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<0.0001). On multivariable analysis, RT after surgery was associated with a 13% incremental increase in overall survival (Hazard Ratio [HR]=0.71, p<0.0001 vs. HR=0.58, p<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<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<0.0001 vs. 0.40, p<0.0001) and class II-III (HR=0.77, p<0.0001 vs. HR=0.66, p<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.

Urinary Phthalate Metabolite Concentrations and Breast Cancer Incidence and Survival following Breast Cancer: The Long Island Breast Cancer Study Project

BACKGROUND

Phthalates, known endocrine disruptors, may play a role in breast carcinogenesis. Few studies have examined phthalates in relation to breast cancer (BC), and, to our knowledge, none have considered survival following BC.

OBJECTIVES

We examined 11 urinary phthalate metabolites, individually and as molar sum groupings, in association with BC incidence and subsequent survival.

METHODS

Our study includes 710 women diagnosed with first primary BC in 1996-1997 and 598 women without BC from Long Island, New York. Within 3 mo of diagnosis, participants provided spot urine samples. Nine phthalate metabolites were measured in all women; two [monocarboxyoctyl phthalate (MCOP) and monocarboxy-isononyl phthalate (MCNP)] were measured in 320 women with and 205 without BC. Women with BC were followed since diagnosis using the National Death Index; during follow-up (median=17.6 y), we identified 271 deaths (98 BC related). We examined creatinine-corrected metabolite concentrations in association with: BC, using logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) and all-cause/BC-specific mortality, using Cox regression to estimate hazard ratios (HRs) and 95% CIs. We also examined effect modification by body mass index (BMI) and estrogen receptor (ER) status.

RESULTS

The highest (vs. lowest) quintiles of mono(3-carboxypropyl) phthalate (MCPP), monobenzyl phthalate (MBzP), MCNP, and MCOP were associated with BC ORs ranging from 0.71-0.73. The highest (vs. lowest) quintiles of mono(2-ethylhexyl) phthalate (MEHP) and MCOP were associated with BC-specific mortality HRs of 0.54 (95% CI: 0.28, 1.04) and 0.55 (95% CI: 0.23, 1.35), respectively. For BC-specific mortality, interactions were significant between BMI and mono(2-ethyl-5-oxyhexyl) phthalate (MEOHP), mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), and mono(2-ethyl-5-carboxypentyl) phthalate (MECPP), with positive associations among women with BMI<25 and inverse associations among women with BMI≥25.0 kg/m².

CONCLUSIONS

Consistent with laboratory evidence, we observed inverse associations between urinary concentrations of several phthalate metabolites and BC and subsequent survival; however, these results should be interpreted with caution given that biospecimen collection among women with BC occurred after diagnosis, which may be of particular concern for our case-control findings. https://doi.org/10.1289/EHP2083.

Adherence to colonoscopy at 1 year following resection of localized colon cancer: a retrospective cohort study

BACKGROUND

For patients with stages I-III colon cancer who have undergone surgical resection, guidelines recommend surveillance colonoscopy at 1 year. However, limited data exist on adherence and associated factors. We aimed to determine the rate of adherence to surveillance colonoscopy at 1 year among nonmetastatic colon cancer patients who underwent resection and factors associated with adherence.

METHODS

In this population-based retrospective cohort study, the Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used. We identified patients with stages I-III colon cancer who underwent surgical resection and survived >3 years without recurrence (no chemotherapy after 8 months) from 2002-2011. Our primary outcome was a colonoscopy claim 10-15 months after resection. We used multivariable regression analysis to assess associations between sociodemographic and clinical factors and receipt of timely colonoscopy.

RESULTS

Among 28,732 patients who survived >3 years without recurrence, 7967 (28%) did not undergo colonoscopy; 12,033 (42%) had it at one year, with 3159 (11%) before 10 months and 5573 (19%) after 15 months. Decreased adherence was associated with older age; being male versus female; being black or Hispanic versus white; higher tumor stage; left-sided tumors versus right sided; and increased comorbidities. Chemotherapy receipt was associated with increased adherence (odds ratio 2.06; 95% confidence interval 1.88-2.24).

CONCLUSIONS

In a large population-based sample of individuals aged ⩾ 65 years, only 42% of colon cancer survivors underwent 1-year surveillance colonoscopy. Demographic and clinical factors were associated with adherence.

Pre-diagnostic aspirin use and mortality after breast cancer

BACKGROUND

Whether aspirin or other nonsteroidal anti-inflammation drug (NSAID) use is associated with mortality following breast cancer remains unclear. Consideration of use patterns and interaction with obesity may help to clarify the inconsistent results.

METHODS

Pre-diagnosis NSAID use, weight, and height were assessed ~ 3 months after diagnosis through in-person interviews with a population-based cohort of 1,442 women with first primary breast cancer. Vital status was determined through the national death index after ~ 18 years of follow-up (N = 237/597 breast cancer-specific/all-cause deaths). We used Cox proportional hazards regression to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Multiplicative interaction by body mass index (BMI) was evaluated using the likelihood ratio test.

RESULTS

Ever aspirin use was inversely associated with breast cancer-specific mortality (HR 0.87, 95% CI 0.59-1.29), but positively associated with all-cause mortality (HR 1.21, 95% CI 0.99-1.48); the CIs included the null values. The HRs, however, were more pronounced for the highest level of duration, frequency, regularity, and timing for all-cause, but not breast cancer-specific mortality. Interactions with BMI revealed no significant heterogeneity (p_interaction = 0.37 and p_interaction = 0.36, respectively).

CONCLUSION

Pre-diagnosis aspirin use was not strongly associated with mortality following breast cancer. The all-cause mortality associations, however, were slightly stronger when we considered patterns of use.

Anti-EGFR Therapy in Small Bowel Adenocarcinoma

Small bowel adenocarcinoma is a rare disease occurring 50–100‐fold less often than colorectal cancer. This commentary describes similarities and differences between the two diseases and related results of recent clinical trials.

Abstract PD7-03: Cost-effectiveness analysis of intraoperative radiotherapy for ductal carcinoma in situ

Background

Whole breast radiation therapy (WBRT) following lumpectomy for ductal carcinoma in situ (DCIS) is standard of care, however, the risk of local recurrence with and without radiation ranges as low as 0.9% vs. 6.7% over 7 years. Intraoperative radiotherapy (IORT) is a potential alternative with advantages of decreased toxicity to adjacent organs, convenience, and improved quality of life. While prospective trials of IORT for DCIS are ongoing, the objective of this study was to estimate the cost-effectiveness of IORT vs. WBRT vs. no radiation for DCIS.

Methods

We developed a Markov model using TreeAge Pro 2016 to evaluate the cost-effectiveness of WBRT, IORT, and no radiation in patients with DCIS following lumpectomy. Health states included disease free, local recurrence (ipsilateral DCIS or invasive cancer), distant recurrence or death due to breast cancer, and death due to non-breast cancer causes. A 10-year time horizon and societal perspective were used. Model input parameters were derived from the literature. Costs reflected 2016 Medicare rates. The primary endpoint was incremental cost-effectiveness ratio (ICER), defined as the difference in cost, divided by the difference in quality-adjusted life years (QALYs) of two interventions. We performed analyses of subgroups defined according to DCIS risk (histologic grade, Oncotype Dx® DCIS recurrence score, low risk per RTOG 9804 criteria) and endocrine therapy use (none, tamoxifen, aromatase inhibitor). Sensitivity analyses explored uncertainty in the model.

Results

IORT was the most cost-effective strategy, with an increase of 0.18 QALYs at an incremental cost of $4,728, corresponding to an ICER of $26,943/QALY when compared with no radiation therapy. WBRT resulted in an increase in 0.18 QALYs at an incremental cost of $6859, corresponding to an ICER of $39,085/QALY. For both strategies, the ICERs did not exceed the willingness to pay (WTP) threshold of $100,000.

IORT remained the most cost-effective strategy across DCIS risk groups, but was more cost-effective in higher risk patients, as demonstrated by lower ICERs. In low risk DCIS defined by RTOG 9804 criteria, no radiation was most cost-effective. The ICERs for IORT and WBRT, $152,753 and $208,204/QALY, respectively, exceeded the WTP threshold. IORT remained cost-effective in the setting of endocrine therapy use.

Incremental Cost-Effectiveness Ratios (ICER) for each radiation strategy for the base case and scenario analyses ICER ($/QALY) No RTIORTWBRTBase Case Analysis 26,94339,085    Scenario Analysis by DCIS Risk GroupHistologic Grade   - Low 36,81152,219- High 25,64337,137    Oncotype Dx DCIS Score   - Low 92,892126,398- High 32,00345,690    Low Risk DCIS 152,753208,204    Scenario Analysis by Endocrine TherapyNo Tamoxifen 23,38734,373Tamoxifen 47,81166,616    Tamoxifen 31,96146,272Aromatase Inhibitor 41,31658,674

Conclusion

IORT was the most cost-effective radiation strategy for DCIS compared to WBRT and no radiation. This applied to all subgroups with the exception of low-risk DCIS defined by RTOG 9804 criteria for whom no radiation was the most cost-effective strategy. These findings provide support for ongoing studies examining the role of IORT for DCIS with high-risk features, as well as alternative treatment strategies for low-risk DCIS.

Citation Format: Onishi M, Connolly EP, Wright JD, Vasan S, Gross T, Tsai W-Y, Chen L, Neugut AI, Accordino MK, Kalinsky K, Crew KD, Hershman DL. Cost-effectiveness analysis of intraoperative radiotherapy for ductal carcinoma in situ [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD7-03.

Neoadjuvant chemotherapy among patients treated for nonmetastatic breast cancer in a population with a high HIV prevalence in Johannesburg, South Africa

Background

Neoadjuvant (primary) chemotherapy (NACT) is the standard of care for locally advanced breast cancer. It also allows for the short-term assessment of chemotherapy response; a pathological complete responses correspond to improved long-term breast cancer outcomes. In sub-Saharan Africa, many patients are diagnosed with large nonresectable tumors. We examined NACT use in breast cancer patients who visited public hospitals in Johannesburg, South Africa.

Methods

We assessed demographic characteristics, tumor stage and grade, hormone receptor status, and human immunodeficiency virus (HIV) status of female patients diagnosed with nonmetastatic invasive carcinoma of the breast at Chris Hani Baragwanath Academic Hospital between January 1, 2009, and December 31, 2011. The patients received neoadjuvant, adjuvant, or no chemotherapy. Trastuzumab was unavailable. We developed logistic regression models to analyze the factors associated with NACT receipt in these patients.

Results

Of 554 women with nonmetastatic breast cancer, the median age at diagnosis was 52 years (range: 28–88 years). Only 5.8% of patients were diagnosed with stage I disease; 49.3% and 44.9% were diagnosed with stages II and III, respectively. Most patients had hormone-responsive tumors: luminal A, 38.1%; luminal B₁ (human epidermal growth factor receptor 2 [HER2]-negative and high grade), 12.5%, and luminal B₂ (HER2-positive any grade), 11.6%; 11.6% had a HER2-enriched tumor and 20.6% a triple-negative tumor. Eighty (14.4%) patients were HIV-positive. In total, 195 patients (35.2%) received NACT, 264 (47.7%) patients received adjuvant chemotherapy, and 95 patients (17.1%) received no chemotherapy, including 62 (11.2%) patients who received only hormonal therapy. Of patients receiving NACT, 125 (64.1%) were evaluable for clinical response. Eighty (64.0%) patients had a clinically significant response; 19 (15.2%) patients had a stable disease, and 26 (20.8%) patients had a progressive disease. Multivariate analysis showed age <40 years and disease stage to be independently associated with the receipt of NACT.

Conclusion

Most women receiving NACT with available response data showed a clinical benefit. Stage III disease at diagnosis and age <40 years were predictors of neoadjuvant versus adjuvant chemotherapy treatment.

Barriers to early presentation of breast cancer among women in Soweto, South Africa

PURPOSE

Reported breast cancer incidence is rising in South Africa, where some women are diagnosed late and have poor outcomes. We studied patient and provider factors associated with clinical stage at diagnosis among women diagnosed at the Chris Hani Baragwanath Academic Hospital in Soweto, Johannesburg in 2015-2016.

METHODS

From face-to-face interviewer-administered questionnaires we compared self-reported socioeconomics, demographics, comorbidities, risk factors, personal and health system barriers, and from patient clinical records, clinical staging, receptor subtype, and tumor grade among 499 consecutive women newly diagnosed with advanced stage (III/IV) breast cancer versus those diagnosed early (stage 0/I/II). Logistic regression models were used to identify factors associated with advanced stage at diagnosis.

RESULTS

Among the women, 243 (49%) were diagnosed at early and 256 (51%) at advanced stages. In the multiple logistic regression adjusted model, completion of high school or beyond (odds ratio (OR) 0.59, and greater breast cancer knowledge and awareness (OR 0.86) were associated with lower stage of breast cancer at presentation. Advanced stage was associated with Luminal B (OR 2.25) and triple-negative subtypes (OR 3.17) compared to luminal A, with delays >3 months from first breast symptoms to accessing the health system (OR 2.79) and with having more than 1 visit within the referral health system (OR 3.19) for 2 visits; OR 2.73 for ≥3 visits).

CONCLUSIONS

Limited patient education, breast cancer knowledge and awareness, and health system inefficiencies were associated with advanced stage at diagnosis. Sustained community and healthcare worker education may down-stage disease and improve cancer outcomes.

Breast cancer survival in Soweto, Johannesburg, South Africa: A receptor-defined cohort of women diagnosed from 2009 to 11

BACKGROUND

South Africa's public healthcare system is better equipped to manage breast cancer than most other SSA countries, but survival rates are unknown.

METHODS

A historical cohort of 602 women newly diagnosed with invasive breast carcinoma during 2009-2011 at Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, was followed using health systems data to December 2014. 'Overall survival' time was defined from diagnosis to death or terminal illness. Cox regression was used to estimate hazard ratios (HR) associated with woman and tumour characteristics.

RESULTS

During a median 2.1 years follow-up (IQR 0.5-3.8), 149 women died or were classified terminally ill; 287 were lost-to-follow-up. 3-year survival was 84% for early stage (I/II) and 56% for late stage (III/IV) tumours (late v early: HR 2.8 (95% confidence interval (CI): 1.9-4.1), however the 42% cumulative losses to follow-up over this period were greater for late stage, half of which occurred within 6 months of diagnosis. After mutual adjustment for stage, grade, age, receptor subtype and HIV status, lower survival was also associated with triple negative (HR 3.1 (95% CI: 1.9-5.0)) and HER2-enriched (2.5 (95% CI: 1.4-4.5)) compared to ER/PR+ HER2- tumours, but not with age or HIV-infection (1.4 (95% CI: 0.8, 2.3)).

CONCLUSION

In this South African cohort, breast cancer survival is suboptimal, but was better for early stage and hormone receptor-positive tumours. Efforts to reduce clinic losses in the immediate post-diagnosis period, in addition to early presentation and accelerated diagnosis and treatment, are needed to prevent breast cancer deaths, and survival improvements need to be monitored using prospective studies with active follow-up.

Racial disparities in young women with endometrial cancer

OBJECTIVE

Although racial disparities in treatment and outcome for endometrial cancer are well recognized, little work has explored disparities in young women. We performed a population-based analysis to compare survival between black and white women with endometrial cancer at <50years of age.

METHODS

We used the National Cancer Data Base to identify women <50years of age with endometrial cancer from 1998 to 2012. Clinical and demographic characteristics were compared between black and white women and survival by race analyzed using Kaplan-Meier curves and multivariable Cox proportional hazards models.

RESULTS

We identified a total of 35,850 women <50years of age including 31,947 (89.1%) white and 3903 (10.9%) black patients. Black women were more likely to have advanced stage, poorly differentiated, and non-endometrioid histology neoplasms (P<0.05 for all). In a multivariable model, survival was 19% worse for black patients than white patients (HR=1.19; 95% CI, 1.08-1.32). A similar effect was seen when limited to women with early-stage tumors (HR=1.24; 95% CI, 1.04-1.49), while among patients with advanced stage tumors, no association between race and survival was seen (HR=1.12; 95% CI, 0.89-1.41). Five-year survival rates were 90.6% (95% CI, 88.6-92.3%) for white and 81.5% (95% CI, 73.0-87.5%) for black women with stage IB tumors, and 75.1% (95% CI, 72.5-77.5%) and 63.3% (95% CI, 54.1-71.2%) for white and black women with stage III tumors, respectively.

CONCLUSIONS

Young black women are more likely to present with pathologically aggressive, advanced stage tumors. Even after adjusting for these pathologic differences, young black women with endometrial cancer have higher mortality than white women.

National Trends in Extended Procedures for Ovarian Cancer Debulking Surgery

OBJECTIVE

Primary cytoreduction for ovarian cancer often requires extended radical procedures and is associated with significant morbidity. In 2010, neoadjuvant chemotherapy was shown to have similar survival to primary cytoreduction but with less need for radical surgery. We hypothesized that the increased use of neoadjuvant chemotherapy would decrease the use of radical cytoreductive procedures and thus examined trends in the performance of radical cytoreductive procedures.

METHODS

We used the Nationwide Inpatient Sample to determine the annual number of extended procedures (colon, small intestine, liver, diaphragm, spleen, and gastric resection, ileostomy, colostomy) performed in women undergoing surgery for ovarian cancer from 1998 to 2013. Estimates were weighted to provide national averages. To account for changes in incidence over time, we used national incidence rates and report procedures performed per 1000 new cases of ovarian cancer. Trends were assessed using Cochrane-Armitage tests.

RESULTS

We identified 274,639 ovarian cancer patients who underwent surgery, ranging from 15,720 to 18,714 procedures performed each year. We identified a significant increase in the use of extended procedures over this period. These differences were significant for absolute numbers of procedures, rate per 1000 new ovarian cancer cases, and percent per hysterectomy/bilateral salpingoophorectomy for rectosigmoid resection, diaphragm resection, splenectomy, ileostomy, and liver resection. Specifically, the use of these procedures rose from 1998 to 2010, declined in 2011, and rose again in 2012 and 2013.

CONCLUSIONS

Although there was a transient decrease in the use of extended cytoreductive procedures from 2010 to 2011 after the publication of randomized neoadjuvant trial data, use of these procedures again rose in 2012 and 2013.

Adherence to treatment recommendations and outcomes for women with ovarian cancer at first recurrence

OBJECTIVE

Treatment selection for recurrent ovarian cancer is typically based on the duration of time between the completion of adjuvant, platinum-based therapy and the time of recurrence, the platinum free interval (PFI). We examined the use of, and outcomes associated with platinum-based chemotherapy based on the PFI in women with recurrent ovarian cancer.

METHODS

The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women aged >65years with epithelial ovarian cancer who underwent surgery and platinum-based chemotherapy and who developed a recurrence >3months after the completion of adjuvant therapy. Patients were stratified by PFI into 3 groups: PFI <6months, PFI 7-12months, and PFI >12months. Multivariable models were used to examine predictors of use of platinum-based therapy and survival for each group.

RESULTS

A total of 2369 patients were identified. In women with a PFI of ≤6months, treatment consisted of platinum-based combination therapy in 28.2%, single agent platinum in 5.2% and non-platinum therapy in 66.6%. Corresponding rates of these treatments among women with a PFI of 7-12months were 39.7%, 12.4% and 47.9%, respectively; the rates were 57.6%, 13.2% and 29.3% in those with a PFI of >12months, respectively. Median survival was 13, 18, and 27months for patients with a PFI of ≤6months, 7-12months, and >12months, respectively (P<0.0001). For all three groups, platinum combination therapy was associated with decreased risk of death compared to non‑platinum based therapy.

CONCLUSION

Platinum free interval is a strong predictor of survival in elderly women with recurrent ovarian cancer. There is widespread variation in treatment selection for women with recurrent ovarian cancer with many women receiving non-guideline based regimens.

All-cause mortality in young women with endometrial cancer receiving progesterone therapy

BACKGROUND

Uterine-preserving therapy with progesterone may be used in young women with endometrial cancer who desire fertility preservation. Such therapy delays definitive treatment with hysterectomy.

OBJECTIVE

We examined the use and safety of progestational therapy in young women with endometrial cancer. The primary outcome of the analysis was overall survival.

STUDY DESIGN

We identified women ≤49 years of age with stage I endometrial cancer in the National Cancer Database from 2004 through 2014. Women treated with hormonal therapy with or without hysterectomy were compared to women treated with hysterectomy. After propensity score weighting, overall survival was examined using proportional hazards models.

RESULTS

A total of 23,231 patients, including 872 (3.8%) women treated with hormonal therapy were identified. Use of hormonal therapy was 2.4% (95% confidence interval, 1.8-3.3%) in 2004 and increased over time to 5.9% (95% confidence interval, 5.0-6.9%) by 2014 (P < .0001). Use of hormonal therapy decreased with older age, higher substage, and increasing grade. Black women were more likely to receive hormonal therapy while Medicaid recipients were less likely to receive hormonal therapy. The 5-year survival for patients treated with hormonal therapy was 96.4% (95% confidence interval, 94.3-98.0%) compared to 97.2% (95% confidence interval, 96.9-97.4%) for hysterectomy. In a multivariable model, women treated with hormonal therapy were 92% (hazard ratio, 1.92; 95% confidence interval, 1.15-3.19) more likely to die compared to women who underwent primary hysterectomy. When stratified by stage, hormonal therapy was associated with increased mortality in women with stage IB and I-not otherwise specified tumors but not for stage IA neoplasms.

CONCLUSION

Use of progestational therapy is increasing. Its use was associated with decreased survival, particularly in women with stage IB tumors.

Association between survival time with metastatic breast cancer and aggressive end-of-life care

PURPOSE

For women with stage IV breast cancer (BC), the association between survival time (ST) and use of aggressive end-of-life (EOL) care is unknown.

METHODS

We used the SEER-Medicare database to identify women with stage IV BC diagnosed 2002-2011 who died by 12/31/2012. Aggressive EOL care was defined as receipt in the last month of life: >1 ED visit, >1 hospitalization, ICU admission, life-extending procedures, hospice admission within 3 days of death, IV chemotherapy within 14 days of death, and/or ≥10 unique physician encounters in the last 6 months of life. Receipt of aggressive EOL care and hospice in the last month of life were determined using claims, and multivariable analysis was used to identify factors associated with receipt. Costs of care were also evaluated.

RESULTS

We identified 4521 eligible patients. Of these, 2748 (60.8%) received aggressive EOL care. Factors associated with aggressive EOL care were race (OR 1.45, 95% CI 1.19-1.81 for blacks compared to whites) and more frequent oncology office visits (OR 1.56, 95% CI 1.28-1.90). Patients who lived >12 months after diagnosis were less likely to receive aggressive EOL care (OR 0.44, 95% CI 0.38-0.52), and more likely to utilize hospice (OR 1.43, 95% CI 1.21-1.69) compared to patients who lived ≤6 months. Patients with a shorter ST had significantly higher costs of care per-month-alive compared to patients with longer ST.

CONCLUSION

Patients with a shorter ST were more likely to receive aggressive EOL care and had higher costs of care compared to patients who lived longer.

Age-Specific Indicators of a Healthy Lifestyle and Postmenopausal Breast Cancer

INTRODUCTION

Modifiable lifestyle factors have been consistently associated with breast cancer, and risk may vary by menopausal status. However, whether these associations vary according to age among postmenopausal women remains unresolved.

METHODS

Using postmenopausal women from a population-based case-control study (990 cases and 1006 frequency-matched controls), we conducted multivariable-adjusted unconditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for lifestyle factors (lifetime alcohol intake, body mass index [BMI] in the year before diagnosis, lifetime recreational physical activity [RPA], and nonsteroidal anti-inflammatory drug use) in association with breast cancer stratified by age (<65 vs. 65+). We examined estrogen-related subgroups by (1) further stratifying by hormone replacement therapy (HRT) use and (2) restricting cases to estrogen receptor (ER)+/progesterone receptor (PR)+ cancers.

RESULTS

Postmenopausal breast cancer incidence in women 65 years and older was positively associated with alcohol intake (OR = 1.79 for 15-30 g/day vs. nondrinkers, 95% CI: 1.03-3.12) and BMI (OR = 1.83 for BMI ≥30 vs. <25, 95% CI: 1.29-2.60), and inversely with RPA (OR = 0.69 for fourth quartile vs. inactive, 95% CI: 0.47-1.03). For postmenopausal women younger than 65, ORs were closer to the null. Tests for heterogeneity by age were significant at the p < 0.10 level for BMI and RPA, but not alcohol. Among older women, associations were stronger among never users of HRT and for those with ER+/PR+ cancers. The inverse associations with aspirin use did not differ by age.

CONCLUSIONS

Interventions targeting modifiable lifestyle factors may reduce the burden of postmenopausal breast cancer among older women.

Quality of Postoperative Venous Thromboembolism Prophylaxis in Neuro-oncologic Surgery

BACKGROUND

Given the vagaries of published guidelines and the lack of high-quality evidence on the method, timing, and dose of venous thromboembolism (VTE) prophylaxis in neurological surgery, little is known about practice patterns regarding VTE prophylaxis in the United States.

OBJECTIVE

To estimate the use of VTE prophylaxis in patients who underwent surgery for a cerebral neoplasm and to identify patient, physician, and hospital characteristics associated with prophylaxis.

METHODS

Using the Premier Perspective database, we classified patients undergoing surgery for intracranial neoplasm between 2006 and 2012 on the basis of the type of VTE prophylaxis they received (mechanical, pharmacological, or combination). Generalized estimating equations were used to analyze the effects of pretreatment patient and system variables, including hospital and surgeon volume, on prophylaxis while controlling for hospital clustering.

RESULTS

A total of 43 327 patients were identified. Venous thromboembolism prophylaxis was given to 70.2% of patients. Overall, 16 957 (39.2%) had only mechanical prophylaxis, 5628 (13%) received only pharmacological prophylaxis, and 7826 (18.1%) received combination prophylaxis. Patients with high-volume providers (odds ratio, 2.22; 95% confidence interval, 1.33-3.69) were more likely to receive prophylaxis.

CONCLUSION

Nearly one-third of patients who underwent surgery for an intracranial tumor did not receive any VTE prophylaxis. We noted that the rate of overall VTE prophylaxis did not significantly change over the course of the 7 years analyzed despite an increasing focus on complication prevention. High-volume surgeons were more likely to provide VTE prophylaxis.

Trends in end-of-life care and health care spending in women with uterine cancer

BACKGROUND

High-intensity care including hospitalizations, chemotherapy, and other interventions at the end of life is costly and often of little value for cancer patients. Little is known about patterns of end-of-life care and resource utilization for women with uterine cancer.

OBJECTIVE

We examined the costs and predictors of aggressive end-of-life care for women with uterine cancer.

STUDY DESIGN

In this observational cohort study the Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify women age ≥65 years who died from uterine cancer from 2000 through 2011. Resource utilization in the last month of life including ≥2 hospital admissions, >1 emergency department visit, ≥1 intensive care unit admission, or use of chemotherapy in the last 14 days of life was examined. High-intensity care was defined as the occurrence of any of the above outcomes. Logistic regression models were developed to identify factors associated with high-intensity care. Total Medicare expenditures in the last month of life are reported.

RESULTS

Of the 5873 patients identified, the majority had stage IV cancer (30.2%), were white (79.9%), and had endometrioid tumors (47.6%). High-intensity care was rendered to 42.5% of women. During the last month of life, 15.0% had ≥2 hospital admissions, 9.0% had a hospitalization >14 days, 15.3% had >1 emergency department visits, 18.3% had an intensive care unit admission, and 6.6% received chemotherapy in the last 14 days of life. The percentage of women who received high-intensity care was stable over the study period. Characteristics of younger age, black race, higher number of comorbidities, stage IV disease, residence in the eastern United States, and more recent diagnosis were associated with high-intensity care. The median Medicare payment during the last month of life was $7645. Total per beneficiary Medicare payments remained stable from $9656 (interquartile range $3190-15,890) in 2000 to $9208 (interquartile range $3309-18,554) by 2011. The median health care expenditure was 4 times as high for those who received high-intensity care compared to those who did not (median $16,173 vs $4099).

CONCLUSION

Among women with uterine cancer, high-intensity care is common in the last month of life, associated with substantial monetary expenditures, and does not appear to be decreasing.

Primary care visit use after positive fecal immunochemical test for colorectal cancer screening

BACKGROUND

For some patients, positive cancer screening test results can be a stressful experience that can affect future screening compliance and increase the use of health care services unrelated to medically indicated follow-up.

METHODS

Among 483,216 individuals aged 50 to 75 years who completed a fecal immunochemical test to screen for colorectal cancer at a large integrated health care setting between 2007 and 2011, the authors evaluated whether a positive test was associated with a net change in outpatient primary care visit use within the year after screening. Multivariable regression models were used to evaluate the relationship between test result group and net changes in primary care visits after fecal immunochemical testing.

RESULTS

In the year after the fecal immunochemical test, use increased by 0.60 clinic visits for patients with true-positive results. The absolute change in visits was largest (3.00) among individuals with positive test results who were diagnosed with colorectal cancer, but significant small increases also were found for patients treated with polypectomy and who had no neoplasia (0.36) and those with a normal examination and no polypectomy performed (0.17). Groups of patients who demonstrated an increase in net visit use compared with the true-negative group included patients with true-positive results (odds ratio [OR], 1.60; 95% confidence interval [95% CI], 1.54-1.66), and positive groups with a colorectal cancer diagnosis (OR, 7.19; 95% CI, 6.12-8.44), polypectomy/no neoplasia (OR, 1.37; 95% CI, 1.27-1.48), and normal examination/no polypectomy (OR, 1.24; 95% CI, 1.18-1.30).

CONCLUSIONS

Given the large size of outreach programs, these small changes can cumulatively generate thousands of excess visits and have a substantial impact on total health care use. Therefore, these changes should be included in colorectal cancer screening cost models and their causes investigated further. Cancer 2017;123:3744-3753. © 2017 American Cancer Society.