Abstract P1-09-05: Survival disparities: Quality of care apparently not the answer

Introduction: In New Mexico (NM), Hispanic women have a 1.6-fold increased risk of breast cancer-specific death compared to non-Hispanic white women. In previous studies, race/ethnic minority women have been less likely to receive recommended adjuvant treatments, including radiation in women undergoing breast conservation, and hormonal therapy.

Objective: To determine whether non-receipt of recommended therapies contributed to disparate survival.

Methods: We conducted a case-cohort study of breast-cancer-specific survival within a population-based cohort of first invasive breast cancer diagnosed in white females from 1997-2009 in six NM counties, identified through Surveillance Epidemiology End Results (SEER). We selected fifteen percent of all women diagnosed with breast cancer and all breast cancer deaths. After IRB approval, data were collected from comprehensive medical chart reviews, supplemented by SEER information. Receipt of standard of care, vs. not, was defined based on age, diagnosis year and tumor characteristics, according to changes in treatment guidelines. Women who had a reported contraindication or refused therapy were omitted from assessment of quality of care for that therapy. Cox proportional hazards models for case-cohort were conducted using weighted estimates, with calculation of robust variance and hazard ratios (HR) and 95% confidence intervals (CI), using an alpha level of .05. Analyses were restricted to women of age 70 or less who survived at least 12 months. The proportional hazards assumption was verified by Schoenfeld residuals. All analyses were adjusted for age.

Results: Comprehensive medical records reviews were completed for 91% of eligible women (674 cohort members, 519 breast cancer deaths; median follow up 7.8 years). All others were omitted from analysis. Of women eligible for guideline-based treatment, receipt of guideline-appropriate therapy did not differ by Hispanic ethnicity for any treatment, and Hispanic women were slightly more likely overall to receive appropriate therapy (difference not significant). Among guideline-eligible women, at least 91% received radiotherapy, 78% received chemotherapy, 82% received endocrine therapy, and 89% received anti-HER2 targeted agents. After adjustment for other treatment, lack of receipt of guideline-appropriate therapy was related to an increased risk of breast cancer death for endocrine (HR 1.76; 95% CI 1.09-2.84) and radiation therapy (HR 2.05; 95% CI 1.14-3.69). The few HER2-positive women not treated precluded further assessment. After accounting for endocrine and radiation therapy the survival disparity HR of 1.6 in Hispanic women was reduced to 1.57 suggesting only 2% of the disparity was due to differences in receipt of these treatments.

Conclusion: Limitations include likely undercounts of appropriate therapy, thus proportions cited are minimal estimates. Appropriate therapy includes only documented receipt as therapy completion could not always be assessed. Hispanic women have a disproportionately higher breast cancer mortality despite apparently receiving adjuvant therapies to a similar degree as non-Hispanic white women. Equalizing standard of care and attempting to reduce treatment disparities may not be sufficient to address the disproportionate mortality in Hispanic women.

Citation Format: Friend SC, Royce ME, Kang H, Lomo L, Barry M, Wiggins C, Prossnitz E, Hill DA. Survival disparities: Quality of care apparently not the answer. [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 P1-09-05.

Generic medicines and generic substitution: contrasting perspectives of stakeholders in Ireland

BACKGROUND

The Health (Pricing and Supply of Medical Goods) Act 2013 passed into law in July 2013 and legislated for generic substitution in Ireland. The aim of the study was to ascertain the knowledge and perceptions of stakeholders i.e. patients, pharmacists and prescribers, of generic medicines and to generic substitution with the passing of legislation.

METHODS

Three stakeholder specific questionnaires were developed to assess knowledge of and perceptions to generic medicines and generic substitution. Purposive samples of patients, prescribers and pharmacists were analysed. Descriptive quantitative and qualitative analyses were undertaken.

RESULTS AND DISCUSSION

A total of 762 healthcare professionals and 353 patients were recruited. The study highlighted that over 84% of patients were familiar with generic medicines and are supportive of the concept of generic substitution. Approximately 74% of prescribers and 84% of pharmacists were supportive of generic substitution in most cases. The main areas of concern highlighted by the healthcare professionals that might impact on the successful implementation of the policy, were the issue of bioequivalence with generic medicines, the computer software systems used at present in general practitioner (GP) surgeries and the availability of branded generics. The findings from this study identify a high baseline rate of acceptance to generic medicines and generic substitution among patients, prescribers and pharmacists in the Irish setting. The concerns of the main stakeholders provide a valuable insight into the potential difficulties that may arise in its implementation, and the need for on-going reassurance and proactive dissemination of the impact of the generic substitution policy.

CONCLUSION

The existing positive attitude to generic medicines and generic substitution among key stakeholders in Ireland to generic substitution, combined with appropriate support and collaboration should result in the desired increase in rates of prescribing, dispensing and use of generic medicines.

Ovariectomy as treatment for ovarian bacterial granulomas in a Duvaucel's gecko (Hoplodactylus duvaucelii)

CASE HISTORY

An adult female Duvaucel's gecko (Hoplodactylus duvaucelii) from a threatened species breeding programme presented due to a prolonged gestation period and distended abdomen.

CLINICAL AND PATHOLOGICAL FINDINGS

The gecko was in lean body condition with an irregularly shaped, firm mass in the coelomic cavity. Radiographically there was a diffuse radio-opacity within the coelomic cavity with cranial displacement of the right lung field. Ultrasonography revealed a round homogenous abdominal mass of medium echogenicity with an echogenic capsule. Haematology showed a leucocytosis with a moderate left shift in heterophils and toxic changes. Bilateral ovariectomy was performed to remove two ovarian granulomas and Salmonella enterica subspecies houtenae (IV) was cultured from the ovarian tissue. The gecko recovered well from the surgery, regained weight and remained in good health 3 years following the surgery.

DIAGNOSIS

Pre-ovulatory stasis and ovarian granulomas associated with infection with Salmonella enterica subsp. houtenae.

CLINICAL RELEVANCE

The surgery described in this case resulted in recovery of the gecko, which despite its loss of reproductive capability is of value as an education animal. This is the first report of pre-ovulatory stasis and ovarian granulomas associated with infection with Salmonella enterica in a Duvaucel's gecko and is also the first reported case of pre-ovulatory stasis in a viviparous lizard species. The case adds to knowledge regarding potential reproductive pathology in lizards, which is particularly important information for managers of captive lizard breeding programmes.

The Budget Impact of Hepatitis C Treatment in Ireland 2001-2012

Chronic Hepatitis C (HCV) is estimated to infect 20,000 to 50,000 people in Ireland. National estimates of the number of patients who have been treated for HCV, their demographics and the cost associated with that treatment have not been published. Prescriptions for the treatment of HCV from 2000-2012 were established by interrogating the records of the High-Tech Drug Scheme and the pharmacy records of the Genitourinary Medicine and Infectious Diseases department of St. James Hospital. 2320 patients were initiated on treatment for HCV. Over €27 million was spent on HCV treatment. €25.5 million was spent on anti-viral therapy and €2 million was spent on haematological growth factor support for the management of adverse effects. The budget impact of HCV treatment has been significant in Ireland. New agents for HCV will have a greater budget impact but should require less spend on adverse event management.

Changing trends in the management of children's fractures

The management of children's fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Surface reconstruction of wheat leaf morphology from three-dimensional scanned data

Realistic virtual models of leaf surfaces are important for several applications in the plant sciences, such as modelling agrichemical spray droplet movement and spreading on the surface. In this context, the virtual surfaces are required to be smooth enough to facilitate the use of the mathematical equations that govern the motion of the droplet. Although an effective approach is to apply discrete smoothing D2-spline algorithms to reconstruct the leaf surfaces from three-dimensional scanned data, difficulties arise when dealing with wheat (Triticum aestivum L.) leaves, which tend to twist and bend. To overcome this topological difficulty, we develop a parameterisation technique that rotates and translates the original data, allowing the surface to be fitted using the discrete smoothing D2-spline methods in the new parameter space. Our algorithm uses finite element methods to represent the surface as a linear combination of compactly supported shape functions. Numerical results confirm that the parameterisation, along with the use of discrete smoothing D2-spline techniques, produces realistic virtual representations of wheat leaves.

The impact of social stress during adolescence or adulthood and coping strategy on cognitive function of female rats

The age of stressor exposure can determine its neurobehavioral impact. For example, exposure of adolescent male rats to resident-intruder stress impairs cognitive flexibility in adulthood. The current study examined the impact of this stressor in female rats. Rats were exposed to resident-intruder stress during early adolescence (EA), mid-adolescence (MA) or adulthood (Adult). They were tested in an operant strategy-shifting task for side discrimination (SD), reversal learning (REV) and strategy set-shifting (SHIFT) the following week. Performance varied with age, stress and coping style. MA and EA rats performed SD and SHIFT better than other ages, respectively. Social stress impaired performance in rats depending on their coping strategy as determined by a short (SL) or long (LL) latency to become subordinate. SL rats were impaired in SD and REV, whereas EA-LL rats were impaired in SHIFT. These impairing effects of female adolescent stress did not endure into adulthood. Strategy set-shifting performance for female adolescents was positively correlated with medial prefrontal cortex (mPFC) activation as indicated by c-fos expression suggesting that this region is engaged during task performance. This contrasts with the inverse relationship between these indices reported for male adolescent rats. Together, the results demonstrate that social stress produces cognitive impairments for female rats that depend on age and coping style but unlike males, the impairing effects of female adolescent social stress are immediate and do not endure into adulthood. Sex differences in the impact of adolescent social stress on cognition may reflect differences in mPFC engagement during the task.

Breast cancer detection among Irish BRCA1 & BRCA2 mutation carriers: a population-based study

BACKGROUND

High-risk breast cancer screening for BRCA1/2 mutation carriers with clinical breast exam, mammography and MRI has reported sensitivity of 100 %, but BRCA1/2 mutation carriers still present with interval cancers.

AIMS

We investigated the presentation and screening patterns of an Irish cohort of BRCA1/2 mutation carriers with breast cancer.

MATERIALS AND METHODS

BRCA1/2 mutation carriers with breast cancer were identified in this retrospective cohort study. Records were reviewed for BRCA1/2 mutation status, demographics, screening regimen, screening modality, stage and histology at diagnosis.

RESULTS

Fifty-three cases of breast cancer were diagnosed between 1968 and 2010 among 60 Irish hereditary breast ovarian cancer (HBOC) families. In 50 of 53 women, the diagnosis of breast cancer predated the identification of BRCA1/2 mutations. Breast cancer detection method was identified in 47 % of patients (n = 25): 80 % (n = 20) by clinical breast exam (CBE), 12 % by mammography (n = 3), 8 % by MRI (n = 2). Fourteen women (26 %) developed a second breast cancer. Ten of these patients (71 %) were involved in regular screening; 50 % were detected by screening mammography, 20 % by MRI and 30 % by CBE alone. Six patients (43 %) had a change in morphology from first to second breast cancers. There was no change in hormone receptor status between first and second breast cancers.

CONCLUSION

In this cohort of Irish BRCA1/2 mutation carriers, compliance with screening was inconsistent. There was a 30 % incidence of interval cancers occurring in women in high-risk screening. Preventive surgery may be a more effective risk reduction strategy for certain high-risk women.

Cognitive impact of social stress and coping strategy throughout development

RATIONALE

Stress experience during adolescence has been linked to the development of psychiatric disorders in adulthood, many of which are associated with impairments in prefrontal cortex function.

OBJECTIVE

The current study was designed to determine the immediate and enduring effects of repeated social stress on a prefrontal cortex-dependent cognitive task.

METHODS

Early adolescent (P28), mid-adolescent (P42), and adult (P70) rats were exposed to resident-intruder stress for 5 days and tested in an operant strategy-shifting task (OSST) during the following week or several weeks later during adulthood. Engagement of prefrontal cortical neurons during the task was assessed by expression of the immediate early gene, c-fos.

RESULTS

Social stress during adolescence had no immediate effects on task performance, but impaired strategy-shifting in adulthood, whereas social stress that occurred during adulthood had no effect. The cognitive impairment produced by adolescent social stress was most pronounced in rats with a passive coping strategy. Notably, strategy-shifting performance was positively correlated with medial prefrontal cortical c-fos in adulthood but not in adolescence, suggesting that the task engages different brain regions in adolescents compared to adults.

CONCLUSIONS

Adolescent social stress produces a protracted impairment in prefrontal cortex-mediated cognition that is related to coping strategy. This impairment may be selectively expressed in adulthood because prefrontal cortical activity is integral to task performance at this age but not during adolescence.

Major cost savings associated with biologic dose reduction in patients with inflammatory arthritis

The purpose of this study was to explore whether patients with Inflammatory Arthritis (IA) (Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS)) would remain in remission following a reduction in biologic dosing frequency and to calculate the cost savings associated with dose reduction. This prospective non-blinded non-randomised study commenced in 2010. Patients with Inflammatory Arthritis being treated with a biologic agent were screened for disease activity. A cohort of those in remission according to standardized disease activity indices (DAS28 < 2.6, BASDAI < 4) was offered a reduction in dosing frequency of two commonly used biologic therapies (etanercept 50 mg once per fortnight instead of weekly, adalimumab 40 mg once per month instead of fortnightly). Patients were assessed for disease activity at 3, 6, 12, 18 and 24 months following reduction in dosing frequency. Cost saving was calculated. 79 patients with inflammatory arthritis in remission were recruited. 57% had rheumatoid arthritis (n = 45), 13% psoriatic arthritis (n = 10) and 30% ankylosing spondylitis (n = 24). 57% (n = 45) were taking etanercept and 43% (n = 34) adalimumab. The percentage of patients in remission at 24 months was 56% (n = 44). This resulted in an actual saving to the state of approximately 600,000 euro over two years. This study demonstrates the reduction in biologic dosing frequency is feasible in Inflammatory Arthritis. There was a considerable cost saving at two years. The potential for major cost savings in biologic usage should be pursued further.

Consequences of a missed ankle dislocation in an adolescent

Ankle dislocation without associated malleolar fracture(s) remains a rare presentation, especially in adolescence. Identified and treated promptly, these injuries can result in good to excellent outcome. We present an anterior ankle dislocation in a 14 year old, missed for approximately 12 months, necessitating multiple surgical interventions to provide a pain-free and stable joint. A review of the current literature is also provided.

Ebola outbreak in Conakry, Guinea: epidemiological, clinical, and outcome features

OBJECTIVES

The authors studied the epidemiological, clinical, and outcome features of the Ebola virus disease in patients hospitalized at the Ebola treatment center (ETC) in Conakry to identify clinical factors associated with death.

MATERIALS AND METHODS

A prospective study was conducted from March 25 to August 20, 2014. The diagnosis of Ebola virus infection was made on real-time PCR.

RESULTS

Ninety patients, with a positive test result, were hospitalized. Their mean age was 34.12±14.29 years and 63% were male patients. Most worked in the informal sector (38%) and in the medical and paramedical staff (physicians 12%, nurses 6%, and laboratory technicians 1%). Most patients lived in the Conakry suburbs (74%) and in Boffa (11%). The main clinical signs were physical asthenia (80%) and fever (72%). Hemorrhagic signs were observed in 26% of patients. The comparison of clinical manifestations showed that hiccups (P=0.04), respiratory distress (P=0.04), and hemorrhagic symptoms (P=0.01) were more frequent among patients who died. Malaria (72%) and diabetes (2%) were the most frequent co-morbidities. The crude case fatality rate was 44% [95% confidence interval (33-54%)]. The average hospital stay was 7.96±5.81 days.

CONCLUSION

The first Ebola outbreak in Conakry was characterized by the young age of patients, discrete hemorrhagic signs related to lethality. Its control relies on a strict use of preventive measures.