High HIV incidence in the postpartum period sustains vertical transmission in settings with generalized epidemics: a cohort study in Southern Mozambique

INTRODUCTION

Acute infection with HIV in the postpartum period results in a high risk of vertical transmission through breastfeeding. A study was done to determine the HIV incidence rate and associated risk factors among postpartum women in Southern Mozambique, where HIV prevalence among pregnant women is 21%.

METHODS

A prospective cohort study was conducted in six rural health facilities in Gaza and Maputo provinces from March 2008 to July 2011. A total of 1221 women who were HIV-negative on testing at delivery or within two months postpartum were recruited and followed until 18 months postpartum. HIV testing, collection of dried blood spot samples and administration of a structured questionnaire to women were performed every three months. Infant testing by DNA-PCR was done as soon as possible after identification of a new infection in women. HIV incidence was estimated, and potential risk factors at baseline were compared using Poisson regression.

RESULTS

Data from 957 women were analyzed with follow-up after the enrolment visit, with a median follow-up of 18.2 months. The HIV incidence in postpartum women is estimated at 3.20/100 women-years (95% CI: 2.30-4.46), with the highest rate among 18- to 19-year-olds (4.92 per 100 women-years; 95% CI: 2.65-9.15). Of the new infections, 14 (34%) were identified during the first six months postpartum, 11 (27%) between 6 and 12 months and 16 (39%) between 12 and 18 months postpartum. Risk factors for incident HIV infection include young age, low number of children, higher education level of the woman's partner and having had sex with someone other than one's partner. The vertical transmission was 21% (95% CI: 5-36) among newly infected women.

CONCLUSIONS

Incidence of HIV is high among breastfeeding women in Southern Mozambique, contributing to increasing numbers of HIV-infected infants. Comprehensive primary prevention strategies targeting women of reproductive age, particularly pregnant and postpartum women and their partners, will be crucial for the elimination of paediatric AIDS in Africa.

Abstract PD5-6: Sustained hyperactivated mTOR & JAK2/STAT3 pathways in inflammatory breast cancer (IBC): Evidence for mTOR plus JAK2 therapeutic targeting

Background: IBC is an aggressive form of breast cancer with poor prognosis. Combined multi-modality therapy results in a 5 year OS of 30%, underscoring the unmet need for targeted therapy. Our preclinical research in cell lines & xenograft tumor models has identified a role for hyper-activated PI3K/mTOR signaling in IBC. IBC cells express IL-6 and IL-8, which recruit tumor activated macrophages (TAMs) that further induce inflammatory cytokines and activate the JAK2/STAT3 pathway. We investigated the independent and combined activity of these pathways in IBC patient tissues.

Methods: Archived tissue specimens of 42 IBC patients (dx 1999-2009) and 27 non-IBC patients (dx 2001-2005) with invasive ductal carcinoma (IDC) were obtained. Surrounding non-tumor normal tissue from IBC (companion controls) was also utilized. All specimens were analyzed using immunohistochemistry (IHC) and scored by 3 independent pathologists. Results were defined as 0 = negative; 1+,2+ = positive for activated mTOR (P-S6); activated JAK2/STAT3 (P-JAK2; P-STAT3); cytokine (IL-6); macrophage infiltration (CD68) and TAM (CD163). Proportions of IBC cases with positive expression were compared with non-IBC cases (Fisher's exact test) & companion controls (McNemar's test). Clinical & survival data were obtained.

Results: Median age at diagnosis: 46 yrs (31-62) in early stage IBC [EIBC] (n = 37) & 41 yrs (29-57) in pts with de novo metastatic IBC [MIBC] (n = 5). In EIBC, 19/36: HER2+ (1 unk); 8/19: ER+/HER2+; 8/36: ER-/HER2-. In MIBC, all were ER- (1 unk) & 3/4 were HER2+ (1 unk). 88% were rx with neoadjuvant &/or adjuvant anthracycline & taxane w/o adjuvant trastuzumab. There were 24 pt deaths (5/5 MIBC). Median f/u for EIBC: 6.3 yrs and for MIBC: 3.4 yrs. Median OS: 81.4 mo (95% CI lower 48 mo) for EIBC & 41 mo (95% CI 8-81 mo) for MIBC. Median RFS: 18 mo (95% CI 18-79 mo) for 23 pts (13 NED; 1 unk). The non-IBC patients were all stage 2-3 with median age at diagnosis: 58 yrs (39-94). 19/27: ER+; 7/25 HER2+ (2 unk); 15/25 ER+/HER2-; 3/25 ER-/HER2-. 78% were rx with adjuvant anthracycline & taxane, 4% were rx with FEC and 18% did not receive adjuvant chemotherapy. 18% received adjuvant trastuzumab. Median f/u: 8.0 yrs. Median OS: not yet reached and median RFS: 111.3 mo (95% CI lower 34.5 mo). EIBC cases were compared with non-IBC cases & companion controls (Table 1). PS6, pJAK2 and pSTAT3 expression was significantly increased in IBC compared to non-IBC. Of the 29 EIBC patients with complete biomarker data who were PS6+, 28/29 (97%) were JAK2+, 15/29 (52%) were STAT3+, 26/29 (90%) were CD68+, 20/29 (69%) were CD163+ and 28/29 (97%) were IL6+.

Conclusion: This is the first study to validate preclinical findings & show a strong co-association between hyper-activation of mTOR & JAK/STAT pathways in most IBC patient tumors when compared to surrounding non-tumor tissue and non-IBC (IDC) tumors and tissues. These findings suggest a key role for dual blockade of mTOR & JAK/STAT pathways for IBC in phase I trials.

BiomarkerMcNemars p-value: Early Stage IBC vs companion controls (N = 37)Fishers p-value: Early stage IBC (N = 37)vs non-IBC (N = 27)PS6<0.00010.0315pJAK2<0.0001<0.0001pSTAT30.0003<0.0001CD163<0.00010.0908CD68<0.00010.0582IL60.00030.3882

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD5-6.

Predictors of sustained reduction in energy and fat intake in the Diabetes Prevention Program Outcomes Study intensive lifestyle intervention

BACKGROUND

Few lifestyle intervention studies examine long-term sustainability of dietary changes.

OBJECTIVE

To describe sustainability of dietary changes over 9 years in the Diabetes Prevention Program and its outcomes study, the Diabetes Prevention Program Outcomes Study, among participants receiving the intensive lifestyle intervention.

DESIGN

One thousand seventy-nine participants were enrolled in the intensive lifestyle intervention arm of the Diabetes Prevention Program; 910 continued participation in the Diabetes Prevention Program Outcomes Study. Fat and energy intake derived from food frequency questionnaires at baseline and post-randomization Years 1 and 9 were examined. Parsimonious models determined whether baseline characteristics and intensive lifestyle intervention session participation predicted sustainability.

RESULTS

Self-reported energy intake was reduced from a median of 1,876 kcal/day (interquartile range [IQR]=1,452 to 2,549 kcal/day) at baseline to 1,520 kcal/day (IQR=1,192 to 1,986 kcal/day) at Year 1, and 1,560 kcal/day (IQR=1,223 to 2,026 kcal/day) at Year 9. Dietary fat was reduced from a median of 70.4 g (IQR=49.3 to 102.5 g) to 45 g (IQR=32.2 to 63.8 g) at Year 1 and increased to 61.0 g (IQR=44.6 to 82.7 g) at Year 9. Percent energy from fat was reduced from a median of 34.4% (IQR=29.6% to 38.5%) to 27.1% (IQR=23.1% to 31.5%) at Year 1 but increased to 35.3% (IQR=29.7% to 40.2%) at Year 9. Lower baseline energy intake and Year 1 dietary reduction predicted lower energy and fat gram intake at Year 9. Higher leisure physical activity predicted lower fat gram intake but not energy intake.

CONCLUSIONS

Intensive lifestyle intervention can result in reductions in total energy intake for up to 9 years. Initial success in achieving reductions in fat and energy intake and success in attaining activity goals appear to predict long-term success at maintaining changes.

Hispanic Overweight and Obese Children

Through Value Enhanced Nutrition Assessment and other techniques, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) engages clients to set their own nutrition goals. A case series of 30 Hispanic children (2-4.5 years) at ≥85th body mass index (BMI) percentile and their caregivers were followed through an urban WIC clinic. The dyads received either standard counseling ( n = 15) or motivational interviewing (MI; n = 15) by one bilingual WIC nutritionist during 4 regularly scheduled visits over 6 months. Repeated measurements of anthropometric data, dietary patterns, and physical activity were obtained at each visit. Longitudinal bivariate analyses of caregiver concerns and goal selection were conducted along with mean comparisons of anthropometric and food frequency measures. Participation in counseling sessions as rated by the nutritionist was assessed by comparing Wilcoxon rank-sum scores. After counseling, children lost an adjusted mean weight of 0.878 kg (95% confidence interval = 0.280-1.717). A decline in median BMI of more than 3 percentiles ( P = .042) was observed with both counseling approaches. Caregiver-reported vegetable intake of children increased an average of one additional serving in the MI-counseled group by visit 3 ( P = .013) despite MI recipient caregivers being scored as significantly more distracted than standard WIC participants in the first visit ( P = .036). MI is a viable option for WIC counseling to improve diet and health outcomes in participants, particularly in addressing child BMI status and vegetable intake. Public health professionals should examine scalability of the MI approach among larger samples of WIC participants and other innovative techniques to improve client focus during counseling.

Hyperactivated mTOR and JAK2/STAT3 pathways: Crucial molecular drivers and potential therapeutic targets of inflammatory breast cancer (IBC)

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Background: IBC is an aggressive form of breast cancer with poor prognosis. Combined multi-modality Rx results in a 5 year OS of 30-50%, underscoring the unmet need for targeted Rx. Our preclinical research in cell lines and xenografts identifies a role for activated PI3K/mTOR pathway in IBC. IBC cells express IL-6 and IL-8 and recruit tumor activated macrophages (TAMs) that further induce IL-6, IL-8 and activate the JAK2/STAT3 pathway. We investigated the independent and combined activity of these pathways in IBC tissues. Methods: Archived tissues of 42 IBC pts and 13 controls (nl breast) were analyzed using IHC and scored by 3 independent pathologists. Results defined as: 0, 1+ = neg; 2+ = pos for activated mTOR (P-S6) and 0 = neg; 1+, 2+ = pos for activated nuclear JAK2/STAT3 (P-JAK2; P-STAT3), cytokine (IL-6), macrophage (mØ) infiltration (CD68) and TAM (CD163). Proportions of IBC cases with pos expression were compared with controls (Fishers exact tests). Clinical and survival data were obtained. Results: Median age at diagnosis: 46 yrs (31-62) in early-stage IBC [EIBC] (n=37) and 41 yrs (29-57) in pts with de novo metastatic IBC [MIBC] (n=5). In EIBC, 19/36: HER2+ (1 unk); 8/19: ER+/HER2+; 8/36: ER-/HER2-. In MIBC, all were ER- (1 unk) and 3/4 were HER2+ (1 unk). 88% Rx with neoadjuvant and/or adjuvant anthracycline and taxane w/o adjuvant trastuzumab. 24 pts died (5/5 MIBC). Median OS: 86 mo (95% CI lower 48 mo) for EIBC & 41 mo (95% CI 8-81 mo) for MIBC. Median RFS: 18 mo (95% CI 18-79 mo) for 23 pts (13 NED; 1 unk). All controls: neg for P-S6, JAK2, STAT3 and TAMs and 92% neg for mØ and IL-6. Proportion of IBC with pos expression when compared to controls listed in table (p <0.0001). Of 31 pts with complete biomarker data who were PS6+, 97% had activated JAK2, 58% had activated STAT3, 80% had strong mØ and TAM infiltration and 97% were IL6+. Conclusions: This is the first study that validates preclinical findings and shows a strong association between mTOR, cytokines, TAMs and JAK/STAT pathways in most IBC pt tissues. Findings suggest a key role for dual blockade of mTOR and JAK/STAT pathways in phase I trials. [Table: see text]

Hyperactivated mTOR and JAK2/STAT3 pathways: Crucial molecular drivers and potential therapeutic targets of inflammatory breast cancer (IBC)

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Background: IBC is an aggressive form of breast cancer with poor prognosis. Combined multimodality Rx results in 5 year median OS of 30-50%, underscoring the unmet need for novel targeted strategies. Our preclinical research in cell lines and xenografts suggests a role for activated PI3K/AKT/mTOR pathway in IBC. IBC cells not only express high levels of IL-6 and IL-8 but can recruit tumor activated macrophages (TAMs), which can further induce IL-6, IL-8 and activate JAK2/STAT3 pathway. We therefore investigated independent and combined activity of these pathways. Methods: Archived tissue specimens of 42 IBC pts (1999 - 2009) and 13 controls (normal breast) were analyzed using IHC and scored by 3 independent pathologists. Results were defined as: 0, 1+ = neg; 2+ = pos for activated mTOR (phosphorylatedS6) and 0 = neg; 1+, 2+ = pos for activated nuclear JAK2/STAT3 (pJAK2; pSTAT3), cytokine (IL-6), macrophage infiltration (CD68) and TAMs (CD163). Proportion of IBC cases with pos expression were compared to proportion among controls (Fishers exact test). Clinical and survival data were obtained. Results: Median age at diagnosis - 44.5 yrs (29-64). 22 had HER2 overexpression (8 also ER+) and 9 were ER-/HER2-; ER & HER2 unknown for 1 and 2 pts respectively. Majority were Rxed with neoadjuvant anthracycline and/taxane without adjuvant trastuzumab. There were 24 deaths. Median OS: 67 mths (95% CI: lower 41). Proportions of IBC cases with pos expression when compared to controls are listed in the table (Fishers p value: <0.0001). Of the 31 pts with complete biomarker data who were PS6 pos, 97% had activated JAK2 & 58% had activated STAT3 (McNemar’s chi square, p <0.001). 24/31 (80%) showed strong infiltration of macrophages and TAMs. All cases had widespread IL6 staining. Conclusions: This study validates our preclinical findings and shows hyperactivation of mTOR and JAK2 signaling in vast majority of IBC specimens, with close association between mTOR, TAMs, cytokines and JAK2/STAT3 pathways. These findings support a role for dual blockade of mTOR and JAK/STAT pathways in clinical trials. [Table: see text]

Analyses of radiation and mesothelioma in the US Transuranium and Uranium Registries

OBJECTIVES

We examined the relationship between radiation and excess deaths from mesothelioma among deceased nuclear workers who were part of the US Transuranium and Uranium Registries.

METHODS

We performed univariate analysis with SAS Version 9.1 software. We conducted proportionate mortality ratio (PMR) and proportionate cancer mortality ratio (PCMR) analyses using the National Institute for Occupational Safety and Health Life Table Analysis System with the referent group being all deaths in the United States.

RESULTS

We found a PMR of 62.40 (P < .05) and a PCMR of 46.92 (P < .05) for mesothelioma. PMRs for the 4 cumulative external radiation dose quartiles were 61.83, 57.43, 74.46, and 83.31. PCMRs were 36.16, 47.07, 51.35, and 67.73. The PMR and PCMR for trachea, bronchus, and lung cancer were not significantly elevated.

CONCLUSIONS

The relationship between cumulative external radiation dose and the PMR and PCMR for mesothelioma suggests that external radiation at nuclear facilities is associated with an increased risk of mesothelioma. The lack of a significantly elevated PMR and PCMR for trachea, bronchus, and lung cancer suggests that asbestos did not confound this relationship.

Progress realized: trends in HIV-1 viral load and CD4 cell count in a tertiary-care center from 1999 through 2011

BACKGROUND

HIV-1 RNA and CD4 cell counts are important parameters for HIV care. The objective of this study was to assess the overall trends in HIV-1 viral load and CD4 cell counts within our clinic.

METHODS

Patients with at least one of each test performed by the Infectious Diseases Laboratory from 1999 through 2011 were included in this analysis. By adapting a novel statistical model, log(10) HIV-1 RNA means were estimated by month, and log(10)-transformed HIV-1 RNA means were estimated by calendar year. Geometric means were calculated for CD4 cell counts by month and calendar year. Log(10) HIV-1 RNA and CD4 cell count monthly means were also examined with polynomial regression.

RESULTS

There were 1,814 individuals with approximately 25,000 paired tests over the 13-year observation period. Based on each patient's final value of the year, the percentage of patients with viral loads below the lower limit of quantitation rose from 29% in 1999 to 72% in 2011, while the percentage with CD4 counts <200 cells/µL fell from 31% to 11%. On average annually, the mean HIV-1 RNA decreased by 86 copies/mL and the mean CD4 counts increased by 16 cells/µL. For the monthly means, the correlations (R(2)) from second-order polynomial regressions were 0.944 for log(10) HIV-1 RNA and 0.840 for CD4 cell counts.

CONCLUSIONS

Marked improvements in HIV-1 RNA suppression and CD4 cell counts were achieved in a large inner-city population from 1999 through 2011. This success demonstrates that sustained viral control with improved immunologic status can be a realistic goal for most individuals in clinical care.

Is frequent CD4+ T-lymphocyte count monitoring necessary for persons with counts >=300 cells/μL and HIV-1 suppression?

Among patients infected with human immunodeficiency virus (HIV), those with HIV-1 RNA <200 copies/mL and CD4 counts ≥300 cells/µL had a 97.1% probability of maintaining durable CD4 ≥200 cells/µL for 4 years. When non-HIV causes of CD4 lymphopenia were excluded, the probability rose to 99.2%. Our data support less frequent CD4 monitoring during viral suppression.

Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia

BACKGROUND

Patient Navigation (PN) originated in Harlem as an intervention to help poor women overcome access barriers to timely breast cancer treatment. Despite rapid, nationally widespread adoption of PN, empirical evidence on its effectiveness is lacking. In 2005, National Cancer Institute initiated a multicenter PN Research Program (PNRP) to measure PN effectiveness for several cancers. The George Washington Cancer Institute, a project participant, established District of Columbia (DC)-PNRP to determine PN's ability to reduce breast cancer diagnostic time (number of days from abnormal screening to definitive diagnosis).

METHODS

A total of 2,601 women (1,047 navigated; 1,554 concurrent records-based nonnavigated) were examined for breast cancer from 2006 to 2010 at 9 hospitals/clinics in DC. Analyses included only women who reached complete diagnostic resolution. Differences in diagnostic time between navigation groups were tested with ANOVA models including categorical demographic and treatment variables. Log transformations normalized diagnostic time. Geometric means were estimated and compared using Tukey-Kramer P value adjustments.

RESULTS

Average-geometric mean [95% confidence interval (CI)]-diagnostic time (days) was significantly shorter for navigated, 25.1 (21.7, 29.0), than nonnavigated women, 42.1 (35.8, 49.6). Subanalyses revealed significantly shorter average diagnostic time for biopsied navigated women, 26.6 (21.8, 32.5) than biopsied nonnavigated women, 57.5 (46.3, 71.5). Among nonbiopsied women, diagnostic time was shorter for navigated, 27.2 (22.8, 32.4), than nonnavigated women, 34.9 (29.2, 41.7), but not statistically significant.

CONCLUSIONS

Navigated women, especially those requiring biopsy, reached their diagnostic resolution significantly faster than nonnavigated women.

IMPACT

Results support previous findings of PN's positive influence on health care. PN should be a reimbursable expense to assure continuation of PN programs.

Subarachnoid hemorrhage and vasospasm following removal of craniopharyngioma

A patient who had transcranial removal of a craniopharyngioma developed a large, postoperative subarachnoid hematoma in the basal cisterns. The patient developed cerebral vasospasm with infarction. A review of the literature found 20 cases of vasospasm associated with surgical removal of intracranial tumors. These cases were reviewed to determine the role of subarachnoid blood in the causation of vasospasm. In most cases, vasospasm is caused by subarachnoid blood. Multiple causes for arterial narrowing may be present, such as radiation vasculopathy, iatrogenic arterial injury and infection, and may be impossible to exclude as factors contributing to arterial narrowing.

Evaluation of lymphangiogenic factors, vascular endothelial growth factor D and E-cadherin in distinguishing inflammatory from locally advanced breast cancer

BACKGROUND

Inflammatory breast cancer (IBC) is an aggressive form of breast cancer that on presentation resembles locally advanced breast cancer (LABC). This study identified molecular features of IBC and LABC to investigate pathogenesis.

MATERIALS AND METHODS

This study involved 100 IBC cases identified in a national IBC registry and 107 non-IBC LABC cases from the National Cancer Institute's Cooperative Breast Cancer Tissue Resource (CBCTR). Vascular endothelial growth factor D (VEGF-D) and E-cadherin levels and lymphatic vessel density (LVD) measured by podoplanin staining were examined by immunohistochemistry on paraffin-embedded tumor specimens. Intralymphatic tumor emboli (ILTE) were assessed in IBC and non-IBC tumors. IBC cases diagnosed by clinicians but not meeting the case definitions of the American Joint Committee on Cancer (AJCC) or the Surveillance, Epidemiology and End Results (SEER) Program of the National Cancer Institute (NCI)(designated atypical IBC) were compared with AJCC- and/or SEER-defined cases (designated classic IBC).

RESULTS

E-cadherin levels were significantly higher in classic IBC cases compared with non-IBC cases (P = .031), whereas compared with classic IBC, patients with non-IBC LABC had significantly higher LVD (P = .0017) and VEGF-D levels (P < .0001). ILTE was marginally greater in classic IBC than in non-IBC (P = .046). The profile of laboratory values in atypical IBC cases more closely resembled those fitting classic IBC than LABC.

CONCLUSION

E-cadherin levels, LVD, VEGF-D expression, and to a lesser extent, ILTE differed between classic IBC and non-IBC LABC. The similarity of laboratory results between atypical IBC and classic IBC vs. LABC suggests the need for broadening both the AJCC and SEER case definitions for this disease.

Energy prediction equations are inadequate for obese Hispanic youth

Assessing energy requirements is a fundamental activity in clinical dietetics practice. A study was designed to determine whether published linear regression equations were accurate for predicting resting energy expenditure (REE) in fasted Hispanic children with obesity (aged 7 to 15 years). REE was measured using indirect calorimetry; body composition was estimated with whole-body air displacement plethysmography. REE was predicted using four equations: Institute of Medicine for healthy-weight children (IOM-HW), IOM for overweight and obese children (IOM-OS), Harris-Benedict, and Schofield. Accuracy of the prediction was calculated as the absolute value of the difference between the measured and predicted REE divided by the measured REE, expressed as a percentage. Predicted values within 85% to 115% of measured were defined as accurate. Participants (n=58; 53% boys) were mean age 11.8±2.1 years, had 43.5%±5.1% body fat, and had a body mass index of 31.5±5.8 (98.6±1.1 body mass index percentile). Measured REE was 2,339±680 kcal/day; predicted REE was 1,815±401 kcal/day (IOM-HW), 1,794±311 kcal/day (IOM-OS), 1,151±300 kcal/day (Harris-Benedict), and, 1,771±316 kcal/day (Schofield). Measured REE adjusted for body weight averaged 32.0±8.4 kcal/kg/day (95% confidence interval 29.8 to 34.2). Published equations predicted REE within 15% accuracy for only 36% to 40% of 58 participants, except for Harris-Benedict, which did not achieve accuracy for any participant. The most frequently accurate values were obtained using IOM-HW, which predicted REE within 15% accuracy for 55% (17/31) of boys. Published equations did not accurately predict REE for youth in the study sample. Further studies are warranted to formulate accurate energy prediction equations for this population.

Abstract B90: Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia

Background: Delays in follow-up after breast cancer screening may contribute to disparities in breast cancer outcomes. To eliminate breast cancer disparities in Washington, D.C., The GW Cancer Institute established the D.C. Citywide Patient Navigation Research Program (DC-PNRP), which is one of nine national PNRP sites funded by the National Cancer Institute and the American Cancer Society to evaluate the effectiveness of patient navigation. The primary objective of this study is to determine the impact of patient navigation in reducing breast cancer diagnostic time, defined as the number of days from abnormal screening to definitive diagnosis.

Methods: This is a prospective study of 1922 women (728 navigated and 1194 concurrent race-matched records-based non-navigated) examined for breast cancer between 1998 and 2010 at nine hospitals and clinics located in Washington, D.C. Analysis of variance (ANOVA) was used to test for significant differences in diagnostic time between navigated and non-navigated women, while controlling for race/ethnicity (non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic), type of health insurance (private, government, none), and age at abnormal screening (&lt;40, 40–49, 50–59, 60+). Two-way interactions between group and each of the demographic variables race/ethnicity, type of health insurance, and age at abnormal screening were considered. To satisfy model assumptions, diagnostic time was normalized through a log transformation. Geometric means were estimated and compared using a Tukey-Kramer p-value adjustment.

Results: Unadjusted average—geometric mean (95% CI)—diagnostic times (in days) were 23.9 (20.5, 27.8) for navigated and 37.2 (33.0, 41.8) for non-navigated women (p&lt;0.0001). A factorial ANOVA model revealed significant interactions between navigation and both race/ethnicity (p=0.02) and age at abnormal screening (p=0.03) after controlling for type of insurance (p=0.0008). Navigated NHW had a significantly shorter adjusted average diagnostic time, 6.1 (3.5, 10.5) days, than non-navigated NHW, 16.0 (11.5, 22.3) days (p=0.03); and navigated Hispanics had a significantly shorter adjusted average diagnostic time, 26.5 (19.5, 36.0) days, than non-navigated Hispanics, 57.2 (44.8, 73.1) days (p=0.0005). While navigated NHB had a shorter adjusted average diagnostic time, 26.2 (21.5, 31.9) days, than non-navigated NHB, 34.3 (28.4, 41.4) days, this decrease was not statistically significant (p=0.32). Navigation reduced the diagnostic time for women of all ages, but this decrease was statistically significant only for women aged 60+ years (p&lt;0.0001). Navigated women younger than 40 or 60+ had significantly shorter adjusted average diagnostic times than those aged 50–59 (p=0.03 for each). Adjusted average diagnostic times (in days) by age group were 11.2 (7.7, 16.3) for navigated and 22.8 (14.9, 35.0) for non-navigated women &lt;40; 21.6 (15.9, 29.2) for navigated and 33.7 (27.4, 41.4) for non-navigated women 40–49; 23.8 (17.0, 33.5) for navigated and 35.5 (28.4, 44.4) for non-navigated women 50–59; 11.9 (8.4, 16.9) for navigated and 36.2 (28.4, 46.2) for non-navigated women 60+.

Conclusions: The time required for navigated women to reach a definitive diagnosis following an abnormal screening was significantly shorter as compared to non-navigated women. While navigation was effective overall, the program proved to be more helpful for Hispanics and NHW than for NHB, especially among women aged 60+ years. Barriers preventing a rapid diagnostic resolution for NHB need to be explored further.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B90.

Utility of frameless stereotaxy in the resection of skull base and Basal cerebral lesions in children

Since 1991, we have performed nearly 300 stereotactic procedures using the ISG viewing wand on a variety of cranial lesions in patients under 22 years of age. Of these, 38 procedures were performed on 34 patients for basal cerebral and skull base lesions. Our patients ranged in age from 3.5 months to 22 years with a mean age of 9.45 years. There were 18 females and 16 males. Twenty-one patients had basal cerebral lesions located in the thalamus (10), basal ganglia (2), third ventricle (2), and hypothalamus (7). Thirteen patients had skull base lesions located within the anterior optic apparatus (3), sella turcica (4), middle and posterior cranial fossae (4), and craniocervical region (2). Preoperative CT and/or MRI scan images were taken as a volume acquisition and transferred to the computer workstation utilizing the ISG Wand software. This workstation was transferred to the operating room where it was calibrated to a faro Surgicom arm which interfaces with the patient and the three-dimensional radiological image. The ISG Wand was utilized to plan the scalp and bone flaps and to select the optional trajectory to lesion. The surgical approaches which were specifically used in this series with the ISG Wand included transcallosal (15), pterional (5), frontal (3), subtemporal (4), transsphenoidal (3), temporal (3), tumor cyst shunt insertion (1), burr hole drainage (1), transoral (2), bifrontal (1), bifrontal mid facial (1), and transnasal (1). Although brain shift occurred following craniotomy and with brain retraction, the relative immobility of these lesions at the skull or cerebral base permitted an accurate targeting of all lesions with an error range of 1.0-2.5 mm throughout the entire procedure. This relatively precise intraoperative feedback led to more accurate recognition of tumor landmarks. It is the authors' impression that a more aggressive resection of these lesions was achieved than could be without the device. We conclude that a frameless stereotactic device such as the ISG Wand is particularly valuable in the approach to skull base and basal cerebral tumors in children.

Relation of vitamin D level to maximal oxygen uptake in adults

Low cardiorespiratory fitness and low serum 25-hydroxy vitamin D (25[OH]D) levels are associated with increased cardiovascular and all-cause mortality, but whether low 25(OH)D is independently associated with cardiorespiratory fitness in healthy adults is not known. We examined 25(OH)D levels and fitness in 200 healthy adults participating in a double-blind clinical trial investigating statins and muscle performance (STOMP study). Maximal aerobic exercise capacity (Vo₂(max)) was measured using metabolic gas analysis during graded treadmill exercise to exhaustion. 25(OH)D was measured using an enzyme-linked immunosorbent assay. Daily physical activity was assessed using the Paffenbarger Physical Activity Questionnaire. Serum 25(OH)D concentration was positively related to Vo₂(max) (r = 0.29, p = 0.0001), even after adjusting for relevant predictors (e.g., age, gender, and body mass index). There was also a significant interaction between 25(OH)D level and self-reported hours of moderate to vigorous physical activity (MVPA; p < 0.02). With each SD increase in 25(OH)D, Vo₂(max) increased by 2.6 ml/kg/min (p = 0.0001) when MVPA was low (16 hours/week) and 1.6 ml/kg/min (p <0.0004) when MVPA was moderate (35 hours/week) but only 0.01 ml/kg/min (p = 0.9) when MVPA was high (64 hours/week). In conclusion, serum 25(OH)D levels predict Vo₂(max) in adults; the effect is greatest in those with low levels of physical activity.

Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the District of Columbia

BACKGROUND

Delays in follow-up after breast cancer screening contribute to disparities in breast cancer outcomes. The objective of this research was to determine the impact of race/ethnicity and health insurance on diagnostic time, defined as number of days from suspicious finding to diagnostic resolution.

METHODS

This retrospective cohort study of 1538 women examined for breast abnormalities between 1998-2010 at 6 hospitals/clinics in the District of Columbia measured mean diagnostic times between non-Hispanic whites (NHWs), non-Hispanic blacks (NHBs), and Hispanics with private, government, or no health insurance by using a full-factorial ANOVA model.

RESULTS

Respective average--geometric mean (95% CI)--diagnostic times (in days) for NHWs, NHBs, and Hispanics were 16 (12, 21), 27 (23, 33), and 51 (35, 76) among privately insured; 12 (7, 19), 39 (32, 48), and 71 (48, 105) among government insured; 45 (17, 120), 60 (39, 92), and 67 (56, 79) among uninsured. Government insured NHWs had significantly shorter diagnostic times than government insured NHBs (P = .0003) and Hispanics (P < .0001). Privately insured NHWs had significantly shorter diagnostic times than privately insured NHBs (P = .03) and Hispanics (P < .0001). Privately insured NHBs had significantly shorter diagnostic times than uninsured NHBs (P = .03).

CONCLUSIONS

Insured minorities waited >2 times longer to reach their diagnostic resolution than insured NHWs. Having private health insurance increased the speed of diagnostic resolution in NHBs; however, their diagnostic time remained significantly longer than for privately insured NHWs. These results suggest diagnostic delays in minorities are more likely caused by other barriers associated with race/ethnicity than by insurance status.

Abstract PR-10: Impact of race, ethnicity and health insurance on delays in breast cancer diagnosis in the District of Columbia

Background: Delays in follow-up after breast cancer screening are thought to contribute to disparities in breast cancer outcomes. The primary objective of this study is to determine the impact of race/ethnicity and type of health insurance on the diagnostic delay time, defined as the number of days from abnormal screening to definitive diagnosis.

Methods: This is a retrospective study of 976 women examined for breast cancer between 1998 and 2009 at six hospitals and clinics located in the District of Columbia. We used a full-factorial ANOVA model to test for significant differences in diagnostic delay time among non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic women with private, government, or no health insurance. A log transformation was taken on the diagnostic delay time to normalize our data, and geometric means were estimated and compared.

Results: The average geometric mean (95% CI) diagnostic delay times were as follows: among those with private insurance, 15.9 (12.2,20.6) days for NHW, 27.0 (22.4,32.6) days for NHB, and 51.4 (34.8,76.0) days for Hispanic women; among those with government insurance, 11.9 (7.3,19.3) days for NHW, 39.5 (32.2,48.6) days for NHB, and 71.6 (47.8,107.1) days for Hispanic women; and among those without insurance, 44.5 (16.4,120.6) days for NHW, 59.7 (38.8,91.8) days for NHB, and 66.4 (55.8,79.1) days for Hispanic women. In fitting a full-factorial ANOVA model, we found that NHW women with government insurance had a significantly shorter delay in diagnosis than NHB (p=0.0003) and Hispanic (p&lt;0.0001) women with government insurance. We also found that NHW women with private insurance had a significantly shorter delay in diagnosis than NHB (p=0.03) and Hispanic (p&lt;0.0001) women with private insurance. However, there were no significant differences within the uninsured women (p&gt;0.05). Finally, we found that NHB women with private insurance had a significantly shorter delay in diagnosis than uninsured NHB women (p=0.03).

Conclusions: NHB and Hispanic women with government or private insurance waited more than twice as long to reach their definitive diagnosis than NHW women with government or private insurance. Uninsured NHB women waited more than twice as long to reach their definitive diagnosis than NHB women with private insurance. Having private health insurance markedly increased the speed of diagnostic resolution in NHB women; however, the speed of diagnostic resolution remained significantly longer for NHB women with private insurance than for NHW women with private insurance. These results suggest that while both insurance and race/ethnicity affect diagnostic resolution, health insurance may not be the primary barrier to optimal diagnostic resolution in NHB women. It will be important to determine what other factors serve as the primary barriers, as well as if these delays affect the final breast cancer outcome for the patients.

Funding Mechanism: Grant Number 1 U01 CA116937; Patient Navigation Research Program (PNRP), Center for Research on Cancer Health Disparities (CRCHD), National Cancer Institute (NCI).

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):PR-10.

Abstract B90: The District of Columbia citywide Patient Navigation Research Program (DC-PNRP): Preliminary descriptive findings

Introduction: Minority breast cancer mortality rates in Washington, DC are among the Nation's highest. To address these disparities we instituted the DC Citywide Patient Navigation Research Program (DC-PNRP) - an inter-institutional collaboration that is one of 9 National PNRP sites funded by NCI/ACS to evaluate the effectiveness of patient navigation in reducing time from suspicious finding to diagnostic resolution and time from resolution to treatment initiation.

Study Procedures: A total of 1024 women, mostly minorities, have been enrolled from 8 recruitment sites at the point of suspicious finding. Utilizing a non-randomized design, 1240 concurrent, medical records-based controls were identified from 6 sites for comparison. Subject recruitment ended March 31,2010, but data collection continues on those women already enrolled. A unique framework of “network navigation” emerged whereby services were integrated across a city-wide network of unaffiliated healthcare sites. Navigators from a broad partnership of clinical and community sites were trained to work collaboratively within a city-wide network to enroll patients in the study and assure each receives timely, quality care. This “integrative navigation”model is collecting data addressing not only structural barriers to access to care (i.e., inadequate insurance, lack of transportation, etc.), but also psychosocial barriers (i.e., fear, medical mistrust, acculturation, etc.). Frequent trainings, efforts that promote increased communication between navigators, and sharing of information about community resources were implemented to enhance care coordination and to assure appropriate referral strategies between community outreach, screening, and treatment sites.

Results and Conclusion: Among controls, 7.66% were non-Hispanic whites (NHW), 35.24% were non-Hispanic blacks (NHB), 30.65% were Hispanic, and 26.45% were of other or unknown race/ethnicity. The corresponding percentages for navigated patients were 7.03%, 48.93%, 29.88%, and 14.16% indicating larger numbers of NHB and fewer with other/unknown race/ethnicity among the navigated patients. When examining age of subjects grouped by &lt;40 years, 40-49 years, 50-59 years, 60-69 years, 70-79 years, and &gt;=80 years, respective proportions among controls were 7.10%, 37.98,28.15,16.29, 6.61, and 3.87%, while the distribution for navigated patients was: 20.70%, 32.03,24.41,14.06,5.57, and 3.22%, respectively, suggesting that navigated patients were slightly younger than controls. Household income level was generally unavailable for controls and for 35.54% of navigated patients. Proportions of navigated patients falling into the income categories &lt;$10,000, $10-19,999, $20-29,999, $30-39,999, $40-49,999, and &gt;=$50,000 are 14.06%, 13.38,9.38,9.18,4.59, and 13.87%, respectively, indicating fairly substantial numbers of low income patients. Among controls, 29.27% indicated they had no form of health insurance. The proportion was similar for navigated patients at 33.98%. Our data indicate we have comparable groups based on demographic attributes of navigated and control patients for our future analyses.

Funding Mechanism: Grant Number 1 U01 CA116937; Patient Navigation Research Program (PNRP), Center for Research on Cancer Health Disparities (CRCHD), National Cancer Institute (NCI).

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B90.

Obesity and outcomes among patients with established atrial fibrillation

Atrial fibrillation (AF) and obesity have reached epidemic proportions. The impact of obesity on clinical outcomes in patients with established AF is unknown. We analyzed 2,492 patients in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study. Body mass index (BMI) was evaluated as a categorical variable (normal 18.5 to <25 kg/m(2), overweight 25 to <30 kg/m(2), obese >or=30 kg/m(2)). Rate of death from any cause was higher in the normal BMI group (5.8 per 100 patient-years) than in the overweight and obese groups (3.9 and 3.7, respectively). Cardiovascular death rate was highest in the normal BMI group (3.1 per 100 patient-years), lowest in the overweight group (1.5 per 100 patient-years), and intermediate in the obese group (2.1 per 100 patient-years). After adjustment for baseline factors, differences in risk of death from any cause were no longer significant. However, overweight remained associated with a lower risk of cardiovascular death (hazard ratio 0.47, p = 0.002). Obese patients were more likely to have an uncontrolled heart rate at rest, but rhythm-control strategy success was similar across BMI categories. In each BMI category, risk of death from any cause was similar for patients randomized to a rhythm- or rate-control strategy. In conclusion, in patients with established AF, overweight and obesity do not adversely affect overall survival. Obesity does not appear to affect the relative benefit of a rate- or rhythm-control strategy.

E, Levine PH, Young HA, Hoffman HJ. Abstract 862: Network patient navigation: An integrative, longitudinal model to reduce breast cancer disparities

Introduction: Minority breast cancer mortality rates in Washington, DC are among the nation's highest. To address disparities we instituted the DC Citywide Patient Navigation Research Program (DC-PNRP) - an inter-institutional collaboration that is one of 9 National PNRP sites funded by NCI/ACS to evaluate the effectiveness of patient navigation in reducing barriers to obtaining health care while also addressing psychosocial factors.

Study Procedures: More than 1000 minority women have been enrolled from 7 recruitment sites at the point of suspicious finding to investigate whether patient navigation decreases time from suspicious breast finding to diagnostic resolution and time from diagnosis to treatment initiation. Utilizing a non-randomized design, concurrent, medical records-based controls have been identified. Data collection will extend through March 2010. A unique framework of “network navigation” emerged whereby services were integrated across a city-wide network of unaffiliated healthcare sites. Navigators from a broad partnership of clinical and community sites were trained to work collaboratively within a city-wide network to enroll patients in the study and assure each patient receives timely, quality care. This “integrative navigation” model is collecting data addressing not only structural barriers to access to care (i.e., inadequate insurance, lack of transportation, etc.), but also psychosocial barriers (i.e., fear, medical mistrust, acculturation, etc.). Frequent trainings, efforts that promote increased communication between navigators, and sharing of information about community resources were implemented to enhance care coordination and to assure appropriate referral strategies between community outreach, screening, and treatment sites.

Results and Conclusion: Implementation of DC-PNRP led us to broaden the original treatment-oriented navigation model to create a “Longitudinal Navigation” paradigm that follows the patient from outreach through survivorship. Data will be shown describing how this model addresses barriers to access and the underlying fragmentation of services that exist in DC for low-income uninsured or under-insured women. Data on the types and distribution of barriers will also be presented. This city-wide program serves as model for inter-institutional cooperation to improve health care access, particularly for the underserved.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 862.