Risk-based Imaging Strategies to Improve Breast Cancer Surveillance Outcomes

目前，美国有280万有乳腺癌个人病史的女性（PHBC）面临多年的影像学监测。乳房成像监测的目的是早期发现第二乳腺癌事件，无论是局部复发还是另一侧乳房的新癌症，目的是降低乳腺癌死亡率。原发性乳腺癌的治疗策略通常要考虑到妇女的临床和肿瘤特征。然而，与治疗指南不同的是，目前的监测指南建议所有PHBC妇女每年进行乳房x光检查，无论其风险如何。随着有关肿瘤生物学的新信息和新兴成像技术（数字乳房断层合成和乳房MRI）的出现，我们可以向女性及其医生基于风险的监测决策迈进。尽管新的成像方法显示出筛查的希望，但它们提高早期第二乳腺癌检测和长期预后的能力尚未确定。该项目的总体目标是促进从对所有妇女进行年度乳房x光检查的单一策略转变为个性化的、基于风险的策略，包括所有可用的成像模式和对妇女监测结果风险的可靠估计。我们建议整合女性的危险因素和肿瘤特征，对重要的监测乳房x光检查结果进行风险评估：获益（早期发现第二浸润性乳腺癌）和失败（乳房x光检查阴性后间隔发现第二浸润性乳腺癌）。早期证据表明，女性的危险因素、原发性乳腺癌特征、诊断年龄、检测方式和治疗选择可用于识别乳房x光检查失败的高风险女性，这些女性可能受益于其他监测策略（单独断层合成或乳房x光检查和MRI）。此外，监测失败风险较低的妇女可以通过单独接受乳房x光检查或断层合成来减少误报的风险。我们的科学前提是，与指南推荐的年度乳房x光检查相比，量身定制的策略将通过减少监测失败和误报来改善监测结果。我们的具体目标是：

Project 3 Currently, 2.8 million women in the United States with a personal history of breast cancer (PHBC) face years of imaging surveillance. Breast imaging surveillance is aimed at the early detection of second breast cancer events, either local recurrence or new cancers in the other breast, with the goal of decreasing breast cancer mortality. Treatment strategies for primary breast cancers routinely take into account women's clinical and tumor characteristics. However, unlike treatment guidelines, current surveillance guidelines recommend annual mammography for all women with a PHBC regardless of risk. With new information about tumor biology and emerging imaging technologies (digital breast tomosynthesis and breast MRI), we can move toward risk-based surveillance decision making by women and their physicians. Although new imaging methods show promise for screening, their ability to improve early second breast cancer detection and longer-term outcomes is not yet established. The overall goal of this project is to facilitate a shift from a single strategy of annual mammography for all women to individualized, risk-based strategies, incorporating the full range of available imaging modalities and reliable estimates of a woman's risk of surveillance outcomes. We propose to integrate women's risk factors and tumor characteristics to produce risk estimates for important surveillance mammography outcomes: benefits (early detection of second invasive breast cancer), and failures (interval detection of second breast cancer after negative mammography). Early evidence suggests that women's risk factors, primary breast cancer characteristics, age at diagnosis, mode of detection, and treatment choices can be used to identify women at high risk of surveillance mammography failure who might benefit from alternative surveillance strategies (tomosynthesis alone or mammography and MRI). In addition, women at low risk of surveillance failure could minimize their risk of false alarms by receiving mammography or tomosynthesis alone. Our scientific premise is that tailored strategies will improve surveillance outcomes by reducing both surveillance failures and false alarms compared with guideline-recommended annual mammography alone. Our specific aims are: Aim 1: Determine the benefits and harms of surveillance tomosynthesis compared with digital mammography among women with a PHBC. Aim 2: Develop novel risk prediction models to identify and directly compare a woman's cumulative absolute risk of surveillance mammography outcomes. This project will combine clinical and imaging risk factors to estimate risks of important surveillance benefits, failures, and false alarms, supporting a shift away from a "one size fits all" annual surveillance strategy, toward individualized, risk-based strategies for women with a PHBC.