R. A. Shuford1, J. Richman1, C. Parker1, R. B. Lancaster1 1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA
Introduction: Women with high-risk breast lesions (HRLs) frequently undergo excisional biopsies to evaluate for upgrade to invasive breast cancer (BC) or DCIS. Women with confirmed HRLs can reduce their risk of developing BC with chemoprevention (CP). This study sought to estimate how often, at a single institution, these HRLs are upgraded to DCIS or BC at the time of excisional biopsy and to estimate the frequency of chemoprevention use within this population of women with HRLs. Secondary aims included identifying factors associated with upgrade of lesions and chemoprevention use in HRL patients.
Methods: After obtaining IRB approval, all patients who underwent breast core needle biopsy from January 2010 to June 2016 were identified. Data for patients with HRLs without history of, or concurrent DCIS, pleomorphic LCIS, or BC was extracted, including age, race, family history, menopausal status, parity, breast density, use of hormone replacement therapy, and palpable breast lesion. HRL type was classified using binary indicators for ADH, ALH or LCIS, allowing for multiple lesion types per person. Chi-square and t-tests were used to test bivariate associations.
Results: 101 biopsies were included. Patients’ mean age was 57, and they were 72% white and 23% black. Overall, 64% had ADH, 25% had LCIS, and 29% had ALH. The overall upgrade rate was 16%, and did not differ significantly by age (upgrade mean age 56 vs. age 57, p=0.18), race (16% white, 22% black, p=0.90), family history (p=0.83), breast density (p=0.18), or menopausal status (p=0.79).
In bivariate analysis, the presence of ADH with or without other HRLs significantly increased the upgrade rate (23% upgrade rate with ADH vs. 6% without ADH, p=0.048). No significant effect on upgrade rate was observed with presence of ALH (10% vs. 19%, p=0.42) or LCIS (8% vs. 20%, p=0.29) with or without the presence of other HRLs.
Among patients without an upgrade, (n = 67), 28% used CP, and CP use did not significantly differ by age (p=0.62), race (black 31%, white 27%, p=0.39), or family history (p=1). A specific reason for declining CP was recorded in 54% of cases (n=48).
Conclusion: Although findings were not statistically significant, likely due to the small sample size, interesting trends were observed. Black patients had a higher estimated upgrade rate. Consistent with other recent studies, our study also showed that a diagnosis of ALH or LCIS alone with the presence of radiographic concordance is associated with a low risk of upgrade to malignancy (6%), making routine surgical excision of these lesions a less favored practice. ADH, present alone or with other HRL, demonstrated the highest risk of upgrade. Future work should identify factors that predict ADH upgrade.
Although our institution has an active High-Risk Clinic, relatively few patients with a HRL initiated CP. Facilitators and barriers to CP treatment should be evaluated in a larger study leading to interventions that increase the use of CP.