Journal of the National Cancer Institute Advance Access published online on November 27, 2007
JNCI Journal of the National Cancer Institute, doi:10.1093/jnci/djm223
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© The Author 2007. Published by Oxford University Press.
ARTICLES |
Projecting Individualized Absolute Invasive Breast Cancer Risk in African American Women
Affiliations of authors: Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA (PAM); Women's Health Initiative Clinical Coordinating Center (GLA) and Division of Public Health Sciences (KEM), Fred Hutchinson Cancer Research Center, Seattle, WA; Information Management Services, Rockville, MD (DP); Division of Hematology and Oncology, Karmanos Cancer Institute at Wayne State University, Detroit, MI (MSS); University of Michigan Breast Care Center, University of Michigan, Ann Arbor, MI (LN); Division of Cancer Epidemiology and Genetics (MHG) and Division of Cancer Prevention (WMS), National Cancer Institute, Bethesda, MD; Contraception and Reproductive Branch, Center for Population Research, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (RS); Center for Clinical Epidemiology and Biostatistics and Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA (SAN); Graduate School of Public Health and Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA (JPC); Department of Preventive Medicine, Keck School of Medicine and Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (GU, LB); Department of Epidemiology (MB) and Department of Clinical Effectiveness (MS), The University of Texas M. D. Anderson Cancer Center, Houston, TX
Correspondence to: Mitchell H. Gail, MD, PhD, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Executive Plaza South Rm 8032, Bethesda, MD 20892-7244 (e-mail: gailm{at}mail.nih.gov).
Background: The Breast Cancer Risk Assessment Tool of the National Cancer Institute (NCI) is widely used for counseling and determining eligibility for breast cancer prevention trials, although its validity for projecting risk in African American women is uncertain. We developed a model for projecting absolute risk of invasive breast cancer in African American women and compared its projections with those from the Breast Cancer Risk Assessment Tool.
Methods: Data from 1607 African American women with invasive breast cancer and 1647 African American control subjects in the Women's Contraceptive and Reproductive Experiences (CARE) Study were used to compute relative and attributable risks that were based on age at menarche, number of affected mother or sisters, and number of previous benign biopsy examinations. Absolute risks were obtained by combining this information with data on invasive breast cancer incidence in African American women from the NCI's Surveillance, Epidemiology and End Results Program and with national mortality data. Eligibility screening data from the Study of Tamoxifen and Raloxifene (STAR) trial were used to determine how the new model would affect eligibility, and independent data from the Women's Health Initiative (WHI) were used to assess how well numbers of invasive breast cancers predicted by the new model agreed with observed cancers.
Results: Tables and graphs for estimating relative risks and projecting absolute invasive breast cancer risk with confidence intervals were developed for African American women. Relative risks for family history and number of biopsies and attributable risks estimated from the CARE population were lower than those from the Breast Cancer Risk Assessment Tool, as was the discriminatory accuracy (i.e., concordance). Using eligibility screening data from the STAR trial, we estimated that 30.3% of African American women would have had 5-year invasive breast cancer risks of at least 1.66% by use of the CARE model, compared with only 14.5% by use of the Breast Cancer Risk Assessment Tool. The numbers of cancers predicted by the CARE model agreed well with observed numbers of cancers (i.e., it was well calibrated) in data from the WHI, except that it underestimated risk in African American women with breast biopsy examinations.
Conclusions: The CARE model usually gave higher risk estimates for African American women than the Breast Cancer Risk Assessment Tool and is recommended for counseling African American women regarding their risk of breast cancer.
| CONTEXT AND CAVEATS Prior knowledge The Breast Cancer Risk Assessment Tool of the National Cancer Institute is widely used for counseling and determining eligibility for breast cancer prevention trials, but its validity for projecting risk in African American women is uncertain. Study design Data from the Women's Contraceptive and Reproductive Experiences (CARE) Study were used to develop a model. The model was validated with data from the Women's Health Initiative. Contribution The numbers of cancers predicted for African American women by the CARE model were higher than those predicted by the Breast Cancer Risk Assessment Tool and agreed well with the numbers of cancers observed among African American women in the Women's Health Initiative. Implications The CARE model is recommended for counseling African American women about their risk of breast cancer. Limitations The CARE model, like the Breast Cancer Risk Assessment Tool, should be used with caution or avoided for certain special populations, including African American women with a history of breast cancer or with mutations associated with an increased risk of breast cancer.
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Manuscript received February 2, 2007; revised September 20, 2007; accepted October 8, 2007.
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