Mammographic Breast Density as a Predictive Tool in Average-risk Women aged 40 to 59: a systematic review

Background: In 1976 Dr. John Wolfe introduced the relationship between breast tissue composition and breast cancer risk. Breast tissue composition is one of several well-established risk factors for breast cancer, but is not currently incorporated into commonly used risk prediction models or routinely used in clinical practice to recommend for or against routine screening. Knowledge of risk factors and their predictive abilities is important for creating appropriate screening strategies. It would be of value if breast tissue composition, alone or in combination with other risk factors, would allow for creating personalized screening plans for every woman based on her individual risk as screening can be harmful and costly. Objective: To assess whether the American College of Radiology (ACR) Breast Imaging-Reporting and Data System (BI-RADS) breast tissue composition categorization has a sufficient degree of incremental value beyond age to predict incidence and/or breast cancer-related mortality in average-risk women aged 40 to 59. Evaluation is based on the following criteria: magnitude of risk estimates, discriminatory ability, net reclassification index, clinical utility and cost-effectiveness. Search methods: I searched PubMed and EMBASE from January 1, 2003 to April 19, 2014. Radiologist assessment of breast tissue composition using mammography was the intervention of interest. I focused on outcomes assessed in the short-term, within 10 years of intervention. I excluded lifetime estimates. Exclusion criteria for the population included risk factors, such as personal history of breast cancer and BRCA 1 or BRCA 2 mutation carrier status. Main results: Eleven studies met the inclusion criteria. While exposure and outcome measurement were relatively consistent across studies, there was heterogeneity in study design, population age range, follow-up duration and outcomes assessed. Despite this, it is clear that there is a dose-response relationship between breast tissue composition and risk of in situ and invasive breast cancer. Across all of the studies, effect sizes were moderate. There was not a meaningful relationship with short-term mortality, though few studies in this review evaluated this outcome. The risk factor's ability to discriminate, separate cases from non-cases, was close to chance and not clinically proven to be superior to existing Breast Cancer Risk Assessment Tool (Gail Model). There were no studies that calculated the Net Reclassification Index (NRI), or evaluated clinical utility or cost-effectiveness. Limitations of the evidence: The BI-RADS lexicon used to describe breast tissue composition is subjective; creating measurement bias that can lead to inaccurate risk estimates. Outcome data (incidence and vital status) were obtained from population-based registries. Equal, valid and reliable measurement of the outcome rests on the completeness, validity and reporting timeliness of utilized databases. This information was variably reported and not easily obtainable. Lastly, breast density is not stable over time. Crossovers, movement from one category to another, can diminish risk estimates. Conclusion: Based on the available evidence, breast tissue composition, as currently assessed in routine clinical practice, does not fulfill the criteria to be valuable as a predictive tool. Authors of breast density notification laws should clarify intentions, critically examine the evidence and evaluate outcomes. Given subjectivity, focus could be shifted to objective measurements and other enterprising technologies, such as breast magnetic resonance imaging or 3D digital breast tomosynthesis.Master of Public Healt

RACIAL AND SOCIOECONOMIC DIFFERENCES IN ORGAN DONATION AND ACCESS TO SOLID ORGAN TRANSPLANTATION

Solid organ transplantation, a curative healthcare intervention for patients with end-stage disease of the liver or kidney, precipitates fervent discourse around supply, from who are deceased donor organs recovered, and demand, to who receives scarce deceased donor organs. Social justice principles are inherent to this discourse, and it is the vocation of public health research to monitor health inequalities, which are unjust differences in health according to social hierarchies. Using population-level registry, mortality, and census-based data, this dissertation examines racial and socioeconomic differences in organ donation and access to the transplant waiting list. First, we use Centers for Disease Control and Prevention mortality data to examine racial differences in organ donation over time in the United States (Chapter 2). We found that differences in deceased organ donation between the White population and some racial minority populations have attenuated over time, and that the greatest gains in donation were observed among the Black population. Second, we use national, transplant registry data linked to American Community Survey data to examine the relationship between multidimensional socioeconomic status, race, and biologic relationship to the recipient (Chapter 3). We found that that socioeconomic status uniquely varies according to race and biologic relationship to the recipient among the Black population, with Black, related donors having lower socioeconomic status than Black, unrelated donors, and the lowest socioeconomic status of all race and relationship combinations in the living kidney donor population. Third, we examine the influence of expanding Medicaid, a social protection policy that was intended to improve healthcare access for low-income and racial minority populations, on waitlisting for kidney transplant (Chapter 4). We found that while Medicaid expansion was associated with increases in kidney transplant waitlist registrations, increases varied across sociodemographic groups. Finally, in a perspective, we reflect on learning to study “race” during our doctoral studies (Chapter 5). We advocate for the routine application of social epidemiologic theory to racial disparities research, increased use of analytic approaches that move beyond describing racial differences as we have, and peer review by surgeon scientists who have social epidemiologic expertise and training. This dissertation demonstrates findings and limitations of big data in organ transplantation research that uses national, transplant registry and public health data sources to examine health inequalities. Our hope is that this dissertation will be used by the transplant community to pause, re-direct resources, collect better data, and conduct population health research that can be used to address health inequalities along social hierarchies in solid organ transplantation

Endovascular repair of tortuous recurrent femoral-popliteal aneurysm in a patient with Loeys-Dietz syndrome

Loeys-Dietz syndrome is a rare connective tissue disorder with widespread arterial tortuosity and aneurysms. This syndrome is most notable for its aortic disease, including aortic root dilation and aortic dissection or rupture. Although not as well studied, peripheral artery aneurysms are a prevalent concurrent manifestation and have previously been repaired with both open and endovascular approaches. There are minimal data about the durability and technical considerations of endovascular repair in this disease. We report a case of a patient who developed an extremely tortuous recurrent femoral-popliteal artery aneurysm secondary to aneurysmal degeneration around previously placed stents that was treated with an endovascular approach

Early national and center-level changes to kidney transplantation in the United States during the COVID-19 epidemic.

In March 2020, coronavirus disease 2019 (COVID-19) spread rapidly nationally, causing widespread emergent changes to the health system. Our goal was to understand the impact of the epidemic on kidney transplantation (KT), at both the national and center levels, accounting statistically for waitlist composition. Using Scientific Registry of Transplant Recipients data, we compared data on observed waitlist registrations, waitlist mortality, and living-donor and deceased-donor kidney transplants (LDKT/DDKT) March 15-April 30, 2020 to expected events calculated from preepidemic data January 2016-February 2020. There were few changes before March 15, at which point the number of new listings/DDKT/LDKT dropped to 18%/24%/87% below the expected value (all P < .001). Only 12 centers performed LDKT March 15-31; by April 30, 40 centers had resumed LDKT. The decline in new listings and DDKT was greater among states with higher per capita confirmed COVID-19 cases. The number of waitlist deaths was 2.2-fold higher than expected in the 5 states with highest COVID-19 burden (P < .001). DCD DDKT and regional/national imports declined nationwide but most steeply in states with the highest COVID-19 burden. The COVID-19 epidemic has resulted in substantial changes to KT; we must adapt and learn rapidly to continue to provide safe access to transplantation and limit the growing indirect toll of an already deadly disease

Early national and center-level changes to kidney transplantation in the United States during the COVID-19 epidemic.

In March 2020, coronavirus disease 2019 (COVID-19) spread rapidly nationally, causing widespread emergent changes to the health system. Our goal was to understand the impact of the epidemic on kidney transplantation (KT), at both the national and center levels, accounting statistically for waitlist composition. Using Scientific Registry of Transplant Recipients data, we compared data on observed waitlist registrations, waitlist mortality, and living-donor and deceased-donor kidney transplants (LDKT/DDKT) March 15-April 30, 2020 to expected events calculated from preepidemic data January 2016-February 2020. There were few changes before March 15, at which point the number of new listings/DDKT/LDKT dropped to 18%/24%/87% below the expected value (all P < .001). Only 12 centers performed LDKT March 15-31; by April 30, 40 centers had resumed LDKT. The decline in new listings and DDKT was greater among states with higher per capita confirmed COVID-19 cases. The number of waitlist deaths was 2.2-fold higher than expected in the 5 states with highest COVID-19 burden (P < .001). DCD DDKT and regional/national imports declined nationwide but most steeply in states with the highest COVID-19 burden. The COVID-19 epidemic has resulted in substantial changes to KT; we must adapt and learn rapidly to continue to provide safe access to transplantation and limit the growing indirect toll of an already deadly disease