustard and urethan gained limited application. However, the groundbreaking success with aminopterin in the treatment of patients with pediatric acute leukemia and methotrexate in the treatment of gestational choriocarcinoma established single-agent chemotherapy as a pioneering contribution to oncology. The landmark discovery that early-stage Hodgkin disease is curable with radiation made radiotherapy into an essential specialty of oncology. Although radical surgical treatment dominated the field of surgery, the excision of localized cancers with or without adjuvant radiation emerged as new modality in therapy. Cytopathology and surgical pathology became new fields in medicine and pathologists became an integral part of the preoperative, intraoperative, and postoperative care of patients with cancer. The discovery of multiple new drugs demonstrated promising results and widened the field of oncology from the laboratory to the clinic. In the etiology of cancer, precancerous conditions were named and carcinoma of the lung was definitively linked to cigarette smoking. All things considered, the progress made between 1942 and 1962 came about through the dedicated work of many individuals. However, there were 7 distinguished pathfinders (2 pathologists, 1 pediatric pathologist-oncologist, 1 radiation therapist, 1 physician-actuary, 1 gynecologist-oncologist, and 1 chemist) who, despite their different backgrounds, interests, and sex, made groundbreaking contributions to oncology.

BACKGROUND. State-specific breast density notification legislation requires that women undergoing mammography be informed about breast density, with variation among states. As mammography facilities are one of the main points of contact for women undergoing mammography, research is needed to understand how facilities communicate information on breast density, cancer risk, and supplemental screening with women. METHODS. A cross-sectional 50-item mailed survey was conducted with 156 American College of Radiology certified mammography facilities in North Carolina in 2017 using the Tailored Design Method. Breast density notification practices, supplemental screening services, and patient educational materials were compared by supplemental screening availability using t-tests and chi-square tests. RESULTS. All responding facilities (n=94; 60.3% response rate) notified women of their breast density in the mammography result letter. Breast cancer risk assessments were performed by 36.3% of facilities, with risk information communicated in the final radiology report for the referring provider to discuss with the woman (79.4%) or in the result letter (58.8%). Supplemental breast cancer screening was offered by 63.8% of facilities, with use based on multiple factors including recommendations from the referring physician (63.3%) or reading radiologist (63.3%), breast density (48.3%), other risk factors (48.3%), and woman request (40.0%). While 75% of facilities offered breast density educational materials, only 36.6% offered educational materials on supplemental screening. CONCLUSION. In a state with a breast density notification law, mammography facilities communicate breast density, cancer risk, and supplemental screening information to women using various approaches. When supplemental screening is offered, facilities utilize multiple decision-making criteria, rather than breast density alone. PRECIS. In a state with breast density notification, mammography facilities communicate breast density, cancer risk, and supplemental screening information to women using various approaches. When supplemental screening is offered, facilities utilize multiple decision-making criteria, rather than breast density alone.

Background Established mammography screening performance metrics use the initial screening mammography assessment because they were developed for radiologist performance auditing, yet these metrics are frequently used to inform health policy and screening decision making. The authors have developed new performance metrics based on the final assessment that consider the entire screening episode, including diagnostic workup. Methods The authors used data from 2,512,577 screening episodes during 2005-2017 at 146 facilities in the United States participating in the Breast Cancer Surveillance Consortium. Screening performance metrics based on the final assessment of the screening episode were compared with conventional metrics defined with the initial assessment. Results were also stratified by breast density and breast cancer risk. Results The cancer detection rates were similar for the final assessment (4.1 per 1000; 95% confidence interval [CI], 3.8-4.3 per 1000) and the initial assessment (4.1 per 1000; 95% CI, 3.9-4.3 per 1000). The interval cancer rate was 12% higher when it was based on the final assessment (0.77 per 1000; 95% CI, 0.71-0.83 per 1000) versus the initial assessment (0.69 per 1000; 95% CI, 0.64-0.74 per 1000), and this resulted in a modest difference in sensitivity (84.1% [95% CI, 83.0%-85.1%] vs 85.7% [95% CI, 84.8%-86.6%], respectively). Absolute differences in the interval cancer rate between final and initial assessments increased with breast density and breast cancer risk (eg, a difference of 0.29 per 1000 for women with extremely dense breasts and a 5-year risk >2.49%). Conclusions Established screening performance metrics underestimate the interval cancer rate of a mammography screening episode, particularly for women with dense breasts or an elevated breast cancer risk. Women, clinicians, policymakers, and researchers should use final-assessment performance metrics to support informed screening decisions.

Background Trends in breast cancer mortality in the United States are decreasing, but racial disparities persist. Using an implementation science framework to inform evidence-based breast cancer screening and navigation within federally qualified health centers (FQHCs) with community stakeholders can mitigate barriers to screening. Methods Using an integrated theoretical framework of the Practical, Robust Implementation and Sustainability Model and the Social Ecological Model, the University of Illinois Cancer Center and Mile Square Health Centers (MSHC) FQHC developed a breast cancer screening and navigation program, known as the Mile Square Accessible Mammogram Outreach and Engagement (Mi-MAMO) program, to tackle breast cancer disparities in Chicago among underresourced communities. To increase access to screening, patient navigators conducted community outreach activities. Partnerships were forged with community-based organizations, health care systems, and insurers. Outcomes were monitored with standardized performance measures. Results Between January and December 2017, 103 women received a screening mammogram at MSHC. To increase screening rates, Mi-MAMO was started in August 2017. Between January and December 2018, the number of women who received a screening mammogram increased to 567. From August 2017 to December 2018, 779 women received navigation to screening and/or diagnostic services through the Mi-MAMO program. The majority of women were uninsured (63.9%), and 95.5% were racial/ethnic minorities. Twenty-four percent (n = 185) completed diagnostic services, and 10 women received positive breast cancer diagnoses (mean age, 49.7 years); all successfully navigated to treatment. The Mi-MAMO program is ongoing. Conclusions Deploying an integrated framework for patient navigation programs can increase breast cancer screening utilization and awareness among underresourced populations at higher risk for breast cancer.

Mammographic screening contributes to a reduction in specific mortality, but it has disadvantages. Decision aids are tools designed to support people's decisions. Because these aids influence patient choice, their quality is crucial. The objective of the current study was to conduct a systematic review of decision aids developed for women eligible for mammographic screening who have an average breast cancer risk and to assess the quality of these aids. The systematic review included articles published between January 1, 1997, and August 1, 2019, in the PubMed, Embase, Cochrane, and PsycInfo databases. The studies were reviewed independently by 2 reviewers. Any study containing a decision aid for women eligible for mammographic screening with an average breast cancer risk was included. Two double-blind reviewers assessed the quality of the selected decision aids using the International Patient Decision Aid Standards instrument, version 3 (IPDASi). Twenty-three decision aids were extracted. Classification of decision aid quality using the IPDASi demonstrated large variations among the decision aids (maximum IPDASi score, 188; mean ± SD score, 132.6 ± 23.8; range, 85-172). Three decision aids had high overall scores. The 3 best-rated dimensions were disclosure (maximum score, 8; mean score, 6.8), focusing on transparency; information (maximum score, 32; mean score, 26.1), focusing on the provision of sufficient details; and probabilities (maximum score, 32; mean score 25), focusing on the presentation of probabilities. The 3 lowest-rated dimensions were decision support technology evaluation (maximum score, 8; mean score, 4.3), focusing on the effectiveness of the decision aid; development (maximum score, 24; mean score, 12.6), evaluating the development process; and plain language (maximum score, 4; mean score, 1.9), assessing appropriateness for patients with low literacy. The results of this review identified 3 high-quality decision aids for breast cancer screening.

Background From 1975 to 1990, female breast cancer mortality rates in the United States increased by 0.4% per year. Since 1990, breast cancer mortality rates have fallen between 1.8% and 3.4% per year, a decrease that is attributed to increased mammography screening and improved treatment. Methods The authors used age-adjusted female breast cancer mortality rate and population data from the Surveillance, Epidemiology, and End Results (SEER) program to estimate the number of breast cancer deaths averted by screening mammography and improved treatment since 1989. Four different assumptions regarding background mortality rates (in the absence of screening mammography and improved treatment) were used to estimate deaths averted for women aged 40 to 84 years by taking the difference between SEER-reported mortality rates and background mortality rates for each 5-year age group, multiplied by the population for each 5-year age group. SEER data were used to estimate annual and cumulative breast cancer deaths averted in 2012 and 2015 and extrapolated SEER data were used to estimate deaths averted in 2018. Results The number of single-year breast cancer deaths averted ranged from 20,860 to 33,842 in 2012, from 23,703 to 39,415 in 2015, and from 27,083 to 45,726 in 2018. Breast cancer mortality reductions ranged from 38.6% to 50.5% in 2012, from 41.5% to 54.2% in 2015, and from 45.3% to 58.3% in 2018. Cumulative breast cancer deaths averted since 1989 ranged from 237,234 to 370,402 in 2012, from 305,934 to 483,435 in 2015, and from 384,046 to 614,484 in 2018. Conclusions Since 1989, between 384,000 and 614,500 breast cancer deaths have been averted through the use of mammography screening and improved treatment.

Background Women and their health care providers need a reliable answer to this important question: If a woman chooses to participate in regular mammography screening, then how much will this choice improve her chances of avoiding a death from breast cancer compared with women who choose not to participate? Methods To answer this question, we used comprehensive registries for population, screening history, breast cancer incidence, and disease‐specific death data in a defined population in Dalarna County, Sweden. The annual incidence of breast cancer was calculated along with the annual incidence of breast cancers that were fatal within 10 and within 11 to 20 years of diagnosis among women aged 40 to 69 years who either did or did not participate in mammography screening during a 39‐year period (1977‐2015). For an additional comparison, corresponding data are presented from 19 years of the prescreening period (1958‐1976). All patients received stage‐specific therapy according to the latest national guidelines, irrespective of the mode of detection. Results The benefit for women who chose to participate in an organized breast cancer screening program was a 60% lower risk of dying from breast cancer within 10 years after diagnosis (relative risk, 0.40; 95% confidence interval, 0.34‐0.48) and a 47% lower risk of dying from breast cancer within 20 years after diagnosis (relative risk, 0.53; 95% confidence interval, 0.44‐0.63) compared with the corresponding risks for nonparticipants. Conclusions Although all patients with breast cancer stand to benefit from advances in breast cancer therapy, the current results demonstrate that women who have participated in mammography screening obtain a significantly greater benefit from the therapy available at the time of diagnosis than do those who have not participated., After 20 years of follow‐up, women who participate in mammography screening have a 47% lower risk of dying from breast cancer. Although all patients with breast cancer potentially can benefit from advances in breast cancer therapy, women who participate in mammography screening obtain a significantly greater benefit from the therapy available at the time of diagnosis than those who do not participate.

Background Breast cancer screening utilization steeply dropped at the start of the coronavirus disease 2019 (COVID-19) pandemic. However, the effects on breast cancer screening in lower income populations are unknown. This study examined changes in breast cancer screening rates (BCSRs) during the pandemic among 32 community health centers (CHCs) that provided health care to lower income populations. Methods Secondary data from 32 CHCs participating in an American Cancer Society grant program to increase breast cancer screening services were used. BCSRs were defined as the percentage of women aged 50 to 74 years who had a medical visit in the past 12 months (142,207 in 2018, 142,003 in 2019, and 150,630 in 2020) and received a screening mammogram within the last 27 months. BCSRs in July 2020, July 2019, and June 2018 were compared with screening rate ratios (SRRs) and corresponding 95% confidence intervals (CIs). Results BCSRs significantly rose by 18% between 2018 and 2019 (from 45.8% to 53.9%; SRR, 1.18; 95% CI, 1.17-1.18) and then declined by 8% between 2019 and 2020 (from 53.9% to 49.6%; SRR, 0.92; 95% CI, 0.92-0.93). If the 2018-2019 BCSR trends had continued through 2020, 63.3% of women would have been screened in 2020 in contrast to the 49.6% who were; this potentially translated into 47,517 fewer mammograms and 242 missed breast cancer diagnoses in this population. Conclusions In this study of 32 CHCs, BCSRs declined by 8% from July 2019 to 2020, and this reversed an 18% improvement between July 2018 and 2019. Declining BCSRs among CHCs during the COVID-19 pandemic call for policies to support and resources to identify women in need of screening.

Background The objective of the current study was to provide insight into the effect of coronavirus disease 2019 (COVID‐19) on breast cancer screening, breast surgery, and genetics consultations. Methods User data from a risk assessment company were collected from February 2 to April 11, 2020. The use of risk assessment was used as a proxy for the use of 3 breast cancer services, namely, breast imaging, breast surgery, and genetics consultation. Changes in the use of these services during the study period were analyzed. Results All 3 services experienced significant declines after the COVID‐19 outbreak. The decline in breast surgery began during the week of March 8, followed by breast imaging and genetics consultation (both of which began during the week of March 15). Breast imaging experienced the most significant reduction, with an average weekly decline of 61.7% and a maximum decline of 94.6%. Breast surgery demonstrated an average weekly decline of 20.5%. When surgical consultation was stratified as breast cancer versus no breast cancer, the decrease among in non–breast cancer patients was more significant than that of patients with breast cancer (a decline of 66.8% vs 11.5% from the pre‐COVID average weekly volume for non–breast cancer patients and patients with breast cancer, respectively). During the week of April 5, use of genetics consultations dropped to 39.9% of the average weekly volumes before COVID‐19. Conclusions COVID‐19 has had a significant impact on the number of patients undergoing breast cancer prevention, screening, diagnosis, and treatment., Coronavirus disease 2019 (COVID‐19) has had a significant impact on the number of patients undergoing breast cancer prevention, screening, diagnosis, and treatment in the United States. In the current study, user data from a risk assessment company were collected from February 2 to April 11, 2020, with the use of risk assessment used as a proxy to analyze changes in the use of 3 breast cancer services: breast imaging, breast surgery, and genetics consultation.

Background More than 1.5 million women per year have a benign breast biopsy resulting in concern about their future breast cancer (BC) risk. This study examined the performance of 2 BC risk models that integrate clinical and histologic findings in this population. Methods The BC risk at 5 and 10 years was estimated with the Breast Cancer Surveillance Consortium (BCSC) and Benign Breast Disease to Breast Cancer (BBD-BC) models for women diagnosed with benign breast disease (BBD) at the Mayo Clinic from 1997 to 2001. Women with BBD were eligible for the BBD-BC model, but the BCSC model also required a screening mammogram. Calibration and discrimination were assessed. Results Fifty-six cases of BC were diagnosed among the 2142 women with BBD (median age, 50 years) within 5 years (118 were diagnosed within 10 years). The BBD-BC model had slightly better calibration at 5 years (0.89; 95% confidence interval [CI], 0.71-1.21) versus 10 years (0.81; 95% CI, 0.70-1.00) but similar discrimination in the 2 time periods: 0.68 (95% CI, 0.60-0.75) and 0.66 (95% CI, 0.60-0.71), respectively. In contrast, among the 1089 women with screening mammograms (98 cases of BC within 10 years), the BCSC model had better calibration (0.94; 95% CI, 0.85-1.43) and discrimination (0.63; 95% CI, 0.56-0.71) at 10 years versus 5 years (calibration, 1.31; 95% CI, 0.94-2.25; discrimination, 0.59; 95% CI, 0.46-0.71) where discrimination was not different from chance. Conclusions The BCSC and BBD-BC models were validated in the Mayo BBD cohort, although their performance differed by 5-year risk versus 10-year risk. Further enhancement of these models is needed to provide accurate BC risk estimates for women with BBD.

BACKGROUND A history of proliferative breast disease with atypia (PBDA) may be indicative of an increased risk not just of breast cancer but also of a more aggressive form of breast cancer. METHODS Multifocal breast cancer (MFBC), defined as 2 or more tumors in the same breast upon a diagnosis of cancer, is associated with a poorer prognosis than unifocal (single-tumor) breast cancer. PBDA, including atypical ductal hyperplasia and atypical lobular hyperplasia, is a known risk factor for breast cancer. Using New Hampshire Mammography Network data collected for 3567 women diagnosed with incident breast cancer from 2004 to 2014, this study assessed the risk of MFBC associated with a previous diagnosis of PBDA. RESULTS Women with a history of PBDA were found to be twice as likely to be subsequently diagnosed with MFBC as women with no history of benign breast disease (BBD; odds ratio [OR], 2.23; 95% confidence interval [CI], 1.08-4.61). Ductal carcinoma in situ on initial biopsy was associated with a 2-fold increased risk of MFBC in comparison with invasive cancer (OR, 2.13; 95% CI, 1.58-2.88). BBD and proliferative BBD without atypia were not associated with MFBC. CONCLUSIONS Women with a history of previous PBDA may be at increased risk for MFBC. Women with a history of PBDA may benefit from additional presurgical clinical workup. Cancer 2018;124:1350-7. © 2017 American Cancer Society.

BACKGROUND Currently, there are several different recommendations for screening mammography from major national health care organizations, including: 1) annual screening at ages 40 to 84 years; 2) screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years; and 3) biennial screening at ages 50 to 74 years. METHODS Mean values of six Cancer Intervention and Surveillance Modeling Network (CISNET) models were used to compare these three screening mammography recommendations in terms of benefits and risks. RESULTS Mean mortality reduction was greatest with the recommendation of annual screening at ages 40 to 84 years (39.6%), compared with the hybrid recommendation of screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years (30.8%), and the recommendation of biennial screening at ages 50 to 74 years (23.2%). For a single-year cohort of US women aged 40 years, assuming 100% compliance, more breast cancers deaths would be averted over their lifetime with annual screening starting at age 40 (29,369) than with the hybrid recommendation (22,829) or biennial screening ages 50-74 (17,153 based on 2009 CISNET estimates, 15,599 based on 2016 CISNET estimates). To achieve the greatest mortality benefit, this single-year cohort of women would have the greatest total number of screening mammograms, benign recalls, and benign biopsies performed over the course of screening by following annual screening starting at age 40 years (90.2 million, 6.8 million, and 481,269, respectively) than by following the hybrid recommendation (49.0 million, 4.1 million, and 286,288, respectively) or biennial screening at ages 50 to 74 years (27.3 million, 2.3 million, and 162,885, respectively). CONCLUSION CISNET models demonstrate that the greatest mortality reduction is achieved with annual screening of women starting at age 40 years. Cancer 2017;123:3673–3680. © 2017 American Cancer Society

BACKGROUND Rural US women experience disparities in breast cancer screening and outcomes. In 2006, a national rural health insurance provider, the National Rural Electric Cooperative Association (NRECA), eliminated out-of-pocket costs for screening mammography. METHODS This study evaluated the elimination of cost sharing as a natural experiment: it compared trends in screening before and after the policy change. NRECA insurance claims data were used to identify all women aged 40 to 64 years who were eligible for breast cancer screening, and mammography utilization from 1998 through 2011 was evaluated. Repeated measures regression models were used to evaluate changes in utilization over time and the association between screening and sociodemographic factors. RESULTS The analysis was based on 45,738 women enrolled in the NRECA membership database for an average of 6.1 years and included 279,940 person-years of enrollment. Between 1998 and 2011, the annual screening rate increased from 35% to a peak of 50% among women aged 40 to 49 years and from 49% to 58% among women aged 50 to 64 years. The biennial screening rate increased from 56% to 66% for women aged 40 to 49 years and from 68% to 73% for women aged 50 to 64 years. Screening rates increased significantly (P < .0001) after the elimination of cost sharing and then declined slightly after changes to government screening guidelines in 2009. Younger women experienced greater increases in both annual screening (6.2%) and biennial screening (5.6%) after the elimination of cost sharing in comparison with older women (3.0% and 2.6%, respectively). In a multivariate analysis, rural residence, lower population income, and lower population education were associated with modestly lower screening. CONCLUSIONS In a national sample of predominantly rural working-age women, the elimination of cost sharing correlated with increased breast cancer screening. Cancer 2017. © 2017 American Cancer Society.

BACKGROUND Out-of-pocket expenditures are thought to be an important barrier to the receipt of cancer preventive services, especially for those of a lower socioeconomic status (SES). The Affordable Care Act (ACA) eliminated out-of-pocket expenditures for recommended services, including mammography and colonoscopy. The objective of this study was to determine changes in the uptake of mammography and colonoscopy among fee-for-service Medicare beneficiaries before and after ACA implementation. METHODS Using Medicare claims data, this study identified women who were 70 years old or older and had not undergone mammography in the previous 2 years and men and women who were 70 years old or older, were at increased risk for colorectal cancer, and had not undergone colonoscopy in the past 5 years. The receipt of procedures in the 2-year period before the ACA's implementation (2009-2010) and after its implementation (2011 to September 2012) was also identified. Multivariate generalized estimating equation models were used to determine the independent association and county-level quartile of median income and education with the receipt of testing. RESULTS For mammography, a lower SES quartile was associated with less uptake, but the post-ACA disparities were smaller than those in the pre-ACA period. In addition, mammography rates increased from the pre-ACA period to the post-ACA period in all SES quartiles. For colonoscopy, in both the pre- and post-ACA periods, there was an association between uptake and educational level and, to some extent, income. However, there were no appreciable changes in colonoscopy and SES after implementation of the ACA. CONCLUSIONS The removal of out-of-pocket expenditures may overcome a barrier to the receipt of recommended preventive services, but for colonoscopy, other procedural factors may remain as deterrents. Cancer 2017;123:1585–1589. © 2017 American Cancer Society.

Background Health determinants are known to influence the stage of breast cancer presentation, but it is unclear to what extent language affects stage. This study investigates whether non-English-speaking (NES) patients present at a later stage than their English-speaking (ES) counterparts and whether language is associated with mammographic screening. Methods This study was a retrospective, single-institution cohort analysis of women undergoing breast radiotherapy from 2012 to 2017 (n = 1057). Patients were categorized as ES (n = 904) or NES (n = 153). Ordinal logistic regression analysis identified variables associated with later stage presentation, including language, race/ethnicity, and age. A subcohort analysis investigated the influence of mammographic screening on stage for NES patients. Results NES patients had greater odds of later stage disease than ES patients (odds ratio, 1.47; 95% confidence, 1.001-2.150). This association persisted across all races/ethnicities. An additional analysis examined age categories associated with mammographic screening. For women eligible for screening (ie, those 40-50 years old or older than 50 years), there was a significant association between language and stage. NES patients older than 50 years were twice as likely to present at an advanced stage in comparison with ES patients (16.19% vs 8.11%; P = .0082). An additional subset analysis accounted for mammograms. NES patients who did not undergo screening had a higher probability of stage III disease (40.3% of NES patients vs 12.7% of ES patients). There was no difference in stage between NES and ES patients who did undergo screening. Conclusions Language is independently associated with later stage breast cancer for NES patients, regardless of race/ethnicity. NES patients may have difficulty in accessing the health care system. Future interventions should seek to reduce language barriers for mammographic screening and diagnosis.

Background Patient advocacy has led to state-level legislative mandates for the release of personal mammographic breast density information to women undergoing screening mammography. More research is needed to understand the impact of this information on women's perceptions and mammography screening behavior. Methods Semistructured interviews were conducted in English and Spanish with 24 self-identified Hispanic women who had undergone at least 1 mammogram since breast density notification was enacted in New York State. The women ranged in age from 43 to 63 years. Women were asked about their understanding and perceptions of the communication of New York State-mandated breast density information, and any actions they have taken or would take in response to this information. A content analysis of the qualitative data from the translated and transcribed interviews was conducted. Results The majority of participants had no prior knowledge of breast density and expressed confusion and apprehension regarding the meaning of dense breasts when presented with the notification information. Many participants understood having dense breasts to be a serious and abnormal condition, and reported feelings of worry and vulnerability. Participants mostly expressed a strong interest in learning about breast density and obtaining additional and more frequent breast cancer screening tests. These behavioral intentions were consistent with participants' overall favorable view of breast cancer screening and a belief that their faith, as well as regular screening, can help to protect them from breast cancer morbidity and mortality. Conclusions Hispanic women conveyed proactive breast cancer screening intentions in response to breast density notification, despite inadequate comprehension of this information and negative emotional responses.