Citations

The NCCN Guidelines for Squamous Cell Skin Cancer provide recommendations for diagnostic workup, clinical stage, and treatment options for patients with cutaneous squamous cell carcinoma. The NCCN panel meets annually to discuss updates to the guidelines based on comments from panel members and the Institutional Review, as well as submissions from within NCCN and external organizations. These NCCN Guidelines Insights focus on the introduction of a new surgical recommendation terminology (peripheral and deep en face margin assessment), as well as recent updates on topical prophylaxis, immunotherapy for regional and metastatic disease, and radiation therapy.

BackgroundThe objective of this randomized trial was to evaluate the short‐term effect of bilingual written and interpersonal education regarding mammographic breast density (MBD).MethodsLatinas aged 40 to 74 years who were presenting for screening mammography were recruited and randomized 1:1:1 to receive a letter with their mammogram and MBD results (usual care [UC]), a letter plus a brochure (enhanced care [ENH]), or a letter plus a brochure and telephonic promotora education (interpersonal care [INT]). Surveys were administered at enrollment (T0) and 2 weeks to 6 months after intervention delivery (T1). Differences were assessed with χ2, Kruskal‐Wallis, and McNemar tests and pairwise comparisons as appropriate. INT metrics and audio recordings were analyzed with descriptive statistics and qualitative content analysis.ResultsBetween October 2016 and October 2019, 943 of 1108 Latina participants (85%) completed both surveys. At T1, INT participants were more likely (P < .001) to report seeing their MBD results in the letter (70.2%) than UC (53.1%) or ENH participants (55.1%). The percentage of INT women who reported speaking with a provider about MBD (29.0%) was significantly greater (P < .001) than the percentage of UC (14.7%) or ENH participants (15.6%). All groups saw significant (P < .001) but nondifferential improvements in their knowledge of MBD as a masking and risk factor. In the INT group, the promotora delivered education to 77.1% of the 446 participants randomized to INT and answered questions at 28.3% of the encounters for an average of $4.70 per participant.ConclusionsAmong Latinas in a low‐resource setting, MBD knowledge may increase with written or interpersonal education, but with modest investment, interpersonal education may better improve MBD awareness and prompt patient‐provider discussions.

Objective The purpose of this study was to determine self-reported knowledge, attitudes, prior experience, and perceived needs for the management of overweight and obese patients within a General Internal Medicine Practice. Patients and Methods An emailed cross-sectional survey was sent between June 20, 2019 and September 12, 2019 to 194 healthcare workers (93 primary care providers (PCPs) and 101 nurses) which focused on management of patients with weight issues. Results In total, 80 of the eligible 194 participants completed the survey (nurses = 42, PCPs = 38). Up to 87% were white, 74.7% female (74.7%). Most of the responders were either in the age group of 30’s (30%) or 50’s (30%). Among the responders, 48.8% reported some type of specialty training in weight management since their medical training with lectures being the most common form of training (36%). When asked about their interest in either weight management training or strategies to initiate weight conversations, 79% of the respondents reported an interest in education on weight management or strategies to initiate weight conversations, while 65.8% indicated they would be interested in both topics. Conclusion Our study suggests that healthcare workers have a self-reported need for further training in management of overweight and obese patients, irrespective of previous training in this area.

Objective To estimate the health care workers (HCWs) self-reported stress, resilience, and coping during the COVID-19 pandemic, and to determine inter-professional differences. Participants and Methods An email survey was sent to 474 HCW at a Midwestern HealthCare facility between April 9, 2020 and April 30, 2020. A total of 311 (65.6%) responses were received by May 31, 2020. The survey utilized 3 validated instruments: Perceived Stress Scale (PSS), Brief Resilience Scale (BRS), Brief Resilience Coping Scale (BRCS). Results Of the 311 responses, 302 were evaluated: 97 from nonmedical staff with patient contact (NMPC); 86 from nonmedical staff with no patient contact (NMNPC); 62 from medical doctors (MD), physician assistants (PA) and nurse practitioners (NP); and 57 from nurses. Significant differences were noted across job categories for stress and resilience, with nurses reporting highest PSS scores (effect estimates: −2.72, P = .009 for NMNPC; −2.50, P = .015 for NMPC; −3.21, P = .006 for MD/NP/PA respectively), and MD/NP/PA group with highest BRS scores: nurses (−0.31, P = .02); NMPC (−0.3333, P = .01); and NMNPC (−0.2828, P = .02). Younger personnel had higher stress (−1.59 per decade of age, P < .01) and more resilience (0.11 per decade of age, P = .002). Conclusion These self-reported data indicate that MD/NP/PA had the highest resilience scores and the nurses had highest stress levels. Efforts are warranted to include all HCWs in systematic stress mitigating interventions with particular attention to understand specific factors contributing to stress for the nursing team.

Abstract Background: Women with benign breast disease (BBD) are at increased risk of breast cancer (BC). Classic studies based on film-based mammographic screening and pathology diagnosis of surgical biopsies conducted in the 1980s established a hierarchy of increasing BC risk: non-proliferative (NP) BBD, proliferative BBD without atypia (PDWA) and atypical hyperplasia (AH). Given changes in epidemiological BC risk factors and introduction of percutaneous core needle biopsy (CNB) in mid-1990s, and later, digital mammography, we hypothesized that the patient characteristics and relative frequency of BBD diagnoses have changed over time. Accordingly, we performed a longitudinal analysis of the frequency of patient characteristics and BBD diagnoses in the Mayo BBD cohort. Methods: Utilizing the Mayo Clinic Surgical and Pathology Indices, women ages 18 to 85 who had a BBD biopsy between 1/1/67 and 12/31/13 were identified. Breast pathologists reviewed biopsies masked to diagnoses of incident BC diagnosed in follow-up. Demographic characteristics and BC events were obtained by query of institutional data sources and participant surveys. Trends were evaluated for the following eras: 1: pre-mammogram (1967-1981), 2: pre-CNB (1982-1992), 3: CNB Transition (1993-2001), and 4: CNB (2002-2013). Demographics were formally compared across eras using chi-square tests for categorical variables and analyses of variance (ANOVAs) for continuous variables. Results: From 1967-2013, the cohort includes 19,582 unique women with BBD. The frequency of CNB increased from eras 1-4: 0.04%, 0.6%, 51.3 %, and 88.9%, respectively. Mean age at BBD diagnosis was younger in era 1 (48.0 years) vs eras 2-4 (53.2, 52.0, and 51.8, respectively, p&lt;0.001). The percentage of biopsies diagnosed as PDWA increased from era 1-4 (25.7%, 34.3%, 35.2%, 46.2%, p&lt;0.001), as did the percentage with AH (2.4%, 5.1%, 8.6%, 12.3%, p&lt;0.001). Over eras 1-4, the percentages of women with a strong family history of BC increased (9.9%, 12.7%, 17.1%, and 29.0%, p&lt;0.001) as did mean BMI (24.8, 26.4, 27.4, and 28.6, p&lt;0.001). With a median follow-up of 10.9 years, 1,719 breast cancers have developed, with increasing proportion of noninvasive (DCIS-only) disease across eras 1-4: 15.0%, 21.1%, 21.2%, and 33.2%, p&lt; 0.001. Conclusions: Analysis of this large, single institution BBD cohort for the 46 year period 1967-2013 demonstrates that BC risk factors among BBD patients has changed over time, with subjects demonstrating increasing age, BMI, and family history, and that the percentages of BBD classified as PDWA and AH have increased. Impact on BC risk will be further investigated. Citation Format: Amy Degnim, Karthik Ghosh, Jodi M Carter, Robert A Vierkant, Matthew R Jensen, Stacey J Winham, Tanya L Hoskin, Marlene Frost, Teresa M Allers, Denise L Gehling, Mindy J Kern, Laura M Pacheco-Spann, Celine M Vachon, Derek C Radisky, Daniel W Visscher, Mark E Sherman. Benign breast disease: Temporal trends from 1967 to 2013 [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-11.

Abstract Background: Women with benign breast disease (BBD) experience an increased risk of breast cancer (BC). Histologic classification of BBD, as non-proliferative disease (NP), proliferative disease without atypia (PDWA) or atypical hyperplasia (AH), stratifies groups of patients into progressively higher categories of BC risk. However, this classification does not comprehensively assess the proliferative state of the epithelium throughout the biopsy. In addition, while AH is considered the most high-risk class of BBD, it is not always a highly proliferative lesion; atypical ductal lesions may reflect focal cytologic and architectural changes. We evaluated the association of an alternative classification of BBD severity and BC risk based on subjective grading of: 1) the maximal degree of epithelial proliferation and 2) multifocality of epithelial proliferation. Methods: Pathologists reviewed biopsies from participants aged 18 to 85 years in the Mayo BBD cohort (2002-2013), masked to BC outcomes, ascertained via questionnaires, tumor registry data and medical record review. Biopsies were classified as NP, PDWA or AH and semi-quantitatively scored for: 1) maximal degree of epithelial proliferation within a focus (DP) (0-3; none to severe) and 2) multifocality of proliferation (MP) (0-3; none to multiple foci). DP and MP scores were also summed to give a DP+MP score (0-6). Associations of DP and MP with BC risk were examined using Cox proportional hazards regression analyses, adjusting for age at BBD biopsy. Women were followed from date of initial biopsy to date of BC, death or last follow-up. Results: Of the 1529 assessable biopsies, 544 (35.6%) were classified as NP, 708 (46.3%) as PDWA and 277 (18.1%) as AH. Both DP and MP scores had significant positive correlation with increasing BBD severity (DP: r=0.51, p&lt; 0.001; MP: r=0.52, p&lt; 0.001). Mean (SD) DP scores were 0.6 (0.6) for NP, 1.6 (0.9) for PDWA, and 1.8 (0.7) for AH (ANOVA p&lt;0.001). Mean (SD) for MP scores were 0.6 (0.6) for NP, 1.4 (0.8) for PDWA, and 1.8 (0.8) for AH (ANOVA p&lt;0.001). Mean (SD) for DP+MP scores were 1.2 (1.2) for NP, 2.9 (1.5) for PDWA, and 3.6 (1.2) for AH (ANOVA p&lt;0.001). With median follow-up of 8.8 years for controls and 5.3 years for cases, 10.6% of the women in the cohort developed BC. Compared to those with DP scores of 0, women with DP scores of 3 had significantly increased BC risk (HR 1.42, 95% CI: 1.16, 1.74, p=0.003). MP was associated with a non-significant increase in BC risk for scores of 3 versus 0 (HR: 1.20, 95% CI: 0.97,1.49, p=0.11). DP+MP scores of 6 conferred the highest BC risk (HR (score 6 vs. 0): 1.62, 95% CI 1.18,2.21, p=0.02). Results did not substantively differ after adjusting for BBD severity as NP, PDWA or AH. Conclusions: In this preliminary analysis within the Mayo BBD cohort, both proliferative degree (DP) and multifocality (MP) scores were correlated with histologic severity of BBD. DP and DP+MP scores were each associated with increased BC risk. We conclude that improved characterization of epithelial proliferation in BBD biopsies may enable refined prediction of individual BC risk. Citation Format: Jodi M Carter, Matthew R Jensen, Robert A Vierkant, Stacey J Winham, Tanya L Hoskin, Marlene Frost, Karthik Ghosh, Derek C Radisky, Amy C Degnim, Mark E Sherman. Epithelial proliferation score as an independent breast cancer risk predictor in benign breast disease [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD10-10.

Abstract Purpose: Among a Latina population in a low resource healthcare setting, to test the effectiveness of bilingual (Spanish/English) written and interpersonal educational interventions in increasing breast density (BD) awareness, knowledge, and conversations with healthcare providers, which are goals of BD notification mandates. Procedures: This randomized trial was conducted at a Federally Qualified Health Center (FQHC) in an urban community of the Southwest U.S. Women ages 40- 74 presenting for screening mammography were recruited and randomized 1:1:1 to usual care (mailed letter with mammogram and BD results), enhanced care (letter plus BD educational brochure), or interpersonal care (letter, brochure, and telephonic promotora education). The baseline survey was administered in person at enrollment prior to the mammogram. Follow-up surveys were by phone or mail after the mammography results letter was mailed and promotora delivery was complete (median days from baseline to follow-up survey = 97 days). Differences between groups at baseline or follow-up were assessed with chi-square tests. Logistic regression using generalized estimating equations to account for repeated data was used to assess differences by time (baseline to follow-up) within group, including a time-by-group interaction. Results: Between October 2016 and October 2019, 1377 women were enrolled. Of these, 1085 (79%) self-identified Latinas completed baseline and follow-up surveys. Median age was 47 years. Most (91%) reported speaking mostly Spanish, and 69.1% had less than a high school degree. At baseline, only 20.9% reported having heard of BD, and only 30.5% of those knew their personal BD category. At follow-up, women in the interpersonal group were more likely to report seeing their BD results in the notification letter compared to the usual care and enhanced groups (70.4% vs. 52.9% and 54.3%, p &lt; 0.001) and to report having spoken with a provider about their BD (27.3% vs. 14.2% and 15.7%, p &lt; 0.001). They also reported higher mean understanding of BD (7.7 on a 0-10 scale vs. 6.3 and 6.6, p &lt; 0.001). There were no significant differences on these outcomes between the usual care and enhanced groups. All groups saw significant improvement in correct responses from baseline to follow-up for questions on the ability of BD to mask tumors on a mammogram and BD as a breast cancer risk factor (p &lt; 0.001 all groups), but the degree of improvement in masking knowledge was significantly higher for the interpersonal vs usual care group [OR for a correct response in follow-up vs baseline: 6.4 (interpersonal) vs 3.7 (usual care), p=0.01]. Conclusion: Among a Latina population in a FQHC, telephonic promotora education was more effective than written notification alone or a mailed brochure on key goals of notification mandates. Adding a brochure does not appear to be more effective than sending a letter alone on key outcomes, but the interpersonal nature of promotora education may prompt attention to mailed information and provide an opportunity for questions. Citation Format: Jennifer L. Ridgeway, Sarah M. Jenkins, Deborah J. Rhodes, Bhavika K. Patel, Edna Ramos, Bijan Borah, Karthik Ghosh, Vera J. Suman, Aaron Norman, Davinder Singh, Celine M. Vachon. Evaluating educational interventions to increase breast density awareness among Latinas: A randomized clinical trial in a Federally Qualified Health Center [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-245.

Abstract Objective: Breast density notification laws aim to increase women’s awareness and knowledge about breast density (BD). This study’s aim was to compare BD knowledge and awareness in two Hispanic populations: a safety-net clinic serving Latina population in Maricopa County, Arizona (AZ) and a national sample of Hispanic women participating in an online research panel. Materials/Methods: Women ages 40-74 were recruited at the AZ clinic from 2016-2019 at a screening mammography appointment as part of a larger clinical trial (AZ cohort). Surveys were completed in person (English or Spanish) at enrollment to assess awareness of BD, understanding of BD risk, and mammography history. The same questions were asked in a nationally representative online panel survey conducted in 2017. All data from the national survey were weighted to adjust for probability of selection into the panel and post-stratified to match known U.S. Hispanic population distributions (NS cohort). Univariate comparisons between the clinic and the national panel were performed using Rao-Scott chi-square tests. Associations with awareness and correct knowledge were examined with multivariable logistic regression. All summaries and analyses are weighted, and were performed with SAS version 9.4 SURVEY procedures (SAS Institute Inc., Cary, NC). Results: The analysis included 1332 Hispanic women from the AZ clinic and 152 Hispanic women who completed the national survey. The AZ cohort was younger (mean age: 48.5 vs 52.8), had less education (less than high school: 68.7% vs 34.8% less than high school), more likely to prefer Spanish (92.3% vs 53.1%) and less likely to have had a prior mammogram as compared NS cohort (82.8% vs 90.4%) (all p≤ 0.03). NS cohort was more likely to have awareness of BD (32.6% vs 20.7%); correct understanding of the masking effect of BD, (67.8% vs 37.0%,) and breast cancer risk (72.2% vs 32.6%,), compared to the AZ cohort (all p &lt; 0.004). When adjusted for differences in education, age, language, and screening mammography history, BD awareness was similar between the two cohorts (adjusted odds ratio [ORadj] 0.95, p=0.83). Awareness was positively associated with more education, previous mammogram history, and English language. However, differences in BD knowledge remained (ORadj=2.8 [p=0.03] and 7.2 [P&lt;0.001] for knowledge of masking and risk, respectively). Conclusions: There were significant differences in BD awareness and knowledge between a nationally-representative sample of Latinas and Latinas in a low-resource setting. The differences in BD awareness, but not knowledge, could be explained by education, screening history and preferred language. These findings suggest that a one-size-fits-all approach to raising BD awareness and knowledge will not work. To ensure equitable dissemination of health care to Latina women undergoing screening mammography, future work should be aimed at developing effective tools and resources for educating Spanish-speaking women about BD and risk-based screening. Citation Format: Jillian Leaver, Bhavika K. Patel, Jennifer L. Ridgeway, Sarah Jenkins, Vera Suman, Deborah J. Rhodes, Aaron Norman, Karthik Ghosh, Bijan Borah, Carrie Hruska, Edna Ramos, Davinder Singh, Matt Jewett, Carmen Radecki-Breitkof, Celine Vachon. Breast density knowledge and awareness among Latinas in a low-resource setting: A comparison nationally-representative sample of Latinas [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-238.

Objective Increasing adoption of social media have revolutionized communications between individuals, groups, and organizations This research study was designed to assess the knowledge, skills, and attitudes of internal medicine physicians’ awareness and engagement with social media (sometimes referred to as #SoMe) within the digital landscape of healthcare delivery. Methods An audience-response survey focused on social media “ Social media in Healthcare: Physician Survey,” was administered during the “A Systematic Approach to Medically Unexplained Symptoms” continuing medical education conference. The Conference took place between August 22, 2019 and August 24, 2019. Data was collected on August 23, 2019. A range of 103 (59.5%) to 112 (64.7%) of the total 173 attendees participated in this cross-sectional audience-response survey, depending on the questions answered. Results Most responders were between the ages of 35 and 65 years (79.6%) and female (60.2%). A majority of responders were aware of social media terminology (88.7%), and many had used it personally (46.7%), but only 12% knew how to use social media to search medical topics, 18% used it to network professionally and most (68.9%) had a distrust of social media when it came to the protection of their privacy or their patients’ privacy. Overall, about 29.6% indicated an interest in future continued medical education focused on social media (and 27.4% were neutral). Conclusions Approximately half of the responders used social media but far less engaged its platforms for professional use likely due to privacy related concerns. Distance from academic institutions, where professional social media use is more common likely, played a role in aversion. Awareness of social media’s role in healthcare has increased among physicians in practice, however their participation and knowledge of opportunities remains limited.

Abstract Background: Several studies have suggested that vitamin D may have antiproliferative and anticarcinogenic properties and a protective effect against breast cancer. Alaskan Natives have demonstrated high rates of vitamin D deficiency, particularly in young individuals. Hence, high breast density has been associated with increased breast cancer risk. Therefore, we examined the association between serum vitamin D levels and mammographic breast density in a population of Alaskan Native women. Methods: Patients seen in the Mayo Clinic-Alaska Native Medical Center telemedicine program from December 2014 to December 2017 were offered to enroll in the study. Consent was obtained by a study coordinator in Minnesota using a telemedicine platform. Participants were asked to complete the Breast Cancer Risk Questionnaire, which includes questions on hormonal, lifestyle factors and family history. Serum vitamin D levels (25-hydroxyvitamin D2 and D3) were obtained and later correlated with mammographic breast density (percent density). Data were summarized with frequencies and percentages or medians and interquartile ranges (IQR), as appropriate. Pearson correlation was used to estimate the association between breast density and vitamin D levels. Results: 33 women were included; median age was 53 years (IQR 45-58), 70% self-identified as American Indian/Alaskan Native, 12% as White, 6% as Native Hawaiian/Pacific islander and 12% as other. Median BMI was 31 kg/m² (IQR 26.4-34.3), menarche was at age 12 or older for 23 (70%) of the participants and 20 women were postmenopausal at the time enrollment. 10 participants had a hysterectomy, of whom 60% also had oophorectomy. 76% reported history of hormonal birth control use and 23% postmenopausal hormonal supplementation. Median number of pregnancies was 3 (IQR 2-5), and 20 women reported breastfeeding. Fifteen women were current or former smokers (&gt;100 cigarettes) and 19 reported none or low alcohol consumption. Median serum vitamin D level was 39 ng/mL (IQR 30-52) and 9 (27%) women had low vitamin D levels. In regard to breast density, median percentage (average of images) was 15% (IQR 7.5-24.9) with a median dense area of 21.8 cm² (IQR 16.4-34.2). Median time from blood draw to mammogram was 110 days (IQR 41-172) and 19 (58%) participants were taking vitamin D supplementation at the time of study enrollment; doses ranged from 400 to 50,000 units. No correlation was identified between breast density and serum vitamin D levels (correlation=0.02). Conclusion: In this cohort, no association between serum vitamin D levels and breast density was observed. More than half of the participants were on vitamin D supplementation and this could have obscured our observations. Larger studies controlling for vitamin supplementation are needed, as this association could potentially impact breast cancer rates in populations at risk for vitamin D deficiency. Citation Format: Narjust Duma, Ivana Croghan, Sarah Jenkins, Loni Neal, Karthik Ghosh, Sandhya Pruthi. Assessing vitamin D and mammographic breast density in a population of Alaskan Native women [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C088.