Survival improvement in hormone-responsive young breast cancer patients with endocrine therapy

Perspectives and needs for fertility preservation decision-making in childbearing-age patients with breast cancer: A qualitative study

Objective

To explore the perspectives and needs related to fertility preservation decision-making in patients of childbearing age with breast cancer.

Methods

Semistructured face-to-face interviews were conducted in a tertiary hospital in Baoding, China from July to October 2023. Purposive sampling was used to ensure the diversity of samples. The interview guide is based on the literature review and the discussions within the research team. A traditional content analysis approach was used for data analysis.

Results

A total of 18 participants were interviewed. Three themes emerged from the data: conflicts between subjective desires and concerns, coexistence of objective benefits and challenges, and decision-making support needs. The conflicts between subjective desires and concerns included five sub-themes, the coexistence of objective benefits and challenges also included five sub-themes, and the decision-making support needs included two sub-themes.

Conclusions

Patients faced a difficult trade-off between desires and concerns, benefits, and challenges regarding fertility preservation decisions, with numerous unmet needs. Healthcare professionals should prioritize patients' fertility desires, providing timely fertility preservation information and adequate counseling after a cancer diagnosis. This approach can help alleviate unnecessary concerns, facilitate satisfactory decision-making, and improve patients' quality of life.

Therapeutic Approaches to Increase the Survival Rate of Cancer Patients in the Younger and Older Population

Various developments have been observed in the treatment of cancer patients, such as higher survival rates and better treatment outcomes. However, expecting similar outcomes in older patients remains a challenge. The main reason for this conclusion is the exclusion of older people from clinical trials for cancer drugs, as well as other factors, such as comorbidity, side effects, age-related frailties and their willingness to undergo multiple treatments. However, the discovery of new techniques and drug combinations has led to a significant improvement in the survival of the elderly population after the onset of the disease. On the other hand, cancer treatments have not become more complex for the younger population when compared to the older population, as the younger population tends to respond well to treatment trials and their physiological conditions are stable in response to treatments. In summary, this review correlates recent cancer treatment strategies and the corresponding responses and survival outcomes of older and younger patients.

Effects of Physical Activity on Quality of Life, Anxiety and Depression in Breast Cancer Survivors: A Systematic Review and Meta-analysis

PURPOSE

Anxiety, depression, and poor quality of life (QOL) were considered important concerns that hindered the rehabilitation of breast cancer survivors. A number of studies have investigated the effects of physical activity, but they have not reached the same conclusions. This review aimed to identify the effects of physical activity on QOL, anxiety, and depression in breast cancer survivors.

METHODS

PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, SinoMed, CNKI, Vip, and WanFang databases were searched for the time period between January 1, 2012, and April 30, 2022. Studies were included if they were randomized controlled trials of the effects of physical activity on QOL, anxiety, or depression in breast cancer survivors. The tools of the Joanna Briggs Institute were used to assess the quality of the included studies. R software version 4.3.1 was used for meta-analysis.

RESULTS

A total of 26 studies, involving 2105 participants, were included in the systematic review. Among these, 20 studies involving 1228 participants were included in the meta-analysis. Compared with the control group, the results indicated that physical activity can significantly improve QOL(Hedges' g = 0.67; 95% CI 0.41-0.92) and reduce anxiety (Hedges' g = -0.28; 95% CI -0.46 to -0.10) in breast cancer survivors. However, the effect of physical activity on depression (Hedges' g = -0.46; 95% CI -0.99 to 0.06) was not statistically significant.

CONCLUSIONS

Physical activity was an effective intervention to improve QOL and reduce anxiety in breast cancer survivors, as well as showed positive trends in depression, although without statistical significance. More well-designed studies are required to clarify the effects of different types of physical activities on the QOL, anxiety, and depression among breast cancer survivors.

REGISTERED NUMBER ON PROSPERO

CRD42022363094. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=363094.

Oncologic efficacy of gonadotropin-releasing hormone agonist in hormone receptor-positive very young breast cancer patients treated with neoadjuvant chemotherapy

BACKGROUND

Breast cancer in young women has been shown to have an aggressive behavior and poor prognosis.

AIM

To evaluate the outcomes of young hormone receptor (HR)-positive patients with breast cancer treated with neoadjuvant chemotherapy (NAC), and the oncologic efficacy of gonadotropin-releasing hormone (GnRH) agonists.

METHODS

This retrospective study involved a prospectively enrolled cohort. We included patients diagnosed with invasive breast cancer who were treated with NAC followed by curative surgery at the Samsung Medical Center and Samsung Changwon Hospital between January 2006 and December 2017. Among patients with HR-positive and human epidermal grow factor 2 (HER2)-negative breast cancer, we analyzed the characteristics and oncology outcomes between the patients equal to or younger than 35 years and the patients older than 35 years.

RESULTS

Among 431 patients with NAC and HR-positive/HER2-negative breast cancer, 78 were 35 years old or younger, and 353 patients were older than 35 years. The median follow-up was 71.0 months. There was no statistically significant difference in disease free survival (DFS, P = 0.565) and overall survival (P = 0.820) between the patients equal to or younger than 35 years and the patients older than 35 years. The two groups differed in that the GnRH agonist was used more frequently in the group of patients equal to or younger than 35 years than in the other group (52.4% vs 11.2%, P < 0.001). Interestingly, for the DFS according to the GnRH agonist in the group of patients equal to or younger than 35 years, patients treated with the GnRH agonist had better DFS (P = 0.037).

CONCLUSION

Administration of GnRH agonists might improve the DFS rate of HR-positive/HER2-negative breast cancer in the equal to or younger than 35 years group of patients with NAC.

The Association between Early-Onset Diagnosis and Clinical Outcomes in Triple-Negative Breast Cancer: A Systematic Review and Meta-Analysis

Early-onset diagnosis, defined by age <40 years, has historically been associated with inferior outcomes in breast cancer. Recent evidence suggests that this association is modified by molecular subtype. We performed a systematic review and meta-analysis of the literature to synthesize evidence on the association between early-onset diagnosis and clinical outcomes in triple-negative breast cancer (TNBC). Studies comparing the risk of clinical outcomes in non-metastatic TNBC between early-onset patients and later-onset patients (≥40 years) were queried in Medline and EMBASE from inception to February 2023. Separate meta-analyses were performed for breast cancer specific survival (BCSS), overall survival (OS), and disease-free survival (DFS), locoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and pathological complete response (pCR). In total, 7581 unique records were identified, and 36 studies satisfied inclusion criteria. The pooled risk of any recurrence was significantly greater in early-onset patients compared to later-onset patients. Better BCSS and OS were observed in early-onset patients relative to later-onset patients aged >60 years. The pooled odds of achieving pCR were significantly higher in early-onset patients. Future studies should evaluate the role of locoregional management of TNBC and the implementation of novel therapies such as PARP inhibitors in real-world settings, and whether they improve outcomes.

Effect of a telehealth-based exercise intervention on the physical activity of patients with breast cancer: A systematic review and meta-analysis

Telehealth-based exercise intervention as a non-pharmacological intervention has gradually emerged in breast cancer (BC), which shows feasibility and high levels of patient satisfaction. This systematic review aims to identify the effect of telehealth-based exercise interventions on the physical activity (PA) of patients with BC. We searched CENTRAL, CINAHL, PsycINFO, EMBASE, PubMed, Web of Science, ClinicalTrials.gov, CNKI, Wanfang, VIP, and SinoMed. Study selection and quality appraisal were performed independently by two reviewers. The review protocol was registered in PROSPERO (CRD42022326484). Nine studies, which included 1127 patients with BC, were identified. Compared with usual care, the telehealth-based exercise intervention had a significantly positive effect on PA (Standardized mean difference (SMD) = 0.26, 95% confidence interval (CI) 0.09 to 0.43, P = 0.003), aerobic capacity (SMD = 0.20, 95% CI 0.03 to 0.38, P = 0.02), upper body function (Mean difference (MD) = −4.56, 95% CI −7.66 to −1.47, P = 0.004), upper muscle strength (SMD = 0.26, 95% CI 0.09 to 0.42, P = 0.002), lower muscle strength (SMD = −0.95, 95% CI −1.27 to −0.62, P < 0.00001), abdominal muscle strength (MD = 23.85, 95% CI 13.84 to 33.86, P < 0.000,01), fatigue (SMD = 0.56, 95% CI 0.13 to 1.00, P = 0.01), and quality of life (SMD = 0.26, 95% CI 0.04 to 0.49, P = 0.02). Conversely, anthropometric and body composition and pain did not differ significantly between the two groups. Telehealth-based exercise intervention improved PA, physical performance, fatigue, and quality of life of patients with BC compared with routine care, which should be promoted clinically as a comprehensive treatment for BC.

Impact of age on clinical outcomes and efficacy of adjuvant dual anti-HER2 targeted therapy

Background

Young age at breast cancer (BC) diagnosis has historically been a rationale for overtreatment. Limited data with short follow-up exist on the prognostic value of age at diagnosis in HER2-positive BC and the benefit of anti-HER2 therapy in young patients.

Methods

APHINITY (NCT01358877) is an international, placebo-controlled, double-blind randomized phase III trial in HER2-positive early BC patients investigating the addition of pertuzumab to adjuvant chemotherapy plus trastuzumab. The prognostic and predictive value of age on invasive disease-free survival (IDFS) as continuous and dichotomous variable (aged 40 years or younger and older than 40 years) was assessed. A subpopulation treatment effect pattern plot analysis was conducted to illustrate possible treatment-effect heterogeneity based on age as a continuous factor.

Results

Of 4804 included patients, 768 (16.0%) were aged 40 years or younger at enrollment. Median follow-up was 74 (interquartile range = 62-75) months. Young age was not prognostic either as dichotomous (hazard ratio [HR] = 1.06, 95% confidence interval [CI] = 0.84 to 1.33) or continuous (HR = 1.00, 95% CI = 1.00 to 1.01) variable. Lack of prognostic effect of age was observed irrespective of hormone receptor status and treatment arm. No statistically significant interaction was observed between age and pertuzumab effect (P_interaction = 0.61). Adding pertuzumab improved IDFS for patients in the young (HR = 0.86, 95% CI = 0.56 to 1.32) and older (HR = 0.75, 95% CI = 0.62 to 0.92) cohorts. Similar results were observed irrespective of hormone receptor status. Subpopulation treatment effect pattern plot analysis confirmed the benefit of pertuzumab in 6-year IDFS across age subpopulations.

Conclusions

In patients with HER2-positive early BC treated with modern anticancer therapies, young age did not demonstrate either prognostic or predictive value, irrespective of hormone receptor status.

The impact of young age at diagnosis (age <40 years) on prognosis varies by breast cancer subtype: A U.S. SEER database analysis

Purpose

Women under 40 years old are at increased risk for developing human epidermal growth factor receptor 2 (HER2) positive or triple negative subtype and more advanced breast cancer, yet young age itself has also historically been an independent prognostic factor.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) Program, we examined data for 271,173 women with stage I-III breast cancer between 2010 and 2015. Using Fine and Gray regression models to account for competing risks, we examined the risk of breast cancer-specific death by age and clinical subtypes, considering grade, hormone receptor (HR) and HER2 status, adjusting for demographic, clinical and treatment variables.

Results

Of 271,173 women eligible for analysis, 14,109 were <40 years of age. Women under 40 years old were more likely to be non-white, uninsured, and to have higher stage, higher grade, HER2-positive and triple-negative subtype disease (all, p < 0.001). Compared to women ages 40–60, women ages <40 had higher breast cancer mortality (hazard ratio, 1.8; 95% confidence interval (CI) 1.6–1.9) in unadjusted analysis. In models controlling for demographic, clinical and treatment factors, young age was significantly associated with an increased risk of breast cancer mortality among women with HR-positive, lower grade disease (hazard ratio 1.7; 95% CI 1.4–2.1) but not for women with high grade/HR-positive, HER2-positive, or triple-negative disease. Women age >75 had increased breast cancer mortality in all subtypes.

Conclusion

With modern clinical subtyping, age under 40 remains independently associated with worse outcomes in 30 months follow-up only in HR-positive, lower grade disease.

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Young women present with more advanced and aggressive types of breast cancer.

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Young age is not an independent prognostic factor in HER2+ breast cancer or TNBC.

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Young age is independently associated with poor outcomes in HR+/lower grade disease.

Breast cancer-related lymphedema and its treatment: how big is the financial impact?

PURPOSE

Decongestive lymphatic treatment (DLT) is still the gold standard for treatment of breast cancer-related lymphedema (BCRL). With up to 17% of the patients treated for breast cancer developing BCRL, this morbidity imposes a tremendous financial burden for patients and society. Knowledge about this economic burden related to BCRL and its conservative treatment in a European setting is lacking. The aim of this prospective, longitudinal cohort study was to estimate the direct healthcare costs related to BCRL and its treatment in a European setting.

METHODS

Patients with BCRL were treated with DLT consisting of an intensive treatment phase of 3 weeks, followed by a maintenance treatment phase of 6 months. Additionally, the follow-up period comprised 6 months. During these 3 weeks and 12 months, all direct costs associated with the treatment of BCRL and its sequelae were documented through billing prices and a self-developed questionnaire which was administered after the intensive treatment phase, and subsequently 3-monthly during the entire period.

RESULTS

A total of 194 patients were enrolled in this study. Of these, 17% (n = 32) showed lymphedema stage I, 56% (n = 109) had lymphedema stage IIa, and 27% (n = 53) had lymphedema stage IIb. Total direct healthcare costs per patient were €2248.93 on average during the entire period of 3 weeks of intensive treatments and 12 months of maintenance decongestive therapy. Within these mean direct costs, €1803.35 (80%) was accounted for statutory health insurances, and €445.58 (20%) was out-of-pocket expenses for patients.

CONCLUSION

This study is one of the first standardized high-quality health economic analyses of BRCL treatment in Europe. The present study indicates that the price tag of BCRL treatment in Belgium is high not only for the health insurance but also for the patients Clinical trial registration number The study makes part of a double-blind, multi-center, randomized controlled trial (EFforT-BCRL trial), which is registered in clinicaltrials.gov (NCT02609724). CME reference S58689, EudraCT Number 2015-004822-33.

Current State of the Art in the Adjuvant Systemic Treatment of Premenopausal Patients With Early Breast Cancer

Breast cancer is the most frequent malignancy diagnosed in premenopausal women. In this age group, breast tumors tend to be diagnosed at more advanced stages and to harbor more aggressive biological features. In addition, specific age-related issues including genetic counseling, fertility preservation, impact on social and couple relationships, working life, and management of long-term side effects should be considered highly relevant when managing early breast cancer in premenopausal women. Therefore, the care of these patients is particularly complex and a multidisciplinary approach is mandatory. The present review summarizes the current state of art in the adjuvant systemic treatment of premenopausal women with early breast cancer focusing on the optimal chemotherapy, endocrine therapy, and targeted therapy approaches in this specific patient population.

Pyridoxine 5'-phosphate oxidase is correlated with human breast invasive ductal carcinoma development

Pyridoxine 5′-phosphate oxidase (PNPO) is a converting enzyme for an active form of vitamin B6. This study aims to evaluate the biological function and the regulatory mechanism of PNPO in human breast invasive ductal carcinoma (IDC). We unveiled for the first time that PNPO was upregulated in patients with IDC and was correlated with the overall survival of patients with metastasis at the later stages. Suppression of PNPO inhibited breast cancer cell proliferation, migration, invasion and colony formation, arrested cell cycle at the G2/M phase and induced cell apoptosis. PNPO was positively correlated with lncRNA MALAT1 which was negatively correlated with miR-216b-5p. PNPO was down-regulated and up-regulated by miR-216b-5p mimics and inhibitors, respectively, in breast cancer cells. A microRNA response element was found in both PNPO and MALAT1 transcripts for miR-216b-5p and the dual-luciferase reporter assay confirmed the binding of these transcripts. Knockdown of MALAT1 resulted in an increase of miR-216b-5p and a decrease of PNPO mRNA, indicating a regulatory mechanism of competing endogenous RNAs. Taken together, these results reveal the biological function and a regulatory mechanism of PNPO, in which the MALAT1/miR-216b-5p/PNPO axis may be important in IDC development. Targeting this axis may have therapeutic potential for breast cancer.

What are the economic burden and costs associated with the treatment of breast cancer-related lymphoedema? A systematic review

OBJECTIVES

To provide an overview of costs associated with the treatment of breast cancer-related lymphoedema (BCRL) and its possible sequelae, borne by patients or by society.

DATA SOURCES

According to the PRISMA guideline, a systematic literature search was carried out in four electronic databases: PubMed, Web of Science, Cochrane Clinical Trials and EMBASE. Searches were performed on October 1, 2018.

STUDY SELECTION

Eligibility criteria: (1) expenses of adults (age > 18 years), (2) concerning patients with BCRL, (3) overview of (in)direct costs associated with BCRL, (4) expenses in which at least one type of conservative treatment modality for lymphoedema is included and/or costs for hospital admissions due to infections. Reviews and meta-analyses were excluded.

DATA EXTRACTION

After assessing the risk of bias and level of evidence, quantitative data on (in)direct costs for BCRL treatment during a well-mentioned timeframe were extracted.

DATA SYNTHESIS

Eight studies were included. Three studies reported on patient-borne costs related to BCRL. Mean direct costs per year borne by patients ranged between USD$2306 and USD$2574. Indirect costs borne by patients ranged between USD$3325 and USD$5545 per year. Five studies estimated society-borne costs related to BCRL from claims data, billing prices and providers' services during 12 to 24 months of follow-up. Mean direct treatment costs after 1 year of decongestive lymphatic therapy (DLT) ranged between €799 (= USD$1126.60) and USD$3165.

CONCLUSION

This systematic review revealed that BCRL imposes a substantial economic burden on patients and society. However, more standardized high-quality health economic analyses among this field are required. Recent economic analyses related to BCRL treatment in Europe, Asia, Africa and South America are lacking. Worldwide, further scrutiny of the economic impact of DLT for BCRL in clinical settings is needed.

CLINICAL TRIAL REGISTRATION NUMBER

The review makes part of a double-blind, multi-center, randomized controlled trial (EFforT-BCRL trial), which is registered in clinicaltrials.gov (NCT02609724). CME reference S58689, EudraCT Number 2015-004822-33.

Improving Adjuvant Endocrine Treatment Tailoring in Premenopausal Women With Hormone Receptor-Positive Breast Cancer

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

The effect of training interventions on physical performance, quality of life, and fatigue in patients receiving breast cancer treatment: a systematic review

OBJECTIVES

The primary purpose of this systematic review is to structure the available evidence concerning physical exercise programs and their effects on (1) physical performance outcomes, (2) experienced fatigue, and (3) quality of life (QoL) in patients during the initial treatment for breast cancer.

DATA SOURCES

A systematic literature search, based upon the PRISMA guideline, up to January 1, 2018, was performed using four databases (Web of Science, Cochrane Library for Clinical Trials, PubMed, and Medline).

STUDY SELECTION

Inclusion criteria were as follows: (1) adults > 18 years; (2) patients with breast cancer undergoing initial treatment; (3) interventions with the aim to influence the patient's physical activity, QoL, or fatigue; (4) randomized controlled trials (RCTs) of all ages. The selected studies were scored for methodological quality, and data concerning physical performance, QoL, and fatigue were extracted. Twenty-eight RCTs were included.

DATA EXTRACTION

Different treatment modalities during initial treatment were identified (radiation therapy, chemotherapy, and combination therapy), as well as different types of physical training interventions (cardiovascular endurance exercise, strengthening programs, or a combination of both). Therefore, the results were clustered with regard to the above-mentioned grouping; extracting every relevant outcome related to physical performance (6 MWT or VO_2peak; grip/muscle strength), QoL (questionnaires), and fatigue (questionnaires).

DATA SYNTHESIS

Different training programs (endurance, resistance, or a combination of both) were found. These programs were applied during different phases of initial treatment. Some programs were supervised while others were home based. Overall, most training interventions provided an improvement in physical performance and a decrease in perceived fatigue. QoL was the outcome variable least susceptible to improvement.

CONCLUSION

Different types of exercise programs are available for rehabilitation purposes of breast cancer patients during adjuvant therapy. Overall resistance training or resistance training in combination with CV endurance training provides the best results, especially on physical performance and perceived fatigue.

Chronologically changing patterns in the survival of korean patients with breast cancer and related clinical factors: a nationwide registry-based study

PURPOSE

Advances in breast cancer treatment have contributed to marked improvements in patient outcomes over the past three decades. This study aims to chronologically evaluate the survival of patients with breast cancer and investigate the observed changes over time.

METHODS

Statistics from the Korean National Cancer Registry, based on all 60,571 patients with invasive breast cancer during the 21 year period, were analyzed. We divided the study interval into four periods (P1: 1988-1992, P2: 1993-1997, P3: 1998-2002, P4: 2003-2008).

RESULTS

The patients treated during P4 showed significantly better 5-year overall survival (OS) than did those treated during P1 (5Y OS; P1 = 79.0 vs. P4 = 92.2, p < 0.001). In the multivariate analyses, younger age, mastectomy, high stage, high tumor grade, lymphovascular invasion, and hormone receptor negativity were poor prognostic factors. The multivariate analysis demonstrated that diagnosis periods significantly and independently associated with OS in the overall group of patients. In our analysis of age-period-interaction models, the hazard ratio (HR) for death for patients who were under 35 years of age, compared to those who were older, tended to decrease over time (HR of age < 35 vs. 35 ~ 50; P1 = 0.739, p = 0.007; P2 = 0.744, p < 0.001; P3 = 0.886, p = 0.041; P4 = 0.983, p = 0.813). The survival rate of patients who underwent breast conserving surgery (BCS) has recently gotten better than that of mastectomy (HR of mastectomy vs. BCS; P1 = 0.957, p = 0.790; P2 = 0.542, p < 0.001; P3 = 0.543, p < 0.001; P4 = 0.425, p < 0.001).

CONCLUSIONS

The clinical factors related to the changes in breast cancer survival have improved and increased patient OS over the past 20 years in Korea. In addition, we provided new insights into the effects of age and surgery methods on prognosis in each period.

A Young Female Athlete With Acute Low Back Pain Caused by Stage IV Breast Cancer

OBJECTIVE

The purpose of this case report is to describe the case of a young female athlete with low back pain caused by metastatic breast cancer.

CLINICAL FEATURES

A 27-year-old woman presented with low back pain after striking a ball during kickball 3 days earlier. Because of the mechanism of injury and onset, the patient was originally diagnosed with a lumbar spine sprain/strain.

INTERVENTION/OUTCOME

After radiographs were obtained and were read as unremarkable, a 2-week trial of care was initiated that included soft-tissue mobilizations, anti-inflammatory medications from her primary care physician, and therapeutic rehabilitation exercises. After this trial concluded, the patient did not improve and continued to be in significant pain. Magnetic resonance imaging was then ordered and revealed an expansile lesion at L2 with cortical compromise. Referral to an oncologist prompted the diagnosis of stage IV breast cancer.

CONCLUSION

Poor response to conservative treatment may indicate the working diagnosis is incorrect and that it must be reconsidered. In this case, a lack of response to care with persistent high severity of pain despite a multimodal approach justified further investigation with advanced imaging, which revealed spinal metastases secondary to breast cancer. Clinicians should be aware of history and physical exam indicators of red flag conditions that may present as low back pain.