Abstract PD2-13: Benefits to breast screening beyond mortality reduction

Background

The value of population-based mammographic screening has been questioned by those who believe that the reduction in mortality from earlier diagnosis is outweighed by harms including overdiagnosis and overtreatment. Much of these commentaries assume that all Early-Stage Breast Cancer (ESBC) is treated the same way after diagnosis; with extensive therapies including surgery, radiotherapy and chemotherapy being standard.

Intensity of treatment received is rarely mentioned in the debate. We hypothesised that those diagnosed through a screening program (Active Screeners (AS)) would receive less extensive surgical treatment and less intense adjuvant therapies than those not recently screened (NRS). If demonstrated, these differences would form an important component of the debate over the role of mammographic screening.

Methods

Retrospective analysis of a consecutive cohort of female patients aged 50-69 and managed for ESBC (invasive or DCIS) during 2007-2013 within a large metropolitan Breast Service, diagnosed either via a population screening program (AS) or outside of the program (NRS). Data on patient characteristics, symptoms, mode of detection, tumour pathology, surgical intervention and adjuvant treatment recommendations were derived from prospectively collected Multi-Disciplinary Meeting (MDM) records. Patients with metastatic disease or prior treatment for breast cancer were excluded.

Results

791 cases were identified (569 with screen-detected cancer, 53 with interval cancers and 169 cancers diagnosed in women not recently screened). Invasive cancers in the AS group were much smaller than in the NRS group – mean 17mm versus 26mm. The AS group had lower grade invasive cancer – grade 1, 2 and 3 were 27%, 42%, 31% - compared with 10%, 39% and 52% in the NRS group. The AS group were more likely to have ER+ve cancers (88% vs 80%) and less likely to have nodal involvement (26% vs 48%). For invasive breast cancer, the NRS group were more than twice as likely to undergo mastectomy than cancers in the AS group (35% vs 16%). Axillary dissections were more common in the NRS than the AS group (43% vs 19%). Adjuvant chemotherapy was recommended more frequently for the NRS group compared to the AS group (65% vs 37%), as was post mastectomy radiotherapy (58% vs 39%). Endocrine therapy was less often recommended to the NRS group (86% versus 77%).

Conclusion

Women diagnosed with early stage breast cancer who are participating in a population based screening program are less likely to receive mastectomy and/or axillary dissection, less likely to receive adjuvant chemotherapy and less likely to receive post-mastectomy radiotherapy. These differences in treatment intensity should be considered in the debate surrounding mammographic screening.

Citation Format: Elder KJ, Nickson C, Cooke S, Machalek D, Rose A, Mou A, Collins JP, Park A, De Boer R, Phillips C, Pridmore V, Farrugia H, Mann GB. Benefits to breast screening beyond mortality reduction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-13.

In vitro assessment of the gastrointestinal tolerance and immunomodulatory function of Bacillus methylotrophicus isolated from a traditional Korean fermented soybean food

AIMS

This study aimed to investigate the potential of Bacillus methylotrophicus as a probiotic.

METHODS AND RESULTS

A Bacillus isolate designated strain C14 was isolated from Korean traditional fermented soybean paste (doenjang). The strain was identified, and its physiological and biochemical properties were characterized. The gastrointestinal tolerance and immunomodulatory function of strain C14 were also investigated. Strain C14 was identified as B. methylotrophicus by analysis of its biochemical properties using the API 50CHB system and by phylogenetic analysis of the 16S rDNA sequence. Strain C14 showed >80% and >75% of survival for artificial gastric juices (pH 2.5 and 1% pepsin) and 0.5% (w/v) bile salt, respectively. Heat-killed B. methylotrophicus C14 inhibited the adhesion of various pathogens and enhanced the adhesion of probiotic bacteria to Caco-2 cells. The heat-killed cells also induced high levels of immune cell proliferation compared with the control and stimulated interleukin-6 and tumour necrosis factor-α production in mouse macrophages.

CONCLUSIONS

Bacillus methylotrophicus C14 could be used as a probiotic.

SIGNIFICANCE AND IMPACT OF THE STUDY

Recently identified B. methylotrophicus is a new potential probiotic with high gastrointestinal tolerance.

Cognitive function and fatigue after diagnosis of colorectal cancer

BACKGROUND

Cognitive impairment and fatigue have been associated with cancer and its treatment. We present baseline data from a large longitudinal study that evaluates cognitive function, fatigue, and potential underlying mechanisms following diagnosis of colorectal cancer (CRC).

PATIENTS AND METHODS

We evaluated CRC patients with stage I-III disease before or after surgery, participants with limited metastatic disease and healthy controls (HC). Neuropsychological evaluation included clinical and computerised tests. Participants completed questionnaires for fatigue and quality of life (QOL)-(FACT-F), anxiety/depression, and cognitive symptoms (FACT-Cog). Ten cytokines, clotting factors, sex hormones, carcinoembryonic antigen (CEA), and apolipoprotein E genotype were evaluated. Primary end points were cognitive function on clinical tests evaluated by a Global Deficit score (GDS) and fatigue. Associations between test results, demographic, and disease related factors were explored.

RESULTS

We assessed 291 participants with early-stage disease [median age 59 (23-75) years, 63% men], 72 with metastatic disease, and 72 HC. Using GDS, 45% (126/281) of participants with early-stage CRC had cognitive impairment versus 15% (11/72) of HC (odds ratio 4.51, 95% confidence interval 2.28-8.93; P < 0.001), with complex processing speed, attention/working memory, and verbal learning efficiency being most affected. Women with early-stage CRC had greater cognitive impairment than men [55/105 (52%) versus 71/176 (40%), P < 0.050]. Cognitive symptoms were self-reported by 21% (59/286) of early-stage patients versus 17% (12/72) of HC; fatigue by 52% (149/287) of early-stage patients and 26% (19/72) of HC (P < 0.0001). Women reported more fatigue than men (P = 0.003). Fatigue, QOL, anxiety/depression, and cognitive symptoms were associated with each other (r = 0.43-0.71), but not with neuropsychological performance. Most cytokines were elevated in cancer patients. Cognitive function was not associated with cytokines, sex hormones, clotting factors, CEA, or apolipoprotein E genotype.

CONCLUSIONS

The incidence of cognitive impairment was three to five times higher in CRC patients than HC, with women having higher impairment rates than men. The cognitive impairment profile suggests dysfunction primarily in fronto-subcortical brain systems.

TRIAL REGISTRATION

NCT00188331.

Personal health records for patients with chronic disease: a major opportunity

BACKGROUND

Personal health records (PHRs) connected to a physician's electronic health record system hold substantial promise for supporting and engaging patients with chronic disease.

OBJECTIVES

To explore how U.S. health care organizations are currently utilizing PHRs for chronic disease populations.

METHODS

A mixed methods study including semi-structured interviews and a questionnaire was conducted. A purposive sample was developed of health care organizations which were recognized as exemplars for PHRs and were high performers in national patient satisfaction surveys (H-CAHPS or CAHPS). Within each organization, participants were health IT leaders or those managing high-risk or chronic disease populations.

RESULTS

Interviews were conducted with 30 informants and completed questionnaires were received from 16 organizations (84% response rate). Most PHRs allowed patients to access health records and educational material, message their provider, renew prescriptions and request appointments. Patient generated data was increasingly being sought and combined with messaging, resulted in greater understanding of patient health and functioning outside of the clinic visit. However for chronic disease populations, there was little targeted involvement in PHR design and few tools to help interpret and manage their conditions beyond those offered for all. The PHR was largely uncoupled from high risk population management interventions and no clear framework for future PHR development emerged.

CONCLUSION

This technology is currently underutilized and represents a major opportunity given the potential benefits of patient engagement and shared decision making. A coherent patient-centric PHR design and evaluation strategy is required to realize its potential and maximize this natural hub for multidisciplinary care co-ordination.

Ligating perforators in abdominoplasty reduces the risk of seroma

BACKGROUND

Seroma formation, a common complication of abdominoplasty, can cause patient discomfort and inconvenience. This study aimed to compare seroma rates after ligation and diathermy of large abdominal perforating vessels during abdominoplasty.

METHODS

Consecutive patients undergoing abdominoplasty with epigastric undermining between 2004 and 2011 were studied. Body mass index (BMI), age at operation, smoking history, preoperative weight loss, operative details, perioperative fluid infiltration, concomitant abdominal liposuction, ligation of perforators by clips, suture or diathermy, use of quilting sutures, weight of tissue removed, postoperative drainage, inpatient stay, and seroma rates were recorded. Statistical analysis was undertaken using the unpaired t test, Fisher's exact test, the Mann-Whitney U test, and Kendall's tau-b test.

RESULTS

The study included 90 patients. The incidence of seroma was significantly lower among the patients who had perforators ligated (4/60, 6.7%) than among those who had diathermy (10/30, 33%) (p=0.002, Fisher's exact test). Seroma formation was significantly associated with a higher BMI, (27.45 vs. 25.16 kg/m2; p=0.025, t test) but not with preoperative weight loss. Postoperative fluid drainage did not differ significantly between ligated and diathermied perforators (p=0.716 Mann-Whitney U test).

CONCLUSIONS

Use of ligation by clip or suture rather than by diathermy to ablate large abdominal perforators significantly reduced the incidence of seroma among abdominoplasty patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abstract P3-08-04: Survivorship care involving a nurse-led survivorship consultation, community support and shared care with primary practitioners

Background

Survivorship care (SC) has gained prominence as the number of patients disease free after breast cancer treatment increases, the specific needs of those patients become recognised, and funding to meet these demands is constrained. Involvement of Primary Care Practitioners in SC is seen as a solution, but models of Shared Care have met varying degrees of success. We report on a model that involves Specialist centres, Primary Care Practitioners and organisations, and a community based patient support organisation.

Patients and Methods

A consortium comprising two hospital based breast services – the Royal Melbourne/Royal Women's and Western Hospitals – a regional consortium of Primary Care Physicians, and BreaCan, a non-government peer support organisation for women diagnosed with breast cancer, collaborated to obtain and implement a government-supported Survivorship Care Program. Patients completing definitive treatment for early breast cancer were invited to a Nurse-led consultation where the disease, its pathology, treatment and follow-up were reviewed. Psychosocial and other issues were explored and a personalised SC plan was devised and agreed upon. This plan included Shared Care with the Primary Care Practitioner in the majority of cases. Unmet needs were identified and addressed. The SC plan was signed off by a senior breast cancer clinician and forwarded to the primary care physician for ratification. Evaluation included satisfaction surveys and interviews with patients and primary care physicians. Intensity of use of hospital based services was calculated and compared to a previous cohort of early breast cancer patients.

Results

282 patients completing definitive treatment were offered Nurse-led survivorship consultation. 29 declined, and 28 cancelled. At 31 May 2013, 148 care plans were completed, 38 were in preparation and 39 appointments were booked. Response to this initiative from hospital based specialists was positive. All believed that this program would reduce the amount of routine consultations and increase capacity for new or returning patients requiring specialist care. Primary care doctors overwhelmingly believed the survivorship care plan contained information needed to allow them to manage breast cancer survivors, and gave them confidence to take on this role, although there was some uncertainty regarding role delineation between Primary Care and hospital. Patient evaluation of the Nurse-led clinics was strongly positive. All reported finding out something during the consultation, and 94% said they considered the hospital and GP to be partners in their on-going follow-up care. Modelling suggests that about 5 fewer hospital appointments will be required for each patient managed under this program compared to routine hospital-based care.

Conclusions

Hospital based specialists embrace Survivorship care including shared care and patients expect it, while Primary physicians will participate if offered education, support and specific direction. A model including an end-of –treatment consultation and Shared care with Primary Practitioners appears to address many of the requirements for a successful Survivorship program.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-04.