Abstract P6-12-08: Healthcare barrier profiles in patients navigated for cancer screening and treatment and the impact of the affordable care act

Background: The underserved community experiences barriers to cancer screening that result in overall greater mortality rates across all cancers. Insurance coverage brought forth by the Affordable Care Act has the potential to significantly impact these barriers through reducing the burden of health care cost on the patient. In this study the authors observe the impact of the Affordable Care Act on the barrier profiles presented by the patients navigated for cancer screening and treatment.

Methods: Patient navigation encounters were recorded for a total of 1146 patients navigated for cancer screening and treatment at the Cleveland Clinic Foundation from the years 2012 through 2015. A total of 3259 encounters were classified into barrier types. Health care billed encounters were retrieved from EPIC for this group of patients from the time they entered patient navigation and classified in terms of insurance coverage. Patients were categorized according to their barrier profile. Appropriate generalized linear regression models were used to test for association of these profiles to number and types of navigation and health care encounters and cost, and to test for change in types of encounters and patient barrier profiles through time.

Results: The insurance barrier is present in 23% of all navigation encounters. Patients presenting with an insurance barrier had a greater mean number of navigation (p<0.001) and health care encounters (p<0.006), had a greater proportion of self-paid health care encounters (p<0.001) and a lower total cost billed for health care encounters after controlling for number of encounters (p<0.001) . The access barrier is present in 53% of navigation encounters while patients that present with only the access barrier account for 42% of the entire sample. Patients that present with only the access barrier have doubled every year (OR 2.2 per year, 95% CI [1.8 2.6]) from 2012 to 2015, while the proportion of self-paid health care encounters (OR 0.26 per year, 95% CI [0.25 0.28]) and the presence of the insurance barrier (OR 0.55 per year, 95% CI [ 0.49 0.62]) have more than halved during this time period.

Conclusion: Although the Affordable Care Act has clearly had an impact by lowering the number of insurance barrier navigation encounters through time, it has uncovered access as the predominant remaining barrier. Understanding and targeting the access barrier will be the most effective way to potentiate the effects of the ACA on patients being navigated for cancer screening and treatment.

Citation Format: Raska P, Ott MA, Steele A, Bailey A, Hickman D, Allen D, Urbanek D, Glass K, Bailey J, Bell K, Montero A, Abraham J. Healthcare barrier profiles in patients navigated for cancer screening and treatment and the impact of the affordable care act. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-08.

Comparative analysis of the transcriptome across distant species

The transcriptome is the readout of the genome. Identifying common features in it across distant species can reveal fundamental principles. To this end, the ENCODE and modENCODE consortia have generated large amounts of matched RNA-sequencing data for human, worm and fly. Uniform processing and comprehensive annotation of these data allow comparison across metazoan phyla, extending beyond earlier within-phylum transcriptome comparisons and revealing ancient, conserved features. Specifically, we discover co-expression modules shared across animals, many of which are enriched in developmental genes. Moreover, we use expression patterns to align the stages in worm and fly development and find a novel pairing between worm embryo and fly pupae, in addition to the embryo-to-embryo and larvae-to-larvae pairings. Furthermore, we find that the extent of non-canonical, non-coding transcription is similar in each organism, per base pair. Finally, we find in all three organisms that the gene-expression levels, both coding and non-coding, can be quantitatively predicted from chromatin features at the promoter using a 'universal model' based on a single set of organism-independent parameters.

Healing rates and subscapularis fatty infiltration after lesser tuberosity osteotomy versus subscapularis peel for exposure during shoulder arthroplasty

BACKGROUND

Controversy exists regarding the optimal technique of subscapularis mobilization during shoulder arthroplasty. The purpose of this study was to compare healing rates and subscapularis fatty infiltration in patients undergoing a lesser tuberosity osteotomy (LTO) versus subscapularis peel for exposure during shoulder arthroplasty.

MATERIALS AND METHODS

Eighty-seven patients, with a mean age of 67.8 ± 10.9 years, undergoing shoulder arthroplasty, were randomized to receive either an LTO (n = 43) or peel (n = 44). Computed tomography scans were conducted preoperatively and at 12 months postoperatively. Outcome variables included healing rates and subscapularis Goutallier fatty infiltration grade, as well as subscapularis strength and Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons outcome scores.

RESULTS

Computed tomography imaging was available in 91% (n = 79) of the cohort. The healing rates for the peel (100%) and for the LTO (95%) did not differ significantly (P = .493). Preoperatively, the mean fatty infiltration grade for the peel (mean, 0.53) was not significantly different (P = .925) from the LTO (mean, 0.54). Postoperatively, the Goutallier mean fatty infiltration grade for the peel (mean, 0.95) did not differ significantly (P = .803) from the LTO (mean, 0.9). A significant increase in subscapularis fatty infiltration grade occurred postoperatively from the preoperative status (peel, P = .003; LTO, P = .0002). No statistically significant associations were observed between postoperative fatty infiltration grades and subscapularis strength, Western Ontario Osteoarthritis of the Shoulder Index scores, or American Shoulder and Elbow Surgeons scores.

DISCUSSION

No statistically significant differences were observed in the healing rates or subscapularis fatty infiltration grades between the peel and the LTO. This trial does not show any clear difference in radiologic and clinical outcomes of one subscapularis management technique over the other.

Comparison of lesser tuberosity osteotomy to subscapularis peel in shoulder arthroplasty: a randomized controlled trial

BACKGROUND

Controversy exists regarding the optimal technique of subscapularis tendon mobilization during shoulder arthroplasty. The purpose of the present randomized double-blind study was to compare two of these techniques-lesser tuberosity osteotomy and subscapularis peel-with regard to muscle strength and functional outcomes.

METHODS

Patients undergoing shoulder arthroplasty were randomized to undergo either a lesser tuberosity osteotomy or a subscapularis peel. The primary outcome was subscapularis muscle strength as measured with an electronic handheld dynamometer at twenty-four months postoperatively. Secondary outcomes included the Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons scores. A sample size calculation determined that eighty-six patients provided 90% power with a 0.79 effect size to detect a significant difference between groups.

RESULTS

Forty-three patients were allocated to subscapularis osteotomy, and forty-four patients were allocated to subscapularis peel. Eighty-three percent of the study cohort returned for the twenty-four-month follow-up. The primary outcome of subscapularis muscle strength at twenty-four months revealed no significant difference (p = 0.131) between the lesser tuberosity osteotomy group (mean [and standard deviation], 4.4 ± 2.9 kg) and the subscapularis peel group (mean, 5.5 ± 2.6 kg). Comparison of secondary outcomes, including the Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons scores, demonstrated no significant differences between groups at any time point. Compared with baseline measures, mean subscapularis muscle strength, Western Ontario Osteoarthritis of the Shoulder Index score, and American Shoulder and Elbow Surgeons score all improved significantly in both groups at twenty-four months (p < 0.001).

DISCUSSION

No significant differences in the primary or secondary outcomes of function were identified between the lesser tuberosity osteotomy group and the subscapularis peel group. For the parameters investigated, this trial does not demonstrate any clear advantage of one subscapularis treatment technique over the other.

Abstract P5-01-09: Identification of Molecular Apocrine Triple Negative Breast Cancer Using a Novel 2-Gene Assay and Comparison with Androgen Receptor Protein Expression and Gene Expression Profiling by DASL

Background: The molecular apocrine (MA) subtype of breast cancer is identified by gene expression profiling. MA tumors are estrogen receptor (ER) negative and progesterone receptor (PR) negative, but still express estrogen responsive genes. The androgen receptor (AR) pathway may be driving growth in these tumors because androgen responsive genes are expressed in tumors with the MA gene signature. The MA gene signature is identified in approximately 10% of triple negative breast cancer (TNBC) and may predict patients with tumors responsive to agents that inhibit the AR pathway. AR protein expression, measured by immunohistochemistry (IHC), may be a surrogate for the MA gene signature, but to date, a careful comparison of gene expression profiles and AR protein expression has not been conducted. In this study, cohorts of TNBCs were assessed for the MA gene signature and these results were compared with AR IHC expression and with a novel gene expression assay that may predict tumors with the MA gene signature.

Methods: Formalin fixed, paraffin-embedded (FFPE) TNBC samples were commercially obtained. ER, PR and HER2 status of these samples was confirmed by IHC. AR expression was detected by IHC using two different antibody clones. Both staining intensity and percent positive cells were recorded for each sample. Gene expression data was collected from a cohort of TNBC FFPE samples using cDNA-mediated Annealing, Selection, extension, and Ligation (DASL) technology. A 2-gene classifier of the MA gene expression signature was derived by interrogating publically available gene expression data from ER-negative breast cancers. A reverse-transcriptase polymerase chain reaction (RT-PCR) assay to detect the 2-gene classifier was developed. Cell lines predicted to have the MA gene signature by the 2-gene assay were tested for sensitivity to R-1881 in vitro.

Results: Using computational approaches and publically available datasets, we confirmed the validity of the MA gene signature and estimated the prevalence to be between 12% and 37% in ER-negative breast tumors. The 2-gene classifier was 100% specific in determining MA tumors in a training set using gene expression data as a standard. In a validation set, the 2-gene assay was 66% correlative with AR IHC positivity when the IHC cut-off was set at 10% positive tumor cells. Cell lines predicted to express the MA gene signature by the 2-gene classifier proliferated in response to androgen. This effect was blocked by Flutamide.

Conclusions: These results indicate that AR IHC using a 10% cut-off may not completely correlate with the MA gene signature. Further refinement of AR IHC scoring criteria may produce greater specificity. Cell proliferation data suggests the 2-gene assay can predict tumors that will proliferate in response to androgen. Work is ongoing to determine the correlation between the 2-gene assay results, AR IHC and DASL gene expression data to fully understand the predictability of this assay. Understanding this correlation may allow use of simple clinical assays to accurately select patients responsive to agents that block AR signaling.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-01-09.

Landscape of transcription in human cells

Eukaryotic cells make many types of primary and processed RNAs that are found either in specific subcellular compartments or throughout the cells. A complete catalogue of these RNAs is not yet available and their characteristic subcellular localizations are also poorly understood. Because RNA represents the direct output of the genetic information encoded by genomes and a significant proportion of a cell's regulatory capabilities are focused on its synthesis, processing, transport, modification and translation, the generation of such a catalogue is crucial for understanding genome function. Here we report evidence that three-quarters of the human genome is capable of being transcribed, as well as observations about the range and levels of expression, localization, processing fates, regulatory regions and modifications of almost all currently annotated and thousands of previously unannotated RNAs. These observations, taken together, prompt a redefinition of the concept of a gene.

A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair

BACKGROUND

Controversy exists regarding the optimal technique for arthroscopic rotator cuff repair. The purpose of this multicenter, randomized, double-blind controlled study was to compare the functional outcomes and healing rates after use of single-row and double-row suture techniques for repair of the rotator cuff.

METHODS

Ninety patients undergoing arthroscopic rotator cuff repair were randomized to receive either a single-row or a double-row repair. The primary objective was to compare the Western Ontario rotator cuff index (WORC) score at twenty-four months. Secondary objectives included comparison of the constant and american shoulder and elbow surgeons (ASES) scores and strength between groups. Anatomical outcomes were assessed with magnetic resonance imaging (MRI) or ultrasonography to determine the postoperative healing rates.

RESULTS

Baseline demographic data including age (p = 0.29), sex (p = 0.68), affected side (p = 0.39), and rotator cuff tear size (p = 0.28) did not differ between groups. The WORC score did not differ significantly between groups at any time point (p = 0.48 at baseline, p = 0.089 at three months, p = 0.52 at six months, p = 0.83 at twelve months, and p = 0.60 at twenty-four months). The WORC score at each postoperative time point was significantly better than the baseline value. The Constant score, ASES score, and strength did not differ significantly between groups at any time point. Logistic regression analysis demonstrated that a smaller initial tear size and double-row fixation were associated with higher healing rates.

CONCLUSIONS

No significant differences in functional or quality-of-life outcomes were identified between single-row and double-row fixation techniques. A smaller initial tear size and a double-row fixation technique were associated with higher healing rates as assessed with ultrasonography or MRI.

LEVEL OF EVIDENCE

Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

The role of plastidial glucose-6-phosphate/phosphate translocators in vegetative tissues of Arabidopsis thaliana mutants impaired in starch biosynthesis

Arabidopsis thaliana mutants impaired in starch biosynthesis due to defects in either ADP glucose pyrophosphorylase (adg1-1), plastidic phosphoglucose mutase (pgm) or a new allele of plastidic phosphoglucose isomerase (pgi1-2) exhibit substantial activity of glucose-6-phosphate (Glc6P) transport in leaves that is mediated by a Glc6P/phosphate translocator (GPT) of the inner plastid envelope membrane. In contrast to the wild type, GPT2, one of two functional GPT genes of A. thaliana, is strongly induced in these mutants during the light period. The proposed function of the GPT in plastids of non-green tissues is the provision of Glc6P for starch biosynthesis and/or the oxidative pentose phosphate pathway. The function of GPT in photosynthetic tissues, however, remains obscure. The adg1-1 and pgi1-2 mutants were crossed with the gpt2-1 mutant defective in GPT2. Whereas adg1-1/gpt2-1 was starch-free, residual starch could be detected in pgi1-2/gpt2-1 and was confined to stomatal guard cells, bundle sheath cells and root tips, which parallels the reported spatial expression profile of AtGPT1. Glucose content in the cytosolic heteroglycan increased substantially in adg1-1 but decreased in pgi1-2, suggesting that the plastidic Glc6P pool contributes to its biosynthesis. The abundance of GPT2 mRNA correlates with increased levels of soluble sugars, in particular of glucose in leaves, suggesting induction by the sugar-sensing pathway. The possible function of GPT2 in starch-free mutants is discussed in the background of carbon requirement in leaves during the light-dark cycle.

Fragile x mental retardation 1 and filamin a interact genetically in Drosophila long-term memory

The last decade has witnessed the identification of single-gene defects associated with an impressive number of mental retardation syndromes. Fragile X syndrome, the most common cause of mental retardation for instance, results from disruption of the FMR1 gene. Similarly, Periventricular Nodular Heterotopia, which includes cerebral malformation, epilepsy and cognitive disabilities, derives from disruption of the Filamin A gene. While it remains unclear whether defects in common molecular pathways may underlie the cognitive dysfunction of these various syndromes, defects in cytoskeletal structure nonetheless appear to be common to several mental retardation syndromes. FMR1 is known to interact with Rac, profilin, PAK and Ras, which are associated with dendritic spine defects. In Drosophila, disruptions of the dFmr1 gene impair long-term memory (LTM), and the Filamin A homolog (cheerio) was identified in a behavioral screen for LTM mutants. Thus, we investigated the possible interaction between cheerio and dFmr1 during LTM formation in Drosophila. We show that LTM specifically is defective in dFmr1/cheerio double heterozygotes, while it is normal in single heterozygotes for either dFmr1 or cheerio. In dFmr1 mutants, Filamin (Cheerio) levels are lower than normal after spaced training. These observations support the notion that decreased actin cross-linking may underlie the persistence of long and thin dendritic spines in Fragile X patients and animal models. More generally, our results represent the first demonstration of a genetic interaction between mental retardation genes in an in vivo model system of memory formation.

Brahman bull fertility in a north Australian rangeland herd

Low and variable bull fertility was identified as a constraint on reproductive rates in beef cattle grazed in an extensive, multiple sire mating regimen on Mount Bundey station in the Darwin pastoral district of northwestern Australia. Erratic conception patterns were attributed to a high proportion of bulls with low breeding soundness evaluation scores (BSE), a high proportion of aged bulls (40%>8 yr), and to running bulls of mixed age groups. Liveweight, scrotal circumference (SC) and age were positively correlated. An experiment was subsequently designed to investigate the ability of a number of bull measurements to predict fertility in an extensively-managed, multiple-sire mating system. Blood typing was used to match calves to sires. It proved to be an accurate and useful technique which successfully identified the parentage of 94% of calves examined. Single measurements of serum testosterone after administration of gonadotrophin-releasing hormone (GnRH) were not correlated with fertility. However six of the seven most fertile bulls exhibited high peak serum testosterone levels in summer, and lower levels in the winter. In contrast, the less fertile bulls did not exhibit seasonal variation in GnRH-induced serum testosterone levels. Social dominance ratio was weakly related to fertility (r=0.51: P<0.05). BSE (r=0.51: P<0.05) and SC (r=0.49: P<0.05) prior to, but not subsequent to, mating were correlated with bull fertility. Under the conditions of this experiment, a bull to cow ratio of 1:20 was excessive for bulls with a satisfactory BSE score.