MRI Scans May Predict A Woman’s Future Risk Of Developing Breast Cancer

Research by Dontchos et al published in Radiology suggests that MRI of the breast may predict a woman’s future risk of developing breast cancer.  They looked whether qualitative magnetic resonance imaging (MRI) assessments of background parenchymal enhancement (BPE), amount of fibroglandular tissue (FGT), and mammographic density are associated with risk of developing breast cancer in women who are at high risk.

They reviewed all screening breast MRI studies obtained from January 2006 to December 2011 in women aged 18 years or older and at high risk for but without a history of breast cancer. Women in whom breast cancer was diagnosed after index MR imaging comprised the cancer cohort, and one-to-one matching (age and BRCA status) of each woman with breast cancer to a control subject was performed by using MR images obtained in women who did not develop breast cancer with follow-up time maximized. Amount of BPE, BPE pattern (peripheral vs central), amount of FGT at MR imaging, and mammographic density were assessed on index images.

Twenty-three women at high risk (mean age, 47 years ± 10 [standard deviation]; six women had BRCA mutations with no history of breast cancer underwent screening breast MR imaging; in these women, a diagnosis of breast cancer (invasive, n = 12; in situ, n = 11) was made during the follow-up interval. Women with mild, moderate, or marked BPE were nine times more likely to receive a diagnosis of breast cancer during the follow-up interval than were those with minimal BPE. BPE pattern, MR amount of FGT on MRI, and mammographic density were not significantly different between the cohorts.

Greater background parenchymal enhancement (BPE) was associated with a higher probability of developing breast cancer in women at high risk for cancer and warrants further study.

USPSTF guidelines for breast cancer screening

On April 20, 2015, the U.S. Preventive Services Task Force (USPSTF) released its draft guidelines for breast cancer screening.

The USPSTF recommends biennial screening mammography for women ages 50 to 74 years.

The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.

•   For women at average risk for breast cancer, most of the benefit of mammography will result from biennial screening during ages 50 to 74 years. Of all age groups, women ages 60 to 69 years are most likely to avoid a breast cancer death through mammography screening. Screening mammography in women ages 40 to 49 years may reduce the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women and the number of false-positive tests and unnecessary biopsies are larger.

•   All women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to her health, or even apparent, during her lifetime (known as “overdiagnosis”). This risk is predicted to be increased when beginning regular mammography before age 50 years.

•   Women with a parent, sibling, or child with breast cancer may benefit more than average-risk women from beginning screening between the ages of 40 and 49 years.

•    The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women age 75 years and older.

•     The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of tomosynthesis (3-D mammography) as a screening modality for breast cancer.

This recommendation applies to asymptomatic women age 40 years and older who do not have pre-existing breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as a BRCA mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age.

Do-Si-Do

Dan Christensen a painter whose paintings were known for their festivity and bright colors was born in Nebraska.  He completed his studies at the Kansas City Art Institute in 1964 and moved to New York shortly thereafter.

Although his brilliant spray-painted bands were well received; he strived to find new ways to express his fascination with color.   Thus his paintings of rectangular blocks came to be known as his “plaid” series. The plaid series evolved into another technique in which he layered different colors thus he created a sense of depth, a technique he called “slab” paintings.   In the 1990s, his work evolved to the “circle” paintings of radiant rounded forms.

An example of the glowing disks that characterized his circle technique is “Do-Si-Do”, in which a series of concentric circles was depicted and shows his long obsession with color.  In this painting Christensen was recalling childhood memories of hot summer days dominated by a relentless sun in the sky. An alternate interpretation of the work involves consideration of the “Do-Si-Do” dance maneuver in which participants move around one another or as the planets rotate around the sun in our solar system occasionally exhibiting paradoxical travels like they are intoxicated from the overpowering brilliance of Ηλιος the Sun-God.

   

Dan Christensen (1942-2007), Do-Si-Do, 1991, American. Acrylic on canvas. 177.8 × 177.8 cm. Courtesy of the Wichita Art Museum (https://www.wichitaartmuseum.org/), Wichita, Kansas.

Excerpt from the article by Jeanette M. Smith, MD JAMA. 2015;313(11):1084-1085

Anatomical versus Functional Testing for Coronary Artery Disease

Douglas et al in their article in NEJM compared the outcomes of anatomical versus functional tests in patients with coronary artery disease. 

They randomly assigned 10,003 symptomatic patients to an initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure.

The mean age of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was 53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group. CTA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% vs. 4.3%, P=0.02), although more patients in the CTA group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). The median cumulative radiation exposure per patient was lower in the CTA group than in the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients in the functional-testing group had no exposure, so the overall exposure was higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P<0.001).

In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years suggesting that patients with chest pain have no less risk of heart attack, dying or being hospitalized than those who take a simple stress test.  

Race and ethnicity play a role in the outcome of patients with Breast Cancer

Javaid et al report in a JAMA article the findings of an observational study of women diagnosed with invasive breast cancer from 2004 to 2011, that were identified in the Surveillance, Epidemiology, and End Results (SEER) 18 registries database (N = 452 215).   The patients belonged in 8 racial/ethnic groups, who had small-sized tumors of 2.0 cm or less with biological aggressiveness (triple-negative cancers, lymph node metastases, and distant metastases).

The odds ratio for being diagnosed at stage I compared with a later stage and the hazard ratio for death from stage I breast cancer by racial/ethnic group were determined.

Breast cancer stage at diagnosis and 7-year breast cancer–specific survival, adjusted for age at diagnosis, income, and estrogen receptor status was assessed.

Of 373 563 women with invasive breast cancer, 268 675 (71.9%) were non-Hispanic white; 34 928 (9.4%), Hispanic white; 38 751 (10.4%), black; 25 211 (6.7%), Asian; and 5998 (1.6%), other ethnicities. Mean follow-up time was 40.6 months (median, 38 months). Compared with non-Hispanic white women diagnosed with stage I breast cancer (50.8%), Japanese women (56.1%) were more likely to be diagnosed and black women (37.0%) were less likely to be diagnosed. Actuarial risk of death from stage I breast cancer at 7 years was higher among black women (6.2%) than non-Hispanic white women (3.0%), and lower among South Asian women (1.7%). Black women were more likely to die of breast cancer with small-sized tumors (9.0%) than non-Hispanic white women (4.6%); the difference remained after adjustment for income and estrogen receptor status.

Among US women diagnosed with invasive breast cancer, the likelihood of diagnosis at an early stage, and survival after stage I diagnosis, varied by race and ethnicity.