Delay in receipt of newly prescribed oral anticancer drugs

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Background: Oral anticancer drug (OACD) prescriptions require coordination between clinicians, payers, specialty pharmacies, and financial assistance (FA) groups, which may delay patient receipt of the drug. Factors associated with delay in receipt of OACDs are unknown. Methods: We prospectively collected data on all new OACD prescriptions (RXs) from the medical oncology practice at the Herbert Irving Comprehensive Cancer Center from 1/1/2018 to 12/1/2018. We collected patient demographic, insurance and clinical information; date of prescription; date of drug delivery; and staff interactions with payers and FA groups. Federal Drug Association (FDA) labels and Micromedex were reviewed for initial drug approval dates, approved indications and average wholesale price. We used multivariable linear and logistic regression to determine factors associated with number of days from prescription to receipt of OACD. Results: During the study period 510 OACD RXs were evaluated. Of these, 84 (16%) were never filled. The most common OACDs were capecitabine (90, 18%), abiraterone (45, 9%), palbociclib (35, 7%) and osimertinib (28, 6%). Of 426 filled RXs, the median time from prescription to receipt was 8 days (IQR 5-13), with 193 RXs (46%) received in ≤7 days, 145 (34%) in 8-14 days and 65 (15%) in 14-28 days, and 23 (5%) at > 28 days. Linear regression showed time to receipt of OACD (log transformed) was associated with having commercial primary insurance (p = 0.02), pursing FA (p = < 0.001), RX of a drug approved by the FDA < 2 years earlier (p = 0.008), drugs without an approved indication for the primary tumor (p = 0.03) and estimated drug cost (p = 0.002). The other included covariates, patient age and prior authorization, were not associated with time to receipt. Logistic regression comparing receipt at ≤14 versus > 14 days found association with FA (OR 3.17; 95%CI 1.78-5.65), FDA approval within 2 years (OR 3.52; 95%CI 1.31-9.45) and off-label use (OR 2.30; 95%CI 1.18-4.50). Conclusions: Over 20% of new OACDs were received 14 days or longer from the date of RX. Financial and insurance related factors; and more expensive and recently approved drugs were associated with longer delays in receipt of therapy. Policy changes to improve the timeliness of OACD access are needed.

Randomized trial of text messaging (TM) to reduce early discontinuation of aromatase inhibitor (AI) therapy in women with breast cancer: SWOG S1105

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Background: Non-adherence to AI’s for breast cancer is common and increases risk of recurrence. Text messaging (TM) has been shown to increase adherence to medications for chronic conditions. We conducted a multicenter randomized trial to evaluate if TM reminders improve AI adherence. Methods: Patients taking an AI for ≥30 days and having ≥36 mos of planned therapy were eligible. Patients were randomly assigned 1:1 to receive either TM or NO-TM twice a week for 36 mos. Randomization was stratified by length of time on prior AI therapy ( < 12 (64%) vs. 12-24 mos (36%)) and AI class (anastrozole, letrozole, exemestane). Content themes of the 36 TMs focused on overcoming barriers to adherence. Patients were assessed for discontinuation of AIs every 3 mos for 36 mos. The primary outcome was time to non-adherence, where non-adherence was defined as urine AI metabolite assay results satisfying the following: < 10 [units], undetectable, or no submitted specimen. A stratified Log-rank test was conducted. Multiple sensitivity analyses were performed using Cox regression. Results: In total, 724 patients were registered between May, 2012 and September, 2013, among whom 696 (338/360 (93.9%) on TM and 338/364 (92.9%) on NO-TM) were eligible and adherent at baseline. Observed (time-independent) adherence at 36 mos was 55.4% for TM and 55.4% for NO-TM. The primary analysis showed no difference in time-to-adherence failure between patients on the TM and NO-TM arms (HR = 0.89, 95% CI:0.76,1.05 p = .18). An analysis of negative urine tests alone resulted in similar non-significant results. With missed appointments not counted as failures, time to self-reported discontinuation (89.6% vs. 89.7%; HR = 1.17, 95% CI:0.69-1.98, p = .57) and site reported discontinuation (78.1% vs. 81.1%; HR = 1.31, 95% CI:0.86-2.01, p = .21) were also similar between the 2 groups. Conclusions: As the first large long-term randomized trial of an intervention directed at improving AI adherence, we found high rates of AI discontinuation. Bi-weekly text reminders did not improve adherence to AIs compared to usual care. Improving long—term adherence will likely require sustained behavioral interventions and support. Clinical trial information: NCT01515800.

Second-line treatment of metastatic gastric cancer in the era of predictive biomarkers: A cost-effectiveness analysis

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Background: Gastric cancer is the third leading cause of cancer-related mortality, with only a 30% five-year survival rate. Patients who progress after one round of systemic therapy face an especially poor prognosis. The National Comprehensive Cancer Network guidelines include both pembrolizumab (PEM) and ramucirumab plus paclitaxel (RAM/PAC) as second-line (2L) therapy for gastric cancer based on data from the Phase II KEYNOTE-059 and Phase III RAINBOW trials, respectively. Recently, the Phase III KEYNOTE-061 trial reported on the effectiveness of PEM for patients with programmed death-ligand 1 (PD-L1) expression and high microsatellite instability (MSI-H). Given the high prices of targeted therapies, it is important to determine if cost-effectiveness is possible using personalized treatment strategies. The aim of this study was to assess the cost-effectiveness of these regimens in both the general patient population and specific biomarker populations. Methods: A decision-analytic (Markov) model was constructed using data from the KEYNOTE-059, KEYNOTE-061, RAINBOW, and REGARD trials. The analysis compared PEM and RAM/PAC for all patients, as well as PEM for patients based on MSI status or PD-L1 expression (combined positive score of 1% or 10%) in the 2L setting. Comparators were paclitaxel monotherapy (PAC) for all patients and best supportive care (BSC) for all patients. Costs (USD) and utility values were estimated from Medicare and the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay (WTP) threshold of $100,000. Results: The only cost-effective strategy was PAC monotherapy for all patients, with an ICER of $53,705/QALY. PEM for MSI-H patients and RAM/PAC for microsatellite stable patients was the most effective strategy (greatest QALYs), but was not cost-effective with an ICER of $1,074,620/QALY. Conclusions: Despite their effectiveness, PEM and RAM/PAC are not cost-effective as 2L treatments for metastatic gastric cancer. Although personalizing treatment based on biomarkers improved cost-effectiveness, the ICERs surpassed the WTP threshold at current drug prices.

Factors associated with over and underuse of response evaluation in elderly myeloma patients

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Background: Most patients with multiple myeloma (MM) have detectable monoclonal protein. While guidelines do not specify the frequency of lab testing for response evaluation, most MM clinical trials perform monthly assessment. We examined the use of 4 serologic tests – protein electrophoresis (SPEP), immunofixation (IFE), quantitative immunoglobulins (QIG), and free light chain (FLC) in newly-diagnosed MM patients. Methods: We identified patients age ≥65 with MM (ICD-O 34000) in the Surveillance, Epidemiology and End Results (SEER)-Medicare database from 2000-2013. Patients were required to have bone marrow biopsy within 6 months of diagnosis, and taken chemotherapy approved for MM. Use of a test was defined as having ≥1 instance of its CPT code within 12 months of diagnosis. Patients with > 12 instances were defined as overusers. Multiple instances of a test on the same date were counted once. Multivariable logistic regression models using covariates including: age and year at MM diagnosis, race, marital status, Charlson comorbidity, chemotherapy use, number of hospitalizations and oncology office visits within 12 months of diagnosis, were developed to examine associations with overuse. Results: Among 6,214 identified patients, users were: SPEP 5,532 (89%), IFE 4,745 (76%), QIG 5,524 (89%), and FLC 3,864 (62%). The median (interquartile range) times each test was used in the first year following diagnosis were: SPEP 6 (3-10), IFE 3 (2-7), QIG 6 (3-10), FLC 5 (2-9). The numbers of overusers were: SPEP 721 (13%), IFE 265 (6%), QIG 498 (9%), FLC 350 (9%). 231 (4%) patients were overusers of 2 tests. Factors associated with overuse common to all 4 tests were: younger age at diagnosis (eg, SPEP: odds ratio (OR) 2.0 for aged 65-74 vs ≥85; P < .001), more oncology office visits (eg, QIG: OR 2.2 for > 15 vs 0-6; P < .001), and use of combination chemotherapy (eg, SPEP: OR 2.2 for proteasome inhibitor + immunomodulatory drug (IMID) vs those on IMID ; P < .001). Conclusions: In our Medicare population, patients on average underwent response evaluation much less often than monthly, but we also found overuse. Further investigation of the use of these tests is warranted given their central importance to MM care and their cumulative financial cost.

A Prospective Cohort Study of Factors Associated With Place of Death Among Patients With Late-Stage Cancer in Southern Africa

CONTEXT

Identifying factors that affect terminally ill patients' preferences for and actual place of death may assist patients to die wherever they wish.

OBJECTIVE

The objective of this study was to investigate factors associated with preferred and actual place of death for cancer patients in Johannesburg, South Africa.

METHODS

In a prospective cohort study at a tertiary hospital in Johannesburg, South Africa, adult patients with advanced cancer and their caregivers were enrolled from 2016 to 2018. Study nurses interviewed the patients at enrollment and conducted postmortem interviews with the caregivers.

RESULTS

Of 324 patients enrolled, 191 died during follow-up. Preferred place of death was home for 127 (66.4%) and a facility for 64 (33.5%) patients; 91 (47.6%) patients died in their preferred setting, with a kappa value of congruence of 0.016 (95% CI = -0.107, 0.139). Factors associated with congruence were increasing age (odds ratio [OR]: 1.03, 95% CI: 1.00-1.05), use of morphine (OR: 1.87, 95% CI: 1.04-3.36), and wanting to die at home (OR: 0.44, 95% CI: 0.24-0.82). Dying at home was associated with increasing age (OR 1.03, 95% CI 1.00-1.05) and with the patient wishing to have family and/or friends present at death (OR 6.73, 95% CI 2.97-15.30).

CONCLUSION

Most patients preferred to die at home, but most died in hospital and fewer than half died in their preferred setting. Further research on modifiable factors, such as effective communication, access to palliative care and morphine, may ensure that more cancer patients in South Africa die wherever they wish.

Reproductive characteristics modify the association between global DNA methylation and breast cancer risk in a population-based sample of women

DNA methylation has been implicated in breast cancer aetiology, but little is known about whether reproductive history and DNA methylation interact to influence carcinogenesis. This study examined modification of the association between global DNA methylation and breast cancer risk by reproductive characteristics. A population-based case-control study assessed reproductive history in an interviewer-administered questionnaire. Global DNA methylation was measured from white blood cell DNA using luminometric methylation assay (LUMA) and pyrosequencing assay (long interspersed elements-1 (LINE-1). We estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) among 1 070 breast cancer cases and 1 110 population-based controls. Effect modification was assessed on additive and multiplicative scales. LUMA methylation was associated with elevated breast cancer risk across all strata (comparing the highest to the lowest quartile), but estimates were higher among women with age at menarche ≤12 years (OR = 2.87, 95%CI = 1.96–4.21) compared to >12 years (OR = 1.66, 95%CI = 1.20–2.29). We observed a 2-fold increase in the LUMA methylation-breast cancer association among women with age at first birth >23 years (OR = 2.62, 95%CI = 1.90–3.62) versus ≤23 years (OR = 1.32, 95% CI = 0.84–2.05). No modification was evident for parity or lactation. Age at menarche and age at first birth may be modifiers of the association between global DNA methylation and breast cancer risk.

Clinico-pathological characteristics among South African women with breast cancer receiving anti-retroviral therapy for HIV

PURPOSE

Breast cancer is the most common cancer in women and a leading cause of cancer-related mortality worldwide. South Africa has the largest global burden of HIV infection and the largest anti-retroviral treatment (ART) program. This study aimed to analyse the association of HIV and ART use with breast cancer clinico-pathological characteristics.

METHODS

Study participants were females, newly diagnosed from May 2015 through September 2017 with invasive breast cancer at two academic Surgical Breast Units in Johannesburg, South Africa at the Charlotte Maxeke Johannesburg Academic Hospital and Chris Hani Baragwanath Academic Hospital. We compared HIV-positive and HIV negative patients' demographic and clinical-pathological characteristics at the time of breast cancer diagnosis.

RESULTS

Of 1050 patients enrolled, 1016 (96.8%) had known HIV status, with 226 (22.2%) being HIV positive. HIV positive patients were younger (median (IQR) age 45 (40-52) years), than HIV-negative patients (median (IQR) age 57 (46-67)) (p < 0.001). HIV positive patients were more likely to be diagnosed with late stage breast cancer (p = 0.01). However, HIV positive patients receiving ART at the time of breast cancer diagnosis were less likely to present with metastatic disease than those not on ART (p = 0.05).

CONCLUSION

HIV-positive patients present with breast cancer at a younger age and later stage disease than HIV-negative patients. Neither the duration of HIV infection nor ART use was associated with clinico-pathological characteristics of breast cancer.

FOLFOX and FOLFIRI Use in Stage IV Colon Cancer: Analysis of SEER-Medicare Data

BACKGROUND

Shortly after the year 2000, randomized trials demonstrated that patients with metastatic colon cancer treated with infusional 5-fluorouracil (5-FU)/leucovorin with either oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) had a comparable progression-free survival benefit, superior to patients who received 5-FU/leucovorin alone. Factors associated with the initial receipt of the FOLFOX or FOLFIRI regimen are unknown. Our goal was to investigate the patterns and predictors of use for first-line FOLFOX and FOLFIRI.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data set to identify patients with newly diagnosed stage IV colon cancer between the years 2005 and 2013 who received either first-line FOLFOX or FOLFIRI. We used logistic regression to assess demographic and clinical predictors for FOLFOX versus FOLFIRI. Survival was compared by Kaplan-Meier models.

RESULTS

Overall, 3000 patients (79.3%) received FOLFOX and 785 (20.7%) FOLFIRI. FOLFOX was associated with later year of diagnosis (odds ratio [OR] = 0.66, 95% confidence interval [CI], 0.54 to 0.82 for 2011-2013 vs. 2005-2007), being female (OR = 0.82; 95% CI 0.69 to 0.98), and living in the southern region of the United States. FOLFIRI was associated with having a higher comorbidity index (OR = 1.33; 95% CI, 1.07 to 1.67 for >1 comorbidity score vs. 0). There was no survival difference observed between the two treatments.

CONCLUSION

The majority of SEER-Medicare patients received FOLFOX and not FOLFIRI as a first-line treatment for stage IV colon cancer. Several demographic and clinical factors were associated with the use of each specific regimen. No survival difference was detected for the 2 groups.

Patterns of care and outcomes for women with uterine cancer and ovarian metastases

OBJECTIVE

For women with uterine cancer with metastases isolated to the adnexa (stage IIIA) optimal adjuvant therapy is unknown. We performed a population-based analysis to examine the use of chemotherapy, vaginal brachytherapy, and external beam therapy (in women with stage IIIA uterine cancer.

METHODS

The National Cancer Database was used to identify women with stage IIIA uterine cancer with ovarian metastasis from 2004 to 2012. We explored the use of chemotherapy, vaginal brachytherapy, and external beam therapy over time. Multivariable models were developed to examine factors associated with survival.

RESULTS

We identified 4088 women with uterine cancer and ovarian metastases. Overall, 56.2% of women received chemotherapy. Vaginal brachytherapy was used in 11.1%, while 36.6% received external beam therapy. Five-year survival was 64.7 % (95% CI, 62.9% to 66.5%). In a multivariable model, chemotherapy was associated with a 38% decrease in mortality (HR = 0.62; 95% CI, 0.54 to 0.71). Similarly, both external beam therapy (HR = 0.74; 95% CI, 0.65 to 0.85) and vaginal brachytherapy (HR = 0.67; 95% CI, 0.53 to 0.85) were associated with improved survival. When the cohort was limited to women who received chemotherapy, radiation was associated with improved overall survival (HR 0.74, 95% CI 0.61 to 0.90). There was no difference in survival between the use of external beam therapy and vaginal brachytherapy.

CONCLUSIONS

Chemotherapy was associated with a decrease in mortality in women with endometrial cancer and ovarian metastases. The addition of radiation therapy was associated with improved overall survival, although there was no difference between external beam therapy and vaginal brachytherapy.

Impact of estrogen monotherapy on survival in women with stage III-IV non-small cell lung cancer

OBJECTIVES

Women with lung cancer have better survival than men. The reasons are unknown, but estrogen is hypothesized to improve survival. Our objective was to examine the association between estrogen monotherapy and cancer-specific and overall survival in elderly women with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

We used the SEER-Medicare database to identify women ≥65 years old who were diagnosed with stage III or IV NSCLC. Estrogen monotherapy (EM) was defined as at least one estrogen claim without any progesterone claims 6 months prior to diagnosis. To assess cancer-specific survival and overall survival, we used Kaplan-Meier and multivariate Cox modeling with propensity score adjustments. As an exploratory analysis, we also examined the effect of combined estrogen and progesterone hormonal therapy on survival using Cox modeling.

RESULTS

We identified 6958 women in our initial cohort: 283 used EM (4%) and 6675 (96%) did not. The median follow-up time was 46.5 months in the EM patients and 49.5 months in the non-EM patients. In a Kaplan-Meier analysis, median overall survival was 8.2 months in patients who receive EM and 6.2 months in those who did not (p = 0.004). In our 1:4 propensity-matched cohort, median follow-up was 46.5 in the EM group and 50.6 in the non-EM group; median overall survival was 8.0 months in the EM group and 6.4 months in the non-EM group (p = 0.02). In a multivariate Cox regression of the matched cohort, EM was significantly associated with overall survival (HR 0.84; 95% CI 0.73 - 0.97). All results were similar for cancer-specific survival. In our exploratory analysis, combined Estrogen-Progesterone did significantly impact overall survival (HR 0.84; 95% CI 0.71-0.99, p = 0.04) but did not appear to effect cancer-specific survival (HR 0.91; 95% CI 0.77-1.09, p = 0.30).

CONCLUSION

EM was associated with a significant improvement in cancer-specific survival and overall survival in women with late stage NSCLC.

Genetic polymorphisms of diabetes-related genes, their interaction with diabetes status, and breast cancer incidence and mortality: The Long Island Breast Cancer Study Project

To examine 143 diabetes risk single nucleotide polymorphisms (SNPs), identified from genome-wide association studies, in association with breast cancer (BC) incidence and subsequent mortality. A population-based sample of Caucasian women with first primary invasive BC (n = 817) and controls (n = 1021) were interviewed to assess diabetes status. Using the National Death Index, women with BC were followed for >18 years during which 340 deaths occurred (139 BC deaths). Genotyping was done using DNA extracted from blood samples. We used unconditional logistic regression to estimate age-adjusted odds ratios and 95% confidence intervals (CIs) for BC incidence, and Cox regression to estimate age-adjusted hazard ratios and CIs for all-cause and BC-specific mortality. Twelve SNPs were associated with BC risk in additive genotype models, at α = 0.05. The top three significant SNPs included SLC30A8-rs4876369 (P = 0.0034), HHEX-rs11187146 (P = 0.0086), and CDKN2A/CDKN2B-rs1333049 (P = 0.0094). Diabetes status modified the associations between rs4876369 and rs2241745 and BC incidence, on the multiplicative interaction scale. Six SNPs were associated with all-cause (CDKAL1-rs981042, P = 0.0032; HHEX-rs1111875, P = 0.0361; and INSR-rs919275, P = 0.0488) or BC-specific (CDKN2A/CDKN2B-rs3218020, P = 0.0225; CDKAL1-rs981042, P = 0.0246; and TCF2/HNF1B-rs3094508, P = 0.0344) mortality in additive genotype models, at α = 0.05. Genetic polymorphisms that increase the risk of developing diabetes may also increase the risk of developing and dying from BC.

Neoadjuvant Chemotherapy Use for Nonmetastatic Breast Cancer at Five Public South African Hospitals and Impact on Time to Initial Cancer Therapy

In sub‐Saharan Africa, clinical decisions can be affected by resource constraints. This article analyzes the clinical and sociodemographic factors associated with receiving neoadjuvant chemotherapy among patients from a previously existing cohort: women enrolled in the prospective South African Breast Cancer and HIV Outcomes study.

Background.

In the U.S., neoadjuvant chemotherapy (NAC) for nonmetastatic breast cancer (BC) is used with extensive disease and aggressive molecular subtypes. Little is known about the influence of demographic characteristics, clinical factors, and resource constraints on NAC use in Africa.

Materials and Methods.

We studied NAC use in a cohort of women with stage I–III BC enrolled in the South African Breast Cancer and HIV Outcomes study at five hospitals. We analyzed associations between NAC receipt and sociodemographic and clinical factors, and we developed Cox regression models for predictors of time to first treatment with NAC versus surgery.

Results.

Of 810 patients, 505 (62.3%) received NAC. Multivariate analysis found associations between NAC use and black race (odds ratio [OR] 0.49; 95% confidence limit [CI], 0.25–0.96), younger age (OR 0.95; 95% CI, 0.92–0.97 for each year), T‐stage (T4 versus T1: OR 136.29; 95% CI, 41.80–444.44), N‐stage (N2 versus N0: OR 35.64; 95% CI, 16.56–76.73), and subtype (triple‐negative versus luminal A: OR 5.16; 95% CI, 1.88–14.12). Sites differed in NAC use (Site D versus Site A: OR 5.73; 95% CI, 2.72–12.08; Site B versus Site A: OR 0.37; 95% CI, 0.16–0.86) and time to first treatment: Site A, 50 days to NAC versus 30 days to primary surgery (hazard ratio [HR] 1.84; 95% CI, 1.25–2.71); Site D, 101 days to NAC versus 126 days to primary surgery (HR 0.49; 95% CI, 0.27–0.89).

Conclusion.

NAC use for BC at these South African hospitals was associated with both tumor characteristics and heterogenous resource constraints.

Implications for Practice.

Using data from a large breast cancer cohort treated in South Africa's public healthcare system, the authors looked at determinants of neoadjuvant chemotherapy use and time to initiate treatment. It was found that neoadjuvant chemotherapy was associated with increasing tumor burden and aggressive molecular subtypes, demonstrating clinically appropriate care in a lower resource setting. Results of this study also showed that time to treatment differences between chemotherapy and surgery varied by hospital, suggesting that differences in resource limitations were influencing clinical decision making. Practice guidelines and care quality metrics designed for low‐ and middle‐income countries should accommodate heterogeneity of available resources.

Factors Associated With Follow-Up Care Among Women With Early-Stage Breast Cancer

PURPOSE

Follow-up guidelines vary widely among national organizations for patients with early-stage breast cancer treated with curative intent. We sought to evaluate the patterns and predictors of provider follow-up care within the first 5 years after diagnosis.

METHODS

Using the SEER-Medicare linked data set, we evaluated patients who were diagnosed with stage I and II breast cancer who underwent breast-conserving surgery from 2002 to 2007 with follow-up until 2012. We defined discontinuation of follow-up as > 12 months from the previous physician visit without a visit claim from either a surgeon, medical oncologist, or radiation oncologist. We performed a multivariable logistic regression and Cox proportional hazards regression analysis to determine factors associated with the discontinuation of follow-up care.

RESULTS

Of the 30,053 patients enrolled in our initial cohort, 25,781 (85.8%) saw a medical oncologist and 21,612 (71.9%) saw a radiation oncologist in the first year in addition to a surgeon. Over the 5 years, 6,302 patients (21.0%) discontinued follow-up visits. Discontinuation of physician visits increased with increasing age. Women with stage II cancer ( v stage I) were less likely to discontinue follow-up visits (odds ratio, 0.78; 95% CI, 0.73 to 0.83). Time to early discontinuation was greater for patients with hormone receptor-negative tumors (hazard ratio, 1.14; 95% CI, 1.05 to 1.24). Women who were diagnosed more recently were less likely to discontinue seeing any physician.

CONCLUSION

Twenty-one percent of patients with early-stage breast cancer discontinued seeing any oncology provider over the 5 years after diagnosis. Coordination of follow-up care between oncology specialists may reduce discontinuation rates and increase clinical efficiency.

Clair CM, Ananth CV, Neugut AI, Hershman DL, Wright JD. Use and outcomes of minimally invasive hysterectomy for women with nonendometrioid endometrial cancers

BACKGROUND

Minimally invasive hysterectomy is now used routinely for women with uterine cancer. Most studies of minimally invasive surgery for endometrial cancer have focused on low-risk endometrioid tumors, with few reports of the safety of the procedure for women with higher risk histologic subtypes.

OBJECTIVE

The purpose of this study was to examine the use of and survival associated with minimally invasive hysterectomy for women with uterine cancer and high-risk histologic subtypes.

STUDY DESIGN

We used the National Cancer Database to identify women with stages I-III uterine cancer who underwent hysterectomy from 2010-2014. Women with serous carcinomas, clear cell carcinomas, and sarcomas were examined. Women who had laparoscopic or robotic-assisted hysterectomy were compared with those who underwent open abdominal hysterectomy. After a propensity score inverse probability of treatment weighted analysis, the effect of minimally invasive hysterectomy on overall, 30-day, and 90-day mortality rates was examined for each histologic subtype of uterine cancer.

RESULTS

Of 94,507 patients who were identified, 64,417 patients (68.2%) underwent minimally invasive hysterectomy. Among women with endometrioid tumors (n=81,115), 70.8% underwent minimally invasive hysterectomy. The rates of minimally invasive surgery in those women with nonendometrioid tumors (n=13,392) was 57.6% for serous carcinomas, 57.0% for clear cell tumors, 47.3% for sarcomas, 32.2% for leiomyosarcomas, 47.9% for stromal sarcomas, and 48.5% for carcinosarcomas. Performance of minimally invasive surgery increased across all histologic subtypes between 2010 and 2014. For nonendometrioid subtypes, robotic-assisted procedures accounted for 47.9-75.7% of minimally invasive hysterectomies by 2014. In a multivariable model, women with nonendometrioid tumors were less likely to undergo minimally invasive surgery than those with endometrioid tumors (P<.05). There was no association between route of surgery and 30-day, 90-day, or overall mortality rates for any of the nonendometrioid histologic subtypes.

CONCLUSION

The use of minimally invasive surgery is increasing rapidly for women with stage I-III nonendometrioid uterine tumors. Performance of minimally invasive surgery does not appear to impact survival adversely.

Epidemiologic trends in neuroendocrine tumors: An examination of incidence rates and survival of specific patient subgroups over the past 20 years

INTRODUCTION

Neuroendocrine tumors (NETs) represent a small proportion of cancers, but are increasing in incidence due to incidental diagnosis. We examined NET incidence and survival over time in a population-based registry.

MATERIALS/METHODS

We identified all NET cases diagnosed between 1995 and 2014 in the Surveillance, Epidemiology, and End Results database, November 2016 submission. We determined incidence rates and calculated overall and cancer-specific survival curves in different subgroups stratified by grade, stage, and age at diagnosis.

RESULTS

We identified 85,133 patients with a diagnosis of NET between 1995 and 2014. Patients with grade 1, localized NETs had the best median overall survival (233 months, 95% confidence intervals [CI] not estimable) and 5-year cancer-specific survival (97.6%; 95% CI, 97.4%, 97.8%). The median overall survival decreased with age across the entire spectrum of ages, with patients >70 years having a particularly poor prognosis (28.0 months; 95% CI, 26.5, 29.5). Patients >70 years old often had distant (34.3%) or grade 3 disease (40.8%), but even elderly patients with lower grade and/or stage disease had worse median overall survival compared with younger subjects.

CONCLUSIONS

Age appears to be associated with a worse prognosis independent of NET stage, and grade at the time of diagnosis. Patients with grade 1, localized NETs have an excellent long-term prognosis. Further research is warranted on reducing intensity of surveillance in these patients.

Regional Market Competition and the Use of Immediate Breast Reconstruction After Mastectomy

BACKGROUND

Prior work has shown that the competitiveness of the market in which hospitals operate is associated with use of surgical procedures. This study examined the association between regional market competition and use of breast reconstruction for women with breast cancer and ductal carcinoma in situ undergoing mastectomy.

METHODS

Women who underwent mastectomy from 2010 to 2011 recorded in the National Inpatient Sample were selected. The competitive market environment for each hospital in which patients were treated was estimated using the Herfindahl-Hirschman Index. Multivariable models were developed to examine the association between regional market competition and breast reconstruction, with adjustment for other clinical, demographic, and structural variables.

RESULTS

Immediate breast reconstruction was performed for 9902 (45%) of 22,011 women. The rate of immediate breast reconstruction was 34.5% at hospitals in non-competitive markets, 49% at hospitals in moderately competitive markets, and 56.4% at hospitals in highly competitive markets (P < 0.0001). In a multivariable model, women in moderately competitive markets were 24% (risk ratio [RR] 1.24; 95% confidence interval [CI] 1.10-1.41) more likely to undergo immediate breast reconstruction than women in noncompetitive markets, whereas those in competitive markets were 25% (RR 1.25; 95% CI 1.11-1.41) more likely to have reconstruction. Later year of treatment, higher census tract income level, and residence in an urban area were associated with an increased likelihood of reconstruction (P < 0.05 for all). In contrast, older age, non-white race, and non-commercial insurance were associated with a lower likelihood of reconstruction (P < 0.05 for all).

CONCLUSION

Patients who undergo mastectomy at hospitals in competitive markets are more likely to undergo immediate breast reconstruction.

Magnetic Resonance Imaging-Based Screening for Asymptomatic Brain Tumors: A Review

Brain tumors comprise 2% of all cancers but are disproportionately responsible for cancer-related deaths. The 5-year survival rate of glioblastoma, the most common form of malignant brain tumor, is only 4.7%, and the overall 5-year survival rate for any brain tumor is 34.4%. In light of the generally poor clinical outcomes associated with these malignancies, there has been interest in the concept of brain tumor screening through magnetic resonance imaging. Here, we will provide a general overview of the screening principles and brain tumor epidemiology, then highlight the major studies examining brain tumor prevalence in asymptomatic populations in order to assess the potential benefits and drawbacks of screening for brain tumors. IMPLICATIONS FOR PRACTICE: Magnetic resonance imaging (MRI) screening in healthy asymptomatic adults can detect both early gliomas and other benign central nervous system abnormalities. Further research is needed to determine whether MRI will improve overall morbidity and mortality for the screened populations and make screening a worthwhile endeavor.

Development, Evaluation, and Implementation of a Pan-African Cancer Research Network: Men of African Descent and Carcinoma of the Prostate

PURPOSE

Cancer of the prostate (CaP) is the leading cancer among men in sub-Saharan Africa (SSA). A substantial proportion of these men with CaP are diagnosed at late (usually incurable) stages, yet little is known about the etiology of CaP in SSA.

METHODS

We established the Men of African Descent and Carcinoma of the Prostate Network, which includes seven SSA centers partnering with five US centers to study the genetics and epidemiology of CaP in SSA. We developed common data elements and instruments, regulatory infrastructure, and biosample collection, processing, and shipping protocols. We tested this infrastructure by collecting epidemiologic, medical record, and genomic data from a total of 311 patients with CaP and 218 matched controls recruited at the seven SSA centers. We extracted genomic DNA from whole blood, buffy coat, or buccal swabs from 265 participants and shipped it to the Center for Inherited Disease Research (Baltimore, MD) and the Centre for Proteomics and Genomics Research (Cape Town, South Africa), where genotypes were generated using the UK Biobank Axiom Array.

RESULTS

We used common instruments for data collection and entered data into the shared database. Double-entered data from pilot participants showed a 95% to 98% concordance rate, suggesting that data can be collected, entered, and stored with a high degree of accuracy. Genotypes were obtained from 95% of tested DNA samples (100% from blood-derived DNA samples) with high concordance across laboratories.

CONCLUSION

We provide approaches that can produce high-quality epidemiologic and genomic data in multicenter studies of cancer in SSA.

Sentinel Lymph Node Biopsy Pathology and 2-Year Postsurgical Recurrence of Breast Cancer in Kenyan Women

PURPOSE

The goal of this study was to describe the pathologic findings and early follow-up experience of patients who underwent a sentinel lymph node biopsy (SLNB) at Aga Khan University Hospital (AKUH) between 2008 and 2017.

PATIENTS AND METHODS

We performed a retrospective analysis of women with breast cancer who underwent an SLNB at AKUH between 2008 and 2017. The SLNB was performed on patients with stage I and stage II breast cancer, and identification of the sentinel lymph node was made by radioactive tracer, blue dye, or both, per availability and surgeon preference. Demographic, surgical, and pathologic data, including immunohistochemistry of the surgical sample for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2, were abstracted from the patient records. Follow-up data were available for a subset of patients.

RESULTS

Between 2008 and 2017, six surgeons performed SLNBs on 138 women, 129 of whom had complete records and were included in the study. Thirty-one of 129 (24%) had a positive SLNB, including 10 of 73 (14%) with stage I and 21 of 56 (38%) with stage II disease. Seventy-eight patients (60%) received systemic adjuvant chemotherapy and 79 (62%) received radiation therapy, and of the 102 patients who were estrogen receptor positive, 86 (85%) received endocrine therapy. Seventy-nine patients were observed for > 2 years, and, of these, four (5.1%) had a regional recurrence.

CONCLUSION

The SLNB positivity rates were similar to those of high-income country (HIC) cohorts. However, preliminary data suggest that recurrence rates are elevated at AKUH as compared with those of HIC cohorts, perhaps because of a lower use of radiotherapy and chemotherapy at AKUH compared with HIC cohorts or because of differences in the characteristics of the primary tumor in patients at AKUH as compared with those in HICs.

Informal Caregiver Challenges for Advanced Cancer Patients During End-of-Life Care in Johannesburg, South Africa and Distinctions Based on Place of Death

CONTEXT

In sub-Saharan Africa, late diagnosis with cancer is common. Many dying patients rely on family members for care; little is known about the challenges African informal caregivers face.

OBJECTIVES

To better understand the challenges of informal caregivers at the end of life in South Africa, both at home and in inpatient facilities.

METHODS

We included advanced cancer patients and caregivers from a public hospital in Johannesburg, South Africa. Study nurses interviewed patients and caregivers about their experiences. Using univariate and multivariate analyses, we determined the factors associated with greater caregiver difficulty, focusing on patients dying at home vs. in inpatient facilities.

RESULTS

Among 174 informal caregivers, 62 (36%) reported "a lot" of challenges. These caregivers struggled most with keeping the patient clean (16%) and with patient interactions (34%). Symptoms associated with greater difficulty included pain (odds ratio [OR] 2.4 [95% CI 1.2-4.7]), urinary incontinence (OR 2.3 [95% CI 1.1-4.9]), fecal incontinence (OR 2.4 [95% CI 1.0-5.7]), insomnia (OR 2.9 [95% CI 1.3-6.9]), fatigue (OR 6.3 [95% CI 1.8-21.6]), extremity weakness (OR 2.9 [95% CI 1.3-6.9]), shame (OR 4.2 [95% CI 1.5-12.0]), and sadness (OR 2.3 [95% CI 1.1-4.8]). Caregivers of patients dying at home reported the greatest difficulty with patients' physical symptoms; caregivers of those dying in facilities reported the greatest difficulty with emotional symptoms.

CONCLUSION

Informal caregivers of patients dying at home reported challenges with practical functional care; this effect was reduced in the inpatient setting. Skills training for these caregivers could relieve some of this burden.

Abstract 664: Surgery plus adjuvant radiation as a valid treatment option for primary central nervous system lymphoma (PCSNL)

Background: Recent studies of primary central nervous system lymphoma (PCNSL) have found an association between cytoreductive surgery and survival, challenging the traditional notion that surgery is not beneficial and potentially harmful. However, no studies have examined outcomes after surgery plus adjuvant treatment. We investigated treatment-related outcomes for surgery plus radiation using data from the Surveillance, Epidemiology, and End Results (SEER) Program.

Methods: The SEER database was queried to collect cases of histologically confirmed non-Hodgkin's lymphoma within the CNS diagnosed between 1995-2014. Median survival times were determined by the Kaplan-Meier method and compared using the log-rank test. Predictors of overall survival and cause-specific survival were determined using the Cox proportional hazards regression model. Treatment modalities were categorized as biopsy alone, biopsy plus radiation therapy (RT), surgery alone, and surgery + RT. Biopsy alone was used as the reference category. Subgroup analysis stratified patients by extent of surgical resection and recursive partition analysis (RPA) risk group.

Results: We identified 5,417 cases that met search criteria, 39% of which received surgical resection. Median survival times for biopsy alone (n=1,824, 34%), biopsy + RT (n=1,460, 27%), surgery alone (n=1,222, 23%), and surgery + RT (n=911, 17%) were 7, 8, 20, and 27 months, respectively (p&lt;0.0001). On multivariable analysis, RT after surgery was associated with a 13% incremental increase in overall survival (Hazard Ratio [HR]=0.71, p&lt;0.0001 vs. HR=0.58, p&lt;0.0001). When analyzing by extent of resection, median survival times for subtotal resection alone (n=111, 2%), gross-total resection alone (n=583, 11%), subtotal resection + RT (n=98, 2%), and gross-total resection + RT (n=459, 8.5%) were 10, 20, 20, and 27 months, respectively (p&lt;0.0001). RT after surgery was independently associated with increased survival in the gross-total resection subgroup (HR=0.85, p=0.046) and in all patients who received surgery (HR=0.87, p=0.017). RT after surgery was also associated with an incremental increase in survival in the RPA class I (HR=0.47, p&lt;0.0001 vs. 0.40, p&lt;0.0001) and class II-III (HR=0.77, p&lt;0.0001 vs. HR=0.66, p&lt;0.0001) subgroups. All findings were confirmed by multivariable analysis of cause-specific survival.

Conclusion: Surgical resection of PCNSL in the general population is more common than previously thought. Radiation therapy after surgery is associated with increased survival, regardless of the extent of surgical resection or the patient's RPA risk category. Neurotoxicity, dosing, and effects of concurrent chemotherapy should be addressed in future studies.

Citation Format: Connor J. Kinslow, Ali I. Rae, Alfred I. Neugut, Christopher M. Adams, Sameer A. Sheth, Guy M. McKhann, Michael B. Sisti, Jeffrey N. Bruce, Fabio M. Iwamoto, Adam M. Sonabend, Tony J. Wang. Surgery plus adjuvant radiation as a valid treatment option for primary central nervous system lymphoma (PCSNL) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 664.

Abstract 243: Genetic polymorphisms of diabetes-related genes, their interaction with diabetes status, and breast cancer incidence and mortality: The Long Island Breast Cancer Study Project

Background: Diabetes is associated with increased risk of breast cancer and subsequent mortality; however, whether genetic variants that increase diabetes risk also influence breast cancer has received little attention. Herein, we examined the associations between 143 single nucleotide polymorphisms (SNPs) identified from genome-wide association studies of diabetes risk, and breast cancer incidence and subsequent mortality. For SNPs significantly associated with breast cancer incidence or mortality, we evaluated effect modification by diabetes status.

Methods: Caucasian women diagnosed with first primary invasive breast cancer (n=817) and controls (n=1,021) from a population-based case-control study were interviewed to assess diabetes status. Using the National Death Index, women with breast cancer were followed for more than 18 years during which we identified 340 deaths including 139 from breast cancer. Genomic DNA was extracted from blood samples and genotyping was done using high-throughput matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. We used logistic regression to estimate age-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for breast cancer incidence and used Cox regression to estimate age-adjusted hazard ratios (HRs) and 95% CIs for all-cause and breast cancer-specific mortality.

Results: Twelve SNPs were associated with incident breast cancer in additive models, at an alpha of 0.05. The top three most significantly associated SNPs included SLC30A8 rs4876369 (P=0.0034), HHEX rs11187146 (P=0.0086), and CDKN2A/CDKN2B rs1333049 (P=0.0086). Diabetes status modified two SNP-breast cancer incidence associations: SLC30A8 rs4876369 was associated with a 25% increase (OR=1.25, 95% CI=1.02-1.53) in odds of breast cancer among women without diabetes, and with a 330% increase (OR=4.30, 95% CI=1.66-11.17) in odds of breast cancer among women with diabetes (PInteraction=0.0150). IRS2 rs2241745 was inversely associated (OR=0.76, 95% CI=0.61-0.94) with breast cancer among women without diabetes, and associated with a 76% increase (OR=1.76, 95% CI=0.86-3.58) in odds of breast cancer among women with diabetes (PInteraction=0.0283). Three SNPs were associated with all-cause (CDKAL1 rs981042, P=0.0032; HHEX rs1111875, P=0.0361; and INSR rs919275, P=0.0488) and three with breast cancer-specific (CDKN2A/CDKN2B rs3218020, P=0.0225; CDKAL1 rs981042, P=0.0246; and TCF2/HNF1B rs3094508, P=0.0344) mortality in additive models, at an alpha of 0.05.

Conclusions: SNPs identified in GWAS studies of diabetes risk were associated with breast cancer incidence and mortality among a population-based sample of women. These associations may highlight important biological mechanisms of breast carcinogenesis and progression.

Citation Format: Humberto Parada, Rebecca J. Cleveland, Kari E. North, June Stevens, Susan L. Teitelbaum, Alfred I. Neugut, Regina M. Santella, Maria E. Martinez, Marilie D. Gammon. Genetic polymorphisms of diabetes-related genes, their interaction with diabetes status, and breast cancer incidence and mortality: The Long Island Breast Cancer Study Project [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 243.