Neoadjuvant Chemotherapy or Endocrine Therapy for Invasive Ductal Carcinoma of the Breast With High Hormone Receptor Positivity and Human Epidermal Growth Factor Receptor 2 Negativity

Statin Therapy Reduces Radiation-Induced Cardiotoxicity in Patients With Breast Cancer Receiving Adjuvant Radiotherapy

BACKGROUND

To evaluate the efficacy of statin therapy in reducing major adverse cardiovascular event (MACE) risk among patients with breast cancer undergoing breast-conserving surgery and adjuvant whole breast radiotherapy.

METHODS AND RESULTS

A retrospective cohort study was conducted using data from the Taiwan Cancer Registry Database linked to the National Health Insurance Research Database. Patients diagnosed with left-sided early breast invasive ductal carcinoma between 2016 and 2019 were included. Propensity score matching was employed to compare MACE risk between statin users and nonusers. Cox regression models were used to estimate adjusted hazard ratios (aHRs) for MACE, considering cumulative defined daily doses and daily defined doses of statins. Among 1481 patients undergoing breast-conserving surgery and adjuvant whole breast radiotherapy, statin use significantly reduced MACE risk (aHR, 0.34 [95% CI, 0.25-0.44]). Hydrophilic statins, particularly rosuvastatin and pravastatin, demonstrated the greatest risk reduction. Higher cumulative defined daily doses and daily intensity doses of statins were associated with lower MACE risk, indicating a dose-response relationship. The 5-year cumulative incidence of MACE was significantly lower in statin users compared with nonusers (12.24% versus 31.70%).

CONCLUSIONS

Statin therapy is associated with a reduced risk of MACE in patients with breast cancer undergoing breast-conserving surgery and adjuvant whole breast radiotherapy. Hydrophilic statins rosuvastatin and pravastatin exhibit the most pronounced cardioprotective effects. These findings suggest a potential role for statins in mitigating cardiovascular complications in this population and highlight the need for further research to optimize statin therapy in survivors of breast cancer undergoing radiotherapy.

Tailoring neoadjuvant systemic therapy in breast cancer: "The advent of a personalized approach"-The Breast-Gynecological and Immuno-Oncology International Cancer Conference (BGICC) consensus and recommendations

BACKGROUND

The management of early breast cancer (BC) has witnessed an uprise in the use of neoadjuvant therapy and a remarkable reshaping of the systemic therapy postneoadjuvant treatment in the last few years, with the evolution of many controversial clinical situations that require consensus.

METHODS

During the 14th Breast-Gynecological and Immuno-Oncology International Cancer Conference held in Egypt in 2022, a panel of 44 BC experts from 13 countries voted on statements concerning debatable challenges in the neo/adjuvant treatment setting. The recommendations were subsequently updated based on the most recent data emerging. A modified Delphi approach was used to develop this consensus. A consensus was achieved when ≥75% of voters selected an answer.

RESULTS AND CONCLUSIONS

The consensus recommendations addressed different escalation and de-escalation strategies in the setting of neoadjuvant therapy for early BC. The recommendations recapitulate the available clinical evidence and expert opinion to individualize patient management and optimize therapy outcomes. Consensus was reached in 63% of the statements (52/83), and the rationale behind each statement was clarified.

Childhood anaesthesia and autism risk: population and murine study

Early childhood exposure to general anaesthesia has been linked to potential changes in infant brain morphology and behaviour in preclinical studies, contributing to long-term behaviours associated with autism spectrum disorder. This study investigates the association between early childhood exposure to general anaesthesia and the risk of autism, using a population-based cohort study with matching for baseline characteristics and evaluates the effect of sevoflurane exposure on autism-like behaviour in mice, using the Taiwan Maternal and Child Health Database. Children aged 0-3 who received at least one exposure to general anaesthesia between 2004 and 2014 were matched 1:1 with children who were not exposed. Risk ratios and confidence intervals were used to assess the relationship between general anaesthesia and the occurrence of autism. Additionally, mice were exposed to sevoflurane for 2 h on postnatal days 5-7, and changes in behaviour related to autism were evaluated. Propensity score matching resulted in 7530 children in each group. The incidence rates (IRs) of autism were 11.26 and 6.05 per 100 000 person-years in the exposed and unexposed groups, respectively. The incidence ratio for autism following exposure to general anaesthesia was 1.86 (95% confidence interval, 1.34-2.59). In mice, sevoflurane exposure induced autism-like behaviours and led to the downregulation of high-risk autism genes, including ARID1B, GABRA5, GABRB3, GRIN2B, SHANK3 and SUV420H1. Early childhood exposure to general anaesthesia is associated with an increased risk of autism. Repeated exposure to sevoflurane in mice induces autism-like behaviours, suggesting a potential link between anaesthesia and the development of autism.

Risk of Pediatric Bipolar Disorder After General Anesthesia in Infants and Toddlers: A Propensity Score-Matched Population-Based Cohort Study

BACKGROUND AND HYPOTHESIS

The potential role of anesthesia as an independent risk factor for childhood bipolar disorder (BD) remains unclear. To address this, we conducted a population-based cohort study employing propensity score matching to compare BD incidence between pediatric patients undergoing surgery with and without general anesthesia.

STUDY DESIGN

Our study included patients aged 0-3 years who received at least 1 episode of general anesthesia and were hospitalized for over 1 day in Taiwan between January 2004 and December 2014. They were matched 1:1 with a population not receiving general anesthesia to assess pediatric BD incidence.

STUDY RESULTS

The study cohort comprised 15 070 patients, equally distributed between the general anesthesia and nongeneral anesthesia groups (7535 each). Multivariate Cox regression analysis revealed adjusted hazard ratios (aHRs; 95% CIs) for pediatric BD in the general anesthesia group as 1.26 (1.04-1.54; P = .021) compared to the nongeneral anesthesia group. Moreover, the incidence rate ratio (95% CI) for the general anesthesia group was 1.26 (1.03-1.53) compared to the nongeneral anesthesia group.

CONCLUSIONS

Early childhood exposure to general anesthesia is significantly associated with an increased risk of pediatric BD. This expands understanding of pediatric BD's complex development, informing preventive strategies, and enhancing mental health outcomes for vulnerable young patients and global pediatric healthcare.

Pathological Changes Following Neoadjuvant Endocrine Therapy (NAET): A Multicentre Study of 391 Breast Cancers

Oestrogen receptor (ER)-positive breast cancer (BC) is generally well responsive to endocrine therapy. Neoadjuvant endocrine therapy (NAET) is increasingly being used for downstaging ER-positive tumours. This study aims to analyse the effect of NAET on a well-characterised cohort of ER-positive BC with particular emphasis on receptor expression. This is a retrospective United Kingdom (UK) multicentre study of 391 patients who received NAET between October 2012 and October 2020. Detailed analyses of the paired pre- and post-NAET morphological changes and hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) expression were performed. The median duration of NAET was 86 days, with median survival and overall survival rates of 380 days and 93.4%, respectively. A total of 90.3% of cases achieved a pathological partial response, with a significantly higher rate of response in the HER2-low cancers. Following NAET, BC displayed some pathological changes involving the tumour stroma including central scarring and an increase in tumour infiltrating lymphocytes (TILs) and tumour cell morphology. Significant changes associated with the duration of NAET were observed in tumour grade (30.6% of cases), with downgrading identified in 19.3% of tumours (p < 0.001). The conversion of ER status from positive to low or negative was insignificant. The conversion of progesterone receptor (PR) and HER2 status to negative status was observed in 31.3% and 38.1% of cases, respectively (p < 0.001). HER2-low breast cancer decreased from 63% to 37% following NAET in the paired samples. Significant morphological and biomarker changes involving PR and HER2 expression occurred following NAET. The findings support biomarker testing on pre-treatment core biopsies and post-treatment residual carcinoma.

Comparing survival outcomes between neoadjuvant and adjuvant chemotherapy within T2N1M0 stage hormone receptor-positive, HER2-negative breast cancer: a retrospective cohort study based on SEER database

BACKGROUND

Guideline recommendations for the application of neoadjuvant chemotherapy (NACT) in T2N1M0 stage hormone receptor-positive, HER2-negative (HR + /HER2-) breast cancer are ambiguous. The debate continues regarding whether NACT or adjuvant chemotherapy (ACT) offers superior survival outcomes for these patients.

MATERIALS AND METHODS

Female patients diagnosed with HR + /HER2- breast cancer at T2N1M0 stage between 2010 and 2020, were identified from the Surveillance, Epidemiology, and End Results database and divided into two groups, the NACT group and the ACT group. Propensity score matching (PSM) was utilized to establish balanced cohorts between groups, considering baseline features. Kaplan-Meier (K-M) analysis and the Cox proportional hazards model were executed to assess the efficacy of both NACT and ACT in terms of overall survival (OS) and breast cancer-specific survival (BCSS). A logistic regression model was employed to examine the association between predictive variables and response to NACT.

RESULTS

After PSM, 4,682 patients were finally included. K-M curves showed that patients receiving NACT exhibited significantly worse OS and BCSS when compared with patients undergoing ACT. Multivariable Cox analysis indicated that not achieving pathologic complete response (non-pCR) after NACT (versus ACT), was identified as an adverse prognostic factor for OS (HR 1.58, 95% CI 1.36-1.83) and BCSS (HR 1.70, 95% CI 1.44-2. 02). The logistic regression model revealed that low tumor grade independently predicted non-pCR.

CONCLUSION

Among T2N1M0 stage HR + /HER2- patients, OS and BCSS of NACT were inferior to ACT. Patients who attained non-pCR after NACT demonstrated significantly worse survival outcomes compared with those who received ACT.

Correlation of maintenance chemotherapy and improved survival in patients with locally advanced unresectable pancreatic head adenocarcinoma receiving neoadjuvant chemotherapy and concurrent chemoradiotherapy

To assess the efficacy of maintenance chemotherapy in the management of unresectable locally advanced pancreatic head adenocarcinoma (PHA) cancer after neoadjuvant chemotherapy and concurrent chemoradiation therapy (CCRT). This study, a large-scale head-to-head propensity score matching (PSM) cohort study, employed real-world data. PSM was used to evaluate the impact of maintenance chemotherapy on overall survival and cancer-specific survival in patients with unresectable locally advanced PHA who underwent neoadjuvant chemotherapy and CCRT. A total of 148 patients with locally advanced pancreatic head adenocarcinoma were included in the study after PSM. These patients were equally divided into two groups, those receiving maintenance chemotherapy and those who did not. Confounding factors were balanced between the groups. The adjusted hazard ratios for all-cause mortality and cancer-specific mortality were 0.56 (95% CI: 0.40-0.77; P = 0.0005) and 0.56 (95% CI: 0.40-0.78; P = 0.0007), respectively, in patients receiving maintenance chemotherapy compared to those who did not. Our large-scale, real-world study demonstrates that maintenance chemotherapy may enhance survival outcomes for patients with unresectable locally advanced pancreatic head adenocarcinoma who underwent neoadjuvant chemotherapy and concurrent chemoradiation therapy.

Maintenance chemotherapy for esophageal squamous cell carcinoma after standard concurrent chemoradiotherapy: a national propensity score matching cohort study

Esophageal squamous cell carcinoma (ESCC) is a common and aggressive cancer, and its standard treatment is concurrent chemoradiotherapy (CCRT). Maintenance chemotherapy is often used to help prevent cancer recurrence, but its efficacy for patients with ESCC receiving CCRT remains unclear. We conducted a large head-to-head propensity score matching cohort study to estimate the effects of maintenance chemotherapy on overall survival and cancer-specific survival in patients with ESCC receiving standard CCRT. After propensity score matching (PSM), we recruited 2724 patients with ESCC (2177 in the maintenance chemotherapy group and 547 in the non-maintenance chemotherapy group). The adjusted hazard ratios (95% confidence intervals) of all-cause mortality and cancer-specific mortality for the maintenance chemotherapy group were 1.15 (1.06-1.26, P = 0.0014) and 1.08 (0.88-1.29, P = 0.1320), respectively, compared with the non-maintenance chemotherapy group. We also found that older age, relatively lower body mass index (BMI), higher American Joint Committee on Cancer clinical stage, and poor response to CCRT as measured using the Response Evaluation Criteria in Solid Tumors were poor independent predictors of all-cause mortality and cancer-specific mortality. Our findings indicated that maintenance chemotherapy may not improve the survival of patients with ESCC who have received CCRT. Additionally, we identified several key prognostic factors for patients with ESCC receiving CCRT, including relatively low BMI and poor response to CCRT. Further research is needed to understand the benefits and risks of maintenance chemotherapy in similar patient populations in order to identify new therapies that could improve treatment responses.

Prognostic factors for survival in unresectable stage III EGFR mutation-positive lung adenocarcinoma: impact of pre-CCRT PET-CT

PURPOSE

To assess the survival impact of pre-concurrent chemoradiotherapy (CCRT) staging with positron emission tomography-CT (PET-CT) in patients with unresectable epidermal growth factor receptor (EGFR) mutation-positive adenocarcinoma.

METHODS

Patients with unresectable stage IIIA-IIIC EGFR mutation-positive adenocarcinoma undergoing definitive CCRT were divided into two groups: those who received PET-CT staging prior to CCRT and those with other staging methods. Survival outcomes were compared after propensity score matching.

RESULTS

Analysis of 11 856 patients (5928 in each group) showed that PET-CT staging was associated with improved survival (adjusted HR of all-cause mortality: 0.74, 95% CI 0.71 to 0.79). Other prognostic factors included male sex, age group, clinical stage, adjuvant treatment, smoking status, Charlson Comorbidity Index score and treatment setting.

CONCLUSION

Pre-CCRT staging with PET-CT in patients with unresectable EGFR mutation-positive adenocarcinoma of clinical stage IIIA-IIIC was associated with enhanced survival. Independent prognostic factors were also identified.

Improved postoperative outcomes in pediatric major surgery: evidence from hospital volume analysis

This study aimed to examine the association between hospital volume and postoperative outcomes in pediatric major surgery using a nationwide database. The study included pediatric patients who underwent first major elective inpatient surgery and hospitalization for more than 1 day. The results showed no significant difference in the risk of 30-day postoperative mortality based on hospital volume. However, patients in the middle- and high-volume groups had significantly lower rates of 30-day major complications, particularly deep wound infection. In terms of 90-day postoperative outcomes, patients in the high-volume group had a significantly lower risk of mortality and lower rates of major complications, particularly deep wound infection, pneumonia, and septicemia.  Conclusions: The study suggests that pediatric patients undergoing major surgery in high and middle-volume groups have better outcomes in terms of major complications compared to the low-volume group. What is Known: • Limited evidence exists on the connection between hospital volume and pediatric surgery outcomes. What is New: • A Taiwan-based study, using national data, found that high and middle hospital-volume groups experienced significantly lower rates of major complications within 30 and 90 days after surgery. • High-volume hospitals demonstrated a substantial decrease in the risk of 90-day postoperative mortality. • The study underscores the importance of specialized pediatric surgical centers and advocates for clear guidelines for hospital selection, potentially improving outcomes and informing future health policies.

Effects of SGLT2 inhibitors on clinical cancer survival in patients with type 2 diabetes

PURPOSE

According to the preclinical data, sodium-glucose cotransporter 2 (SGLT2) inhibitors (SGLT2is) may exert anticancer effects. Here, we clarified the cancer-specific mortality (primary outcome) and all-cause mortality (secondary outcome) of SGLT2is and their dose-dependency in patients with cancer undergoing standard curative treatments.

METHODS

We analyzed data from patients with type 2 diabetes mellitus (T2DM) diagnosed with cancer between January 1, 2016, and December 31, 2018, enrolled from the Taiwan Cancer Registry database. Kaplan-Meier method was used to estimate all-cause mortality and cancer-specific mortality, comparing survival curves between SGLT2i users and nonusers using the stratified log-rank test. Cox proportional hazards regression was conducted to identify independent predictors for all-cause and cancer-specific mortality among the covariates.

RESULTS

We performed 1:2 propensity score matching of our data, which yielded a final cohort of 50,133 patients with cancer; of them, 16,711 and 33,422 were in the SGLT2i user and nonuser groups, respectively. The adjusted hazard ratio (aHR) for cancer-specific and all-cause mortality in SGLT2i users compared with nonusers was 0.21 (95 % confidence interval [CI]: 0.20-0.22) and 0.22 (95 % CI: 0.21-0.23). We divided the patients into four subgroups stratified by quartiles (Q) of cumulative defined daily doses per year (cDDDs), and all-cause and cancer-specific mortality was noted to significantly decrease with increases in dosage (from Q1 to Q4 cDDDs) in SGLT2i users compared with in nonusers (P < 0.001).

CONCLUSION

SGLT2is increase overall survival and cancer-specific survival in patients with cancer in a dose-dependent manner.

Comparative Effectiveness of Intensity-Modulated Proton Therapy Versus Intensity-Modulated Radiotherapy for Patients With Inoperable Esophageal Squamous Cell Carcinoma Undergoing Curative-Intent Concurrent Chemoradiotherapy

INTRODUCTION

This study compared outcomes in patients with inoperable esophageal squamous cell carcinoma (ESCC) undergoing curative-intent concurrent chemoradiotherapy (CCRT) with intensity-modulated radiotherapy (IMRT) versus intensity-modulated proton therapy (IMPT).

METHODS

The study encompassed a retrospective cohort analysis of patients with inoperable ESCC who underwent curative-intent CCRT from January 1, 2015, to December 31, 2020, with data sourced from the Taiwan Cancer Registry Database. In this study, both IMRT and IMPT delivered a total equivalent effective dose of approximately 5040 cGy in 28 fractions, accompanied by platinum-based chemotherapy administered as per established protocols. Multivariate Cox regression analyses were performed to assess oncologic outcomes, and statistical analyses were conducted, including inverse probability of treatment-weighted and Fine and Gray method for competing risks.

RESULTS

The observed risks of ESCC-specific and all-cause mortality were lower in patients treated with IMPT compared with those treated with IMRT, with adjusted hazard ratios (aHRs) of 0.62 (95% confidence interval [CI]: 0.58-0.70) and 0.72 (95% CI: 0.66-0.80), respectively. IMPT also reduced grade 2 radiation-induced side effects, such as pneumonitis, fatigue, and major adverse cardiovascular events, with aHRs (95% CI) of 0.76 (0.66-0.82), 0.10 (0.07-0.14), and 0.70 (0.67-0.73), respectively. However, IMPT was associated with an increased risk of grade 2 radiation dermatitis, with aHR (95% CI) of 1.48 (1.36-1.60). No substantial differences were found in the incidence of radiation esophagitis between IMPT and IMRT when adjusting for covariates.

CONCLUSION

IMPT seems to be associated with superiority over IMRT in managing patients with inoperable ESCC undergoing curative-intent CCRT, suggesting improved survival outcomes and reduced toxicity. These findings have significant implications for the treatment of ESCC, particularly when surgery is not an option.

Long-Term Opioid Use and Dementia Risk in Patients With Chronic Pain

OBJECTIVE

This study aimed to investigate the association between long-term opioid use and the risk of dementia in patients with chronic pain.

DESIGN

A head-to-head propensity score-matched (PSM) comparative cohort study was conducted to examine the effect of long-term opioid use on dementia risk. A time-varying Cox regression analysis was performed to calculate adjusted hazard ratios (aHRs) with 95% CIs to identify independent predictors of dementia risk.

SETTING AND PARTICIPANTS

The study included 41,636 patients after PSM, with 20,968 in the opioid use group (≥180 defined daily doses per year) and 20,968 in the non-opioid use group.

METHODS

Multivariate Cox regression analysis was conducted to compare the dementia risk between the opioid use and non-opioid use groups. The incidence of dementia was calculated as the number of cases per 10,000 person-years for each group. Adjusted incidence ratios were determined to assess the dementia risk associated with opioid use.

RESULTS

The multivariate Cox regression analysis showed that the aHR for dementia risk in the opioid use group, compared with the non-opioid use group, was 1.86 (95% CI 1.25-2.09; P < .001). The incidence of dementia was higher among opioid users (44.09 per 10,000 person-years) compared with nonusers (38.85 per 10,000 person-years). The adjusted incidence ratio for dementia risk in the opioid use group, compared with the nonuse group, was 1.13 (95% CI: 1.07-1.21, P < .001).

CONCLUSIONS AND IMPLICATIONS

Long-term opioid use may be associated with an increased risk of dementia in patients with chronic pain. These findings highlight the need for cautious prescribing and monitoring of opioid use in this population, considering the potential long-term cognitive implications.

The Protective Effect of Vitamin D on Dementia Risk in Hemodialysis Patients

BACKGROUND

Patients with end-stage renal disease (ESRD) undergoing hemodialysis are at an elevated risk of developing dementia, potentially linked to the high prevalence of vitamin D deficiency in this population, which may contribute to cognitive impairment. Nevertheless, the impact of vitamin D supplementation on the risk of dementia in hemodialysis patients remains uncertain, necessitating further investigation to elucidate the potential benefits of vitamin D intervention in this vulnerable group.

METHODS

In this propensity-score-matched comparative cohort study, we sought to assess the impact of vitamin D supplementation on the occurrence of dementia in patients with end-stage renal disease (ESRD) undergoing hemodialysis. A total of 1424 patients were included and matched 1:1 using propensity scores. The study population was divided into two groups: those receiving vitamin D supplementation at a dose of ≥70 μg/week and those without any supplementation. The primary outcome of interest was the incidence of dementia. We calculated adjusted hazard ratios (aHRs) to examine the association between vitamin D supplementation and the risk of dementia while controlling for relevant covariates.

RESULTS

The adjusted hazard ratio (aHR) comparing vitamin D supplementation to no supplementation was 0.44 (95% CI 0.29-0.69; p < 0.0001), demonstrating a significant decrease in the risk of dementia associated with vitamin D supplementation. The aHRs for vitamin D supplementation at different dose ranges (70-105, 106-350, 351-1000, and >1000 μg/week) were 0.51, 0.49, 0.43, and 0.41, respectively (p for trend < 0.0001). These findings suggest a potential dose-dependent relationship between vitamin D supplementation and the reduction of dementia risk.

CONCLUSIONS

In our study, we found that vitamin D supplementation at doses of ≥70 μg/week significantly reduced the risk of dementia in patients with end-stage renal disease (ESRD) undergoing hemodialysis. Furthermore, our results indicated a dose-dependent effect, with higher doses of supplementation correlating with a greater reduction in dementia risk. These findings underscore the potential of vitamin D supplementation as a preventive approach for cognitive impairment in this high-risk population.

Statin Use During Concurrent Chemoradiotherapy With Improved Survival Outcomes in Esophageal Squamous Cell Carcinoma: A Propensity Score-Matched Nationwide Cohort Study

INTRODUCTION

To determine the effect of statin use during concurrent chemoradiotherapy (CCRT) on overall survival and esophageal squamous cell carcinoma (ESCC)-specific survival in patients with ESCC receiving standard CCRT.

METHODS

In this propensity score-matching cohort study, we used data from the Taiwan Cancer Registry Database and National Health Insurance Research Database to investigate the effects of statin use during the period of CCRT on overall survival and ESCC-specific survival.

RESULTS

Statin use during the period of CCRT was found to be a considerable and independent prognostic factor for overall survival and ESCC-specific survival. The adjusted hazard ratio (aHR) for all-cause mortality in the statin group compared with that of the non-statin group was 0.65 (95% confidence interval: 0.51-0.84, p = 0.0009). The aHR for ESCC-specific mortality in the statin group compared with that of the non-statin group was 0.63 (95% confidence interval: 0.47-0.84, p = 0.0016). The use of hydrophilic statins such as rosuvastatin and pravastatin was associated with the greatest survival benefits. A dose-response relationship was also found, with higher cumulative defined daily doses and higher daily intensity of statin use associated with lower mortality.

CONCLUSIONS

This study is the first to reveal that statin use during the period of CCRT for ESCC is associated with improvement in overall survival and ESCC-specific survival. In addition, we found that use of rosuvastatin, pravastatin, and simvastatin was associated with better survival outcomes for patients with ESCC receiving CCRT. Furthermore, we found a dose-response relationship of statin use associated with lower ESCC-specific mortality.

The Impact of Sarcopenia Onset Prior to Cancer Diagnosis on Cancer Survival: A National Population-Based Cohort Study Using Propensity Score Matching

PURPOSE

The relationship between the onset of sarcopenia prior to cancer diagnosis and survival outcomes in various types of cancer is not well understood. To address this gap in knowledge, we conducted a propensity score-matched population-based cohort study to compare the overall survival of cancer patients with and without sarcopenia.

PATIENTS AND METHODS

In our study, we included patients with cancer and divided them into two groups based on the presence or absence of sarcopenia. To ensure comparability between the groups, we matched patients in both groups at a ratio of 1:1.

RESULTS

After the matching process, our final cohort included 20,416 patients with cancer (10,208 in each group) who were eligible for further analysis. There were no significant differences between the sarcopenia and nonsarcopenia groups in terms of confounding factors such as age (mean 61.05 years versus 62.17 years), gender (52.56% versus 52.16% male, 47.44% versus 47.84% female), comorbidities, and cancer stages. In our multivariate Cox regression analysis, we found that the adjusted hazard ratio (aHR; 95% confidence interval [CI]) of all-cause death for the sarcopenia group compared to the nonsarcopenia group was 1.49 (1.43-1.55; p < 0.001). Additionally, the aHRs (95% CIs) of all-cause death for those aged 66-75, 76-85, and >85 years (compared to those aged ≤65 years) were 1.29 (1.23-1.36), 2.00 (1.89-2.12), and 3.26 (2.97-3.59), respectively. The aHR (95% CI) of all-cause death for those with a Charlson comorbidity index (CCI) ≥ 1 compared to those with a CCI of 0 was 1.34 (1.28-1.40). The aHR (95% CI) of all-cause death for men compared to women was 1.56 (1.50-1.62). When comparing the sarcopenia and nonsarcopenia groups, the aHRs (95% CIs) for lung, liver, colorectal, breast, prostate, oral, pancreatic, stomach, ovarian, and other cancers were significantly higher.

CONCLUSION

Our findings suggest that the onset of sarcopenia prior to cancer diagnosis may be linked to reduced survival outcomes in cancer patients.

Dementia risk amongst older adults with hip fracture receiving general anaesthesia or regional anaesthesia: a propensity-score-matched population-based cohort study

BACKGROUND

Preclinical studies have indicated that anaesthesia is an independent risk factor for dementia, but the clinical associations between dementia and different types of general anaesthesia or regional anaesthesia remain unclear. We conducted a population-based cohort study using propensity-score matching to compare dementia incidence in patients included in the Taiwanese National Health Insurance Research Database who received various anaesthetic types for hip fracture surgery.

METHODS

Patients aged ≥65 yr who received elective hip fracture surgery from 2002 to 2019 were divided into three groups receiving either inhalational anaesthesia (GA), total intravenous anaesthesia-general anaesthesia (TIVA-GA), or regional anaesthesia (RA), and matched in a 1:1 ratio. The incidence rates of dementia were then determined.

RESULTS

Propensity-score matching yielded 89 338 patients in each group (N=268 014). Dementia incidence rates in the inhalational GA, TIVA-GA, and RA groups were 4821, 3400, and 2692 per 100 000 person-years, respectively. The dementia incidence rate ratio (95% confidence interval [CI]) for inhalational GA to TIVA-GA was 1.19 (1.14-1.25), for inhalational GA to RA was 1.51 (1.15-1.66), and for TIVA-GA to RA was 1.28 (1.09-1.51).

CONCLUSIONS

The incidence rate ratios of dementia amongst older adults undergoing hip fracture surgery were higher for those receiving general anaesthesia than for those receiving regional anaesthesia, with inhalational anaesthesia associated with a higher incidence rate ratio for dementia than total intravenous anaesthesia (TIVA).

Pre-CCRT 18-fluorodeoxyglucose PET-CT improves survival in patients with advanced stages p16-negative oropharyngeal squamous cell carcinoma via accurate radiation treatment planning

PURPOSE

No large-scale prospective randomized study with a long-term follow-up period has evaluated the survival outcomes of preconcurrent chemoradiotherapy (CCRT) 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG PET-CT) in patients with non-human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC).

PATIENTS AND METHODS

We included patients with stage I-IVA p16-negative OPSCC receiving definitive CCRT and categorized them into two groups according to pre-CCRT ¹⁸FDG PET-CT and compared their outcomes: the case group consisted of patients who underwent pre-CCRT ¹⁸FDG PET-CT, whereas the comparison group consisted of patients who did not receive pre-CCRT ¹⁸FDG PET-CT.

RESULTS

The final cohort consisted of 3942 patients (1663 and 2279 in the case and comparison groups, respectively). According to multivariable Cox regression analysis, pre-CCRT ¹⁸FDG PET-CT was not a significant prognostic factor for overall survival in patients with stages I-II of p16-negative OPSCC receiving standard CCRT. The adjusted hazard ratio (95% confidence interval) of all-cause death for the patients with advanced stages (III-IVA) of p16-negative OPSCC receiving pre-CCRT ¹⁸FDG PET-CT was 0.75 (0.87-0.94, P = 0.0236).

CONCLUSIONS

Routine use of pre-CCRT ¹⁸FDG PET-CT is not necessary for each patient with p16-negative OPSCC. Pre-CCRT ¹⁸FDG PET-CT is associated with improved survival in patients with stage III-IVA p16-negative OSCC, but might be not in those with stage I-II p16-negative OPSCC. No large-scale prospective randomized study with a long-term follow-up period has evaluated the survival outcomes of preconcurrent chemoradiotherapy (CCRT) 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG PET-CT) in patients with p16-negative oropharyngeal squamous cell carcinoma (OPSCC). Our study is the first, largest, homogenous modality study on PET-CT including a long-term follow-up cohort to examine the survival outcomes of pre-CCRT ¹⁸FDG PET-CT or non-pre-CCRT PET-CT for patients with p16-negative OPSCC receiving standard CCRT stratified by different clinical stages. Routine use of pre-CCRT ¹⁸FDG PET-CT is not necessary for each patient with p16-negative OPSCC. Pre-CCRT ¹⁸FDG PET-CT is associated with improved survival in patients with stage III-IVA p16-negative OPSCC, but might be not in those with stage I-II p16-negative OPSCC.

Neoadjuvant endocrine therapy in postmenopausal women with HR+/HER2- breast cancer

INTRODUCTION

While endocrine therapy is the standard-of-care adjuvant treatment for hormone receptor-positive (HR+) breast cancers, there is also extensive evidence for the role of pre-operative (or neoadjuvant) endocrine therapy (NET) in HR+ postmenopausal women.

AREAS COVERED

We conducted a thorough review of the published literature, to summarize the evidence to date, including studies of how NET compares to neoadjuvant chemotherapy, which NET agents are preferable, and the optimal duration of NET. We describe the importance of on-treatment assessment of response, the different predictors available (including Ki67, PEPI score, and molecular signatures) and the research opportunities the pre-operative setting offers. We also summarize recent combination trials and discuss how the COVID-19 pandemic led to increases in NET use for safe management of cases with deferred surgery and adjuvant treatments.

EXPERT OPINION

NET represents a safe and effective tool for the management of postmenopausal women with HR+/HER2- breast cancer, enabling disease downstaging and a wider range of surgical options. Aromatase inhibitors are the preferred NET, with evidence suggesting that longer regimens might yield optimal results. However, NET remains currently underutilised in many territories and institutions. Further validation of predictors for treatment response and benefit is needed to help standardise and fully exploit the potential of NET in the clinic.

Biomarker Alteration after Neoadjuvant Endocrine Therapy or Chemotherapy in Estrogen Receptor-Positive Breast Cancer

In estrogen receptor (ER)-positive breast cancer, changes in biomarker expression after neoadjuvant therapy indicate the therapeutic response and are prognostic. However, there is limited information about the biomarker alteration caused by neoadjuvant endocrine therapy in ER-positive and human epidermal growth factor receptor 2 (HER2)-negative breast cancer. We recruited ER-positive/HER2-negative breast cancer patients who received neoadjuvant chemotherapy (NCT), neoadjuvant endocrine therapy (NET), or sequential neoadjuvant endocrine-chemotherapy (NECT) at Peking University Cancer Hospital from 2015 to 2021. A total of 579 patients had paired immunohistochemistry information in both diagnostic biopsy samples and post-neoadjuvant therapy surgical samples. Through a paired comparison of the immunohistochemical information in pre-treatment and post-treatment samples, we found that progesterone receptor (PR) expression reductions were more frequent than ER expression reductions (70.8% vs. 35.2%) after neoadjuvant therapy. The percentage of patients who had a decreased Ki-67 index in the post-operative samples was similar in the three groups (79.8% vs. 79.7% vs. 78.4%). Moreover, PR losses caused by NET were related to low baseline PR expression (p = 0.001), while we did not find a significant association between PR losses and Ki-67 reductions (p = 0.428) or ER losses (p = 0.274). All three types of neoadjuvant therapies caused a reduction in ER, PR, and Ki-67 expression. In conclusion, we found that PR loss after NET was only significantly related to low baseline PR expression, and there is no significant difference in the extent of prognostic factor change including Ki-67 and ER between the PR loss and non-loss groups.

The Association of Preoperative PET-CT and Survival in Patients with Resectable Cervical Cancer

PURPOSE

No randomized study with a long-term follow-up has investigated the effect of pretreatment 18-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG-PET-CT) on the survival of patients with stage IB-IIA cervical cancer receiving curative surgery. Therefore, in this propensity score-matched, population-based cohort study, we investigated the effect of preoperative ¹⁸FDG-PET-CT on the survival outcomes of patients with potentially resectable cervical cancer.

PATIENTS AND METHODS

We included 2550 patients with stage IB-IIA cervical cancer receiving curative surgery with complete data on clinical stages. The patients were categorized into two 1:4 propensity, score-matched groups depending on whether they underwent pretreatment ¹⁸FDG-PET-CT, and their outcomes were compared.

RESULTS

We included 2030 and 520 patients with cervical cancer in the non-pretreatment and pretreatment PET-CT groups, respectively. Multivariable analyses revealed that the most prominent correlation between preoperative PET-CT and all-cause death was observed in the patients with stage IB-IIA cervical cancer receiving surgery (aHR [95% CI]: 1.16 [0.83-1.63]; p = 0.3752).

CONCLUSIONS

Preoperative ¹⁸FDG-PET-CT was not associated with longer survival in the patients with clinical stage IB-IIA cervical cancer receiving curative surgery.

Use of preoperative PET-CT and survival of p16-negative oropharyngeal cancer

No comparative study with a long-term follow-up period has evaluated the survival outcomes of preoperative 18-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸FDG PET/CT) in patients with p16-negative OPSCC. We included patients with stage I-IVB p16-negative OPSCC undergoing surgery and categorized them into two groups based on whether they underwent preoperative ¹⁸FDG PET/CT and compared their outcomes: the case group comprised patients who did not undergo preoperative ¹⁸FDG PET/CT, whereas the control group comprised patients who underwent preoperative ¹⁸FDG PET/CT. The findings of the multivariable Cox regression analysis revealed no association between preoperative ¹⁸FDG PET/CT and overall survival (OS) in the case and control groups in the patients with stage I-III p16-negative OPSCC undergoing surgery (after multivariable adjustment, the hazard ratio [HR] was 1.12; 95% confidence interval [CI] = 0.86-1.48: P = 0.4028). However, we noted an association between preoperative ¹⁸FDG PET/CT and OS in the case and control groups in the patients with stage IVA and IVB p16-negative OPSCC undergoing surgery (after multivariable adjustment, the HR of all-cause mortality for nonpreoperative PET/CT was 1.82 compared with preoperative PET/CT; 95% CI = 1.47-2.26; P < 0.0001). Preoperative ¹⁸FDG PET/CT use was associated with a lower risk of mortality in the patients with stage IVA and IVB p16-negative OPSCC without metastasis.

Intraductal delivery of nanocarriers for ductal carcinoma in situ treatment: a strategy to enhance localized delivery

Ductal carcinoma in situ describes the most commonly occurring, noninvasive malignant breast disease, which could be the leading factor in invasive breast cancer. Despite remarkable advancements in treatment options, poor specificity, low bioavailability and dose-induced toxicity of chemotherapy are the main constraint. A unique characteristic of nanocarriers may overcome these problems. Moreover, the intraductal route of administration serves as an alternative approach. The direct nanodrug delivery into mammary ducts results in the accumulation of anticancer agents at targeted tissue for a prolonged period with high permeability, significantly decreasing the tumor size and improving the survival rate. This review focuses mainly on the intraductal delivery of nanocarriers in treating ductal carcinoma in situ, together with potential clinical translational research.

The Protective Effects of Influenza Vaccination in Elderly Patients with Breast Cancer in Taiwan: A Real-World Evidence-Based Study

In elderly patients with newly diagnosed breast cancer, clarity is lacking regarding the effects of influenza vaccines, particularly on clinical outcomes. This study conducted two nationwide, population-based, and propensity score-matched cohorts to estimate and compare the protective effects of influenza vaccine in elderly women and elderly patients with breast cancer. Data were derived from the National Health Insurance Research Database and Cancer Registry Database. Generalized estimating equations (GEEs) were used to compare outcomes between the vaccinated and unvaccinated cohorts. Adjusted odds ratios (aORs) were used to estimate the relative risks, and stratified analyses in the breast cancer cohort were performed to further evaluate elderly breast cancer patients undergoing a variety of adjuvant therapies. The GEE analysis showed that the aORs of death and hospitalization, including for influenza and pneumonia, respiratory diseases, respiratory failure, and heart disease, did not significantly decrease in vaccinated elderly patients with newly diagnosed breast cancer. Conversely, the aORs of all influenza-related clinical outcomes were significantly decreased in elderly women. No protective effects of influenza vaccination were found in the elderly patients with a newly diagnosed breast cancer. More studies focusing on identifying strategies to improve the real-world effectiveness of influenza vaccination to the immunocompromised are needed. Our clinical outcomes will be valuable for future public health policy establishment and shared decision making for influenza vaccine use in elderly patients with newly diagnosed breast cancer. According to our findings, regular influenza vaccine administration for elderly patients with newly diagnosed breast cancer may be reconsidered, with potential contraindications for vaccination. On the other hand, implementing the vaccination of close contacts of patients with breast cancer may be a more important strategy for enhancing protection of those fragile patients.

Breast Cancer Patients: Who Would Benefit from Neoadjuvant Chemotherapies?

Neoadjuvant chemotherapy (NACT) was developed with the aims of shrinking tumors or stopping cancer cells from spreading before surgery. Unfortunately, not all breast cancer patients will benefit from NACT, and thus, patients must weigh the risks and benefits of treatment prior to the initiation of therapy. Currently, the data for predicting the efficacy of NACT is limited. Molecular testing, such as Oncotype DX, MammaPrint, and Curebest 95GC, have been developed to assist which breast cancer patients will benefit from the treatment. Patients with an increased level of Human Leukocyte Antigen-DR isotype, tumor-infiltrating lymphocytes, Fizzy-related protein homolog, and a decreased level of tumor-associated macrophages appear to benefit most from NACT.

Use of Preoperative FDG PET/CT and Survival of Patients with Resectable Non-Small Cell Lung Cancer

Background The added value of preoperative PET/CT for the overall survival of patients with resectable non-small cell lung cancer (NSCLC) is unknown. Purpose To investigate the association of the use of preoperative PET/CT on survival of patients with resectable stage I-IIIB NSCLC. Materials and Methods In this retrospective study, patients with resectable stage I-IIIB NSCLC who underwent thoracic surgery from January 1, 2009, to December 31, 2018, from the Taiwan Cancer Registry were included. The last follow-up date was December 31, 2019. Patients were categorized into two groups according to whether they underwent preoperative metabolic imaging with fluorine 18 fluorodeoxyglucose PET/CT. Patients who did not undergo preoperative imaging were used as the control group. The primary outcome of interest was all-cause mortality. Patients in both groups were propensity score matched at a ratio of 1:1. Matching variables used were sex, age, histologic findings, American Joint Committee on Cancer clinical stage, cT stage, cN stage, current and past smoker history, adjuvant chemotherapy, adjuvant chemoradiation, Charlson comorbidity index, and hospital type. Survival curves were generated using the Kaplan-Meier method and compared using the log-rank test. Results In the matched cohort, 6754 patients (3349 men, mean age ± SD: 64 years ± 11) underwent PET/CT and 6754 did not (3362 men, mean age: 64 years ± 11). In adjusted analysis, patients with stage IIIA or IIIB NSCLC and preoperative PET/CT had a lower risk of death versus those without PET/CT (for stage IIIA: hazard ratio [HR] = 0.90 [95% CI: 0.79, 0.94], P = .02; for stage IIIB: HR = 0.80 [95% CI: 0.71, 0.90], P < .01). There was no improvement in a lower risk of death for patients with stage I-II NSCLC (after multivariable adjustment, the HR was 1.19 [95% CI: 0.89, 1.30], P = .65). Conclusion Use of preoperative PET/CT was associated with lower risk of death in patients with stage IIIA-IIIB non-small cell lung cancer compared with those without preoperative PET/CT. © RSNA, 2022 Online supplemental material is available for this article.

The Latest Data Specifically Focused on Long-Term Oncologic Prognostication for Very Old Adults with Acute Vulnerable Localized Prostate Cancer: A Nationwide Cohort Study

Purpose: Few studies have evaluated the prime treatment choice for men older than 80 years with acute vulnerable localized prostate cancer (AV-LPC). Clinicians have been deeply troubled by this near end-of-life medical choice for a very specific group of patients. We compared the oncological prognostication of very old patients with AV-LPC after they underwent either radical prostatectomy (RP) or massive-dose intensity-modulated radiotherapy (IMRT) coupled with long-term androgen deprivation therapy (ADT) over a long-term investigation. Methods: In this nationwide cohort study, we used the Taiwan Cancer Registry Database and retrieved information related to patients (aged ≥ 80 years) with AV-LPC who underwent standard RP (the RP group) or massive-dose IMRT + long-term ADT (at least 72 Gy and ADT use ≥18 months; the IMRT + ADT group). After potential confounders were controlled for using propensity score matching (PSM), we utilized the Cox proportional hazards regression to evaluate the oncologic prognostication. Results: The IMRT + ADT group had a significantly higher adjusted hazard ratio (aHR) for all-cause mortality (aHR, 2.00; 95% confidence interval [CI], 1.41−2.87) than the RP group. Analysis of the secondary outcomes revealed that compared with the RP group, the aHRs of biochemical failure, locoregional recurrence, and distant metastasis in the IMRT + ADT group were 1.77 (95% CI: 1.36−2.11, p < 0.0001), 1.12 (95% CI: 1.04−1.33, p < 0.0001), and 1.15 (95% CI: 1.06−1.71, p = 0.0311), respectively. Conclusion: RP provides more favorable oncological prognostication than IMRT in very old adults with AV-LPC.

Association of Diabetes Severity and Mortality with Lung Squamous Cell Carcinoma

Simple Summary

The survival impact of diabetes severity on lung cancer survival remains unclear. We performed head-to-head propensity score matching to estimate the survival impact of various adapted diabetes complications severity index (aDCSI) scores in patients with both diabetes and lung squamous cell carcinoma (SqCLC). The results indicated that diabetes severity (aDCSI ≥ 2) is an independent prognostic factor for the overall survival of patients with both diabetes and lung SqCLC who receive standard treatments. Prevention of diabetes progression is necessary for patients with diabetes; it affects not only diabetes control but also improves survival for patients with lung SqCLC.

Abstract

Purpose: The survival impact of diabetes severity on lung cancer remains unclear. We performed head-to-head propensity score matching to estimate the survival impact of various adapted diabetes complications severity index (aDCSI) scores in patients with both diabetes and lung squamous cell carcinoma (SqCLC). Patients and Methods: We enrolled patients with both diabetes and lung SqCLC and categorized them into the mild (aDCSI = 0–1) and moderate-to-severe (aDCSI ≥ 2) diabetes groups. The patients in both groups were matched at a 1:1 ratio. Results: the matching process yielded a final cohort of 5742 patients with both diabetes and lung SqCLC (2871 patients in the mild diabetes group and 2871 patients in the moderate-to-severe diabetes groups) who were eligible for further analysis. A multivariate Cox regression analysis revealed that the adjusted hazard ratio (aHR; 95% confidence interval) of all-cause death for the mild diabetes group relative to the moderate-to-severe diabetes group was 1.17 (1.08–1.28; p = 0.0005). Conclusion: severe diabetes (aDCSI ≥ 2) is an independent prognostic factor for OS among patients with both diabetes and lung SqCLC who receive standard treatments. Preventing diabetes progression is necessary for patients with diabetes because it not only supports diabetes control but also improves survival for patients with lung SqCLC.

Current-Smoking-Related COPD or COPD With Acute Exacerbation is Associated With Poorer Survival Following Oral Cavity Squamous Cell Carcinoma Surgery

BACKGROUND

The survival effect of smoking-related chronic obstructive pulmonary disease (COPD) and COPD with acute exacerbation (COPDAE) before surgery on patients with oral cavity squamous cell carcinoma (OCSCC) is unclear.

METHODS

Using the Taiwan Cancer Registry Database, we enrolled patients with OCSCC (pathologic stages I-IVB) receiving surgery. The Cox proportional hazards model was used to analyze all-cause mortality. We categorized the patients into 2 groups by using propensity score matching based on the pre-existing COPD status (≤1 year before surgery) to compare overall survival outcomes: Group 1 (never smokers without COPD) and Group 2 (current smokers with COPD).

RESULTS

In multivariate Cox regression analyses, the adjusted hazard ratio (aHR; 95% confidence interval [CI]) of all-cause mortality in Group 2 compared with Group 1 was 1.07 (1.02-1.16, P = 0.041). The aHR (95% CIs) of all-cause mortality for ≥1 hospitalizations for COPDAE within 1 year before surgery for patients with OCSCC was 1.31 (1.02-1.64; P = 0.011) compared with no COPDAE in patients with OCSCC receiving surgery. Among patients with OCSCC undergoing curative surgery, current smokers with smoking-related COPD demonstrated poorer survival outcomes than did nonsmokers without COPD, for both OCSCC death and all-cause mortality. Hospitalization for COPDAE within 1 year before surgery was found to be an independent risk factor for overall survival in these patients with OCSCC.

CONCLUSION

Prevention of COPD progression to COPDAE may lead to an increase in overall survival in patients with OCSCC receiving curative surgery.

Anesthesia With Propofol Sedation Reduces Locoregional Recurrence in Patients With Breast Cancer Receiving Total Mastectomy Compared With Non-Propofol Anesthesia

Purpose

We examined locoregional recurrence (LRR) in patients with breast invasive ductal carcinoma (IDC) receiving total mastectomy (TM) under propofol-based paravertebral block-regional anesthesia (PB-RA) versus sevoflurane-based inhalational general anesthesia (INHA-GA) without propofol. All-cause death and distant metastasis were secondary endpoints.

Patients and Methods

Patients with breast IDC receiving TM were recruited through propensity score matching and categorized into INHA-GA with sevoflurane and PB-RA with propofol groups. Cox regression analysis was performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

In the multivariate Cox regression analysis, the adjusted HR (aHR; 95% CI) of LRR for the PB-RA with propofol group was 0.52 (0.28–0.96) compared with the INHA-GA with sevoflurane group. The aHRs of LRR for differentiation grade II, grade III, the American Joint Committee on Cancer clinical stage II, stage III, pathological tumor (pT) stage 2, pT stage 3–4, pathological nodal (pN) stage 1, and pN stage 2–3 were 1.16 (1.04–2.08), 1.28 (1.07–2.12), 3.71 (1.82–7.59), 4.67 (1.65–13.18), 1.09 (1.02–1.21), 1.17 (1.03–2.16), 1.10 (1.03–1.33), and 1.22 (1.06–2.41), respectively, compared with differentiation grade I, clinical stage I, pT1, and pN0. The aHR of LRR for adjuvant RT was 0.88 (0.64–0.94) compared with that for no adjuvant RT.

Conclusion

PB-RA with propofol might be beneficial for reducing LRR in women with breast IDC receiving TM compared with INHA-GA without propofol.

Survival Impact of Long-Term Tramadol Use on Breast Cancer for Patients with Chronic Pain: A Propensity Score-Matched Population-Based Cohort Study

Purpose: The impact of tramadol analgesic use before breast cancer diagnosis on survival in patients with chronic pain is unclear. Therefore, we designed a propensity score-matched population-based cohort study to compare the breast cancer-related survival of patients with chronic pain who received long-term tramadol analgesic treatment with that of those who did not receive such treatment. Patients and Methods: We included patients with chronic pain and categorized them into two groups according to their analgesic use, comparing their breast cancer-related survival; patients with breast cancer and chronic pain who were prescribed ≥180 defined daily doses (DDDs) of tramadol analgesics per year >3 months before breast cancer diagnosis comprised the case group, and those who were prescribed non-tramadol analgesics before breast cancer diagnosis comprised the control group. Patients in both groups were matched at a ratio of 1:5. Results: The matching process yielded a final cohort of 624 patients (104 and 520 in the case and control groups, respectively) who were eligible for further analysis. According to both univariate and multivariate Cox regression analyses, the adjusted hazard ratio for all-cause death in the case group compared with in the control group was 3.45 (95% confidence interval = 2.36−5.04; p < 0.001). Conclusion: Long-term tramadol analgesic use prior to breast cancer diagnosis might be associated with poor overall survival in patients with chronic pain compared with such patients that did not receive long-term tramadol analgesic treatment.

Adjuvant Radiotherapy Is Associated with an Increase in the Survival of Old (Aged over 80 Years) and Very Old (Aged over 90 Years) Women with Breast Cancer Receiving Breast-Conserving Surgery

This study is the first to examine the effect of adjuvant whole-breast radiotherapy (WBRT) on oncologic outcomes such as all-cause death, locoregional recurrence (LRR), and distant metastasis (DM) in old (aged ≥80 years) and very old (aged ≥90 years) women with breast invasive ductal carcinoma (IDC) receiving breast-conserving surgery. After propensity score matching, adjuvant WBRT was associated with decreases in all-cause death, LRR, and DM in old and very old women with IDC compared with no use of adjuvant WBRT. Background: To date, no data on the effect of adjuvant whole-breast radiotherapy (WBRT) on oncologic outcomes, such as all-cause death, locoregional recurrence (LRR), and distant metastasis (DM), are available for old (aged ≥80 years) and very old (≥90 years) women with breast invasive ductal carcinoma (IDC) receiving breast-conserving conservative surgery (BCS). Patients and Methods: We enrolled old (≥80 years old) and very old (≥90 years old) women with breast IDC who had received BCS followed by adjuvant WBRT or no adjuvant WBRT. We grouped them based on adjuvant WBRT status and compared their overall survival (OS), LRR, and DM outcomes. To reduce the effects of potential confounders when comparing all-cause mortality between the groups, propensity score matching was performed. Results: Overall, 752 older women with IDC received BCS followed by adjuvant WBRT, and 752 with IDC received BCS with no adjuvant WBRT. In multivariable Cox regression analysis, the adjusted hazard ratio (aHR) and 95% confidence interval (95% CI) of all-cause death for adjuvant WBRT compared with no adjuvant WBRT in older women with IDC receiving BCS was 0.56 (0.44–0.70). The aHRs (95% CIs) of LRR and DM for adjuvant WBRT were 0.29 (0.19–0.45) and 0.45 (0.32–0.62), respectively, compared with no adjuvant WBRT. Conclusions: Adjuvant WBRT was associated with decreases in all-cause death, LRR, and DM in old (aged ≥80 years) and very old (aged ≥90 years) women with IDC compared with no adjuvant WBRT.

Adjuvant postmastectomy radiotherapy might be associated with better survival in women with heart failure receiving total mastectomy

Background

To date, no data on the effect of adjuvant postmastectomy radiotherapy (PMRT) on oncologic outcomes, such as all-cause death, locoregional recurrence (LRR), and distant metastasis (DM), are available in women with left-side breast invasive ductal carcinoma (IDC) and heart failure with reduced ejection fraction (HFrEF).

Patients and methods

We enrolled 646 women with left-breast IDC at clinical stages I–IIIC and HFrEF receiving radical total mastectomy (TM) followed by adjuvant PMRT or non-adjuvant PMRT. We categorized them into two groups based on their adjuvant PMRT status and compared their overall survival (OS), LRR, and DM outcomes. We calculated the propensity score and applied inverse probability of treatment weighting (IPTW) to create a pseudo-study cohort. Furthermore, we performed a multivariate analysis of the propensity score–weighted population to obtain hazard ratios (HRs).

Results

In the IPTW-adjusted model, adjuvant PMRT (adjusted HR [aHR]: 0.52; 95% confidence interval [CI]: 0.37–0.74) was a significant independent prognostic factor for all-cause death (P = 0.0003), and the aHR (95% CI) of LRR and DM for adjuvant PMRT was 0.90 (0.79–0.96; P = 0.0356) and 0.89 (0.54–1.50; P = 0.6854), respectively, compared with the nonadjuvant PMRT group.

Conclusion

Adjuvant PMRT was associated with a decrease in all-cause death, and LRR in women with left IDC and HFrEF compared with nonadjuvant PMRT.

Effect of opioids on cancer survival in patients with chronic pain: a propensity score-matched population-based cohort study

BACKGROUND

The impact of opioid analgesic use before cancer diagnosis on survival in patients with chronic pain is unclear. Therefore, we designed a propensity score-matched population-based cohort study to compare overall and cancer-related survival of patients with chronic pain who received long-term opioid analgesic treatment with that of those who did not receive such treatment.

METHODS

We included patients with chronic pain and categorised them into the following two groups according to their analgesic use: patients with cancer and chronic pain who were prescribed ≥180 defined daily doses of opioid analgesics per year >3 months before cancer diagnosis comprised the case group, and those who were prescribed <28 defined daily doses of opioid analgesics per year before cancer diagnosis comprised the control group. Patients in both groups were matched at a ratio of 1:5. The primary outcome was overall long-term survival.

RESULTS

The matching process yielded a final cohort of 1716 patients (286 and 1430 in the case and control groups, respectively) who were eligible for further analysis. The adjusted hazard ratio for overall survival in patients receiving long-term opioids was 3.53 (95% confidence interval: 3.03-4.11; P<0.001).

CONCLUSIONS

Long-term opioid analgesic use before cancer diagnosis might be associated with poor overall survival in patients with chronic pain compared with such patients who did not receive long-term opioid analgesics.

Association between Pre-Existing Sleep Disorders and Survival Rates of Patients with Breast Cancer

PURPOSE: To investigate the effects of pre-existing sleep disorders on the survival outcomes of women receiving standard treatments for breast invasive ductal carcinoma (IDC). METHODS: We recruited patients from the Taiwan Cancer Registry Database who had received surgery for clinical stage I–III breast IDC. The Cox proportional hazards model was used to analyze all-cause mortality. We categorized the patients into those with and without sleep disorders (Groups 1 and 2, respectively) through propensity score matching. RESULTS: In the multivariate Cox regression analysis, the adjusted hazard ratio for all-cause mortality for Group 1 compared with Group 2 was 1.51 (95% confidence interval: 1.19, 1.91; p < 0.001). CONCLUSION: Our study demonstrated that the sleep disorder group had poorer survival rates than the non-sleep disorder group in breast cancer. Therefore, patients should be screened and evaluated for pre-existing sleep disorders prior to breast surgery, with such disorders serving as a predictor of survival in patients with breast cancer. Future studies may investigate the survival benefits of pharmacological and behavioral treatments for sleep problems in patients with breast cancer.

Association between Preexisting Sarcopenia and Stroke in Patients with Type 2 Diabetes Mellitus

OBJECTIVES

This propensity score-matched population-based cohort study compared stroke risk between patients with type 2 diabetes mellitus with and without preexisting sarcopenia.

RESEARCH DESIGN AND METHODS

We used data from Taiwan's National Health Insurance Research Database for the period from January 2008 to December 2019. We recruited patients with type 2 diabetes mellitus and categorized them into two groups at a ratio of 1:1 on the basis of diagnosed sarcopenia. The matching variables were age, sex, income level, urbanization level, diabetes severity (adapted Diabetes Complications Severity Index [aDCSI Scores]), Charlson Comorbidity Index (CCI), other comorbidities associated with stroke, smoking status, medication use, and types of antidiabetic medications. The matching process yielded a final cohort of 104,120 patients (52,060 and 52,060 in the sarcopenia and nonsarcopenia groups, respectively) who were eligible for inclusion in subsequent analyses.

RESULTS

In the multivariate Cox regression analysis, the adjusted hazard ratio (aHR; 95% CI) of stroke for the sarcopenia diabetes group compared with the control group was 1.13 (1.10, 1.16; P < 0.001), after controlling for age, sex, CCI, and aDCSI scores. The incidence rates of stroke for the sarcopenia and nonsarcopenia groups were 295.98 and 260.68 per 10,000 person-years, respectively. The significant IRR (95% CI) of stroke was 1.14 (1.09, 1.17) for the sarcopenia diabetes group compared with the nonsarcopenic diabetes group.

CONCLUSION

Preexisting sarcopenia increased the risk of stroke in patients with type 2 diabetes mellitus.

Adjuvant Whole Breast Radiotherapy Improve Survival in Women with Heart Failure with Reduced Ejection Fraction Receiving Breast-Conserving Surgery

BACKGROUND

to date, no data on the effect of adjuvant whole breast radiotherapy (WBRT) on oncologic outcomes, such as all-cause death, locoregional recurrence (LRR), and distant metastasis (DM), are available in women with left-side breast invasive ductal carcinoma (IDC) and heart failure with reduced ejection fraction (HFrEF).

PATIENTS AND METHODS

we included 294 women with left-breast IDC at clinical stages IA-IIIC and HFrEF receiving breast-conserving surgery (BCS) followed by adjuvant WBRT or non-adjuvant WBRT. We categorized them into two groups based on their adjuvant WBRT status and compared their overall survival (OS), LRR, and DM outcomes. We calculated the propensity score and applied inverse probability of treatment weighting (IPTW) to create a pseudo-study cohort. Furthermore, we performed a multivariate analysis of the propensity score-weighted population to obtain hazard ratios (HRs).

RESULTS

in the IPTW-adjusted model, adjuvant WBRT (adjusted HR [aHR]: 0.60; 95% confidence interval [CI]: 0.44-0.94) was a significant independent prognostic factor for all-cause death (p = 0.0424), and the aHR (95% CI) of LRR and DM for adjuvant WBRT was 0.33 (0.24-0.71; p = 0.0017) and 0.37 (0.22-0.63; p = 0.0004), respectively, compared with the non-adjuvant WBRT group.

CONCLUSION

Adjuvant WBRT was associated with a decrease in all-cause death, LRR, and DM in women with left IDC and HFrEF compared with non-adjuvant WBRT.

Delays in operative management of early-stage, estrogen receptor-positive breast cancer during the COVID-19 pandemic: A multi-institutional matched historical cohort study

Background

During the COVID-19 pandemic, guidelines recommended that breast cancer centers delay estrogen receptor–positive breast cancer surgeries with neoadjuvant endocrine therapy. We aimed to evaluate pathologic upstaging of breast cancer patients affected by these guidelines.

Methods

Female patients with stage I/II breast cancer receiving neoadjuvant endocrine therapy were prospectively identified and were matched to a historical cohort of stage I/II estrogen receptor–positive breast cancer patients treated with upfront surgery ≤35 days. Primary outcomes were pathologic T and N upstaging versus clinical staging.

Results

After matching, 28 neoadjuvant endocrine therapy and 48 control patients remained. Median age in each group was 65 (P = .68). Most patients (78.6% and 79.2%) had invasive ductal carcinoma with a clinical tumor size of 0.9 cm vs 1.7 cm (P = .056). Time to surgery was 68 days in the neoadjuvant endocrine therapy group and 26.5 days in the control (P < .001). A total of 23 neoadjuvant endocrine therapy patients (82.1%) had the same or lower pT-stage compared with 31 (64.5%) control patients (P = .115). Only 3 (10.7%) neoadjuvant endocrine therapy patients had increased pN-stage vs 14 (29.2%) control patients (P = .063).

Conclusion

Despite 2.5-times longer delays, patients with early-stage estrogen receptor–positive breast cancer receiving neoadjuvant endocrine therapy did not experience pathologic upstaging during the COVID-19 pandemic. These findings may support the use of neoadjuvant endocrine therapy in similar patients if delays to surgery are projected.

Survival Impact of Current-Smoking-Related COPD or COPD with Acute Exacerbation on Bladder Preservation through Concurrent Chemoradiotherapy for Muscle-Invasive Bladder Urothelial Carcinoma

PURPOSE: The survival effect of smoking-related chronic obstructive pulmonary disease (COPD) and COPD with acute exacerbation (COPDAE) on patients with muscle-invasive bladder urothelial carcinoma (MIBUC) receiving concurrent chemoradiotherapy (CCRT) for bladder preservation is unclear. METHODS: We recruited patients with MIBUC, clinical stages IIA-IVB, who had received maximal transurethral resection of bladder tumor (TURBT) followed by CCRT from the Taiwan Cancer Registry Database. The Cox proportional hazards model was used to analyze all-cause mortality. We categorized the patients into two groups by using propensity score matching based on the preexisting COPD status (within 1 year before CCRT) to compare overall survival outcomes: Group 1 (never smokers without COPD) and Group 2 (current smokers with COPD). RESULTS: In multivariate Cox regression analyses, the adjusted hazard ratio (aHR; 95% confidence interval (CI)) of all-cause mortality in Group 2 compared with Group 1 was 1.89 (1.12-3.18), p = 0.017. The aHRs (95% CIs) of all-cause mortality for ≥1 and ≥2 hospitalizations for COPDAE within 1 year before CCRT for bladder preservation were 3.26 (1.95-5.46) and 6.33 (3.55-11.281) compared with non-COPDAE patients with MIBUC undergoing CCRT for bladder preservation. CONCLUSIONS: Among patients with MIBUC undergoing TURBT followed by CCRT for bladder preservation, current smokers with smoking-related COPD had worse survival outcomes than did nonsmokers without COPD. CONDENSED ABSTRACT: This was the first study to estimate the survival impact of smoking-related chronic obstructive pulmonary disease (COPD) on patients with muscle-invasive bladder urothelial carcinoma (MIBUC) receiving maximal transurethral resection of bladder tumor (TURBT) followed by concurrent chemoradiotherapy (CCRT) for bladder preservation. Smoking-related COPD was a significant independent risk factor for all-cause mortality in patients with clinical stages IIA-IVB receiving TURBT followed by CCRT. Hospitalization frequency for COPD with at least one acute exacerbation within 1 year before CCRT was highly associated with high mortality for patients with MIBUC receiving CCRT for bladder preservation. Not only all-cause death but also bladder cancer death and COPD death were significantly higher in the current-smoking COPD group than in the never-smoking non-COPD group.

Paravertebral block in regional anesthesia with propofol sedation reduces locoregional recurrence in patients with breast cancer receiving breast conservative surgery compared with volatile inhalational without propofol in general anesthesia

PURPOSE

We examined locoregional recurrence (LRR) in patients with breast invasive ductal carcinoma (IDC) receiving breast conservative surgery (BCS) under propofol-based paravertebral block-regional anesthesia (PB-RA) versus sevoflurane-based inhalational general anesthesia (INHA-GA) without propofol. All-cause death and distant metastasis were secondary endpoints.

PATIENTS AND METHODS

Patients with breast IDC receiving BCS were recruited through propensity score matching and categorized into INHA-GA with sevoflurane and PB-RA with propofol groups. Cox regression analysis was performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

In the multivariate Cox regression analysis, the adjusted HR (aHR; 95% CI) of LRR for the PB-RA with propofol group was 0.67 (0.46-0.99) compared with the INHA-GA with sevoflurane group. The aHRs of LRR for differentiation grade II, grade III, the American Joint Committee on Cancer clinical stage II, stage III, pathological tumor (pT) stage 2, pT stage 3-4, pathological nodal (pN) stage 2-3, and Her-2 positivity were 1.87 (1.03-3.42), 2.31 (1.20-4.44), 1.67 (1.09-2.56), 2.43 (1.18-4.97), 1.17 (1.03-1.19), 1.28 (1.13-2.24), 1.20 (1.05-2.22), and 1.59 (1.01-2.51), respectively, compared with those for differentiation grade I, clinical stage I, pT1, pN0, and HER-2 negativity. The aHR of LRR for adjuvant radiotherapy was 0.60 (0.38-0.97) compared with that for no adjuvant radiotherapy.

CONCLUSION

PB-RA with propofol might be beneficial for reducing LRR in women with breast IDC receiving BCS compared with INHA-GA without propofol.

Survival Impact of Chronic Obstructive Pulmonary Disease or Acute Exacerbation on Patients with Rectal Adenocarcinoma Undergoing Curative Resection: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study

PURPOSE

The survival effect of current smoking-related chronic obstructive pulmonary disease (COPD) and COPD with acute exacerbation (COPDAE) is unclear for patients with rectal adenocarcinoma undergoing curative resection.

METHODS

We recruited patients with clinical stage I-IIIC rectal adenocarcinoma from the Taiwan Cancer Registry Database who had received surgery. The Cox proportional hazards model was used to analyze all-cause mortality. We categorized the patients into two groups by using propensity score matching based on COPD status to compare overall survival outcomes: Group 1 (current smokers with COPD) and Group 2 (nonsmokers without COPD).

RESULTS

In the multivariate Cox regression analyses, the adjusted hazard ratio (aHR; 95% confidence interval (CI)) of all-cause mortality for Group 1 compared with Group 2 was 1.25 (1.04-1.51). The aHRs (95% cis) of all-cause mortality for frequency of ≥1 hospitalizations for COPDAE or ≥2 hospitalizations within 1 year before diagnosis were 1.17 (1.05-1.51) and 1.48 (1.03-2.41) compared with no COPDAE in patients with rectal adenocarcinoma undergoing curative resection.

CONCLUSION

In patients with rectal adenocarcinoma undergoing curative resection, being a current smoker with COPD (Group 1) was associated with worse survival outcomes than being a nonsmoker without COPD (Group 2). Being hospitalized at least once for COPDAE within 1 year before the diagnosis of rectal adenocarcinoma is an independent risk factor for poor overall survival in these patients, and a higher number of hospitalizations for COPDAE within 1 year before diagnosis was associated with poorer survival.

Comparison of Acute and Chronic Surgical Complications Following Robot-Assisted, Laparoscopic, and Traditional Open Radical Prostatectomy Among Men in Taiwan

IMPORTANCE

Few studies have evaluated long-term surgical complications in patients with prostate cancer (PC) who receive open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), or robot-assisted radical prostatectomy (RARP).

OBJECTIVE

To examine the perioperative and postoperative surgical complications among patients with PC who underwent ORP, LRP, or RARP.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included patients who received a diagnosis of resectable PC and underwent RP between January 1 and December 31, 2015. Participants were enrolled in the Taiwan Cancer Registry. The index date was the date of surgery, and the follow-up duration was the period from the index date to December 31, 2018. Data analysis was performed in September 2020.

EXPOSURES

ORP, LRP, or RARP.

MAIN OUTCOMES AND MEASURES

Two multivariate mixed models accounting for hospital clusters were fitted to ascertain the association of RARP with treatment outcomes (ie, hospital stay, blood transfusion, postoperative pain, erectile dysfunction, urinary incontinence, and hernia); general linear regression models were used for continuous outcomes, the amount of blood transfused, and hospital stay, and logistic regression models were used for analyzing postoperative outcomes and surgical complications.

RESULTS

Of the 1407 patients included in this study, 315 (22.4%) received ORP (mean [SD] age, 66.4 [6.8] years), 276 (19.6%) received LRP (mean [SD] age, 66.8 [6.4] years), and 816 (58.0%) received RARP (mean [SD] age, 66.1 [6.7] years). Mean (SD) follow-up in the full cohort was 36.7 (4.6) months. No statistically significant differences were observed in age, clinical tumor stage, pathological tumor stage, Gleason score, Gleason grade group, preoperative prostate-specific antigen concentration, D'Amico risk classification, and hospital level. A shorter hospital stay was observed for patients undergoing RARP vs those undergoing ORP (mean [SE] difference, -1.64 [0.22] days; P < .001) and LRP (mean [SE] difference, -0.57 [0.23] days; P = .01). Patients undergoing RARP had lower odds of receiving a blood transfusion (RARP vs ORP: adjusted odds ratio [aOR], 0.25; 95% CI, 0.17-0.36; RARP vs LRP: aOR, 0.58; 95% CI, 0.37-0.91). For postoperative pain, RARP was associated with a decrease in the odds of moderate to severe postoperative pain for as long as 12 weeks compared with both ORP and LRP (eg, RARP vs LRP at week 12: aOR, 0.40; 95% CI, 0.19-0.85; P = .02). The aORs for RARP vs those for ORP and LRP in the third year after RP were, for erectile dysfunction, 0.74 (95% CI, 0.45-0.92) and 0.60 (95% CI, 0.36-0.98), respectively; for urinary incontinence, 0.93 (95% CI, 0.65-0.99) and 0.60 (95% CI, 0.42-0.86), respectively; and for hernia, 0.51 (95% CI, 0.31-0.84) and 0.82 (95% CI, 0.46-0.92), respectively.

CONCLUSIONS AND RELEVANCE

In this study, undergoing RARP was associated with fewer acute and chronic postoperative complications than undergoing ORP or LRP.

Impact of Smoking-Related Chronic Obstruction Pulmonary Disease on Mortality of Invasive Ductal Carcinoma Patients Receiving Standard Treatments: Propensity Score-Matched, Nationwide, Population-Based Cohort Study

Simple Summary

This study is the first to estimate the impact of smoking-related chronic obstructive pulmonary disease (COPD) on invasive ductal carcinoma (IDC) patients receiving standard treatments. Smoking-related COPD was not a significant independent risk factor for all-cause mortality in women with stage I–III IDC receiving standard treatments. The frequency of hospitalization for COPD with at least one acute exacerbation within one year before breast surgery was highly associated with high mortality for women with IDC receiving standard treatments.

Abstract

Purpose: the survival effect of smoking-related chronic obstructive pulmonary disease (COPD) and COPD with acute exacerbation (COPDAE) is unclear for patients with invasive ductal carcinoma (IDC) receiving standard treatments. Methods: we recruited women with clinical stage I–III IDC from the Taiwan Cancer Registry Database who had received standard treatments between 1 January 2009 and 31 December 2018. The time-dependent Cox proportional hazards model was used to analyze all-cause mortality. To reduce the effects of potential confounders when all-cause mortality between Groups 1 and 2 were compared, 1:2 propensity score matching (PSM) was performed. We categorized the patients into two groups based on COPD status to compare overall survival outcomes: Group 1 (current smokers with COPD) and Group 2 (nonsmokers without COPD group). Results: PSM yielded 2319 patients with stage I–III IDC (773 and 1546 in Groups 1 and 2, respectively) eligible for further analysis. In the multivariate time-dependent Cox regression analyses, the adjusted hazard ratio (aHR; 95% confidence interval (CI)) of all-cause mortality for Group 1 compared with Group 2 was 1.04 (0.83–1.22). The aHRs (95% CIs) of all-cause mortality for ≥1 hospitalization for COPDAE within one year before breast surgery was 1.51 (1.18–2.36) compared with no COPDAE. Conclusion: smoking-related COPD was not a significant independent risk factor for all-cause mortality in women with stage I–III IDC receiving standard treatments. Being hospitalized at least once for COPDAE within one year before breast surgery is highly associated with high mortality for women with IDC receiving standard treatments. The severity of smoking-related COPD before treatments for breast cancer might be an important prognostic factor of survival. Thus, the information of the severity of COPD before treatment for breast cancer might be valuable for increasing the survival rate in treatment of breast cancer, especially in the prevention of progress from COPD to COPDAE.