Comorbidities and Their Management: Potential Impact on Breast Cancer Outcomes

Clinically relevant gene signatures provide independent prognostic information in older breast cancer patients

BACKGROUND

The clinical utility of gene signatures in older breast cancer patients remains unclear. We aimed to determine signature prognostic capacity in this patient subgroup.

METHODS

Research versions of the genomic grade index (GGI), 70-gene, recurrence score (RS), cell cycle score (CCS), PAM50 risk-of-recurrence proliferation (ROR-P), and PAM50 signatures were applied to 39 breast cancer datasets (N = 9583). After filtering on age ≥ 70 years, and the presence of estrogen receptor (ER) and survival data, 871 patients remained. Signature prognostic capacity was tested in all (n = 871), ER-positive/lymph node-positive (ER + /LN + , n = 335) and ER-positive/lymph node-negative (ER + /LN-, n = 374) patients using Kaplan-Meier and multivariable Cox-proportional hazard (PH) modelling.

RESULTS

All signatures were statistically significant in Kaplan-Meier analysis of all patients (Log-rank P < 0.001). This significance remained in multivariable analysis (Cox-PH, P ≤ 0.05). In ER + /LN + patients all signatures except PAM50 were significant in Kaplan-Meier analysis (Log-rank P ≤ 0.05) and remained so in multivariable analysis (Cox-PH, P ≤ 0.05). In ER + /LN- patients all except RS were significant in Kaplan-Meier analysis (Log-rank P ≤ 0.05) but only the 70-gene, CCS, ROR-P, and PAM50 signatures remained so in multivariable analysis (Cox-PH, P ≤ 0.05).

CONCLUSIONS

We found that gene signatures provide prognostic information in survival analyses of all, ER + /LN + and ER + /LN- older (≥ 70 years) breast cancer patients, suggesting a potential role in aiding treatment decisions in older patients.

Importance of primary care for underserved cancer patients with multiple chronic conditions

PURPOSE

To understand the impact of pre-existing conditions on healthcare utilization among under- and uninsured patients in the transition from cancer treatment to post-treatment survivorship.

METHODS

Using electronic health record data, we constructed a cohort of patients seen in an integrated county health system between 1/1/2010 and 12/31/2016. Six hundred thirty-one adult patients diagnosed with non-metastatic breast or colorectal cancer during this period (cases) were matched 1:1 on sex and Charlson comorbidity index to non-cancer patients who had at least two chronic conditions and with at least one visit to the health system during the study period (controls). Conditional fixed effects Poisson regression models compared number of primary care and emergency department (ED) visits and completed [vs. no show or missed] appointments between cancer and non-cancer patients.

RESULTS

Cancer patients had significantly lower number of visits compared with non-cancer patients (N = 46,965 vs. 85,038). Cancer patients were less likely to have primary care (IRR = 0.25; 95% CI: 0.24, 0.27) and ED visits (IRR = 0.57; 95% CI: 0.50, 0.64) but more likely to complete a scheduled appointment (AOR = 4.83; 95% CI: 4.32, 5.39) compared with non-cancer patients. Cancer patients seen in primary care at a higher rate were more likely to visit the ED (IRR = 2.06; 95% CI: 1.52, 2.80) than those seen in primary care at a lower rate.

CONCLUSION

Health systems need to find innovative, effective solutions to increase primary care utilization among cancer patients with chronic care conditions to ensure optimal management of both chronic conditions and cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Maintaining regular connections with primary care providers during active cancer treatment should be promoted.

Association of cardiovascular disease with health-related quality of life among older women with early-stage breast cancer undergoing adjuvant endocrine therapy

INTRODUCTION

Due to the improved overall survival and life expectancy of older women with breast cancer, cardiovascular disease (CVD) arose as the primary cause of non-cancer-related deaths in this population. Therefore, assessing the health-related quality of life (HRQoL) of breast cancer patients with comorbid CVD is becoming increasingly vital. Our study aimed to evaluate the association between comorbid CVD and HRQoL among older women with early-stage breast cancer who are receiving adjuvant endocrine therapy (AET) in the United States.

MATERIALS AND METHODS

We conducted a retrospective cohort study using the 2006-2017 Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data. We identified female patients over the age of 65 who were diagnosed with stage I-III hormone receptor-positive breast cancer and treated with AET. HRQoL was assessed by the physical and mental component summary (PCS & MCS) in the health survey. CVD was defined as a history of acute myocardial infarction (AMI), congestive heart failure (CHF), angina, stroke, or other heart-related conditions. We performed multivariate linear regression models while controlling for covariates.

RESULTS

Among 3,904 older women, a history of CHF [β = -1.97, p = 0.025], stroke [β = -3.00, p < 0.010], or other heart-related condition [β = -1.10, p = 0.046] was significantly associated with lower PCS. However, no significant differences in PCS scores were found between women with a history of AMI or angina and those without these conditions. Having a history of CHF [β = -1.72, p = 0.033] or stroke [β = -1.48, p = 0.038] was significantly associated with lower MCS, whereas a history of angina, AMI, or other heart conditions was not associated with significant differences in MCS. Our study did not observe any significant differences in PCS and MCS between the two types AETs.

DISCUSSION

The study found that older women with early-stage breast cancer who were being treated with AETs had a lower HRQoL if they had a history of CHF or stroke. These comorbidities were identified as strong predictors for decreased HRQoL. The findings highlight the significance of managing cardiovascular diseases in such patients for better HRQoL while they receive AET treatment.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia

BACKGROUND

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis.

METHODS

Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis.

RESULTS

Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors.

CONCLUSIONS

Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

Case Report: Intraoperative radiotherapy as the new standard of care for breast cancer patients with disabling health conditions or impairments

In selected patients, intraoperative radiotherapy (IORT) offers an alternative to standard external beam radiotherapy (EBRT) while providing equivalent breast cancer control outcomes. After IORT, most patients do not require external beam radiotherapy and thus avoid the need to travel to and from a radiotherapy centre in the weeks after surgery. EBRT is associated with an increased risk of non-breast cancer mortality and poorer cosmetic outcomes while increasing patient travel time, emissions associated with travel and time spent in the hospital. Consequently, EBRT is associated with an overall reduction in quality of life compared to IORT. Patients with other on-going health conditions or clinical impairments are likely to be affected by the daily radiotherapy requirement. Should these patients be consulted during their pre-operative assessment as to options to undergo IORT? This paper describes a case of IORT and follow up in a functionally blind patient. Quality of life effects are elucidated and further support the use of IORT in selected breast cancer patients with health conditions or impairments.

Lifestyle factors in Black female breast cancer survivors—Descriptive results from an online pilot study

Background

Breast cancer (BC) research examining disparities in cancer survivorship and modifiable risk behaviors has been mostly cancer-specific, leaving relevant gaps in disparities research relating to other cancer survivorship outcomes, including cardiovascular disease (CVD). Maintaining healthy lifestyle behaviors is a critical component of successful cancer survivorship, where unhealthy behaviors may increase the risk for recurrence, second primary cancers, and incidence of new comorbid conditions, including CVD. The current study describes BC survivorship factors among an online pilot study of Black BC survivors in Maryland, with a focus on the burden of obesity, comorbidity, and behavioral factors associated with CVD risk.

Methods

Utilizing social media recruitment strategies and survivor networks, we recruited 100 Black female BC survivors to complete an online survey. Descriptive characteristics (demographic, clinical, and lifestyle factors) were analyzed in terms of frequencies, means, standard deviations (SD) overall and by county.

Results

The average ages at time of survey and at primary BC diagnosis were 58.6 years (SD = 10.1) and 49.1 years (SD = 10.2), respectively. More than half of the survivors reported having hypertension (51%); and while only 7% reported being obese at the time of BC diagnosis, 54% reported being obese at the time of survey which was on average 9 years post BC diagnosis. Only 28% of the survivors reported meeting weekly exercise recommendations. While 70% were never smokers, most ever smokers resided in Baltimore City/Baltimore County (n = 18 ever smokers).

Conclusion

Our pilot study identified at-risk BC survivors in Maryland due to the high prevalence of CVD risk factors (hypertension, obesity, limited exercise). These pilot study methods will inform a future statewide multilevel prospective study to improve health behaviors among Black BC survivors.

Association between epidemiological and clinico-pathological features of breast cancer with prognosis, family history, Ki-67 proliferation index and survival in Tunisian breast cancer patients

Breast cancer has different epidemio-clinical characteristics in Middle East and North-African populations compared to those reported in the Western countries. The aim of this study is to analyze the epidemiological and clinico-pathological features of breast cancer in Tunisia and to determine prognostic factors with special interest to family history, Ki-67 proliferation index and comorbidity. We retrospectively reviewed epidemiological and clinico-pathological data from patients’ medical records, treated in the Medical Oncology Department at Abderrahmane Mami Hospital, in the period 2011–2015. Data has been collected on 602 breast cancer patients and analyzed using SPSS software V.23.0. Our study showed high fractions of young breast cancer patients and cases with dense breasts. The most prevalent comorbidities observed in the studied cohort were cardiovascular diseases and diabetes. Familial breast cancer was found in 23.3% of cases and was associated with younger age at diagnosis (p<0.001) and advanced stage (p = 0.015). Ki-67 index >20% was significantly associated with early age at diagnosis, lymph node involvement (p = 0.002), advanced tumor grade (p<0.001) and high risk of relapse (p = 0.007). Ki-67 cut-off 30% predicted survival in luminal cases. Survival was worse in patients with triple negative breast cancer compared to non-triple negative breast cancer, inflammatory breast cancer compared to non-inflammatory breast cancer, moderately to poorly differentiated tumors compared to well-differentiated tumors and with positive lymph nodes compared to pN0 (p<0.05). Our study showed new insights into epidemiological and clinico-pathological characteristics of breast cancer that are not well explored in Tunisian population. Considering our findings along with the implementation of electronic health record system may improve patient health care quality and disease management.

Increased morbidity evaluated on hospital contacts and prescriptions among 100,834 Danish breast cancer survivors

BACKGROUND

Cardiovascular disease competes with breast cancer (BC) as the leading cause of death for females diagnosed with breast cancer. Not much is known concerning morbidity and medicine use in the short and long term after a BC diagnosis.

AIM

The aim of this study was to determine acute and long-term morbidity in Danish women treated for BC.

METHOD

A nationwide registry-based cohort study of 100,834 BC patients identified in the clinical database of Danish Breast Cancer Cooperative Group (DBCG) and 1,100,320 (10 per patient) age-matched Danish women without BC, serving as controls. Morbidity was studied using complete data on hospital contacts and medicinal use.

RESULTS

The risk of hospital contacts was significantly increased in BC survivors compared with controls evaluated both by means of Cox regression and negative binomial regression analysis both during and after cessation of breast cancer treatment. Young age at breast cancer diagnosis was associated with the most pronounced increase in risk of hospital contacts, both during and after cessation of BC treatment. Medicinal use was significantly increased among BC patients compared to controls, both during (HR 1.27 (1.26-1.28), p < 0.0001) and after BC treatment (HR 1.18 (1.17-1.19), p < 0.0001, and present for all subgroups of medicine.

CONCLUSION

Overall, BC survivors have a pronounced increase in hospital contacts and medicinal use compared to women without BC. Premenopausal status at BC diagnosis was associated with an overall higher excess morbidity and a higher burden both during and after treatment.

Utilizing Social Media Advertisements and Participant Social Networks to Recruit African American Breast Cancer Survivors: Design and Rationale

Purpose

Our objective is to pilot an advertisement-driven sampling procedure among African American (AA) breast cancer survivors living in Maryland. These pilot study methods will inform a future population-based study of AA breast cancer survivors at high risk of poor outcomes due to biological differences and social inequities.

Methods

This cross-sectional study utilizes an innovative, social media-based advertisement campaign with an associated social media study page to recruit 100 AA breast cancer survivors. Participants are biologically female, aged 18 and older, identify as AA/Black, have a diagnosis of breast cancer, and reside in Maryland. A preset "Audience" was created via Meta (formerly Facebook) to automatically target potential interest in the online study via geolocation and public social media interests (estimated range = 101,000 women). Eligible participants complete an online survey including demographic and clinical characteristics, cancer screening, healthcare access, and utilization, COVID-19 impact, quality of doctor-patient communication, and preferences for future study participation.

Results

Recruitment began on 5 January 2022 and remains ongoing. As of 7 June 2002: 124 completed the screener, 110/124 (88.7%) consented passively, 24/110 (21.8%) started but did not complete survey, 86/110 (78.1%) completed the survey.

Conclusions

Results from this study will inform a statewide multilevel prospective population-based study to improve health behaviors, disease management, and self-efficacy of chronic disease management among AA breast cancer survivors.

The impact of chronic comorbidities at the time of breast cancer diagnosis on quality of life, and emotional health following treatment in Canada

INTRODUCTION

Advances in breast cancer screening and treatment have led to an increasing number of breast cancer survivors. The objective of this study was to determine the impact of comorbidities on self-reported quality of life (QOL) and emotional health following a breast cancer diagnosis and treatment.

METHODS

Women with a personal history of breast cancer (N = 3,372) were identified from the cross-sectional Canadian Partnership Against Cancer (CPAC) Experiences of Cancer Patients in Transitions Survey. Multinomial (nominal) logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the relationship between burden of comorbidities and overall QOL and emotional health (very poor/poor, fair, good, very good).

RESULTS

Of the 3,372 participants, 57% reported at least one chronic condition at the time of breast cancer diagnosis. As the number of chronic conditions at diagnosis increased, the odds of reporting worse quality of life and emotional health following treatment also increased. Specifically, compared to women reporting very good QOL, for each additional chronic condition, women reported significantly higher odds of reporting good (OR = 1.22, 95% CI: 1.12, 1.32), fair (OR = 1.76, 95% CI: 1.58, 1.96), or poor/very poor (OR = 2.31, 95% CI: 1.86, 2.88) QOL. Similarly, for each additional comorbidity, women reported significantly higher odds of reporting good (OR = 1.17, 95% CI: 1.07, 1.28), fair (OR = 1.63, 95% CI: 1.46, 1.82), or poor/very poor (OR = 2.17, 95% CI: 1.81, 2.60) emotional health, relative to very good emotional health.

CONCLUSION

Breast cancer survivors coping with a high comorbidity burden experience worse overall QOL and emotional health following treatment. This highlights the importance of integrating information on comorbidities into survivorship care to improve the experience and overall outcomes of patients with complex needs.

Metabolic syndrome and unfavorable outcomes on body composition and in visceral adiposities indexes among early breast cancer women post-chemotherapy

PURPOSE

The study objected to investigate potential changes in metabolic, dietary, and nutritional status in women with stages I-III breast cancer exposed to chemotherapy.

METHODS

Women who were starting chemotherapy with no previous treatment were recruited. Anthropometrics, bioelectrical impedance analysis, handgrip strength, blood pressure and blood sample were collected. Visceral adiposity index and lipid accumulation product were calculated. Dietary intake was evaluated, and the multiple source methods program was applied. Metabolic syndrome (MetS) was assessed following the NCEP-ATP III criteria (defined as 3 of 5 components of MetS). All data were collected at 2-time points: diagnosis (T0) and after 1 month of completion of therapy (T1). Mean, standard deviation, percentage, and ANOVA in SAS Studio® were used to explore the results.

RESULTS

61 women were included. We did not find any changes in anthropometrics and body composition. However, phase angle, extracellular water (EX) and ratio EX to total body water had expressive changes (p < 0.001). The results showed changes in lipid profile (p < 0.001), and greater unfavorable outcomes on adiposities index (p < 0.001). At the end of the study, 68,8% (N = 42) of the women developed MetS post-chemotherapy.

CONCLUSION

We have found supporting evidence for chemotherapy treatment resulting in worsening of nutritional markers, lipid profile and adiposity markers. After chemotherapy part of the sample developed MetS, even without changes in body weight, fat mass, and food intake. Breast cancer patients may benefit from targeted interventions before starting chemotherapy to prevent MetS post-treatment, and therefore reduce the risk of cardiovascular disease. Further investigation into this theme is needed.

Comorbidities and the risk of cardiovascular disease mortality among racially diverse patients with breast cancer

BACKGROUND

Women who have coexisting comorbidities at the time of breast cancer diagnosis have an increased risk of breast cancer and overall mortality. However, the associations between newly diagnosed comorbidities and the risk of cardiovascular disease (CVD) mortality among these patients have not been examined.

METHODS

The authors compared the associations between coexisting and newly diagnosed CVD, type 2 diabetes, and hypertension and the risk of CVD mortality among patients with breast cancer identified in the Missouri Cancer Registry. In total, 33,099 women who had incident invasive breast cancer with inpatient and outpatient hospital discharge data within 2 years after breast cancer diagnosis were included: 9.3% were Black. Subdistribution hazard ratios (sdHRs) and 95% CIs were calculated for the risk of CVD-related mortality using adjusted Cox proportional hazards regression models, accounting for a competing risk of breast cancer deaths.

RESULTS

Within the first 2 years after breast cancer, the most reported newly diagnosed comorbidity was hypertension (9%), followed by CVD (4%), and type 2 diabetes (2%). CVD mortality was increased in women who had newly diagnosed CVD (sdHR, 2.49; 95% CI, 2.09-2.99), diabetes (sdHR, 2.16; 95% CI, 1.68-2.77), or hypertension (sdHR, 2.06; 95% CI, 1.71-2.48) compared with women who did not have these conditions. Associations were similar by race. The strongest association was among women who received chemotherapy and then developed CVD (sdHR, 3.82; 95% CI, 2.69-5.43).

CONCLUSIONS

Monitoring for diabetes, hypertension, and CVD from the time of breast diagnosis may reduce CVD mortality.

Patterns of chronic disease management and health outcomes in a population-based cohort of Black women with breast cancer

PURPOSE

Diabetes and hypertension are two common comorbidities that affect breast cancer patients, particularly Black women. Disruption of chronic disease management during cancer treatment has been speculated. Therefore, this study examined the implementation of clinical practice guidelines and health outcomes for these comorbidities before and during cancer treatment.

METHODS

We used a population-based, prospective cohort of Black women diagnosed with breast cancer (2012-2016) in New Jersey (n = 563). Chronic disease management for diabetes and hypertension was examined 12 months before and after breast cancer diagnosis and compared using McNemar's test for matched paired and paired t tests.

RESULTS

Among this cohort, 18.1% had a co-diagnosis of diabetes and 47.2% had a co-diagnosis of hypertension. Implementation of clinical practice guidelines and health outcomes that differed in the 12 months before and after cancer diagnosis included lipid screening (64.5% before versus 50.0% after diagnosis; p = 0.004), glucose screening (72.7% versus 90.7%; p < 0.001), and blood pressure control < 140/90 mmHg (57.6% versus 71.5%; p = 0.004) among patients with hypertension-only. For patients with diabetes, eye and foot care were low (< 35%) and optimal HbA1c < 8.0% was achieved for less than 50% of patients in both time periods.

CONCLUSION

Chronic disease management continued during cancer treatment; however, eye and foot exams for patients with diabetes and lipid screening for patients with hypertension-only were inadequate. Given that comorbidities may account for half of the Black-White breast cancer survival disparity, strategies are needed to improve chronic disease management during cancer, especially for Black women who bear a disproportionate burden of chronic diseases.

Thymic epithelial tumors: Do we know all the prognostic factors?

BACKGROUND

Thymic epithelial tumors constitute a morphologically and clinically diverse group of rare neoplasm of the anterior mediastinum.

METHODS

Here, we present an analysis of 188 patients diagnosed with primary thymic tumors between 1995 and 2015. The prognostic value of selected clinical and morphological factors was assessed in relation to overall survival and recurrence-free survival.

RESULTS

The risk of recurrence increased significantly in thymic carcinoma diagnosis (P = 0.0036), co-occurrence of other diseases, and weight loss (P = 0.0012 and 0.0348, respectively). Multivariate analysis showed that the most important independent risk factor for disease recurrence was clinical stage IV (P = 0.0036). A total of 63 patients (33.5%) died. In the univariate analysis, the following factors were considered as independent prognostic factors for overall survival: clinical stage (P < 0.0001), histological type (P < 0.0001), lymph node involvement (P < 0.001), WHO performance status 2 (P < 0.0001), anemia (Hb <9.5 g/dL; P = 0.0002), leucocytosis (>12.5 G/L; P = 0.0011), LDH level (>185 U/L; P < 0.0001), concomitant diseases (P = 0.0012) and weight loss (P < 0.0001).The strongest independent risk factor for death was stage IV disease (P < 0.001).

CONCLUSIONS

The results confirmed a fairly good prognosis for patients with thymic epithelial tumors. Clinical stage was the most important prognostic factor, but, some additional clinical factors may also have prognostic value.

Comorbidity Management in Black Women Diagnosed with Breast Cancer: the Role of Primary Care in Shared Care

BACKGROUND

Black women are more likely to have comorbidity at breast cancer diagnosis compared with White women, which may account for half of the Black-White survivor disparity. Comprehensive disease management requires a coordinated team of healthcare professionals including primary care practitioners, but few studies have examined shared care in the management of comorbidities during cancer care, especially among racial/ethnic minorities.

OBJECTIVE

To examine whether the type of medical team composition is associated with optimal clinical care management of comorbidities.

DESIGN

We used the Women's Circle of Health Follow-up Study, a population-based cohort of Black women diagnosed with breast cancer. The likelihood of receiving optimal comorbidity management after breast cancer diagnosis was compared by type of medical team composition (shared care versus cancer specialists only) using binomial regression.

PARTICIPANTS

Black women with a co-diagnosis of diabetes and/or hypertension at breast cancer diagnosis between 2012 and 2016 (N = 274).

MAIN MEASURES

Outcome-optimal clinical care management of diabetes (i.e., A1C test, LDL-C test, and medical attention for nephropathy) and hypertension (i.e., lipid screening and prescription for hypertension medication). Main predictor-shared care, whether the patient received care from both a cancer specialist and a primary care provider and/or a medical specialist within the 12 months following a breast cancer diagnosis.

KEY RESULTS

Primary care providers were the main providers involved in managing comorbidities and 90% of patients received shared care during breast cancer care. Only 54% had optimal comorbidity management. Patients with shared care were five times (aRR: 4.62; 95% CI: 1.66, 12.84) more likely to have optimal comorbidity management compared with patients who only saw cancer specialists.

CONCLUSIONS

Suboptimal management of comorbidities during breast cancer care exists for Black women. However, our findings suggest that shared care is more beneficial at achieving optimal clinical care management for diabetes and hypertension than cancer specialists alone.

Obesity, comorbidities, and treatment selection in Black and White women with early breast cancer

BACKGROUND

This study investigates obesity and comorbidity in Black and White women with early breast cancer (stages I-III) and their potential impact on treatment decisions for patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) tumors.

METHODS

In this retrospective chart review, comparisons of frequencies for Black and White patients were calculated with the Fisher exact test. Log binomial regression was used to estimate prevalence ratios (PRs) with 95% confidence intervals for total and individual comorbidities, and multivariable modeling was used to estimate PRs adjusted for age and body mass index (BMI).

RESULTS

In a sample of 548 patients, 26% were Black, and 74% were White. Sixty-two percent of Black patients and 32% of White patients were obese (BMI ≥ 30 kg/m² ; P < .0001). Seventy-five percent of Black patients and 87% of White patients had HR+ tumors (P = .001). Significant intergroup differences were seen for 2 or more total comorbidities (62% of Blacks vs 47% of Whites; P = .001), 2 or more obesity-related comorbidities (33% vs 10%; P < .0001), hypertension (60% vs 32%; P < .0001), diabetes mellitus (23% vs 6%; P < .0001), hypercholesterolemia or hyperlipidemia (28% vs 18%; P = .02), and hypothyroidism (4% vs 11%; P = .012). In women with HR+/HER2- tumors, there were no intergroup differences in treatment decisions regarding the type of surgery, chemotherapy regimen, radiation, or endocrine treatment despite significant differences in the prevalence of obesity and comorbidities.

CONCLUSIONS

This study documents significant disparities between Black and White women with early breast cancer with regard to high rates of obesity, overall comorbidities, and obesity-related comorbidities, and it highlights the prevalence of competing risks that may complicate outcomes in breast cancer.

The Need for Accurate Risk Assessment in a High-Risk Patient Population: A NSQIP Study Evaluating Outcomes of Cholecystectomy in the Patient With Cancer

BACKGROUND

Cholecystectomy is considered a low-risk procedure with proven safety in many high-risk patient populations. However, the risk of cholecystectomy in patients with active cancer has not been established.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried to identify all patients with disseminated cancer who underwent cholecystectomy from 2005 to 2016. Postcholecystectomy outcomes were defined for patients with cancer and those without by comparing several outcomes measures. A multivariate model was used to estimate the odds of 30-d mortality.

RESULTS

We compared outcomes in 3097 patients with disseminated cancer to a matched cohort of patients without cancer. Patients with cancer had more comorbidities at baseline: dyspnea (10.5% versus 7.0%, P < 0.0001), steroid use (10.1% versus 3.0%, P < 0.0001), and loss of >10% body weight in 6-mo prior (9.3% versus 1.6%, P < 0.0001). Patients with cancer sustained higher rates of wound (2.3% versus 5.6%, P < 0.0001), respiratory (1.4% versus 3.9%, P < 0.0001), and cardiovascular (2.0% versus 6.8%, P < 0.0001) complications. In addition, patients with disseminated cancer experienced a longer length of stay and higher 30-d mortality. Multivariate modeling showed that the odds of 30-d mortality was 3.3 times greater in patients with cancer.

CONCLUSIONS

Compared to patients without cancer, those with disseminated cancer are at higher risk of complication and mortality following cholecystectomy. Traditional treatment algorithms should be used with caution and care decisions individualized based on the patient's disease status and treatment goals.

Association of body composition with function in women with early breast cancer

BACKGROUND

Advances in breast cancer research are making treatment options increasingly effective and reducing mortality. Body composition is an example of a prognostic tool that can help personalize breast cancer treatments and further increase their effectiveness. In this study, we examine the association of several body composition measures with comorbidities, physical function, and quality of life.

METHODS

This study is a cross-sectional analysis of 99 women with early breast cancer scheduled for chemotherapy. Univariate regression models were used to identify significant associations of body composition metrics with patient demographics, clinical characteristics, measures of physical function, and patient-reported outcomes (PRO)s. Multivariable modeling was used to evaluate associations adjusted for age.

RESULTS

Median age was 58 (range 24-83), 27% were non-white, and, 47% were obese (≥ 30 kg/m2). Increasing age was associated with lower Skeletal Muscle Density (SMD) (p = 0.0001), lower Skeletal Muscle Gauge (SMG) (p = 0.0005), and higher Visceral Adipose Tissue (VAT) (p < 0.0001). In patients with a prolonged Timed Up and Go tests (> 14 s), mean VAT was 57.87 higher (p = 0.004), SMD 5.70 lower (p = 0.04), and SMG 325.4 lower (p = 0.02). For each point of higher performance on the Short Physical Performance Battery (SPPB), VAT decreased 12.24 (p = 0.002) and SMD rose 1.22 (p = 0.02). In multivariable analysis adjusting for age, the association of TUG > 14 with higher VAT remained significant (p = 0.02).

CONCLUSIONS

Suboptimal body composition prior to treatment is associated poor physical function and may be an indicator of clinical importance.

The Women's Circle of Health Follow-Up Study: a population-based longitudinal study of Black breast cancer survivors in New Jersey

PURPOSE

The Women's Circle of Health Follow-Up Study is an ongoing longitudinal study of African American/Black breast cancer survivors in New Jersey, specifically designed to evaluate the impact of obesity and related comorbidities on breast cancer survival and health-related quality-of-life in this understudied population. Here, we describe our recruitment and data collection methods and compare characteristics of the overall cohort and the subcohort with follow-up data.

METHODS

Newly diagnosed breast cancer cases have been recruited into the study since 2006. Pre-diagnosis data on relevant factors and a saliva sample are collected during an in-person interview within 12 months from diagnosis. In 2013, we began active follow up by recontacting participants annually, including two home visits at approximately 2 and 3 years post-diagnosis, during which blood samples are collected. Mortality outcomes (all-cause and breast cancer-specific mortality) are ascertained through linkage with New Jersey State Cancer Registry files. We expect to assemble a cohort of over 2000 Black breast cancer survivors with at least 800 of them having detailed post-diagnosis data.

RESULTS

Distribution of sociodemographic characteristics, body mass index, comorbidities, clinicopathologic characteristics, and treatment modalities were very similar between those in the full cohort and the subset with follow-up data and blood samples. Obesity (> 50%), hypertension (> 58%), and diabetes (22%) were common in this population.

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

This ongoing longitudinal study represents a unique resource to better understand breast cancer outcomes, patient-reported symptoms, and health-related quality of life among Black breast cancer survivors.

The role of comorbidity assessment in guiding treatment decision-making for women with early breast cancer: a systematic literature review

PURPOSE

Comorbidity in breast cancer patients impacts treatment choice, toxicity, and outcomes. While comorbidity measurement tools are frequently used by researchers, little is known about their use in clinical practice. The aim of this review was to examine the use of comorbidity measurement tools in clinical practice and their role in treatment decision-making in breast cancer.

METHODS

Six electronic databases were searched from inception to 21 March 2019. Quantitative or mixed methods studies addressing primary treatment of breast cancer and identifying a comorbidity measurement tool used in clinical practice treatment decision-making were included. Data was extracted on tool utilized, impact on treatment decisions or outcomes, pattern of use, and psychometric properties.

RESULTS

A systematic search of literature yielded 752 studies. Of the four studies that met inclusion criteria, each utilized a comprehensive geriatric assessment tool, though only in a subset of patients. No studies found direct comorbidity measurement tools utilized independently of geriatric assessment. Assessment results had variable impact on treatment decisions. Impacts on patient mortality and treatment toxicity, cost-effectiveness, and psychometric characteristics of the tools were not identified.

CONCLUSIONS

There is little evidence on use of specific comorbidity tools in clinical decision-making in breast cancer outside of comorbidity assessment as part of geriatric assessment tools. There was limited impact on decision-making or patient outcomes when these were utilized. Further research is needed to identify barriers to comorbidity assessment in clinical practice and identify comorbidity tools that have the potential to improve patient outcomes.

Associations between physical activity and comorbidities in Korean cancer survivors

PURPOSE

To examine the associations between physical activity, metabolic risk factors, and comorbidities in Korean cancer survivors.

METHODS

We used multiple cross-sectional data sets from the 2007-2013 Korean National Health and Nutrition Examination Surveys (KNHANES) that included 1225 cancer survivors. Physical activity and comorbidities were self-reported. Metabolic risk factors were measured via blood analyses and included fasting glucose, insulin, total cholesterol, triglycerides, and blood pressure.

RESULTS

The sample was 38.4% male with a mean age of 59.9 ± 12.4 years. The most common cancers were stomach (22.5%), cervical (14.6%), breast (14.4%), and colorectal (11.8%). Cancer survivors meeting aerobic physical activity guidelines, compared to those completely inactive, had significantly lower fasting glucose (p = .001), HbA1c (p = .006), and systolic blood pressure (p = .001), and significantly lower risks of hypertension (odds ratio [OR] = 0.55, 95% confidential interval [CI] = 0.32 to 0.93), diabetes (OR = 0.64, 95% CI = 0.43 to 0.95), and arthritis (OR = 0.64, 95% CI = 0.41 to 0.99). Moreover, cancer survivors meeting strength exercise guidelines, compared to those not meeting guidelines, had significantly lower levels of fasting glucose (p = .001), HbA1c (p < .001), and total cholesterol (p = .031), and significantly lower risks of arthritis (OR = 0.42, 95% CI = 0.25 to 0.85) and back pain (OR = 0.50, 95% CI = 0.30 to 0.83).

CONCLUSION

Aerobic physical activity and strength exercise were significantly associated with lower risks of metabolic disturbances and comorbidities in Korean cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors should engage in at least 150 min/week of aerobic exercise and at least 2 days/week of strength exercise to lower their risk of metabolic disturbances and comorbidities.

Influence of specific comorbidities on survival after early-stage breast cancer

BACKGROUND

While comorbidity indices are useful for describing trends in survival, information on specific comorbidities is needed for the clinician advising the individual breast cancer patient on her treatment. Here we present an analysis of overall survival, breast cancer-specific mortality, and effect of medical adjuvant treatment among breast cancer patients suffering from 12 major comorbidities compared with breast cancer patients without comorbidities.

MATERIAL AND METHODS

The study population was identified from the Danish Breast Cancer Cooperative Group and included 59,673 women without prior cancer diagnosed with early-stage breast cancer in Denmark from 1990 to 2008 with an estimated median potential follow-up of 14 years and 10 months. Information on comorbidity and causes of death was derived from population-based registries. Multivariable proportional hazards regression models were used to assess the effect of comorbidities on mortality, all-cause and breast cancer specific, using patients without comorbidity as reference.

RESULTS

At breast cancer diagnosis, 16% of patients had comorbidities and 84% did not. Compared with the latter, the risk of dying from all causes was significantly increased for all types of comorbidity, but the risk of dying from breast cancer was significantly increased only for peripheral vascular disease, dementia, chronic pulmonary disease, liver, and renal diseases. Comorbidities diagnosed within 5 years of breast cancer diagnosis correlated with a greater risk of dying than comorbidities diagnosed more than 5 years before breast cancer diagnosis. With a few exceptions, the effect of adjuvant treatment on breast cancer mortality was similar among patients with and without comorbidity.

CONCLUSION

Breast cancer mortality was not significantly elevated for patients with prior myocardial infarction, congestive heart failure, cerebrovascular disease, connective tissue disease, ulcer disease, and diabetes. The similar effect of adjuvant treatment in patients with and without comorbidity underlines the importance of adhering to guideline therapy.

An observational study to examine changes in metabolic syndrome components in patients with breast cancer receiving neoadjuvant or adjuvant chemotherapy

BACKGROUND

The authors sought to determine the effect of chemotherapy on the development of metabolic syndrome (MetS) in premenopausal and postmenopausal women undergoing (neo)adjuvant therapy for early‐stage breast cancer.

METHODS

A total of 86 women with early‐stage (AJCC stage I‐III) breast cancer who were free from clinically diagnosed MetS (defined as 3 of 5 components of MetS) were prospectively tested for the presence of the 5 components of MetS within 1 week before initiating and after completing (neo)adjuvant chemotherapy. The 5 components of MetS measured were waist circumference; blood pressure; and fasting levels of blood glucose, triglycerides, and high‐density lipoprotein cholesterol. Anthropometrics (body weight, percentage body fat, fat mass), lipid profile (total cholesterol, low‐density lipoprotein cholesterol), glucose metabolism (insulin, homeostatic model assessment of insulin resistance, glycated hemoglobin), and inflammation (C‐reactive protein) also were examined before initiating and after completing treatment.

RESULTS

The current study included 46 premenopausal and 40 postmenopausal women. All individual MetS components and the overall MetS score were found to be statistically significantly increased (P<.01) after chemotherapy. Body weight, percentage body fat, fat mass, lipids, glucose metabolism, and inflammation also were found to be statistically significantly increased (P<.01).

CONCLUSIONS

A 12‐week to 18‐week course of chemotherapy appears to statistically significantly increase MetS and related anthropometrics, biomarkers of glucose metabolism, and inflammation in patients with early‐stage breast cancer with no preexisting MetS. Lifestyle interventions such as diet and exercise may be preventive approaches for use during chemotherapy to reduce the onset of MetS in patients with breast cancer. Cancer 2016. © 2016 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. Cancer 2016;122:2646–2653. © 2016 American Cancer Society.

Patients with breast cancer who receive (neo)adjuvant chemotherapy experience an impaired metabolic presentation as noted by worsened components of metabolic syndrome, anthropometrics, and biomarkers of glucose metabolism. Lifestyle interventions such as diet and exercise may be preventive approaches for use during chemotherapy to reduce the onset of metabolic syndrome in patients with breast cancer.