Medical comorbidities predict mortality in women with a history of early stage breast cancer

Caregivers with Cancer Patients: Focus on Hispanics

Cancer is a public health concern and causes more than 8 million deaths annually. Cancer triggers include population growth, aging, and variations in the prevalence and distribution of the critical risk factors for cancer. Multiple hallmarks are involved in cancer, including cell proliferation, evading growth suppressors, activating invasion and metastasis, resisting cell death, enabling replicative immortality, reprogramming energy metabolism, and evading immune destruction. Both cancer and dementia are age-related and potentially lethal, impacting survival. With increasing aging populations, cancer and dementia cause a burden on patients, family members, the health care system, and informal/formal caregivers. In the current article, we highlight cancer prevalence with a focus on different ethnic groups, ages, and genders. Our article covers risk factors and genetic causes associated with cancer and types of cancers and comorbidities. We extensively cover the impact of cancer in Hispanics in comparison to that in other ethnic groups. We also discuss the status of caregivers with cancer patients and urgent needs from the state and federal support for caregivers.

Prognostic Predictors of Mortality in Male Breast Cancer: Outcomes in an Urban Population

INTRODUCTION

Male breast cancer (MBC) accounts for 0.5% to 1% of all breast cancers diagnosed annually. The purpose of this study is to evaluate prognostic factors in MBC.

METHODS

We performed a retrospective chart review of patients with MBC between 2010 and 2021. Demographics, comorbidities, cancer characteristics, recurrence, and mortality were collected. Cox proportional hazards regression model was used to determine prognostic factors. A Kaplan-Meier curve was used to plot survival probabilities.

RESULTS

A total of 47 male patients were identified. The mean age at presentation was 64.1 y. Twenty eight (59.6%) patients were African American and 14 patients (29.8%) were Caucasian. Most patients had invasive ductal carcinoma (89.4%) and presented with T1 or T2 tumors (40.4% and 38.3%, respectively). Three patients (6.4%) had a recurrence and eight patients (17%) died. Using mortality as an end point, age (≥ 76.1 y) indicated a hazard ratio (HR) of 1.13 (P = 0.004), diabetes mellitus (HR = 5.45, P = 0.023), atrial fibrillation (HR = 8.0, P = 0.009), end-stage renal disease (HR 6.47, P = 0.023), Eastern Cooperative Oncology Group performance status of 3 (HR = 7.92, P = 0.024), poorly differentiated grade (HR = 7.21, P = 0.033), and metastatic disease (HR = 30.94, P = 0.015) had an increased risk of mortality. Overall survival at 3 y was 79.2%.

CONCLUSIONS

Advanced age, diabetes mellitus, atrial fibrillation, end-stage renal disease, Eastern Cooperative Oncology Group score of 3, poorly differentiated tumors, and metastatic disease are unfavorable prognostic factors in MBC. Compared to female breast cancer, MBC showed poorer overall survival.

Obesity: An Independent Risk Factor for Complications in Anterior Lumbar Interbody Fusion? A Systematic Review

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVES

Raised patient BMI is recognised as a relative contraindication to posterior lumbar interbody fusion (PLIF) due to the anaesthetic challenges, difficult positioning and increased intraoperative and postoperative complications, with the relative risk rising in patients with a BMI >25 kg/m2. The impact of obesity defined as a BMI > 30 kg/m² on Anterior Lumbar Interbody Fusion (ALIF) outcomes is not yet established. The aim of this review was to evaluate if the presence of a raised BMI in patients undergoing ALIF procedures was an independent risk factor for intra- and postoperative complications.

METHODS

A systematic review of search databases PubMed; Google Scholar and OVID Medline was made to identify studies related to complications in patients with increased body mass index during anterior lumbar interbody fusion. PRISMA guidelines were utilised for this review. Complication rates in raised BMI patient cohort was compared to normal BMI complication rates with meta-analysis where available.

RESULTS

315 articles returned with search criteria applied. Six articles were included for review, with 2190 patients included for analysis. Vascular complications in obese vs. non-obese patients undergoing the anterior approach demonstrate no significant difference in complication rates (P = .62; CI = -.03-.02). Obesity is found to result in an increased rate of overall complications (P = .002; CI = .04-.16).

CONCLUSIONS

Obesity was demonstrated to have an impact on overall complication rates in Anterior Lumbar Interbody Fusion procedures, with postoperative complications including wound infections and lower fusion rates more common in patients in increased BMIs. Increased focus on patient positioning and reporting of outcomes in this patient cohort is warranted to further evaluate perioperative complications.

Social Determinants of Health and Comorbidities Among Individuals with Atherosclerotic Cardiovascular Disease: The Behavioral Risk Factor Surveillance System Survey

Individuals with atherosclerotic cardiovascular disease (ASCVD) often have a high burden of comorbidities. Social determinants of health (SDOH) may complicate adherence to treatment in these patients. This study assessed the association of comorbidities and SDOH among individuals with ASCVD. Cross-sectional data from the 2016 to 2019 Behavioral Risk Factor Surveillance System, a nationally representative US telephone-based survey of adults ages ≥18 years, were used. Cardiovascular comorbidities included hypertension, hyperlipidemia, diabetes mellitus, current cigarette smoking, and chronic kidney disease. Non-cardiovascular comorbidities included chronic obstructive pulmonary disease, asthma, arthritis, cancer, and depression. SDOH associated with being at or above the 75^th percentile of comorbidity burden were analyzed using multivariable adjusted logistic regression models. The study population included 387,044 individuals, 9% of whom had ASCVD. The mean (SD) numbers of total, cardiovascular, and non-cardiovascular comorbidities were 1.97 (1.27), 1.28 (0.74), 0.69 (0.91) among those without ASCVD and 3.28 (1.62), 1.73 (0.91), and 1.54 (1.22) among those with ASCVD, respectively (P < 0.001 for all comparisons). Female gender, household income ≤$75,000, being unemployed, and difficulty accessing health care were significantly associated with a higher burden of comorbidities among those with ASCVD. The mean (SD) numbers of comorbidities for those with 0, 1, 2, and ≥3 of the aforementioned SDOH were 2.89 (1.45), 2.86 (1.47), 3.39 (1.58), and 4.01 (1.73), respectively (P < 0.001). Among persons with ASCVD, the burden of cardiovascular and non-cardiovascular comorbidities is directly proportional to SDOH in any given individual. Clinicians should address SDOH when managing high-risk individuals.

Causes of death among women with breast cancer: A follow-up study of 50 481 women with breast cancer in Finland

Our study aims to assess mortality from causes other than breast cancer among women with breast cancer with focus on indications of joint aetiology. Data on female breast cancer patients were obtained from the Finnish Cancer Registry and their underlying causes of death in 54 categories from the Statistics Finland. Standardised mortality ratios (SMR) and their 95% confidence intervals (CIs) were calculated for 50 481 patients diagnosed between 1971 and 2000 and followed until December 2012, stratified by histology, age at diagnosis and time since diagnosis. The expected numbers of deaths were based on respective mortality rates among the Finnish general population. Hazard ratio (HR) was estimated from Poisson regression model to compare risks of cause of death by histology. 41% of 30 841 deaths were due to causes other than breast cancer. Significant excess mortality was observed for stomach cancer (SMR 1.43, 95% CI 1.26-1.62), circulatory system diseases (SMR 1.17, 95% CI 1.14-1.20) and suicide (SMR 1.51, 95% CI 1.28-1.78). In an age-adjusted analysis, significantly higher relative risk of stomach cancer mortality was observed for lobular vs ductal subtype (HR 2.00, 95% CI 1.32-3.02). Significantly increased SMRs were observed for cancers of respiratory organs among premenopausal women, and for other respiratory system diseases, dementia and Alzheimer disease among postmenopausal women. We conclude that female breast cancer patients are at increased risk of death from causes other than the breast cancer diagnosis including circulatory and respiratory system diseases and cancer of stomach, ovary and respiratory systems. The excess mortality because of different causes varies based on menopausal status and histology. There might be shared aetiological factors between the diagnosis of breast cancer and the causes of death among these patients.

Evaluating and Balancing the Risk of Breast Cancer-Specific Death and Other Cause-Specific Death in Elderly Breast Cancer Patients

Purpose: The dilemma of undertreatment and overtreatment of elderly breast cancer patients is common. This study aimed to investigate clinicopathological features, treatment modalities, and survival in women diagnosed with breast cancer at age 70 years or over, and to assist clinicians in developing individualized treatment plans by balancing the risks of breast cancer-specific death (BCSD) and other cause-specific death (OCSD). Methods: This retrospective study included 420 women who were diagnosed with pathologically confirmed invasive breast cancer at age 70 years or older from January 2008 to December 2015 at Peking University People's Hospital (PKUPH). We collected baseline health status, tumor characteristics, treatment choices, and outcomes and created nomograms for clinicians to estimate individualized BCSD and OCSD risk directly. Results: During a median follow-up of 71.5 months (range 2 to 144 months) in patients with stage I-III tumors, breast cancer specific survival (BCSS) was 92.4% (376/407) and overall survival (OS) was 78.1% (318/407). There were 89 deaths, and 65.2% (58/89) were non-breast cancer related. Upon multivariate analysis by Cox regression model, tumor size, positive lymph nodes, Ki-67, and surgery were independent predictors of BCSS, and comorbidities, positive lymph nodes, Ki-67, surgery, and endocrine therapy were independent predictors of OS. Propensity score weighted (PSW) was applied to analyze therapeutic efficacy, and there was BCSS and OS benefit with surgery (both p < 0.001), BCSS benefit with chemotherapy (p = 0.029), BCSS and OS benefit with endocrine therapy (p = 0.006 and 0.004), and neither BCSS nor OS benefit with radiotherapy (RT) (p = 0.348 and 0.289). Competing-risk nomograms were developed to estimate cumulative mortality probabilities for BCSD and OCSD for individual patients according to clinicopathologic characteristics and treatments. The calibration curves displayed exceptionally, with C-indexes 0.714 for BCSD and 0.717 for OCSD. Conclusions: Older patients had greater risk of dying from non-breast cancer causes. Surgery, chemotherapy, and endocrine therapy were associated with improved survival. Competing risk nomograms allowed individual assessment of BCSD and OCSD, based on clinicopathological characteristics and treatment options, and can be used as a tool to help in choosing appropriate treatment strategies. This study was approved by the Peking University People's Hospital Research Ethics Board on September 4, 2018.

Dietary Fiber and Survival in Women with Breast Cancer: A Dose-Response Meta-Analysis of Prospective Cohort Studies

We aimed to investigate the association of dietary fiber consumption with mortality risk in women with breast cancer. A systematic search was undertaken in PubMed, Scopus, and ISI Web of Science till March 2020 to find cohort studies investigating the association of dietary fiber consumption with mortality risk in women with breast cancer. A random-effects model was used to combine study-specific results. The quality of evidence was rated by NutriGrade score. Seven prospective cohort studies with 1,426 cases of all-cause mortality and 679 cases of breast cancer-specific mortality among 11,295 patients with breast cancer were included. The relative risks for the highest compared to the lowest category of dietary fiber consumption were 0.63 (95%CI: 0.52, 0.77; I² = 0%, n = 5) for all-cause mortality, and 0.72 (95%CI: 0.54, 0.96; I² = 0%, n = 5) for breast cancer-specific mortality. There was a strong linear association between fiber intake and all-cause mortality risk. The quality of evidence was rated moderate for all-cause mortality, and low for breast cancer-specific mortality. Higher dietary fiber consumption may improve survival in patients with breast cancer. More research is needed to confirm the present results, considering types of fiber consumed and tumor estrogen receptor status.

Improving health engagement and lifestyle management for breast cancer survivors with diabetes

Breast cancer survivors with type 2 diabetes are at high risk for cancer recurrence, serious health complications, more severe symptoms, psychological distress, and premature death relative to breast cancer survivors without diabetes. Maintaining glycemic control is critical for decreasing symptoms and preventing serious health problems. Many breast cancer survivors with type 2 diabetes have difficulty maintaining diabetes self-management behaviors and achieving glycemic control. Both cancer and diabetes-related symptoms (e.g., physical symptoms and psychological distress) are often barriers to engaging in diabetes self-management strategies. This study evaluates a novel diabetes coping skills training (DCST) intervention for improving breast cancer survivors' abilities to manage symptoms and adhere to recommended diabetes self-management behaviors. The telephone-based DCST protocol integrates three key theory-based strategies: coping skills training for managing symptoms, adherence skills training, and healthy lifestyle skills training. A randomized clinical trial will test the DCST intervention plus diabetes education by comparing it to diabetes education alone. Symptoms, distress, diabetes self-management behaviors, and self-efficacy will be assessed at baseline and 3, 6, and 12 months. Glycosylated hemoglobin (HbA1c) will be assessed at baseline, 6, and 12 months. This study addresses a critical gap in the care of breast cancer survivors by evaluating a novel behavioral intervention to improve the management of symptoms, adherence, and glycemic control in breast cancer survivors with type 2 diabetes. Special considerations for this medically underserved population are also provided. The findings of this study could lead to significant improvements in clinical care and beneficial outcomes for breast cancer survivors. Trials registration: ClinicalTrials.gov, NCT02970344, registered 11/22/2016.

Characterization of Metabolic Syndrome Risk Factors and Health-Related Behaviors in Korean Patients With Breast Cancer by Abdominal Obesity Status

BACKGROUND

Breast cancer is the second most prevalent malignancy among Korean women. Changes in lifestyle during and after remission of breast cancer tend to increase abdominal visceral fat, leading to increased risks of metabolic syndrome and chronic diseases.

PURPOSE

This cross-sectional study examined the differences in metabolic syndrome risk factors and health-related behaviors between abdominally obese and nonabdominally obese groups of Korean patients with breast cancer.

METHODS

The participants were assigned to nonabdominal obesity (waist circumference < 85 cm, n = 77) and abdominal obesity (waist circumference ≥ 85 cm, n = 59) groups, and a questionnaire was used to assess the prevalence of risk factors of metabolic syndrome and health-related behaviors in each. The chi-square test and t test were used to analyze the data.

RESULTS

The average age was 54.2 years in the abdominal obesity group and 51.3 years in the nonabdominal obesity group. The average blood pressure and fasting blood glucose levels were higher in the abdominal obesity than the nonabdominal obesity group (117.3/76.3 vs. 108.9/70.4 mmHg, respectively [p = .001]; 96.9 and 90.1 mg/dl, respectively [p = .007]). High-density lipoprotein cholesterol was lower in the abdominal obesity than the nonabdominal obesity group (55.4 and 62.5 mg/dl, respectively [p = .005]), whereas triglycerides were higher in the abdominal obesity than the nonabdominal obesity group (151.6 and 111.3 mg/dl, respectively [p = .006]). The prevalence of metabolic syndrome in the abdominal obesity and nonabdominal obesity groups were 42.4% and 9.1%, respectively (p = .001). Moreover, eating habits differed between the two groups, with the frequency of vegetable consumption lower in the abdominal obesity than the nonabdominal obesity group (p = .040) and the frequencies of salty and sweet food consumption and of overeating higher in the abdominal obesity than the nonabdominal obesity group. The percentage of participants who exercised for 30 minutes three times per week was 52.5% in the abdominal obesity group and 71.4% in the nonabdominal obesity group (p = .024).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

This observational study found more metabolic syndrome risk factors in the abdominal obesity group than the nonabdominal obesity group. Consumption of sweet foods and overeating were higher and the frequencies of vegetable intake and exercise were lower in the abdominal obesity group. These findings suggest that female abdominally obese patients with breast cancer exhibit health-related behaviors that require improvement and better management. Interventional programs should be developed based on the findings of this study to reduce cancer recurrence and mortality in patients with breast cancer.

Endocrine Therapy-related Endocrinopathies-Biology, Prevalence and Implications for the Management of Breast Cancer

Nearly 270,000 new breast cancer cases are predicted to be diagnosed in the USA in 2019 with more than 70% being estrogen receptor positive and treated using endocrine therapy. The suppression of estrogen biosynthesis or action via the use of ovarian suppression, aromatase inhibitors and selective estrogen receptor modulators/degraders, respectively, is effective in approximately 70% of women. The systemic inhibition of estrogen during breast cancer treatment is also associated with side effects due to the important endocrine functions of this steroid hormone, including its role in the maintenance of energy homeostasis and bone health. The current work will present perspectives of the impact of endocrine therapy from the point of view of breast medical oncology, endocrinology, and basic science.

High risk for cardiovascular disease in postmenopausal breast cancer survivors

OBJECTIVE

Breast cancer patients have a higher mortality risk of cardiovascular disease (CVD) than women from the general population. CVD risk may increase significantly in postmenopausal women with early-stage breast cancer. The aim of this study was to evaluate risk factors for CVD in postmenopausal breast cancer survivors.

METHODS

In this cross-sectional study, 96 postmenopausal breast cancer survivors were compared with 192 postmenopausal women. The main group included women with amenorrhea >12 months, aged ≥45 years, with breast cancer, and without established CVD. The control group fulfilled the same criteria, but did not have breast cancer. Groups were matched by age, time since menopause, and body mass index, in a ratio of 1 case to 2 controls (1:2). Women with three or more of the following criteria were diagnosed with metabolic syndrome: waist circumference >88 cm; triglycerides ≥150 mg/dL; high-density lipoprotein cholesterol <50 mg/dL; blood pressure ≥130/85 mm Hg; and glucose ≥100 mg/dL. Immunoassays were used (enzyme-linked immunosorbent assay test) for measurement of plasma heat shock proteins (HSP) 60 and 70 concentrations. Atherosclerotic disease was determined by intima-media thickness (>1 mm) of the carotid arteries and/or the presence of atheromatous plaque assessed by carotid artery ultrasound (scanner duplex).

RESULTS

Breast cancer patients had higher HSP60 levels and lower HSP70 levels than controls (P < 0.05). Analysis showed that the odds of developing metabolic syndrome (odds ratio [OR] = 4.21, 95% CI, 2.28-7.76), atheromatous plaque (OR = 2.61, 95% CI, 1.19-5.72), diabetes (OR = 4.42; 95% CI, 1.86-10.49), hypertriglyceridemia (OR = 2.32, 95% CI, 1.33-4.0), and increased waist circumference (OR = 11.22, 95% CI, 4.0-31.65) was significantly higher in women treated for cancer than in women without breast cancer.

CONCLUSIONS

Postmenopausal breast cancer survivors had a stronger association with risk factors for cardiovascular disease than postmenopausal women without breast cancer.

The effect of modifiable risk factors on breast cancer aggressiveness among black and white women

INTRODUCTION

Although breast cancer incidence is higher among white women, black women are more likely to have aggressive tumors with less favorable histology, and to have a worse prognosis. Obesity and alcohol consumption have been identified as two modifiable risk factors for breast cancer, while physical activity may offer protection. Little however is known about the association of these factors with race on the severity of breast cancer.

METHODS

Data collected as part of a large prospective study looking at insulin resistance and race among women with breast cancer was queried for patient characteristics, lifestyle factors and tumor characteristics. The association with Nottingham Prognostic Index (NPI) was assessed with different models using univariate and multivariate linear regression.

RESULTS

Among 746 women in our cohort, 82% (n = 615) were white and 18% (n = 131) were black, mean age 58 years. Black patients were more likely to have high BMI (31.0 vs. 26.7, p < 0.0001), comorbidities (69% vs 55%, p = 0.01), self-reported poor diet (70% vs 42%, p < 0.001), be sedentary (56% vs 46%, p = 0.03) and were less likely to consume alcohol (8% vs 32%, p < 0.0001) compared to white patients. Overall, 137 (18%) of the patients had poorer prognosis (NPI > 4.4), which was significantly associated with younger age (55.6 vs 58.5 years, p = 0.02), black race (27% vs 15%, p = 0.001), triple negative cancer (15% vs 6%, p = 0.003), and poor diet (54% vs 45%, p = 0.046) compared to patients with better prognosis (NPI ≤ 4.4). On multivariate analysis, (model R² = 0.12; p < 0.001), age (β = -0.011 per year, p = 0.002), healthy diet (β = -0.195, p = 0.02), and exercise (β = -0.004, p = 0.02) were associated with better prognosis, while black race (β = 0.247, p = 0.02) and triple negative cancer (β = 0.908, p < 0.0001) were associated with poor prognosis. Neither alcohol use nor BMI was significantly associated with NPI.

CONCLUSION

Among modifiable risk factors, diet and exercise are associated with NPI. Unmodifiable factors including race and biologic subtype remain the most important determinants of prognosis.

Breast Cancer Screening Participation of Women with Chronic Diseases in Korea: Analysis of the 2012 Korean National Health and Nutrition Examination Survey

Chronic disease morbidity is a concern for cancer research. Contradictory results have been reported concerning adherence to breast cancer screening among patients with chronic diseases. The study was conducted to assess the adherence to breast cancer screening among women with chronic diseases in Korea. It was a cross sectional and population based study; the data came from the Korean National Health and Nutrition Examination Survey (KNHANES) 2012. Participation in breast cancer screening was analyzed among women who had at least one of eight chronic diseases (hypertension, diabetes, cancer, dyslipidemia, stroke, depression, osteoarthritis and asthma). Pearson’s chi-squared test and multiple logistic regression analysis were performed using STATA version 14. A total 2,404 women aged 40 years or older were included in analysis. Among them, 77.3% had experienced breast cancer screening. In logistic regression model, adherence to breast cancer screening was lower in women who have ever been diagnosed as diabetes mellitus (odds ratio (OR)= 0.47, 95% confidence interval (95%CI) = 0.31-0.72), asthma (OR=0.44, 95%CI=0.24-0.82) and higher in women who have ever been diagnosed as dyslipidemia (OR= 1.85, 95%CI= 1.27-2.69), osteoarthritis (OR= 1.42, 95%CI= 1.31-2.06) and cancers (OR= 2.70, 95%CI= 1.26-5.79) compared to women without those chronic diseases. Based on treatment of chronic diseases, lower participation in breast cancer screening was observed in women who were on treatment of diabetes mellitus (OR= 0.48, 95%CI= 0.31-0.74), asthma (OR= 0.41, 95%CI= 0.15-0.92) and stroke (OR= 0.37, 95%CI= 0.14-0.97), and higher in women who were on treatment of dyslipidemia (OR= 1.37, 95%CI=1.42-2.14). In conclusion, low participation rate in breast cancer screening in women with some chronic diseases was identified. The results from this study may provide an important contribution for helping to maintain and increase participation in cancer screening of patients with chronic diseases.

Atherosclerotic disease and cardiovascular risk factors in postmenopausal breast cancer survivors: a case-control study

OBJECTIVE

Breast cancer (BC) therapies and the longevity that the women achieve imply a higher cardiovascular risk. The aim of the study was to evaluate the frequency of atherosclerotic disease and its association with cardiovascular risk factors in postmenopausal breast cancer survivors (BCS) compared to postmenopausal women without BC.

METHODS

In this study, 96 women with BC (case group) were compared to 192 women without BC (control group), age range 45-75 years. The case group included women with a histological diagnosis of BC, amenorrhea ≥ 12 months, and age ≥ 45 years, without metastatic disease or cardiovascular disease (CVD). The control group consisted of women with amenorrhea ≥ 12 months and age ≥ 45 years, without BC or CVD. Total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, glucose, and insulin were measured. Atherosclerotic disease was determined by increased intima-media thickness (thickness > 1.0 mm) of the carotid arteries and/or presence of atheromatous plaques evaluated by carotid duplex ultrasound.

RESULTS

The frequency of diabetes and metabolic syndrome were higher in BCS compared to controls (19.8% vs. 6.8% and 54.2% vs. 37.0%, respectively, p < 0.05). There was no difference in subclinical atherosclerosis between groups (BCS 26% vs. controls 18.7%, p = 0.062). However, atheromatous plaques were more frequent in BCS compared to controls (19.8% vs. 9.4%, p = 0.013). In the risk analysis, adjusted for age, time since menopause, and body mass index, BCS had a 2.4-fold higher risk of atheromatous plaques (odds ratio = 2.42; 95% confidence interval 1.18-4.93, p = 0.033) than women without BC.

CONCLUSION

Postmenopausal BCS had a higher risk of developing atherosclerotic disease, associated with a higher frequency of cardiovascular risk factors such as metabolic syndrome and diabetes, when compared to women of the same age group without BC.

Fructosamine and diabetes as predictors of mortality among Hispanic and non-Hispanic white breast cancer survivors

Epidemiologic studies have found that elevated insulin levels and chronic hyperglycemia among breast cancer (BC) survivors are associated with poor prognosis; few of these studies have included Hispanic women in whom diabetes is highly prevalent. We examined the associations between circulating fructosamine-a biomarker of hyperglycemia and blood glucose control, self-reported diabetes, and risk of BC-specific and all-cause mortality among Hispanic and non-Hispanic white (NHW) women diagnosed with invasive BC. A total of 399 BC survivors (96 Hispanic, 303 NHW) contributed baseline data and plasma samples. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using multivariable Cox proportional hazards regression models. After a median follow-up time of 13 years, a total of 134 deaths occurred, of which 56 deaths were from BC. Diabetes was associated with BC-specific (HR, 2.89; 95% CI 1.27-6.60) and all-cause (HR, 2.10; 95% CI 1.24-3.55) mortality. Associations were stronger among women with clinically high fructosamine levels (>285 µmol/L) (BC-specific: HR, 4.25; 95% CI 1.67-10.80; all-cause: HR, 2.32; 95% CI 1.30-4.14) compared to women with normal levels (≤285 µmol/L). In mediation analysis, fructosamine explained 47% of the association between diabetes and all-cause mortality and 41% of BC-specific mortality; the largest attenuation was among Hispanics for all-cause mortality (56%). Our results demonstrate that poor glycemic control explains a large extent of the relationship between diabetes and mortality among women with invasive BC, particularly among Hispanic women. The associations we observed for BC mortality should be confirmed in larger studies of ethnically diverse BC patients.

Lifestyle Medicine-Focused Shared Medical Appointments to Improve Risk Factors for Chronic Diseases and Quality of Life in Breast Cancer Survivors

OBJECTIVES

Poor lifestyle choices play a significant role in the development and progression of preventable chronic diseases, including cancer. In this study, we evaluate the effectiveness of a comprehensive lifestyle medicine intervention on chronic disease risk factors and quality of life in breast cancer survivors.

DESIGN

This is a retrospective review of a clinical program from January 2016 to July 2017.

SETTINGS/LOCATION

It includes seven 2-h group medical visits held every other week at an outpatient wellness facility.

SUBJECTS

Eligible participants are breast cancer survivors who have completed treatment, including those who remain on hormonal therapy.

INTERVENTION

Patients receive education and experience in nutrition, culinary medicine, physical activity, and stress relief practices.

OUTCOME MEASURES

Participants' weight, body mass index (BMI), body fat mass, lean body mass, and percent body fat were measured at visit 1 and visit 7. Standard validated questionnaires were used to measure perceived stress, depression, patient activation, physical and mental quality of life, dietary fat consumption, and dietary fruit, vegetable, and fiber consumption.

RESULTS

A total of 31 patients participated in the group visits. Pre-post comparison data were not available for 10 patients. More than three-quarters of the 21 breast cancer survivors who attended 5 or more of the 7 group visits and provided data at the first and the last group visit decreased their body weight. On average, patients lost 4.9 pounds (-2.6%, p < 0.01), and their BMI decreased by 0.8 kg/m² (-2.5%, p < 0.01). Changes in psychosocial variables of perceived stress, depression, patient activation, and quality of life trended in a positive direction, but did not reach statistical significance. Patients reported a significant decrease in average weekly fat consumption (-31.5%, p < 0.01). Most patients found the program educational and enjoyable, and nearly half of them described it as life changing.

CONCLUSIONS

Breast cancer survivors could employ the prescribed lifestyle modifications to produce clinically relevant health benefits. Interdisciplinary teams of health care professionals may help breast cancer survivors with chronic diseases implement evidence-based, individualized, and effective lifestyle prescription through group medical visits.

Comprehensive Lifestyle Modification Intervention to Improve Chronic Disease Risk Factors and Quality of Life in Cancer Survivors

OBJECTIVES

Healthy lifestyle modifications, including weight management, regular physical activity, prudent diet, and stress relief, have been identified as key components of tertiary cancer prevention. In this study, we evaluate the effectiveness of a comprehensive, lifestyle medicine intervention, Lifestyle 180^®, on chronic disease risk factors and quality of life in cancer survivors.

DESIGN

Retrospective subgroup analysis of a clinical program.

SETTINGS/LOCATION

An outpatient medical facility.

SUBJECTS

Lifestyle 180 participants with a diagnosis of past cancer.

INTERVENTION

Sixty-four hours of intensive nutrition, culinary medicine, physical activity, and stress relief practices over a 6-month period, with 9- and 12-month follow-up.

OUTCOME MEASURES

Pre-postanalysis (baseline vs. 12 months) included biometrics: weight, body mass index (BMI), waist circumference, and blood pressure; standard laboratory tests: lipids, C-reactive protein, fasting insulin/glucose, and insulin resistance; and empirically validated questionnaires: perceived stress, depression, and quality of life.

RESULTS

Fifty-eight cancer survivors participated in Lifestyle 180. Average age was 63 years, roughly 75% of participants were female, and the greatest majority had a diagnosis of breast, prostate, or skin cancer. Diagnosis of hyperlipidemia, hypertension, diabetes, and prediabetes presented in 47%, 57%, 22%, and 50% of patients, respectively. Forty-five percent of patients were obese, 24% were overweight, and 16% were depressed. At 12 months, participants lost an average of 14 pounds (-6.6%, p < 0.001) and 2.6 inches off their waist (-5.9%, p < 0.001). BMI decreased significantly by an average of 2.4 kg/m² (-6.8%, p < 0.001). Significant decreases from well-managed baseline levels also occurred in most measured biomarkers (average change: high-density lipoprotein +3.3 mg/dL, p < 0.05; triglycerides -23.0 mg/dL, p < 0.01; C-reactive protein -1.3 mg/L, p < 0.01; fasting insulin -4.2 μU/mL, p < 0.05; and homeostasis model assessment-insulin resistance -1.5, p < 0.01; n = 40). Changes in psychosocial variables included significant improvements in perceived stress (-20%, p < 0.01) and quality of life (+54%, p < 0.001). We were unable to detect a difference in depressive symptoms.

CONCLUSIONS

Cancer survivors participating in a comprehensive intervention could employ the prescribed lifestyle modifications to produce clinically relevant health and quality-of-life benefits. These data support the American Cancer Society (ACS) and American Society of Clinical Oncology (ASCO) recommendations to incorporate healthy lifestyle modifications into long-term cancer survivorship care.

Changes in metabolic risk, insulin resistance, leptin and adiponectin following a lifestyle intervention in overweight and obese breast cancer survivors

Adiposity and physical activity are modifiable factors that could be important determinants of breast cancer (BC) prognosis through their effects on endogenous reproductive hormones, chronic inflammation and metabolic changes. Therefore, it is necessary to evaluate whether offering lifestyle interventions to BC survivors could affect the levels of certain biomarkers involved in these mechanisms. We designed a pre-post intervention study offering diet and exercise sessions over 12 weeks to 42 overweight/obese BC survivors. Before and after the intervention, we obtained dietary information, anthropometry and cardiorespiratory fitness (CRF) measurements and blood samples to measure metabolic risk, insulin resistance and adipokines biomarkers. Wilcoxon signed-rank tests and Spearman partial correlation coefficients were used to compare pre- and post-measurements and assess the correlations between changes in biomarkers and changes in anthropometry and CRF. Breast cancer survivors showed significant improvements in metabolic risk biomarkers and insulin resistance indicators along with a non-significant leptin decrease and a significant adiponectin decrease. The improvements in metabolic risk biomarkers, insulin resistance indicators and leptin were moderately correlated (0.32 ≤ |r| ≤ 0.55) with the decrease in body mass index and the increase in CRF. Diet and exercise interventions implemented in overweight/obese BC survivors may improve metabolic risk, insulin resistance and leptin biomarkers.

The associations of comorbidities and consumption of fruit and vegetable with quality of life among stomach cancer survivors

BACKGROUND

Stomach cancer survivors (SCS) often carry the dual burden of the cancer itself and other comorbidities; meanwhile, they are highly motivated to seek health advice about lifestyles to improve their health and quality of life (QOL). The associations of the comorbidity and the consumption of vegetable and fruit with QOL remain even less clear among the SCS. This study aimed to investigate the associations of comorbidities and consumption of fruit and vegetable with QOL among SCS.

METHODS

A cross-sectional study was conducted among 969 SCS between April and July 2015 in Shanghai, People's Republic of China. Data were collected using a self-reported questionnaire, which included questions on sociodemographic characteristics, comorbidities and fruit and vegetable consumption, and a simplified Chinese version of the European Organization for Research and Treatment quality of life version 3 (EORTC QLQ-C30) questionnaire. In order to mitigate the bias caused by confounding factors, multiple linear regression models were employed to calculate the adjusted means of QOL scores.

RESULTS

The proportion of participants without any comorbidity was only 23.3%, and the most common comorbidity among SCS was digestive diseases (49.8%). Participants with comorbidity generally reported lower scores for global health and functioning subscales and higher scores for symptom in EORTC QLQ-C30 compared to participants without comorbidity, indicating poorer QOL. Higher scores in most functioning subscales and lower scores in some symptoms subscales were found in participants (38.7%) who ate more than 250 g vegetables every day, compared to participants with less vegetable consumption, and in participants (58.1%) who ate fruit every day, compared to participants who didn't eat fruit every day indicating better QOL.

CONCLUSIONS

The comorbidities are common health problems among SCS and have significantly negative influence on QOL, and participants with comorbidities generally reported lower QOL scores. The enough vegetables and fruit consumption are positively associated with QOL of SCS. These findings suggested that a multidisciplinary team approach and a variety of delivery systems are needed to address the medical, psychosocial, and lifestyle components for enriching patient-centered care among SCS.

Good glycaemic control is associated with a better prognosis in breast cancer patients with type 2 diabetes mellitus

Although diabetes mellitus (DM) is one of the risk factors associated with increased breast cancer (BC) mortality, the effects of glycaemic control on the prognosis of BC have not been thoroughly evaluated. This retrospective study aimed to evaluate the relationship between glycaemic control and BC prognosis and to determine an optimal target of glycaemic control for BC patients with diabetes. We included 2812 stage 0-3 BC women, of whom 145 were diabetic and were 2667 non-diabetic. In those with diabetes, a mean haemoglobin A1C (HbA1C) < 7% (n = 77) was defined as well-controlled diabetes, while a mean HbA1C > 9% (n = 16) was defined as poorly controlled diabetes. All of the BC populations were followed from the date on which BC was diagnosed until 31 December 2015. Cox regression analysis was performed to estimate the adjusted hazards for all-cause mortality and BC-specific mortality. After controlling for the baseline and BC-related confounders, the adjusted hazard ratio (HR) for all-cause mortality and the HR for BC-specific mortality were 3.65 (95% confidence interval [95% CI] 1.13-11.82) and 8.37 (95% CI 1.90-36.91), respectively, for poorly controlled diabetic women and non-DM women. However, for the diabetic women with good glycaemic control, the HRs of all-cause mortality and BC-specific mortality were not significantly different (HR 0.91, 95% CI 0.42-1.01; HR 0.77, 95% CI 0.18-3.32, respectively) from those for both mortalities in non-DM patients. For moderate controlled diabetic women, the HRs for all-cause mortality and BC-specific mortality were 1.95 (95% CI 0.89-4.27) and 3.55 (95% CI 1.369-9.30), respectively. This pilot and retrospective cohort study reveals a relationship between glycaemic control and BC prognosis in diabetic women. In addition, well-controlled HbA1C, with maintained mean HbA1C values under 7%, may be associated with a better progression outcome of BC.

Association of type 2 diabetes with in-hospital complications among women undergoing breast cancer surgical procedures. A retrospective study using the Spanish National Hospital Discharge Database, 2013-2014

OBJECTIVES

To compare the type of surgical procedures used, comorbidities, in-hospital complications (IHC) and in-hospital outcomes between women with type 2 diabetes mellitus (T2DM) and age-matched women without diabetes who were hospitalised with breast cancer. In addition, we sought to identify factors associated with IHC in women with T2DM who had undergone surgical procedures for breast cancer.

DESIGN

Retrospective study using the National Hospital Discharge Database, 2013-2014.

SETTING

Spain.

PARTICIPANTS

Women who were aged ≥40 years with a primary diagnosis of breast cancer and who had undergone a surgical procedure. We grouped admissions by T2DM status. We selected one matched control for each T2DM case.

MAIN OUTCOME MEASURES

The type of procedure (breast-conserving surgery (BCS) or mastectomy), clinical characteristics, complications, length of hospital stay and in-hospital mortality.

RESULTS

We identified 41 458 admissions (9.23% with T2DM). Overall, and in addition to the surgical procedure, we found that comorbidity, hypertension and obesity were more common among patients with T2DM. We also detected a higher incidence of mastectomy in women with T2DM (44.69% vs 42.42%) and a greater rate of BCS in patients without T2DM (57.58% vs 55.31%). Overall, non-infectious complications were more common among women with T2DM (6.40% vs 4.56%). Among women who had undergone BCS or a mastectomy, IHC were more frequent among diabetics (5.57% vs 3.04% and 10.60% vs 8.24%, respectively). Comorbidity was significantly associated with a higher risk of IHC in women with diabetes, independent of the specific procedure used.province CONCLUSIONS: Women with T2DM who undergo surgical breast cancer procedures have more comorbidity, risk factors and advanced cancer presentations than matched patients without T2DM. Mastectomies are more common in women with T2DM. Moreover, the procedures among women with T2DM were associated with greater IHC. Comorbidity was a strong predictor of IHC in women with T2DM.

Low bone mineral density is associated with breast cancer in postmenopausal women: a case-control study

OBJECTIVE

To evaluate risk factors for low bone mineral density (BMD) in postmenopausal breast cancer survivors compared with postmenopausal women without breast cancer (controls).

METHOD

In this study, 112 breast cancer survivors were compared to 224 women (controls). Inclusion criteria were amenorrhea ≥12 months, age 45-75 years, treated for breast cancer, and metastasis-free for at least 5 years. The control group consisted of women without breast cancer, matched by age and menopause status (in a proportion of 1: 2 as sample calculation). The risk factors for low BMD (osteopenia/osteoporosis) were assessed by interview. BMD was measured by dual-energy X-ray absorptiometry in the lumbar spine (L1-L4) and femoral neck. Logistic regression models (odds ratio, OR) were used to identify factors associated with low BMD.

RESULTS

The mean (standard deviation) age of breast cancer survivors was 61.3 (9.7) years, with a mean follow-up of 10.2 (3.9) years. These women had a higher incidence of osteopenia (45.1%) and osteoporosis (22.3%) in the femoral neck than controls (39.3% and 9.0%, respectively) (p = 0.0005). Lumbar spine BMD did not differ between groups (p = 0.332). Univariate analysis adjusted for age and time since menopause revealed that chemotherapy (OR 6.90; 95% confidence interval (CI) 5.57-9.77) was associated with a higher risk of low BMD. Contrarily, regular physical exercise (OR 0.24; 95% CI 0.06-0.98) and a body mass index ≥30 kg/m² (OR 0.09; 95% CI 0.02-0.37) reduced the risk among breast cancer survivors.

CONCLUSION

Postmenopausal breast cancer survivors had a higher incidence of osteopenia and osteoporosis in the femoral neck than women without breast cancer. A history of chemotherapy was a risk factor for low BMD, whereas regular physical activity and high body mass index reduced the risk among breast cancer survivors.

Reproducibility, reliability and validity of population-based administrative health data for the assessment of cancer non-related comorbidities

BACKGROUND

Patients with comorbidities do not receive optimal treatment for their cancer, leading to lower cancer survival. Information on individual comorbidities is not straightforward to derive from population-based administrative health datasets. We described the development of a reproducible algorithm to extract the individual Charlson index comorbidities from such data. We illustrated the algorithm with 1,789 laryngeal cancer patients diagnosed in England in 2013. We aimed to clearly set out and advocate the time-related assumptions specified in the algorithm by providing empirical evidence for them.

METHODS

Comorbidities were assessed from hospital records in the ten years preceding cancer diagnosis and internal reliability of the hospital records was checked. Data were right-truncated 6 or 12 months prior to cancer diagnosis to avoid inclusion of potentially cancer-related comorbidities. We tested for collider bias using Cox regression.

RESULTS

Our administrative data showed weak to moderate internal reliability to identify comorbidities (ICC ranging between 0.1 and 0.6) but a notably high external validity (86.3%). We showed a reverse protective effect of non-cancer related Chronic Obstructive Pulmonary Disease (COPD) when the effect is split into cancer and non-cancer related COPD (Age-adjusted HR: 0.95, 95% CI:0.7-1.28 for non-cancer related comorbidities). Furthermore, we showed that a window of 6 years before diagnosis is an optimal period for the assessment of comorbidities.

CONCLUSION

To formulate a robust approach for assessing common comorbidities, it is important that assumptions made are explicitly stated and empirically proven. We provide a transparent and consistent approach useful to researchers looking to assess comorbidities for cancer patients using administrative health data.

Sleep duration and breast cancer prognosis: perspectives from the Women's Healthy Eating and Living Study

PURPOSE

To examine whether baseline sleep duration or changes in sleep duration are associated with breast cancer prognosis among early-stage breast cancer survivors in the multi-center Women's Healthy Eating and Living Study.

METHODS

Data were collected from 1995 to 2010. Analysis included 3047 women. Sleep duration was self-reported at baseline and follow-up intervals. Cox proportional hazard models were used to investigate whether baseline sleep duration was associated with breast cancer recurrence, breast cancer-specific mortality, and all-cause mortality. Time-varying models investigated whether changes in sleep duration were associated with breast cancer prognosis.

RESULTS

Compared to women who slept 7-8 h/night at baseline, sleeping ≥9 h/night was associated with a 48% increased risk of breast cancer recurrence (Hazard ratio [HR] 1.48, 95% Confidence interval [CI] 1.01, 2.00), a 52% increased risk of breast cancer-specific mortality (HR 1.52, 95% CI 1.09, 2.13), and a 43% greater risk of all-cause mortality (HR 1.43, 95% CI 1.07, 1.92). Time-varying models showed analogous increased risk in those who inconsistently slept ≥9 h/night (all P < 0.05), but not in those who consistently slept ≥9 h/night.

CONCLUSIONS

Consistent long or short sleep, which may reflect inter-individual variability in the need for sleep, does not appear to influence prognosis among early-stage breast cancer survivors.

Diabetes and breast cancer mortality in Black women

PURPOSE

Breast cancer mortality is higher in Black women than in White women. The prevalence of type 2 diabetes mellitus is also higher, yet data on whether diabetes affects breast cancer mortality in this population are lacking. We investigated the relation of diabetes at the time of breast cancer diagnosis to breast cancer mortality in the Black Women's Health Study, a prospective cohort study.

METHODS

1,621 Black women with invasive breast cancer diagnosed in 1995-2013 were followed by mailed questionnaires and searches of the National Death Index. Multivariable Cox regression analysis was used to compute hazard ratios (HRs) for diabetes in relation to breast cancer mortality and all-cause mortality, with adjustment for age, stage, treatment modality, estrogen receptor (ER) status, and body mass index.

RESULTS

There were 368 deaths during follow-up, of which 273 were due to breast cancer. Breast cancer mortality was significantly increased in women who had been diagnosed with diabetes at least 5 years before breast cancer occurrence, HR 1.86 (95% CI 1.20-2.89), with elevations observed for both ER+ and ER- breast cancer. All-cause mortality was also higher in diabetics, with HRs of 1.54 (95% CI 1.12-2.07) overall and 2.26 (95% CI 1.62-3.15) for ≥5-year duration of diabetes relative to non-diabetics.

CONCLUSIONS

Our results present the first solid evidence of a positive association of type 2 diabetes with breast cancer mortality in Black women. Given the higher prevalence and earlier onset of type 2 diabetes in Black women, it is likely that diabetes contributes to racial disparities in breast cancer mortality.

Cardiovascular Disease Mortality Among Breast Cancer Survivors

BACKGROUND

Cardiovascular disease (CVD) is of increasing concern among breast cancer survivors. However, the burden of this comorbidity in this group relative to the general population, and its temporal pattern, remains unknown.

METHODS

We compared deaths due to CVD in a population-based sample of 1,413 women with incident breast cancer diagnosed in 1996-1997, and 1,411 age-matched women without breast cancer. Date and cause of death through December 31, 2009 were assessed through the national death index and covariate data was gathered through structured interviews and medical record abstraction. Hazard ratios (HR) and 95% confidence intervals were calculated using Cox regression for overall mortality (HR) and CVD-specific death (cause-specific HR). Subdistribution HRs for CVD death were estimated from the Fine-Gray model.

RESULTS

Risk of death was greater among breast cancer survivors compared with women without breast cancer (HR: 1.8 [1.5, 2.1]). An increase in CVD-related death among breast cancer survivors was evident only 7 years after diagnosis (years 0-7, cause-specific HR: 0.80 [0.53, 1.2], subdistribution HR: 0.59 [0.40, 0.87]); years 7+, cause-specific HR: 1.8 [1.3, 2.5], subdistribution HR: 1.9 [1.4, 2.7]; P interaction: 0.001). An increase in CVD-related mortality was observed among breast cancer survivors receiving chemotherapy.

CONCLUSIONS

Breast cancer survivors are at greater risk for CVD-related mortality compared with women without breast cancer and this increase in risk is manifested approximately 7 years after diagnosis. Efforts should be made to identify risk factors and interventions that can be employed during this brief window to reduce the excess burden of CVD in this vulnerable population.

Post-treatment problems of African American breast cancer survivors

PURPOSE

African American breast cancer survivors (AABCS) have a lower survival rate across all disease stages (79 %) compared with White survivors (92 %) and often have more aggressive forms of breast cancer requiring multimodality treatment, so they could experience a larger burden of post-treatment quality of life (QOL) problems. This paper reports a comprehensive assessment of the number, severity, and domains of problems faced by AABCS within 5 years after treatment completion and identifies subgroups at risk for these problems.

METHODS

A population-based random sample was obtained from the Pennsylvania Cancer Registry of African American females over 18 years of age who completed primary treatment for breast cancer in the past 5 years. A mailed survey was used to document survivorship problems.

RESULTS

Two hundred ninety-seven AABCS completed the survey. The median number of survivor problems reported was 15. Exploratory factor analysis of the problem scale revealed four domains: emotional problems, physical problems, lack of resources, and sexuality problems. Across problem domains, younger age, more comorbid conditions, and greater medical mistrust were risk factors for more severe problems.

CONCLUSIONS

The results demonstrated that AABCS experienced significant problem burden in the early years after diagnosis and treatment. In addition to emotional and physical problem domains that were documented in previous research, two problem domains unique to AABCS included lack of resources and sexuality concerns. At risk groups should be targeted for intervention. The study results reported in this manuscript will inform future research to address problems of AABCS as they make the transition from cancer patient to cancer survivor.

Impact of a behavioral weight loss intervention on comorbidities in overweight and obese breast cancer survivors

PURPOSE

Comorbid medical conditions are common among breast cancer survivors, contribute to poorer long-term survival and increased overall mortality, and may be ameliorated by weight loss. This secondary analysis evaluated the impact of a weight loss intervention on comorbid medical conditions immediately following an intervention (12 months) and 1-year postintervention (24 months) using data from the Exercise and Nutrition to Enhance Recovery and Good health for You (ENERGY) trial-a phase III trial which was aimed at and successfully promoted weight loss.

METHODS

ENERGY randomized 692 overweight/obese women who had completed treatment for early stage breast cancer to either a 1-year group-based behavioral intervention designed to achieve and maintain weight loss or to a less intensive control intervention. Minimal support was provided postintervention. New medical conditions, medical conditions in which non-cancer medications were prescribed, hospitalizations, and emergency room visits, were compared at baseline, year 1, and year 2. Changes over time were analyzed using chi-squared tests, Kaplan-Meier, and logistic regression analyses.

RESULTS

At 12 months, women randomized to the intervention had fewer new medical conditions compared to the control group (19.6 vs. 32.2 %, p < 0.001); however, by 24 months, there was no longer a significant difference. No difference was observed in each of the four conditions for which non-cancer medications were prescribed, hospital visits, or emergency visits at either 12 or 24 months.

CONCLUSIONS

These results support a short-term benefit of modest weight loss on the likelihood of comorbid conditions; however, recidivism and weight regain likely explain no benefit at 1-year postintervention follow-up.

The Effect of Patient and Contextual Characteristics on Racial/Ethnic Disparity in Breast Cancer Mortality

BACKGROUND

Racial/ethnic disparity in breast cancer-specific mortality in the United States is well documented. We examined whether accounting for racial/ethnic differences in the prevalence of clinical, patient, and lifestyle and contextual factors that are associated with breast cancer-specific mortality can explain this disparity.

METHODS

The California Breast Cancer Survivorship Consortium combined interview data from six California-based breast cancer studies with cancer registry data to create a large, racially diverse cohort of women with primary invasive breast cancer. We examined the contribution of variables in a previously reported Cox regression baseline model plus additional contextual, physical activity, body size, and comorbidity variables to the racial/ethnic disparity in breast cancer-specific mortality.

RESULTS

The cohort comprised 12,098 women. Fifty-four percent were non-Latina Whites, 17% African Americans, 17% Latinas, and 12% Asian Americans. In a model adjusting only for age and study, breast cancer-specific HRs relative to Whites were 1.69 (95% CI, 1.46-1.96), 1.00 (0.84-1.19), and 0.52 (0.33-0.85) for African Americans, Latinas, and Asian Americans, respectively. Adjusting for baseline-model variables decreased disparity primarily by reducing the HR for African Americans to 1.13 (0.96-1.33). The most influential variables were related to disease characteristics, neighborhood socioeconomic status, and smoking status at diagnosis. Other variables had negligible impact on disparity.

CONCLUSIONS

Although contextual, physical activity, body size, and comorbidity variables may influence breast cancer-specific mortality, they do not explain racial/ethnic mortality disparity.

IMPACT

Other factors besides those investigated here may explain the existing racial/ethnic disparity in mortality. Cancer Epidemiol Biomarkers Prev; 25(7); 1064-72. ©2016 AACR.

Cervical and breast cancer screening participation for women with chronic conditions in France: results from a national health survey

Background

Comorbidity at the time of diagnosis is an independent prognostic factor for survival among women suffering from cervical or breast cancer. Although cancer screening practices have proven their efficacy for mortality reduction, little is known about adherence to screening recommendations for women suffering from chronic conditions. We investigated the association between eleven chronic conditions and adherence to cervical and breast cancer screening recommendations in France.

Method

Using data from a cross-sectional national health survey conducted in 2008, we analyzed screening participation taking into account self-reported: inflammatory systemic disease, cancer, cardiovascular disease, chronic respiratory disease, depression, diabetes, dyslipidemia, hypertension, obesity, osteoarthritis and thyroid disorders. We first computed age-standardized screening rates among women who reported each condition. We then estimated the effect of having reported each condition on adherence to screening recommendations in logistic regression models, with adjustment for sociodemographic characteristics, socioeconomic position, health behaviours, healthcare access and healthcare use. Finally, we investigated the association between chronic conditions and opportunistic versus organized breast cancer screening using multinomial logistic regression.

Results

The analyses were conducted among 4226 women for cervical cancer screening and 2056 women for breast cancer screening. Most conditions studied were not associated with screening participation. Adherence to cervical cancer screening recommendations was higher for cancer survivors (OR = 1.73 [0.98–3.05]) and lower for obese women (OR = 0.73 [0.57–0.93]), when accounting for our complete range of screening determinants. Women reporting chronic respiratory disease or diabetes participated less in cervical cancer screening, except when adjusting for socioeconomic characteristics. Adherence to breast cancer screening recommendations was lower for obese women and women reporting diabetes, even after accounting for our complete range of screening determinants (OR = 0.71 [0.52–0.96] and OR = 0.55 [0.36–0.83] respectively). The lower breast cancer screening participation for obese women was more pronounced for opportunistic than for organized screening.

Conclusion

We identified conditions associated with participation in cervical and breast cancer screening, even when accounting for major determinants of cancer screening. Obese women participated less in cervical cancer screening. Obese women and women with diabetes participated less in mammographic screening and organized breast cancer screening seemed to insufficiently address barriers to participation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2295-0) contains supplementary material, which is available to authorized users.

Validation of self-reported comorbidity status of breast cancer patients with medical records: the California Breast Cancer Survivorship Consortium (CBCSC)

PURPOSE

To compare information from self-report and electronic medical records for four common comorbidities (diabetes, hypertension, myocardial infarction, and other heart diseases).

METHODS

We pooled data from two multiethnic studies (one case-control and one survivor cohort) enrolling 1,936 women diagnosed with breast cancer, who were members of Kaiser Permanente Northern California.

RESULTS

Concordance varied by comorbidity; kappa values ranged from 0.50 for other heart diseases to 0.87 for diabetes. Sensitivities for comorbidities from self-report versus medical record were similar for racial/ethnic minorities and non-Hispanic Whites, and did not vary by age, neighborhood socioeconomic status, or education. Women with a longer history of comorbidity or who took medications for the comorbidity were more likely to report the condition. Hazard ratios for all-cause mortality were not consistently affected by source of comorbidity information; the hazard ratio was lower for diabetes, but higher for the other comorbidities when medical record versus self-report was used. Model fit was better when the medical record versus self-reported data were used.

CONCLUSIONS

Comorbidities are increasingly recognized to influence the survival of patients with breast or other cancers. Potential effects of misclassification of comorbidity status should be considered in the interpretation of research results.

Impact of very low physical activity, BMI, and comorbidities on mortality among breast cancer survivors

The purpose of this study was to examine post-diagnosis BMI, very low physical activity, and comorbidities, as predictors of breast cancer-specific and all-cause mortality. Data from three female US breast cancer survivor cohorts were harmonized in the After Breast Cancer Pooling Project (n = 9513). Delayed entry Cox proportional hazards models were used to examine the impact of three post-diagnosis lifestyle factors: body mass index (BMI), select comorbidities (diabetes only, hypertension only, or both), and very low physical activity (defined as physical activity <1.5 MET h/week) in individual models and together in multivariate models for breast cancer and all-cause mortality. For breast cancer mortality, the individual lifestyle models demonstrated a significant association with very low physical activity but not with the selected comorbidities or BMI. In the model that included all three lifestyle variables, very low physical activity was associated with a 22 % increased risk of breast cancer mortality (HR 1.22, 95 % CI 1.05, 1.42). For all-cause mortality, the three individual models demonstrated significant associations for all three lifestyle predictors. In the combined model, the strength and significance of the association of comorbidities (both hypertension and diabetes versus neither: HR 2.16, 95 % CI 1.79, 2.60) and very low physical activity (HR 1.35, 95 % CI 1.22, 1.51) remained unchanged, but the association with obesity was completely attenuated. These data indicate that after active treatment, very low physical activity, consistent with a sedentary lifestyle (and comorbidities for all-cause mortality), may account for the increased risk of mortality, with higher BMI, that is seen in other studies.

Understanding the Association of Type 2 Diabetes Mellitus in Breast Cancer Among African American and European American Populations in South Carolina

BACKGROUND

In South Carolina, the co-occurrence of diabetes mellitus (DM) and breast cancer (BrCA) is much more prevalent among African American populations than among European American populations. The underlying relationship between diabetes and breast cancer may influence breast cancer survival. The purpose of this investigation is to examine the effect of diabetes on developing breast cancer and to reduce racial disparities in breast cancer outcomes.

METHODS

Study participants included women of European American (EA) and African American (AA) ethnicity from both the Medicaid ICD-9 designations and the South Carolina Central Cancer Registry (SCCCR). A historical prospective cohort design was used to determine the risk of developing breast cancer among women of different ethnicities with and without DM. The chi-square test was used to determine the significance of the association; the logistic model was used to assess the relationship between breast cancer and other factors among EA and AA women.

RESULTS

Menopause may have protective properties for AA compared to EA women. AA women have twice the odds of not surviving from each breast cancer stage compared to EA women with respect to their breast cancer stage. Adherence to diabetes medication may contribute to lower breast cancer death in EA.

CONCLUSION

This study illustrates the discrepancy between EA and AA women in terms of breast cancer survival. AA women bear a higher disease burden than EA women. To create ethnic-appropriate public health policies, it is imperative that we understand the effect of comorbidities on breast cancer and how we can prevent them from occurring.

Barriers and facilitators to recruitment to a culturally-based dietary intervention among urban Hispanic breast cancer survivors

PURPOSE

The purpose of this study was to understand factors related to recruitment to behavioral intervention trials among Spanish-speaking urban Hispanic breast cancer (BC) survivors.

METHODS

Potentially eligible Hispanic BC survivors were recruited from the Columbia University Breast Oncology Clinic, signed informed consent, and completed a screening interview on demographics, medical history, acculturation (Short Acculturation Scale for Hispanics), quality of life (QOL), and perceived benefits/risks of research participation. Trial eligibility criteria included stage 0-III BC, completion of adjuvant treatment, Hispanic, fluency in Spanish, willing to be randomized to active arm (9-session in-person culturally-based ¡Cocinar para su salud! dietary modification program) or control arm (written materials). We compared characteristics between eligible women who did and did not enroll in the trial.

RESULTS

102 women completed the screening interview and were eligible to participate. Overall mean age was 57.3 ± 9.5 years, mean time since diagnosis was 3.4 ± 2.1 years, 71% reported annual household income <$15,000 and mean acculturation index score was 1.6 ± 0.6 (scale 1-5, low-high). Of the 102 women, 70 enrolled and 32 declined participation. Reasons stated for non-participation included lack of interest in dietary change, illness, and work constraints. Compared to women who enrolled, women who did not enroll were less likely to be employed (P=0.03) and more likely to only read/speak Spanish (P=0.02). Compared to women who enrolled, non-enrollers were more likely to state that research is costly to participants (P=0.03).

CONCLUSION

Lower participation was associated with unemployment, monolingualism, and the perception that research is costly to participants. Future behavioral intervention trials among minority BC survivors need to account for these and other factors that may be related to trial participation.

Practical clinical interventions for diet, physical activity, and weight control in cancer survivors

Answer questions and earn CME/CNE The importance of expanding cancer treatment to include the promotion of overall long-term health is emphasized in the Institute of Medicine report on delivering quality oncology care. Weight management, physical activity, and a healthy diet are key components of tertiary prevention but may be areas in which the oncologist and/or the oncology care team may be less familiar. This article reviews current diet and physical activity guidelines, the evidence supporting those recommendations, and provides an overview of practical interventions that have resulted in favorable improvements in lifestyle behavior change in cancer survivors. It also describes current lifestyle practices among cancer survivors and the role of the oncologist in helping cancer patients and survivors embark upon changes in lifestyle behaviors, and it calls for the development of partnerships between oncology providers, primary care providers, and experts in nutrition, exercise science, and behavior change to help positively orient cancer patients toward longer and healthier lives.

Diabetes and other comorbidities in breast cancer survival by race/ethnicity: the California Breast Cancer Survivorship Consortium (CBCSC)

BACKGROUND

The role of comorbidities in survival of patients with breast cancer has not been well studied, particularly in non-white populations.

METHODS

We investigated the association of specific comorbidities with mortality in a multiethnic cohort of 8,952 breast cancer cases within the California Breast Cancer Survivorship Consortium (CBCSC), which pooled questionnaire and cancer registry data from five California-based studies. In total, 2,187 deaths (1,122 from breast cancer) were observed through December 31, 2010. Using multivariable Cox proportional hazards regression, we estimated HRs and 95% confidence intervals (CI) for overall and breast cancer-specific mortality associated with previous cancer, diabetes, high blood pressure (HBP), and myocardial infarction.

RESULTS

Risk of breast cancer-specific mortality increased among breast cancer cases with a history of diabetes (HR, 1.48; 95% CI, 1.18-1.87) or myocardial infarction (HR, 1.94; 95% CI, 1.27-2.97). Risk patterns were similar across race/ethnicity (non-Latina white, Latina, African American, and Asian American), body size, menopausal status, and stage at diagnosis. In subgroup analyses, risk of breast cancer-specific mortality was significantly elevated among cases with diabetes who received neither radiotherapy nor chemotherapy (HR, 2.11; 95% CI, 1.32-3.36); no increased risk was observed among those who received both treatments (HR, 1.13; 95% CI, 0.70-1.84; P(interaction) = 0.03). A similar pattern was found for myocardial infarction by radiotherapy and chemotherapy (P(interaction) = 0.09).

CONCLUSION

These results may inform future treatment guidelines for patients with breast cancer with a history of diabetes or myocardial infarction.

IMPACT

Given the growing number of breast cancer survivors worldwide, we need to better understand how comorbidities may adversely affect treatment decisions and ultimately outcome.

Impact of type 2 diabetes mellitus on the prognosis of early stage triple-negative breast cancer in People's Republic of China

Background

Type 2 diabetes mellitus (T2DM) is one of the most common chronic metabolic diseases. Increased cause-specific mortality and decreased disease-free survival (DFS) have been reported among cancer patients with T2DM compared with patients without T2DM, even after adjustments of other comorbidities. However, less is known about the impact of T2DM and other comorbidities on DFS in Chinese patients with early stage triple-negative breast cancer (TNBC).

Patients and methods

We assessed patients who were newly diagnosed with early stage primary TNBC at the Department of Breast Surgery, Fudan University, from 2003 to 2011. Of the 1,100 TNBC patients, 865 female patients had invasive and early stage TNBC. The association of the variables in the T2DM and non-T2DM groups was compared using the Pearson’s chi-square and independent t-tests. DFS was estimated using the Kaplan–Meier method. The effects of T2DM and other possible risk factors on DFS were assessed by Cox proportional hazards regression using univariate or multivariate analysis.

Results

A total of 865 early stage primary TNBC cases were studied, including 104 (12.02%) subjects with T2DM. Metastatic or recurrent disease was detected in 24 (23.08%) patients in the T2DM group and 35 (4.60%) patients in the non-T2DM group. Patients with T2DM exhibited a significantly lower DFS than patients without T2DM (log-rank P<0.001). Similar results were observed when patients with positive lymph nodes were compared with patients with negative lymph nodes (log-rank P=0.003). T2DM was independently associated with a lower DFS after adjustments of other variables (adjusted hazard ratio, 7.719; 95% confidence interval, 4.304–13.843; P<0.001) and adjustments of lymph node positivity (adjusted hazard ratio, 2.407; 95% confidence interval, 1.391–4.166; P=0.002). The DFS rates at 2 years for the T2DM group and the non-T2DM group were 78% and 97%, respectively. The prognostic influence of T2DM was consistent across the subgroups, including subgroups by age (>50 or ≤50), menopausal status (post- or premenopausal), tumor size (>5 cm or ≤5 cm), lymph node involvement (positive or negative), and adjuvant chemotherapy (received or not) using the Kaplan–Meier method (log-rank P<0.05).

Conclusion

In the People’s Republic of China, T2DM is an independent prognostic risk factor that indicates an increased likelihood of recurrence and metastasis in patients with early stage TNBC. The presence of T2DM should be taken into account when evaluating the risk for an early stage TNBC patient. More effective therapeutic regimens are needed for early stage TNBC patients with T2DM.

Non-steroidal anti-inflammatory drug use, hormone receptor status, and breast cancer-specific mortality in the Carolina Breast Cancer Study

Epidemiologic studies report a protective association between non-steroidal anti-inflammatory drug (NSAID) use and hormone receptor-positive breast cancer risk, a finding consistent with NSAID-mediated suppression of aromatase-driven estrogen biosynthesis. However, the association between NSAID use and breast cancer-specific mortality is uncertain and it is unknown whether this relationship differs by hormone receptor status. This study comprised 935 invasive breast cancer cases, of which 490 were estrogen receptor (ER)-positive, enrolled between 1996 and 2001 in the Carolina Breast Cancer Study. Self-reported NSAID use in the decade prior to diagnosis was categorized by duration and regularity of use. Differences in tumor size, stage, node, and receptor status by NSAID use were examined using Chi-square tests. Associations between NSAID use and breast cancer-specific mortality were examined using age- and race-adjusted Cox proportional hazards analysis. Tumor characteristics did not differ by NSAID use. Increased duration and regularity of NSAID use was associated with reduced breast cancer-specific mortality in women with ER-positive tumors (long-term regular use (≥8 days/month for ≥ 3 years) versus no use; hazard ratio (HR) 0.48; 95 % confidence interval (CI) 0.23-0.98), with a statistically significant trend with increasing duration and regularity (p-trend = 0.036). There was no association for ER-negative cases (HR 1.19; 95 %CI 0.50-2.81; p-trend = 0.891). Long-term, regular NSAID use in the decade prior to breast cancer diagnosis was associated with reduced breast cancer-specific mortality in ER-positive cases. If confirmed, these findings support the hypothesis that potential chemopreventive properties of NSAIDs are mediated, at least in part, through suppression of estrogen biosynthesis.

Risk of metabolic syndrome in postmenopausal breast cancer survivors

OBJECTIVE

The aim of this study was to assess the risk of metabolic syndrome (MetS) in postmenopausal breast cancer survivors as compared with postmenopausal women without breast cancer.

METHODS

In this cross-sectional study, 104 postmenopausal breast cancer survivors were compared with 208 postmenopausal women (controls) attending a university hospital. Eligibility criteria included the following: amenorrhea longer than 12 months and aged 45 years or older, treated for breast cancer, and metastasis-free for at least 5 years. The control group consisted of women with amenorrhea longer than 12 months and aged 45 years or older and without breast cancer, matched by age and menopause status (in a proportion of 1:2 as sample calculation). Clinical and anthropometric data were collected. Biochemical parameters, including total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, glucose, and C-reactive protein, were measured. Women showing three or more diagnostic criteria were diagnosed as having MetS: waist circumference of 88 cm or larger, blood pressure of 130/85 mm Hg or higher, triglycerides level of 150 mg/dL or higher, high-density lipoprotein cholesterol level lower than 50 mg/dL, and glucose level of 100 mg/dL or higher. For statistical analysis, Student's t test, χ2 test, and logistic regression (odds ratio [OR]) were used.

RESULTS

The mean (SD) age of breast cancer survivors was 60.6 (8.6) years, with a mean (SD) follow-up of 9.4 (4.4) years. A higher percentage of breast cancer survivors (46.2%) were obese as compared with controls (32.7%; P < 0.05), and a smaller percentage showed optimal values for low-density lipoprotein cholesterol, glucose, and C-reactive protein versus controls (P < 0.05). MetS was diagnosed in 50% of breast cancer survivors and in 37.5% of control group women (P < 0.05). Among the MetS diagnostic criteria, the most prevalent was abdominal obesity (waist circumference >88 cm), affecting 62.5% and 67.8% of the participants, respectively. In the control group, breast cancer survivors had a higher risk for MetS (OR, 1.66; 95% CI, 1.04-2.68), dysglycemia (OR, 1.05; 95% CI, 1.09-3.03), and hypertension (OR, 1.71; 95% CI, 1.02-2.89).

CONCLUSIONS

Postmenopausal breast cancer survivors present a higher risk of developing MetS as compared with women without breast cancer.

Long-term outcomes among African-American and white women with breast cancer: what is the impact of comorbidity?

OBJECTIVES

We examined the association between comorbidity and long-term mortality from breast cancer and other causes among African-American and white women with breast cancer.

METHODS

A total of 170 African-American and 829 white women aged 40-84years were followed for up to 28years with median follow-up of 11.3years in the Health and Functioning in Women (HFW) study. The impact of the Charlson Comorbidity Score (CCS) in the first few months following breast cancer diagnosis on the risk of mortality from breast cancer and other causes was examined using extended Cox models.

RESULTS

Median follow-up was significantly shorter for African-American women than their white counterparts (median 8.5years vs. 12.3years). Compared to white women, African-American women had significantly fewer years of education, greater body mass index, were more likely to have functional limitations and later stage at breast cancer diagnosis, and fewer had adequate financial resources (all P<0.05). Proportionately more African-American women died of breast cancer than white women (37.1% vs. 31.4%, P=0.15). A positive and statistically significant time-varying effect of the Charlson Comorbidity Score (CCS) on other-cause mortality persisted throughout the first 5years of follow-up (P<0.001) but not for its remainder.

CONCLUSIONS

Higher CCS was associated with increased risk of other-cause mortality, but not breast cancer specific mortality; the association did not differ among African-American and white women.

The psychosocial impact of lymphedema-related distress among breast cancer survivors in the WHEL Study

OBJECTIVE

Lymphedema is a distressing and chronic condition affecting up to 30% of breast cancer survivors. Using a cross-sectional study design, we examined the impact of self-reported lymphedema-related distress on psychosocial functioning among breast cancer survivors in the Women's Healthy Eating and Living Study. The Women's Healthy Eating and Living Study has a dataset that includes self-report data on lymphedema status, symptoms, and distress.

METHODS

Chi-square tests and binary logistic regression models were used to examine how specific participant characteristics, including lymphedema-related distress, were associated with physical health and mental health as measured by the SF-36-Item Health Survey and depressive symptoms assessed by the Center for Epidemiologic Studies Depression Scale screening form.

RESULTS

Of the 2431 participants included in the current study population, 692 (28.5%) self-reported ever having lymphedema. A total of 335 (48.9%) women reported moderate to extreme distress as a result of their lymphedema and were classified as having lymphedema-related distress. The logistic regression models showed that women with lymphedema-related distress had 50% higher odds of reporting poor physical health (p = 0.01) and 73% higher odds of having poor mental health (p < 0.01) when compared with women without lymphedema. In contrast, even though lymphedema-related distress was significantly associated (p = 0.03) with elevated depressive symptoms in the bivariate analyses, it was not significant in the logistic regression models.

CONCLUSION

Breast cancer survivors with lymphedema-related distress had worse physical health and mental health outcomes than women with lymphedema who were not distressed and women with no lymphedema. Our findings provide further evidence of the relationship between lymphedema and psychosocial outcomes in breast cancer survivors.

The impact of comorbidity on cancer survival: a review

Background

A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence.

Methods

All English-language articles published during 2002–2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted.

Results

Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity.

Conclusion

Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.

Exercise after diagnosis and metabolic syndrome among breast cancer survivors: a report from the Shanghai Breast Cancer Survival Study

Metabolic syndrome (MetS) is an established risk factor for cardiovascular diseases and mortality. Limited data are available on the prevalence of MetS and its association with exercise among breast cancer survivors. The present study included 1,696 breast cancer survivors from the Shanghai Breast Cancer Survival Study, a population-based prospective cohort study conducted between April 2002 and October 2011 in Shanghai, China. All women had a physical examination taken at study clinic approximately 60 months post-diagnosis. Exercise was assessed at approximately 6, 18, 36, and 60 months post-diagnosis. Information on medical history, tumor characteristics, cancer treatment, anthropometrics, and lifestyle was collected at study enrollment. Associations between exercise and MetS at 60 months post-diagnosis were evaluated with multivariable logistic regression models. The mean age of the study population was 56.68 at 60-month survey, and the mean follow-up since cancer diagnosis was 63.66 months. The prevalence of MetS using National Cholesterol Education Program Adult Treatment Panel III criteria at approximately 60 months after diagnosis was 33.14%. Among overweight and obesity breast cancer survivors (body mass index (BMI) ≥ 25 kg/m(2) at baseline), the prevalence was 55.18%. The most common type of exercise in this population was walking (45.40%) at baseline. Exercise participation between 6 and 60 months post-diagnosis was inversely associated with the prevalence of MetS with the adjusted odds ratio (OR) for exercise participation of ≥ 3.5 h/week (30 min/day) being 0.69 (95% confidence interval (CI) 0.48-0.98). In addition consistent exercise participation reduced the prevalence of MetS (adjusted OR 0.70 (95% CI 0.50-1.00). Associations of exercise with MetS were not modified by baseline waist circumference, BMI, comorbidity, baseline menopausal status, TNM stage, cancer treatment, or ER/PR status (p interactions > 0.05). Regular and persistent exercise after cancer diagnosis, even at low-to-moderate intensity level, decreases the prevalence of MetS among long-term breast cancer survivors.

Multimorbidity: an issue of growing importance for oncologists

As our population ages, more are afflicted with chronic conditions. Likewise, as more patients survive the diagnosis of cancer, they are likely to experience the sequelae of cancer treatment in the context of other coexisting medical conditions. Oncologists can expect that more than half of the patients they see who are older than 65 years will have at least one other meaningful chronic condition that may affect their treatment regimen. Multimorbidity can increase both treatment and illness burden and influence the benefit and burden of cancer treatment. Recognition of the impact of multiple co-occurring conditions on a patient's cancer care plan and development of strategies to address the challenges associated with multimorbidity will enable oncologists to provide higher quality, patient-centered care. Increased efforts should be focused on educating clinical providers to practice the collaborative, team-based care required by these patients. Finally, research is desperately needed to guide oncologists and other providers in the unique management issues presented by patients with multimorbidity.

Demographic and clinico-pathological characteristics in patients with invasive breast cancer receiving metformin

There was a contradictory data with metformin use on breast cancer risk, but there is growing evidence that the use of metformin in diabetic patients was associated with lower risks of breast cancer mortality and incidence. The effect of metformin on clinical and pathological properties of breast cancer was not known exactly, and we aimed to investigate the demographic and clinico-pathological characteristics of patients with metformin users at the time of breast cancer diagnosis. Patients with breast cancer diagnosed from 2000 to 2012 in our clinic were retrospectively analyzed. Patient's demographics, including survival data and tumor characteristics were obtained from medical charts. Breast cancer patients who were taking metformin at the time of breast cancer diagnosis were enrolled as metformin users (n = 148), where the patients matched with the same age who were not taking metformin were included as a control group (n = 636). A total of 784 patients were included in this study. Median age of both metformin users and nonusers was 57 (23-87). There were no significant differences in baseline tumor size (P = 0.60), tumor stage (P = 0.76), and node positivity (P = 0.13) between the two groups. Metformin user patients compared to nonusers had significantly lower incidence of histological grade III tumor (P = 0.03). A similar significant trend for lower incidence of triple negative (P = 0.01) and higher incidence ER positivity (P = 0.008) and PR positivity (P = 0.01) was also seen in metformin users. In survival analysis, the estimated median disease-free survival was 118 months in metformin users, whereas 69 months in nonusers (P = 0.09). Median overall survival (OS) could not be obtained due to low events. In patients with metformin users, OS rate was 98.4, 97.1, and 93.8 %, and in nonusers was 99.6, 94.4, and 90.5 %, the first, third, and fifth years, respectively. The use of metformin at the time of breast cancer diagnosis was associated with better clinico-pathological properties and nonsignificantly improved disease-free survival in breast cancer patients.

Comorbidities and breast cancer survival: a report from the Shanghai Breast Cancer Survival Study

We investigated the association of major comorbidities with breast cancer outcomes using the Shanghai Breast Cancer Survival Study, a population-based, prospective cohort study of Chinese women diagnosed with breast cancer. Analyses included 4,664 women diagnosed with stage I-III incident breast cancer aged 20-75 years (median age = 51) during 2002-2006. Women were interviewed at 3-11 months post-diagnosis (median = 6.4) and followed up by in-person interviews and linkage with the vital statistics registry. Multivariable hazard ratios (HRs) and (95 % confidence intervals (CIs)) for the associations of comorbidities with breast cancer outcomes were estimated using Cox regression models. After a median follow-up of 5.3 years (range: 0.64-8.9), 647 women died (516 from breast cancer) and 632 recurrence/metastases were documented. The main comorbidities reported included: hypertension (22.4 %), chronic gastritis (14.3 %), diabetes mellitus (6.2 %), chronic bronchitis/asthma (5.8 %), coronary heart disease (5.0 %), and stroke (2.2 %). Diabetes was associated with increased risk of total mortality (adjusted HR: 1.40 (1.06-1.85)) and non-breast cancer mortality (adjusted HR: 2.64 (1.63-4.27)), but not breast cancer-specific mortality (adjusted HR: 0.98 (0.68-1.41)), adjusting for socio-demographics, clinical characteristics, selected lifestyle factors, and other comorbidities. Women with a history of stroke had a non-significant increased risk of total mortality (adjusted HR: 1.42 (0.91-2.22)) and a significant increased risk of non-breast cancer mortality (adjusted HR: 2.52 (1.33-4.78)), but not breast cancer-specific mortality (adjusted HR: 0.78 (0.38-1.62)). Overall, none of the comorbidities investigated were significantly associated with recurrence. In this large prospective cohort of breast cancer survivors, diabetes was significantly associated with increased risk of total and non-breast cancer mortality, and history of stroke was associated with increased risk of non-breast cancer mortality.

Exercise as a prescription therapy for breast and colon cancer survivors

BACKGROUND

Breast and colon tumors are the most common types of cancer in the general population. As a result of improved diagnosis and treatment, more people are now surviving cancer. Lifestyle has been identified as one of the potential risk factors for cancer, and it has been demonstrated recently that physical activity reduces the physiological and psychological symptoms and side effects of chemotherapy. Muscular atrophy, weight changes, decreased aerobic capacity, fatigue, and depression are the most common symptoms in cancer patients. The exact amount of moderate to vigorous physical activity needed to overcome these effects has not yet been established, but an individualized and variable exercise program as prescription therapy could be considered a helpful tool for improving quality of life. This paper proposes a model of lifestyle analysis and dedicated individualized exercise programs for the treatment of cancer patients. The program starts with a preliminary evaluation of the patient's lifestyle using a questionnaire and accelerometer, which provides information on the amount of daily physical activity and number of steps taken, as well as an assessment of aerobic capacity, cardiovascular response, muscle strength, and resistance. Two different levels of aerobic exercise, ie, low-to-moderate (40% of maximal heart rate) to moderate (60% of maximal heart rate) can be prescribed. This model of exercise prescription in patients with cancer offers a flexible program for assisting in the management of this complex disease. It is projected to ensure easier management of medical problems related to cancer, and to attract a greater number of participants over time.

Diet and breast cancer: understanding risks and benefits

BACKGROUND

Breast cancer is the most commonly diagnosed cancer among women in the United States. Extensive research has been completed to evaluate the relationship between dietary factors and breast cancer risk and survival after breast cancer; however, a summary report with clinical inference is needed. Materials and

METHODS

This review summarizes the current epidemiological and clinical trial evidence relating diet to breast cancer incidence, recurrence, survival, and mortality. The review includes emerging epidemiological studies that assess risk within breast cancer subtypes as well as a summary of previous and ongoing dietary intervention trials designed to modify breast cancer risk.

RESULTS

The available literature suggests that both low-fat and high-fiber diets may be weakly protective against breast cancer, whereas total energy intake and alcohol appear to be positively associated. Fiber may be weakly protective possibly through modulation of estrogen, whereas fruit and vegetable intake is not clearly associated with risk. Obesity is a risk factor for postmenopausal disease, and adult weight gain should be avoided to reduce risk. In survivors, diet has the greatest potential influence on overall mortality rather than breast cancer-specific events.

CONCLUSION

Diet is modestly associated with breast cancer risk; associations appear more pronounced for postmenopausal disease, and healthy choices after diagnosis and treatment likely support longevity more so than reduced risk for recurrent disease.