Predictors of Interventional Treatment Use for Venous Thromboembolism in Cancer Patients

Venous thromboembolic disease is a major cause of morbidity in cancer patients. The Perspective database was used to identify patients with solid tumors and a diagnosis of VTE from 2006 to 2012. We examined use of IVC filters, thrombolysis, and thrombectomy. Among 32,545 patients, 23.1% received an IVC filter, 1.9% thrombolytic therapy, and 0.4% underwent thrombectomy. Use of IVC filters decreased between 2006 and 2012 (23.4% to 21.2%, p = 0.012). Older patients, uninsured patients, Hispanics, and those with more comorbidities were more likely to undergo filter placement while patients at rural hospitals were less likely to receive an IVC filter (p < 0.05 for all).

Prevalence of colorectal neoplasms in young, average risk individuals: A turning tide between East and West

AIM

To determine the prevalence of colorectal neoplasia in average risk persons 40-59 years of age in Israel and to compare the results with other populations.

METHODS

We reviewed the results of asymptomatic average-risk subjects, aged 40 to 59 years, undergoing their first screening colonoscopy between April 1994 and January 2014. The detection rates of adenoma, advanced adenoma (AA) and colorectal cancer (CRC) were determined in the 40’s and 50’s age groups by gender. The prevalence of lesions was compared between age groups. After meticulous review of the literature, these results were compared to published studies addressing the prevalence of colorectal neoplasia in similar patient groups, in a variety of geographical locations.

RESULTS

We included first screening colonoscopy results of 1750 individuals. The prevalence of adenomas, AA and CRC was 8.3%, 1.0% and 0.2% in the 40-49 age group and 13.7%, 2.4% and 0.2% in the 50-59 age group, respectively. Age-dependent differences in adenoma and AA rates were significant only among men (P < 0.005). Literature review disclosed 17 relevant studies. As expected, in both Asian and Western populations, the risks for overall adenoma and advanced adenoma was significantly higher in the 50's age group as compared to the 40's age group in a similar fashion. The result of the current study were similar to previous studies on Western populations. A substantially higher rate of adenoma, was observed in studies conducted among Asian populations in both age groups.

CONCLUSION

The higher rate of colorectal neoplasia in Asian populations requires further investigation and reconsideration as to the starting age of screening in that population.

Use and Costs of Disease Monitoring in Women With Metastatic Breast Cancer

PURPOSE

The optimal frequency of monitoring patients with metastatic breast cancer (MBC) is unknown; however, data suggest that intensive monitoring does not improve outcomes. We performed a population-based analysis to evaluate patterns and predictors of extreme use of disease-monitoring tests (serum tumor markers [STMs] and radiographic imaging) among women with MBC.

METHODS

The SEER-Medicare database was used to identify women with MBC diagnosed from 2002 to 2011 who underwent disease monitoring. Billing dates of STMs (carcinoembryonic antigen and/or cancer antigen 15-3/cancer antigen 27.29) and imaging tests (computed tomography and/or positron emission tomography) were recorded; if more than one STM or imaging test were completed on the same day, they were counted once. We defined extreme use as > 12 STM and/or more than four radiographic imaging tests in a 12-month period. Multivariable analysis was used to identify factors associated with extreme use. In extreme users, total health care costs and end-of-life health care utilization were compared with the rest of the study population.

RESULTS

We identified 2,460 eligible patients. Of these, 924 (37.6%) were extreme users of disease-monitoring tests. Factors significantly associated with extreme use were hormone receptor-negative MBC (odds ratio [OR], 1.63; 95% CI, 1.27 to 2.08), history of a positron emission tomography scan (OR, 2.92; 95% CI, 2.40 to 3.55), and more frequent oncology office visits (OR, 3.14; 95% CI, 2.49 to 3.96). Medical costs per year were 59.2% higher in extreme users. Extreme users were more likely to use emergency department and hospice services at the end of life.

CONCLUSION

Despite an unknown clinical benefit, approximately one third of elderly women with MBC were extreme users of disease-monitoring tests. Higher use of disease-monitoring tests was associated with higher total health care costs. Efforts to understand the optimal frequency of monitoring are needed to inform clinical practice.

Cancer Outcomes at the Hufeland (Complementary/Alternative Medicine) Klinik: A Best-Case Series Review

Purpose: A best-case series review is an efficient tool with which to screen complex complementary and alternative treatments for cancer as candidates for further study. Study Design: The National Cancer Institute and other agencies have adopted the best-case series method to evaluate cancer treatments involving complementary and alternative medicine (CAM) for further study. The authors conducted a best-case series review of the Hufeland Klinik. Established in 1985 in Bad Mergentheim, Germany, this facility treats more than 500 cancer patients per year. Hufeland treatment includes dietary modification, injections, ozone therapy, active fever therapy, psychotherapy, and sometimes hormone therapy and/or low-dose chemotherapy. The goal of the treatment is to prolong survival and to maintain good quality of life. Methods: The clinic provided summaries of 27 cases in which patients with longer than expected survival had agreed to make their medical records available for review. The review involved pathologic confirmation of disease and radiologic confirmation of complete response (CR) or partial response (PR) not attributable to conventional treatment. Results: Based on the summaries and an exhaustive 2-year search for medical records, slides, and imaging data, 12 of 27 cases were selected for full review, and 5 (3 CRs and 2 PRs) were judged best cases. Conclusion: Most patients with common cancers receive conventional treatment before coming to Hufeland, and many are treated with chemotherapy and/or hormonal therapy while there. Hence, only a few could be considered for review. With 5 of 12 patients showing a treatment response, the authors conclude that the Hufeland treatment merits further study. They also recommend the development of criteria with which to evaluate best-case series reviews of complex CAM treatments for patients with advanced cancer.

Abstract 2637: Impact of pre-diagnosis weight loss on outcomes in a prospective cohort of esophageal cancer patients

Background: Esophageal cancer survival rates remain extremely low and factors influencing outcomes for this malignancy are not well understood. Tumor cachexia is a poor prognostic factor for certain tumor types, but is not well-studied in esophageal cancer. Weight loss in esophageal cancer is likely multifactorial; it can be due to tumor cachexia as well as dysphagia from obstructing tumors. In this present study, we aimed to investigate the relationship between weight loss and overall survival in a cohort of esophageal cancer patients and to determine whether these associations differed with tumor size.

Methods: We prospectively enrolled subjects with recently diagnosed esophageal cancer at two tertiary care centers. Using a baseline questionnaire, we assessed demographics, medical history, medication use, and lifestyle factors. We recorded self-reported height and weight one year prior to and at diagnosis, which we used to calculate body mass index (BMI) and percent weight change, categorized by tertile. We ascertained from the medical records tumor characteristics including T stage (T1/2 or T3/4), location, pathology, and metastasis status, and collected follow-up data on treatment, imaging, and death. We used Cox regression to assess the association between percent weight loss and all-cause mortality.

Results: We included 134 subjects in the analyses, the majority of whom were male (81.3%) and had adenocarcinoma (82.1%). The median BMI one year prior to diagnosis was 28.3 (IQR 24.4 - 31.0) and median percent weight loss was 4.7% (IQR 0 - 10.9%). There was no association between BMI one year prior and all-cause mortality (HR 0.98, 95% CI 0.93 - 1.03). Increasing percent weight loss was associated with increased risk of all-cause mortality (unadjusted HR 2.74 for highest vs. lowest tertile, 95% CI 1.34 - 5.58, Ptrend = 0.005) and this remained significant when adjusted for BMI one year prior (HR 2.87 for highest vs. lowest tertile, 95% CI 1.40 - 5.89, Ptrend = 0.003). We found significant interaction between weight loss and T stage. Percent weight loss was significantly associated with all-cause mortality, adjusted for BMI one year prior, among patients with T stages 1 or 2 (HR 6.49 for highest vs. lowest tertile, 95% CI 1.30 - 32.4, Ptrend = 0.012), but not T stages 3 or 4 (HR 1.42 for highest vs. lowest tertile, 95% CI 0.54 - 3.71). In the final multivariable model, there remained a significant association between percent weight loss and all-cause mortality among patients with T stages 1 or 2 (HR 6.34 for highest vs. lowest tertile, 95% CI 1.22 - 33.1, Ptrend = 0.022).

Conclusions: In this cohort of esophageal cancer patients, we found that pre-diagnosis weight loss was associated with increased risk of all-cause mortality in patients with earlier stage tumors, independent of baseline BMI. We suspect that weight loss in early stage esophageal cancer may be due to tumor cachexia, a potential marker of more aggressive disease and worse prognosis.

Citation Format: Sherry Shen, James L. Araujo, Nasser K. Altorki, Joshua R. Sonett, Adriana Rodriguez, Kivilcim Sungur-Stasik, Alfred I. Neugut, Julian A. Abrams. Impact of pre-diagnosis weight loss on outcomes in a prospective cohort of esophageal cancer patients. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2637.

Nonadherence to Oral Medications for Chronic Conditions in Breast Cancer Survivors

PURPOSE

Nonadherence to oral endocrine therapy is common among women with breast cancer (BC). Less is known about nonadherence to medications for other chronic conditions among survivors of BC.

METHODS

We used the MarketScan Database to identify women older than 18 years who had nonmetastatic BC diagnosed between January 1, 2009, and December 31, 2013. Prescriptions were identified for the following six non-cancer-related conditions: hypertension, thyroid disease, hyperlipidemia, gastroesophageal reflux disease, diabetes, and osteoporosis. The study period was defined as 1 year before BC diagnosis (index date) through 1.5 years after the index date, with a 6-month washout period after the index data to control for adherence during the preoperative period and during chemotherapy if necessary. Adherence was defined as a medication possession ratio ≥ 80%. Change in adherence was defined as a 20% decrease in the medication possession ratio from the time before diagnosis compared with after treatment. Factors associated with change in adherence were evaluated in multivariable logistic models.

RESULTS

Among 36,149 patients diagnosed with BC, the average adherence to these medications before BC was 91.4%. However, after BC treatment, adherence decreased to 77.9% (P < .001). Looking at drugs for each condition, nonadherence ranged from 15.6% to 38% (P < .001). Factors associated with an increase in nonadherence included older age, insurance type, number of medications, and comorbid conditions.

CONCLUSION

Decreased adherence to medications for chronic diseases was found in the first year after breast cancer treatment. Breast cancer survivors may need additional interventions to improve their adherence to their medications for chronic conditions.

Overuse of external beam radiotherapy for stage I endometrial cancer

BACKGROUND

Radiation therapy has long been part of the treatment of endometrial cancer. Despite the long history of radiation use, prospective trials in the United States and Europe have been unable to demonstrate a survival benefit with adjuvant radiotherapy compared with observation. Whereas radiation has been associated with a decreased rate of locoregional failure, the treatment is also associated with substantial toxicity. However, a randomized trial published in 2010 demonstrated that, compared with external beam radiation therapy (EBRT), vaginal brachytherapy was less toxic and as effective in reducing locoregional relapses.

OBJECTIVE

We examined patterns of use of external beam radiation therapy for women with high intermediate risk endometrial cancer.

STUDY DESIGN

We examined the use of external beam radiation therapy in women registered in the National Cancer Data Base with high intermediate risk, stage I endometrial cancer treated from 2008 through 2012. High intermediate risk was defined as age > 60 years with a stage IA, grade 3 tumors or stage IB, grade 1 or 2 tumors. Multivariable models of EBRT use were developed.

RESULTS

Among 8242 women, 915 (11.1%) received EBRT, 2614 (31.7%) were treated with brachytherapy, and 4713 (57.2%) did not receive any adjuvant radiation. The use of EBRT was 18.1% in 2008 and declined to 8.6% in 2012, whereas the use of brachytherapy rose each year from 26.5% in 2008 to 37.6% in 2012 (P < .0001). External beam radiation was administered to 7.9% of patients with stage IA/grade 3 tumors, 8.8% of those with stage IB/grade 1 cancers, and to 15.2% of women with stage IB/grade 2 neoplasms (P < .0001). EBRT was utilized in 10.1% of women who underwent lymphadenectomy compared with 22.0% who did not undergo lymphadenectomy (P < .0001). In a multivariable model, black women were more likely to receive EBRT than white women (relative risk [RR], 1.33; 95% confidence interval [CI], 1.03-1.70). Similarly, patients in the eastern United States, those treated at community cancer centers and comprehensive community cancer programs, patients in metropolitan areas, and those diagnosed in earlier years were more likely to undergo EBRT. Patients with stage IB/grade 2 tumors (RR, 1.96; 95% CI, 1.65-2.32) were more likely to receive EBRT than those with stage IA/grade 3 neoplasms. Those women who did not undergo lymphadenectomy were more than twice as likely to receive EBRT compared with those who had a lymphadenectomy (RR, 2.32; 95% CI, 1.99-2.72).

CONCLUSION

Despite data from randomized trials, approximately 9% of women with high intermediate risk of endometrial cancer continue to receive EBRT. Performance of lymphadenectomy is associated with a lower likelihood of external beam radiation therapy.

A prospective cohort study of early discontinuation of adjuvant chemotherapy in women with breast cancer: the breast cancer quality of care study (BQUAL)

For many women with non-metastatic breast cancer, adjuvant chemotherapy prevents recurrence and extends survival. Women who discontinue chemotherapy early may reduce those benefits, but little is known about what predicts early discontinuation. We sought to determine prospectively the rate and reasons for early discontinuation of adjuvant chemotherapy in women with breast cancer. We conducted a prospective cohort study among three U.S. health care organizations. Of 1158 women with newly diagnosed non-metastatic breast cancer, 2006-2010, we analyzed 445 (38.4 %) patients who initiated standard adjuvant chemotherapy as defined by accepted guidelines. We interviewed patients at baseline and twice during treatment regarding sociodemographic/psychosocial factors and treatment decision-making and collected clinical data. They were categorized according to the number of cycles required by the chemotherapy regimen they had initiated. The outcome was early discontinuation (<80 % of planned cycles). Of patients analyzed, 392 (88.1 %) completed the prescribed therapy. The strongest predictor was receipt of a regimen entailing >4 cycles of therapy (18.1 % for longer regimens, 7.4 % for 4 cycles) (odds ratio [OR] 2.59, 95 % CI 1.32-5.08), controlling for race, age, stage, hormone receptor status, social support, optimism, spirituality, stress, and physical symptoms. Higher levels of psychological symptoms on the Memorial symptom assessment scale also increased the odds of early discontinuation (OR 1.92, 95 % CI 0.998-3.68). The large majority of patients who initiated adjuvant chemotherapy for breast cancer completed their prescribed regimens, but early discontinuation was associated with lengthier regimens and, with borderline statistical significance, for those with psychological side effects.

A Randomized Trial to Compare Alternative Educational Interventions to Increase Colorectal Cancer Screening in a Hard-to-Reach Urban Minority Population with Health Insurance

This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180); in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185); in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5% of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7%, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. ClinicalTrials.gov Identifier: NCT02392143.

Characteristics, treatment and outcomes of women with immature ovarian teratoma, 1998-2012

OBJECTIVE

To explore the presentation, management and outcomes of adult women diagnosed with immature ovarian teratoma.

METHODS

The National Cancer Database (NCDB) was used to identify women≥18years of age diagnosed with an immature teratoma from 1998 to 2012. We analyzed demographic, clinical and tumor characteristics, and treatment trends. Multivariable models were employed to examine predictors of adjuvant chemotherapy use and survival.

RESULTS

We identified a total of 1045 adult women with immature teratoma. The median age of diagnosis was 27years and most were diagnosed between ages 18 and 39 (88.9%). The majority presented with early-stage (I/II) disease (76.0%), underwent unilateral salpingo-oophorectomy (52.5%) and received adjuvant chemotherapy (56.8%). The probability of receiving chemotherapy increased with stage, grade, and treatment at academic compared to community based centers (P<0.05.). Older age, advanced stage, and grade III histology were associated with worse survival (P<0.05). Five-year survival rates were: 98.3% (95% CI 96.8-99.1), 93.2% (95% CI 82.8-97.4), 82.7% (95% CI 74.3-88.5), and 72.0% (95% CI 50.1-85.5) for stages I, II, III, and IV disease, respectively.

CONCLUSIONS

The incidence of immature teratoma is highest in young adults aged 18 to 39. Most patients present with early-stage disease, are managed with fertility sparing surgery and chemotherapy and have an excellent prognosis. Later age at diagnosis, advanced stage, and high-grade histology confer a worse prognosis.

Survivorship care plans and adherence to lifestyle recommendations among breast cancer survivors

PURPOSE

The effectiveness of survivorship care plans has not been widely tested. We evaluated whether a one-time brief lifestyle consultation as part of a broader survivorship care plan was effective at changing diet and lifestyle patterns.

METHODS

A diverse sample of women with stage 0-III breast cancer were randomized to control or intervention groups within 6 weeks of completing adjuvant treatment. Both groups received the National Cancer Institute publication, "Facing Forward: Life after Cancer Treatment." The intervention group also met with a nurse (1 h) and a nutritionist (1 h) to receive personalized lifestyle recommendations based upon national guidelines. Diet, lifestyle, and perceived health were assessed at baseline, 3 and 6 months. Linear regression analyses evaluated the effects of the intervention adjusted for covariates.

RESULTS

A total of 126 women completed the study (60 control/66 intervention, 61 Hispanic/65 non-Hispanic). At 3 months, the intervention group reported greater knowledge of a healthy diet (P = 0.047), importance of physical activity (P = 0.03), and appropriate use of dietary supplements (P = 0.006) and reported lower frequency of alcohol drinking (P = 0.03) than controls. At 6 months, only greater knowledge of a healthy diet (P = 0.01) persisted. The intervention was more effective among non-Hispanics than Hispanics on improving attitude towards healthy eating (P = 0.03) and frequency of physical activity (P = 0.006).

CONCLUSIONS

The intervention changed lifestyle behaviors and knowledge in the short-term, but the benefits did not persist.

IMPLICATIONS FOR CANCER SURVIVORS

Culturally competent long-term behavioral interventions should be tested beyond the survivorship care plan to facilitate long-term behavior change among breast cancer survivors.

Psychosocial factors related to non-persistence with adjuvant endocrine therapy among women with breast cancer: the Breast Cancer Quality of Care Study (BQUAL)

Non-adherence to adjuvant endocrine therapy (ET) for breast cancer (BC) is common. Our goal was to determine the associations between psychosocial factors and ET non-persistence. We recruited women with BC receiving care in an integrated healthcare system between 2006 and 2010. Using a subset of patients treated with ET, we investigated factors related to ET non-persistence (discontinuation) based on pharmacy records (≥90 days gap). Serial interviews were conducted at baseline and every 6 months. The Functional Assessment of Cancer Therapy (FACT), Medical Outcomes Survey, Treatment Satisfaction Questionnaire (TSQM), Impact of Events Scale (IES), Interpersonal Processes of Care measure, and Decision-making beliefs and concerns were measured. Multivariate models assessed factors associated with non-persistence. Of the 523 women in our final cohort who initiated ET and had a subsequent evaluation, 94 (18 %) were non-persistent over a 2-year follow-up. The cohort was primarily white (74.4 %), stage 1 (60.6 %), and on an aromatase inhibitor (68.1 %). Women in the highest income category had a lower odds of being non-persistent (OR 0.43, 95 % CI 0.23-0.81). Quality of life and attitudes toward ET at baseline were associated with non-persistence. At follow-up, the FACT, TSQM, and IES were associated with non-persistence (p < 0.001). Most women continued ET. Women who reported a better attitude toward ET, better quality of life, and more treatment satisfaction, were less likely to be non-persistent and those who reported intrusive/avoidant thoughts were more likely to be non-persistent. Interventions to enhance the psychosocial well-being of patients should be evaluated to increase adherence.

Safety, Utilization, and Cost of Image-Guided Percutaneous Liver Biopsy Among Cancer Patients

Image-guided percutaneous liver biopsy (PLB) is a diagnostic tool for lesions in the liver. Hemorrhage is the most common complication. We selected patients with a diagnostic claim for cancer who had undergone PLB. There were a total of 26,941 patients who underwent PLB. Hemorrhage risk was 1.43% among patients undergoing PLB. When stratified by setting, odds of hemorrhage were 4.5 times higher when biopsy was performed in an inpatient setting (p < .001). Risk factors associated with hemorrhage included marital status, liver cancer and comorbidity score. The use of PLB has increased over time. Reassuringly, the hemorrhage risk associated with PLB is low.

Polymorphisms in DNA repair genes, traffic-related polycyclic aromatic hydrocarbon exposure and breast cancer incidence

Vehicular traffic polycyclic aromatic hydrocarbons (PAHs) have been associated with breast cancer incidence in epidemiologic studies, including our own. Because PAHs damage DNA by forming adducts and oxidative lesions, genetic polymorphisms that alter DNA repair capacity may modify associations between PAH-related exposures and breast cancer risk. Our goal was to examine the association between vehicular traffic exposure and breast cancer incidence within strata of a panel of nine biologically plausible nucleotide excision repair (NER) and base excision repair (BER) genotypes. Residential histories of 1,508 cases and 1,556 controls were assessed in the Long Island Breast Cancer Study Project between 1996 and 1997 and used to reconstruct residential traffic exposures to benzo[a]pyrene, as a proxy for traffic-related PAHs. Likelihood ratio tests from adjusted unconditional logistic regression models were used to assess multiplicative interactions. A gene-traffic interaction was evident (p = 0.04) for ERCC2 (Lys751); when comparing the upper and lower tertiles of 1995 traffic exposure estimates, the odds ratio (95% confidence interval) was 2.09 (1.13, 3.90) among women with homozygous variant alleles. Corresponding odds ratios for 1960-1990 traffic were also elevated nearly 2-3-fold for XRCC1(Arg194Trp), XRCC1(Arg399Gln) and OGG1(Ser326Cys), but formal multiplicative interaction was not evident. When DNA repair variants for ERCC2, XRCC1 and OGG1 were combined, among women with 4-6 variants, the odds ratios were 2.32 (1.22, 4.49) for 1995 traffic and 2.96 (1.06, 8.21) for 1960-1990 traffic. Our study is first to report positive associations between traffic-related PAH exposure and breast cancer incidence among women with select biologically plausible DNA repair genotypes.

Exposure to multiple sources of polycyclic aromatic hydrocarbons and breast cancer incidence

BACKGROUND

Despite studies having consistently linked exposure to single-source polycyclic aromatic hydrocarbons (PAHs) to breast cancer, it is unclear whether single sources or specific groups of PAH sources should be targeted for breast cancer risk reduction.

OBJECTIVES

This study considers the impact on breast cancer incidence from multiple PAH exposure sources in a single model, which better reflects exposure to these complex mixtures.

METHODS

In a population-based case-control study conducted on Long Island, New York (N=1508 breast cancer cases/1556 controls), a Bayesian hierarchical regression approach was used to estimate adjusted posterior means and credible intervals (CrI) for the adjusted odds ratios (ORs) for PAH exposure sources, considered singly and as groups: active smoking; residential environmental tobacco smoke (ETS); indoor and outdoor air pollution; and grilled/smoked meat intake.

RESULTS

Most women were exposed to PAHs from multiple sources, and the most common included active/passive smoking and grilled/smoked food intake. In multiple-PAH source models, breast cancer incidence was associated with residential ETS from a spouse (OR=1.20, 95%CrI=1.03, 1.40) and synthetic firelog burning (OR=1.29, 95%CrI=1.06, 1.57); these estimates are similar, but slightly attenuated, to those from single-source models. Additionally when we considered PAH exposure groups, the most pronounced significant associations included total indoor sources (active smoking, ETS from spouse, grilled/smoked meat intake, stove/fireplace use, OR=1.45, 95%CrI=1.02, 2.04).

CONCLUSIONS

Groups of PAH sources, particularly indoor sources, were associated with a 30-50% increase in breast cancer incidence. PAH exposure is ubiquitous and a potentially modifiable breast cancer risk factor.

Prescription of extended-duration thromboprophylaxis after high-risk, abdominopelvic cancer surgery

OBJECTIVE

Extended-duration thromboprophylaxis for 4weeks after discharge has been demonstrated to reduce venous thromboembolic events (VTE) in cancer patients undergoing abdominopelvic surgery and is recommended in national guidelines. We examined the utilization and effectiveness of extended-duration low molecular weight heparin prophylaxis in high-risk cancer patients.

METHODS

We analyzed patients with colon, ovarian, and uterine cancer who underwent surgery from 2009 to 2013 and who were recorded in the MarketScan database. Multivariable models and propensity score analysis with inverse probability of treatment weight were developed to examine uptake and predictors of use of post-discharge low molecular weight heparin (LMWH), as well as associated adverse events (transfusion, and hemorrhage).

RESULTS

A total of 63,280 patients were identified. Use of extended-duration prophylaxis increased from 2009 to 2013 from 1.4% to 1.7% (P=0.67) for colectomy, 5.9% to 18.3% for ovarian cancer surgery (P<0.001), and 6.3% to 12.2% (P<0.001) for hysterectomy for endometrial cancer. There was no association between use of extended-duration prophylaxis and reductions in VTE for any of the procedures: colectomy (2.4% with extended-duration prophylaxis vs. 2.9% without prophylaxis, OR=0.84; 95% CI, 0.54-1.31), ovarian cancer-directed surgery (3.7% vs. 3.6%, OR=1.01; 95% CI, 0.76-1.33), hysterectomy (2.1% vs. 2.1%; OR=0.96; 95% CI, 0.67-1.38). Extended-duration prophylaxis was associated with an increased risk of adverse postoperative events: 2.20 (95% CI, 1.51-3.19) after colectomy, 1.24 (95% CI, 0.92-1.68) following ovarian cancer-directed surgery and 0.99 (95% CI, 0.66-1.48) for hysterectomy for endometrial cancer.

CONCLUSION

Use of extended-duration thromboprophylaxis is low among high-risk cancer patients undergoing surgery.

Phenotype and Treatment of Breast Cancer in HIV-Positive and -Negative Women in Cape Town, South Africa

Purpose

An estimated 5.9 million people in South Africa are infected with HIV. Because antiretroviral therapy has made infection with HIV a treatable, chronic condition, HIV-infected individuals are now surviving to middle and older age. We investigated the implications of HIV status for breast cancer in South Africa.

Methods

We compared clinical and demographic characteristics of women newly diagnosed with a first primary breast cancer at Tygerberg Hospital, Cape Town, South Africa, from January 2010 to December 2011 by HIV status. We then compared HIV-positive patients with HIV-negative controls, matched 2:1 on age and ethnicity, with respect to chemotherapy regimens, toxicities, completion of systemic chemotherapy, and changes in CD4 cell count.

Results

Of 586 women with breast cancer, 31 (5.3%) were HIV positive, 420 (71.7%) were HIV negative, and 135 (23%) were untested for HIV. Women with HIV were younger than other women (P < .001). The groups did not differ in regard to stage at presentation, histologic subtype, tumor grade, nodal involvement, or hormone receptor positivity. More than 84% of patients who initiated systemic chemotherapy, regardless of HIV status, completed it without serious toxicity. Among HIV-positive patients receiving chemotherapy, the mean baseline CD4 cell count was 477 cells/µL (standard deviation, 160 cells/µL), and the mean nadir was 333 cells/µL (standard deviation, 166 cells/µL).

Conclusion

HIV-infected women were younger at breast cancer diagnosis than HIV-negative women but otherwise similar in phenotype and completion of chemotherapy. Longer term follow-up is needed to evaluate the effects of HIV, antiretroviral therapy, and chemotherapy on the survival and quality of life of patients with breast cancer.

Radiation Duration in Women with Cervical Cancer Treated with Primary Chemoradiation: A Population-Based Analysis

This study examines factors associated with prolonged radiation duration and its impact on survival in women with cervical cancer treated with primary chemoradiation. Women in the National Cancer Database with stage IB2-IVA cervical cancer from 2003 to 2011 who received radiation and chemotherapy were included. Of 7209 women, who met inclusion criteria, 3401 (47.1%) and 3808 (52.8%) completed radiation in ≤ 8 and > 8 weeks, respectively. There was no overall survival difference for radiation duration ≤ 8 vs. > 8 weeks. Sensitivity analyses showed that inferior overall survival is only seen with radiation duration of > 10-12 weeks.

Impact of end-of-life discussions on the reduction of Latino/non-Latino disparities in do-not-resuscitate order completion

BACKGROUND

Compared with non-Latino, white patients with advanced cancer, Latino patients with advanced cancer are less likely to sign do-not-resuscitate (DNR) orders, which is a form of advance care planning associated with better quality of life at the end of life (EOL). Latinos' completion of DNR orders may be more sensitive to clinical discussions regarding EOL care. The current study examined differences between Latino and white terminally ill patients with cancer with regard to the association between EOL discussions and DNR order completion.

METHODS

A total of 117 participants with advanced cancer (61 of whom were Latino and 56 of whom were non-Latino white individuals) were recruited between 2002 and 2008 from Parkland Hospital (a public hospital in Dallas, Texas) as part of the Coping with Cancer study, which is a large, multiinstitutional, prospective cohort study of patients with advanced cancer that is designed to examine social and psychological influences on EOL care. In structured interviews, patients reported if they had EOL discussions with their physicians, and if they completed DNR orders.

RESULTS

The association between EOL discussions and DNR order completion was significantly greater in Latino compared with white patients, adjusting for potential confounds (interaction adjusted odds ratio, 6.64; P = .041). Latino patients who had an EOL discussion were >10 times more likely (adjusted odds ratio, 10.91; P = .001) to complete a DNR order than those who had not, and were found to be equally as likely to complete a DNR order as white patients.

CONCLUSIONS

Differences in the impact of EOL discussions on DNR order completion may explain Latino/non-Latino ethnic disparities in DNR order completion in EOL care, and point to a means to eliminate those disparities. Cancer 2016;122:1749-56. © 2016 American Cancer Society.

DNA methylation modifies the association between obesity and survival after breast cancer diagnosis

Mechanisms underlying the poor breast cancer prognosis among obese women are unresolved. DNA methylation levels are linked to obesity and to breast cancer survival. We hypothesized that obesity may work in conjunction with the epigenome to alter prognosis. Using a population-based sample of women diagnosed with first primary breast cancer, we examined modification of the obesity-mortality association by DNA methylation. In-person interviews were conducted approximately 3 months after diagnosis. Weight and height were assessed [to estimate body mass index (BMI)], and blood samples collected. Promoter methylation of 13 breast cancer-related genes was assessed in archived tumor by methylation-specific PCR and Methyl Light. Global methylation in white blood cell DNA was assessed by analysis of long interspersed elements-1 (LINE-1) and with the luminometric methylation assay (LUMA). Vital status among 1308 patients (with any methylation biomarker and complete BMI assessment) was determined after approximately 15 years of follow-up (N = 194/441 deaths due to breast cancer-specific/all-cause mortality). We used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) using two-sided p values of 0.05. Breast cancer-specific mortality was higher among obese (BMI ≥ 30) patients with promoter methylation in APC (HR = 2.47; 95 % CI = 1.43-4.27) and TWIST1 (HR = 4.25; 95 % CI = 1.43-12.70) in breast cancer tissue. Estimates were similar, but less pronounced, for all-cause mortality. Increased all-cause (HR = 1.81; 95 % CI = 1.19-2.74) and breast cancer-specific (HR = 2.61; 95 % CI = 1.45-4.69) mortality was observed among obese patients with the lowest LUMA levels. The poor breast cancer prognosis associated with obesity may depend on methylation profiles, which warrants further investigation.