Comparison of care process for newly diagnosed breast cancer in insured versus uninsured populations: Opportunities for improving health equity.

e18518 Background: Initiatives enhancing equitable oncologic care are an increasingly emphasized priority. Our study aims to identify aspects of breast cancer (BC) care in which differences exist based on insurance coverage status. Methods: We performed a retrospective, case control study consisting of 39 Hispanic ethnicity uninsured patients (UP) with newly diagnosed BC at federally qualified health centers and 119 insured patients (IP) diagnosed at Mayo Clinic Arizona (MCA). Patients were matched 3:1 for age, stage, year of diagnosis, ER and HER2 status. Demographic information, clinical variables, and zip code level specific socioeconomic information were compared. Continuous variables were compared by Wilcoxon rank-sum test and categorical variables by chi-square test. All patients ultimately received their cancer treatment at MCA. Results: Similar treatment patterns with chemotherapy, surgery, and radiation treatment were observed between groups. Primary language was Spanish for 94% of UP and English for 97.5% of IP. The majority of UP were of Hispanic ethnicity (97.4%); IP were 83.2% non-Hispanic White, 9.2% Hispanic, 3.4% African American. Zip code level information reflected more unemployment with a median of 10.6% versus 6.9% p ˂ 0.001, percent of high school or lower (53.0 % v 23.2 %, p ˂ 0.001), and lower income for UP (33733.5 v 64728.0 p values ˂ 0.001). UP BMI was significantly higher (30.6 V 24.7, p=0.005), with presence of more co-morbidities; diabetes (28.2% v 5.0%, p ˂ 0.001), hypertension (35.9 % v 20.2%, p= 0.046), dyslipidemia (28.2% v 12.6%, p = 0.023), metabolic syndrome (p 23.7% v 8.5, p= 0.013), and tobacco use (17.9% v 2.5%, p ˂ 0.001). IP had higher alcohol use (52.9% v 5.3%, p ˂ 0.001). Genetics consultation was performed for 62.2% IP versus 35.9% UP (p=0.004), lower acceptance of oncology nutrition consultation for UP (29.4% vs 7.4%, p= 0.024) Median time from abnormal mammogram to biopsy (25.5 days vs. 14 days, p=0.056), and interval from diagnosis to treatment (62 days vs. 39 days) (p=0.001) were less favorable for UP compared to IP. Conclusions: In comparing the status of UP (primarily Hispanic, Spanish-speaking) and IP (primarily non-Hispanic White, English-speaking) with newly diagnosed BC we identified greater prevalence of co-morbidities and adverse social determinants of health in the former group. We identified access to genetic counseling services, access to oncology nutrition consultation, and timeliness of diagnostic biopsy and initiation of treatment as disparate features in the care pathway. These observations can allow development of tailored interventions to achieve greater equity in delivery of BC care.

Breast tumor segmentation in mammography image via Chan-Vese technique

The accurate segmentation of tumours is a crucial stage of diagnosis and treatment, reducing the damage that breast cancer causes, which is the most common type of cancer among women, especially after the age of forty. The task of segmenting breast tumours in mammograms is very difficult, as its difficulty lies in the lack of contrast between the tumour and the surrounding breast tissue, especially when dealing with small tumours that are not clear boundaries and hidden under the tissues. As algorithms often lose an automatic path toward the boundaries of the tumour at try to determine the site of this type of tumour. The study aims to create a clear contrast between the tumour and the healthy breast area. For this purpose, we used a Gaussian filter as a pre-processing as it works to intensify the low-frequency components while reducing the high-frequency components as the breast structure is enhanced and noise suppression. Then, CLAHE was used to improve the contrast of the image, which increases the contrast between the tumour and the surrounding tissue and sharpens the edges of the tumour. Next, the tumour was segmented by using the Chan-Vese method with appropriate parameters defined. The proposed method was applied to all abnormal mammogram images taken from a publicly available mini-MIAS database. The proposed model was tested in two ways, the first is statistical that got results (90.1, 94.8, 95.5, 92.1, 99.5) for Jaccard, Dice, PF-Score, precision, and sensitivity respectively. And the other is based on the segmented region's characteristics that results showed the algorithm could identify the tumour with high efficiency.

Biomarkers for predicting cancer in women with a suspicious mammogram.

e15533 Background: Biomarker identification for early breast cancer diagnosis is confounded by comparing healthy control patients to patients undergoing surgical procedures and stress of a potential cancer diagnosis. We implemented a clinical research protocol that combines biomarker harvesting and identification with Breast Imaging-Reporting and Data System (BIRADS) results, within a cohort of women with a suspicious mammogram who donated samples prior to biopsy. The primary goals were to discover candidate novel plasma markers for stage I breast cancer versus benign lesions, and validate the markers by mass spectrometry and immunohistochemistry. Methods: 150 women found on screening mammography to have a BIRADS IV or V mammographic abnormality were enrolled in the IRB approved study, with one year follow-up. After informed consent, serum, plasma, and saliva specimens were obtained and frozen. The patient underwent image guided biopsy of the mammographic abnormality. Hydrogel nanoparticles were used to harvest and concentrate low abundance protein biomarkers from plasma. Proteins were identified by mass spectrometry. The BIRADS score and biopsy outcome were blinded to the laboratory researchers. Results: 37/150 women (median age 64, 73% ER+, 70% PR+) were diagnosed with biopsy-proven breast cancer. 15/37 had a family history of breast cancer. Within the context of stress of an abnormal mammogram and invasive biopsy, we identified 5478 plasma peptides. A model to predict endpoints that discriminate cancer vs no cancer was developed using cross-validation and lasso shrinkage method. The best fit multi-analyte ROC/AUC model of peptide spectral matches revealed 10 candidate peptides, including PLAA, TRAPPC9, PROS1, DDX41, ANKRD63, EGFLAM (AUC = 0.81), that discriminated cancer versus no cancer. The functional mechanisms of these proteins are calcium metabolism, GPI anchor biosynthesis, neural-immune crosstalk, DNA repair, and ubiquitin-mediated protein trafficking. Conclusions: Molecular profiling of blood can potentially complement imaging to improve diagnostic specificity in the setting of a suspicious mammogram. This unique trial design, enhanced by nanotechnology protein harvesting, identified potential novel cancer biomarkers in the presence of a suspicious mammogram. A confirmation trial is underway.

Breast Cancer screening patterns in Jamaican women: review of the largest national mammography clinic

Background Breast cancer is the leading cause of cancer and cancer related deaths in Jamaican women. In Jamaica, women often present with advanced stages of breast cancer, despite the availability of screening mammography for early detection. The utilization of screening mammography for early breast cancer diagnosis seems to be limited, and this study investigated the national patterns of mammographic screening and the impact of mammography on the diagnosis of breast cancer in Jamaica.Methods A retrospective analysis of the records of the largest mammography clinic in Jamaica was done for the period January 2011 to December 2016. Descriptive statistics was performed on relevant patient characteristics with calculation of rates and proportions; cross-tabulations were utilized to assess relationship of covariates being studied on the outcomes of interest. Results are reported in aggregate form with no identifiable patient data.Results 48,203 mammograms were performed during the study period. 574 women (1.2%) had mammograms suspicious for breast cancer with median age of 57 years (range 30 – 95 years); 35% were under the age of 50. 4 women with suspicious findings had undergone ‘routine mammography’, with the remaining having ‘diagnostic mammography’. 38% reported previous mammograms, with a mean interval of 8 years between previous normal mammogram and abnormal mammogram. Median age at first screening mammogram was 51 years (range 41-77).Conclusion Breast cancer screening mammography is underutilized in Jamaica. An organized national breast cancer screening programme is recommended to improve adherence to international breast cancer screening guidelines.

Breast papillary lesions: a retrospective analysis from oncology set up of Pakistan

Background: Papillary lesions of the breast are a heterogeneous group of breast lesions that are difficult to diagnose as benign or malignant. These lesions have varied morphologic features that carry differing prognostic implications for affected patients. Accurate diagnosis is required to ensure that effective treatment is achieved. Papillary lesions can have increased risk of carcinoma and recurrence, in these patients even for lesions yielding a benign concordant diagnosis of papilloma at percutaneous biopsy, surgical excision may be warranted. Malignant lesions are usually surgically treated. Depending on stage-adjuvant chemotherapy and/or radiation therapy is given.Methods: A retrospective study was conducted at Shaukat Khanum Memorial hospital and Research Centre Lahore Pakistan. We reviewed the electronic records of diagnostic and registered patients from January 2007 till December 2017 in women imaging section, in age range of 25 to 75 years. Total 150 diagnosed patients with benign or malignant breast papillary lesions were selected and their conventional breast imaging (mammography and ultrasound) and histopathology was retrospectively analyzed on SPSS.Results: Patients were predominantly asymptomatic or on follow-up to an abnormal mammogram. Of the 150 cases most of the patients had intra-ductal papilloma followed by invasive papillary carcinoma and intra cystic papillary carcinoma. Few patients had intra-ductal papillomatosis and invasive micro papillary carcinoma.Conclusions: Conventional breast imaging remains the first main stay and quite sensitive in detecting breast papillary lesions leading to early detection and management.

A Deep Learning–Based Decision Support Tool for Precision Risk Assessment of Breast Cancer

PURPOSE The Breast Imaging Reporting and Data System (BI-RADS) lexicon was developed to standardize mammographic reporting to assess cancer risk and facilitate the decision to biopsy. Because of substantial interobserver variability in the application of the BI-RADS lexicon, the decision to biopsy varies greatly and results in overdiagnosis and excessive biopsies. The false-positive rate from mammograms is estimated to be 7% to approximately 10% overall, but within the BI-RADS 4 category, it is greater than 70%. Therefore, we developed the Breast Cancer Risk Calculator (BRISK) to target a well-characterized and specific patient subgroup (BI-RADS 4) rather than a broad heterogeneous group in assessing breast cancer risk. METHODS BRISK provides a novel precise risk assessment model to reduce overdiagnosis and unnecessary biopsies. It was developed by applying natural language processing and deep learning methods on 5,147 patient records archived in the Houston Methodist systemwide data warehouse from 2006 to May 2015, including imaging and pathology reports, mammographic images, and patient demographics. Key characteristics for BI-RADS 4 patients were collected and computed to output an index measure for biopsy recommendation that is clinically relevant and informative and improves upon the traditional BI-RADS 4 scores. RESULTS For the validation set, we assessed data from 1,247 BI-RADS 4 patients, including mammographic images and medical reports. The BRISK model sensitivity to predict malignancy was 100%, whereas the specificity was 74%. The total accuracy of our implemented model in BRISK was 81%. Overall area under the curve was 0.93. CONCLUSION BRISK for abnormal mammogram uses integrative artificial intelligence technology and has demonstrated high sensitivity in the prediction of malignancy. Prospective evaluation is under way and can lead to improvement in patient-physician engagement in making informed decisions with regard to biopsy.

Incidental atypical hyperplasia/LCIS in mammoplasty specimens and subsequent risk of breast cancer.

1561 Background: Proliferative breast lesions with atypia (atypical hyperplasia and lobular carcinoma in-situ (LCIS)) increase the risk of breast cancer (BC). Most cases are diagnosed in the context of an abnormal mammogram. Little is known about BC risk for patients with these lesions who are asymptomatic. Mammoplasty specimens allow us to study breast tissue in asymptomatic healthy women. We previously published the rate of atypia in the largest reported mammoplasty cohort. The aim of this study is to examine the risk of BC in the atypia cohort. Methods: Breast pathology reports were retrospectively reviewed for evidence of atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH) or LCIS in bilateral reduction mammoplasty specimens from five institutions within a single healthcare system between 1990 to 2017. Patients with prior or concurrent BC or prior atypia were excluded. Data was extracted from electronic medical records using natural language processing and manual review to assess subsequent risk of BC. Results: From our mammoplasty cohort of 4771 patients, 295 patients were found to have atypia (6.2%) at baseline. 40 of these patients were lost to follow-up and excluded from the study. For the remaining 255 patients, 13 had severe ADH bordering on ductal carcinoma in situ, 52 had LCIS, 119 had ALH, and 71 had ADH at baseline. The median age at baseline was 52.1 (range 17.9 – 74.3). With a median follow-up of 7.7 years, of the 255 patients 9 patients developed BC (8 invasive carcinomas, 1 ductal carcinoma in situ). 81.3% of the cohort did not receive chemoprevention. Only one patient out of the nine who developed BC received chemoprevention. The risk of developing BC among women with atypia at baseline was 0.5%, 2.9% and 4.1%, at 3, 5 and 10 years respectively. Conclusions: Patients with asymptomatic atypias found in reduction mammoplasty specimens appear to be at lower risk of developing BC than those diagnosed with atypia in the context of an abnormal mammogram. These results may provide guidance on how to manage this group of patients related to future screening and/or chemoprevention.