Association between the month of diagnosis and prognosis in breast carcinoma

No Impact of Seasonality of Diagnoses on Baseline Tumor Immune Infiltration, Response to Treatment, and Prognosis in BC Patients Treated with NAC

Simple Summary

High tumor-infiltrating lymphocyte (TIL) levels are associated with an increased response to neoadjuvant chemotherapy (NAC) in breast cancer (BC). The seasonal fluctuation of TILs in breast cancer is poorly documented. In this study, we compared pre- and post-treatment immune infiltration, the treatment response as assessed by means of pathological complete response (pCR) rates, and survival according to the seasonality of BC diagnoses in a clinical cohort of patients treated with NAC. We found no association between seasonality and baseline TIL levels or pCR rates. We found that post-NAC stromal lymphocyte infiltration was lower when cancer was diagnosed in the summer, especially in the subgroup of patients with TNBC. Our data do not support the hypothesis that the seasonality of diagnoses has a major impact on the natural history of BC treated with NAC.

Abstract

Breast cancer (BC) is the most common cancer in women worldwide. Neoadjuvant chemotherapy (NAC) makes it possible to monitor in vivo response to treatment. Several studies have investigated the impact of the seasons on the incidence and detection of BC, on tumor composition, and on the prognosis of BC. However, no evidence is available on their association with immune infiltration and the response to treatment. The objective of this study was to analyze pre- and post-NAC immune infiltration as assessed by TIL levels, the response to treatment as assessed by pathological complete response (pCR) rates, and oncological outcomes as assessed by relapse-free survival (RFS) or overall survival (OS) according to the seasonality of BC diagnoses in a clinical cohort of patients treated with neoadjuvant chemotherapy. Out of 1199 patients, the repartition of the season at BC diagnosis showed that 27.2% were diagnosed in fall, 25.4% in winter, 24% in spring, and 23.4% in summer. Baseline patient and tumor characteristics, including notable pre-NAC TIL levels, were not significantly different in terms of the season of BC diagnosis. Similarly, the pCR rates were not different. No association for oncological outcome was identified. Our data do not support the idea that the seasonality of diagnoses has a major impact on the natural history of BC treated with NAC.

Circannual variation of efficacy outcomes in patients with newly diagnosed metastatic colorectal cancer and treated with first-line chemotherapy

Seasonal variation of baseline diagnosis (or clinical suspect) of stage I-III colorectal cancer patients has been repeatedly reported as an independent variable influencing overall survival. However, data are conflicting and no information is available about such a rhythm in advanced stage patients. To test whether a circannual rhythm of efficacy outcomes can be detected in this setting, we collected data about response rate (RR), progression-free survival (PFS), and overall survival (OS) to first-line chemotherapy of 1610 newly diagnosed metastatic patients treated at four independent centers. Responses to first-line chemotherapy were available for 1495 patients. A strong circannual rhythm in RR was evident, with the higher proportion of responding patients in the subgroup diagnosed in January (acrophase). At the time of data cutoff, 1322 patients progressed and 986 died, with median PFS and OS of 11 and 25.6 months, respectively. A circannual rhythmicity of the proportion of patients progressing at 6 months and surviving at 1 year was demonstrated, with acrophases located both in winter (February and January, respectively), similar to what reported for RR. Several interpretations about the genesis of this cyclic variation could be claimed: the rhythm in sunlight exposure and, as a consequence, of vitamin D serum levels and folate degradation, the variability in toxic effect intensity of chemotherapy, and the rhythm in the biological behavior of tumor cells. This observation is worth of further investigation both in preclinical and in clinical settings in order to better elucidate the underlying mechanisms.

Is season a prognostic factor in breast cancer?

BACKGROUND

Some studies have indicated an inverse relationship between cancer risk and sunlight exposure. Others have reported that the prognosis of some cancers such as prostate, colon, ovarian and non melanoma skin cancer, were affected by the season in which the cancer was diagnosed. In our study, we evaluated whether season is prognostic in Turkish patients with breast cancer.

MATERIALS AND METHODS

A total of 517 patients from Kayseri Training and Research Hospital were analysed retrospectively. Patients were divided into 4 groups according to season of cancer diagnosis: winter, spring, summer and autumn. The prognostic factors for disease free survival and overall survival were investigated.

RESULTS

No significant differences were found among groups regarding prognostic factors overall. Only estrogen receptor status and lymphovascular invasion were independent prognostic factors (p=0.001 and p=0.001 respectively). We found significantly differences for mean disease free survival among groups (p=0.019). Winter group had better mean DFS while summer group had worse DFS. Mean overall survival was similar in the four groups (p=0.637).

CONCLUSIONS

The season is not an independent predictive factor. However, due to interaction with other factors, we think that the season of cancer diagnosis is important for cancer prognosis.

Seasonal variations of cancer incidence and prognosis

The overall death rates are highest in the winter season in many countries at high latitudes. In some but not all countries, this is also true for more specific diseases such as cancer, cardiovascular diseases and influenza. For internal cancers we find no consistent, significant seasonal variation, neither of incidence nor of death rates. On the other hand, we find a significant seasonal variation of cancer prognosis with season of diagnosis in Norway. Best prognosis is found for summer and autumn diagnosis; i.e., for the seasons of the best status of vitamin D in the population. There were no corresponding seasonal variations, neither of the rates of diagnosis, nor of the rates of death which could explain the variations of prognosis. The most likely reason for this variation is that the vitamin D status in Norway is significantly better in summer and autumn than in winter and spring. Earlier, seasonal variations have been explained by circannual variations of certain hormones, but the data are not consistent.

Seasonal modulation of post-resection breast cancer metastasis

BACKGROUND

Human breast cancer incidence, histopathologic grade, invasiveness, and mortality risk vary significantly throughout each year. In order to better understand this seasonal cancer biology, we investigated the circannual pattern of post-resection breast cancer metastasis, under genetically and environmentally controlled conditions.

METHODS

Over a span of 14 consecutive years, we conducted 22 similar experiments to investigate metastatic biology of breast cancer among 1,214 C3HeB/FeJ female mice. All mice were kept in temperature-controlled environment with 12 h light:12 h dark photoperiod, with food and water freely available, from birth until death. At 10-13 weeks of age, each mouse received 20,000 viable syngeneic mammary cancer cells subcutaneously and the tumor bearing leg was resected 10-12 days after tumor inoculation for potential cure. Once 10% of resected mice were found moribund, due to autopsy proven pulmonary metastases, all remaining mice were sacrificed and metastatic lung nodules were counted.

RESULTS

The incidence of post-resection pulmonary metastasis was not randomly distributed throughout the year, but peaked prominently in Summer and Winter. Although tumor volume at resection was strongly associated with metastatic potential, a significantly higher probability of pulmonary metastasis was observed if surgery was performed in Summer and Winter, regardless of tumor volume at resection, compared to Spring and Fall.

CONCLUSION

These results support the likelihood that human breast cancer seasonality is real and of biological origin. There are implications of this cancer chronobiology for breast cancer prevention, screening, diagnosis, and treatment.

Season, Sun, Sex, and Cervical Cancer

INTRODUCTION

Sunlight's UV B component, a known cellular immunosupressant, carcinogen, and activator of viral infections, is generally seasonally available. Venereal human papillomavirus (HPV) transmission, at least in part, causes cervical cancer. We have previously inspected the monthly rates of venereal HPV infection and sunlight fluency in Southern Holland over 16 consecutive years. Both peak in August with at least 2-fold seasonality. The amount of available sunlight and the rate of Papanicolaou (Pap) smear screen-detected HPV are positively correlated. We now investigate whether premalignant and malignant cervical epithelial changes are also seasonal and related to seasonal sunlight fluency.

METHODS

We have studied >900,000 consecutive, serially independent, interpretable screening Pap smears obtained by a single cervical cancer screening laboratory in Leiden, Holland, during a continuous 16-year span from 1983 through 1998. The average monthly rates of premalignant and malignant epithelial change were inspected and the annual patterns contrasted to the annual pattern of sunlight fluency at this global location and to monthly average HPV infection rate. Because HPV is venereally transmitted, Dutch seasonal sexual behavior was evaluated by assessment of the annual pattern of Dutch conception frequency as a competing cause for cervical cancer seasonality.

RESULTS

(a) Twice as many premalignant and malignant epithelial changes were found among Pap smears obtained in the summer months, with an August peak concurrent with histopathologic evidence of HPV infection and sunlight fluency in Southern Holland. (b) Monthly sunlight fluency is correlated positively with both the monthly rates of Pap smear-detected cervical epithelial dysplasia and carcinomatous histopathology, as well as HPV. (c) Conception frequency, in this location, peaks in Spring not summer, and has a 4.8% annual amplitude.

CONCLUSIONS

(a) Cervical epithelial HPV infection and HPV-induced cervical epithelial dysplasia and carcinomatous change may each be novel sun exposure risks and thereby behaviorably avoidable. (b) Because screening Pap smears uncover many abnormalities that resolve spontaneously (false positives), these data may argue for screening and follow-up Pap smear examinations in seasons other than summer in the Northern Hemisphere, to diminish the false-positive smear rate. Global data are available to confirm and further test each of these conclusions.

Seasonal fluctuations in the cervical smear detection rates for (pre)malignant changes and for infections

The detection of diseases can exhibit seasonal fluctuations. This can be studied in cervical smears. Over a 9-year observation span (January 1983-January 1992) a series of 504,093 cervical smears obtained from a routine cytology laboratory in The Netherlands were examined for infections (monilia, trichomonas, actinomyces, human papilloma virus [HPV], chlamydia, and herpes) as well as for mild, moderate, and severe dysplasias, carcinoma in situ, and squamous carcinoma. Statistical analysis (principal component analysis) demonstrates clear seasonal rhythms in the detection of infections as well as in precursor lesions. These findings suggest that we are dealing with "true" detection rhythms. For the detection of (pre)malignancy and HPV, yearly fluctuations in women being screened might be the explanation for our observations.

Reproductive history and prognosis in patients with operable breast cancer

BACKGROUND

Late menarche, early menopause, high parity, and early first birth decrease the risk of development of breast cancer. The influence of these factors on the survival of breast cancer patients has not been explained.

METHODS

A group of 1885 patients with operable breast cancer was studied retrospectively. A univariate analysis was used to calculate 10-year overall survival (OS) and disease free survival (DFS) in relation to age, menopausal status, age at menarche and menopause, and number of pregnancies and deliveries. A multivariate analysis (Cox model) was performed in which classic prognostic factors (tumor size and grade, lymph node involvement) were included in addition to reproductive factors.

RESULTS

Univariate analysis demonstrated better prognosis in patients who had never been pregnant compared with those who had (OS, 62% vs. 54%, respectively; P = 0.01; DFS, 53% vs. 44%, respectively; P = 0.005) and in nulliparous compared with parous patients (OS, 62% vs. 53%, respectively; P = 0.006; DFS, 52% vs. 44%, respectively; P = 0.004). Survival rates decreased with the number of pregnancies and deliveries. Patients with late menarche had worse survival then those whose first menstruation occurred before the age of 16 years (DFS, 47% vs. 41%, respectively; P = 0.04). By multivariate analysis, parity remained an independent prognostic indicator in addition to classic highly significant prognostic factors (nodal involvement, tumor grade and size).

CONCLUSIONS

Results suggest that reproductive factors known to decrease the risk of breast cancer development have an adverse effect on prognosis.

Does the month of diagnosis affect survival of cancer patients?

Some earlier studies based on relatively small data sets have suggested that the month of diagnosis affects survival of breast cancer patients. This phenomenon has been suggested to be attributable to daylight-related hormonal factors. Factors related to the holidays of both the medical personnel and the women themselves might also provide the explanation. In this study we assessed the effect of the month of diagnosis on the survival of 32,807 female breast cancer patients diagnosed in Finland in 1956-1985. Our results indicate that the month of diagnosis is a significant prognostic factor after adjusting for age at diagnosis, period of diagnosis, and stage at diagnosis. The adjusted relative excess risk of death was highest among those diagnosed in July and August, and lowest in March and November, the difference between the lowest and highest risk being 18%. Since colorectal cancer should not have any daylight-related hormone dependent risk determinants, a control cohort of 12,950 women with a diagnosis of colorectal cancer in the same calendar period was studied in a similar way. The survival pattern by month of diagnosis among the colorectal cancer patients was similar to that among breast cancer patients, indicating that general factors associated with the health behaviour of women and the health services (such as holidays) rather than biological factors may cause seasonal variations in survival of cancer patients.

The changing importance of prognostic factors in breast cancer during long-term follow-up

A cohort of 464 breast-cancer patients were followed up for over 10 years and the clinical, histological and morphometric factors were related to survival within different time periods during follow-up. Tumor diameter, axillary lymph-node status (pN), tubule formation and the fraction of intraductal growth as determined from the primary tumor biopsy specimen had prognostic value up to 5 years. Histological grade, morphometric nuclear factors and the M/V index had only short-term prognostic value immediately after the primary therapy. In axillary lymph-node-negative (ANN) tumors tubule formation, intraductal growth, tumor necrosis and tumor diameter had prognostic value during the first 3 postoperative years. In axillary lymph-node-positive (ANP) tumors, tumor diameter, intraductal growth and tubule formation had long-term prognostic value whereas the M/V index had prognostic value only for 1 postoperative year. Tumor diameter, axillary lymph-node status, tubule formation and the proportion of intraductal growth also had independent long-term prognostic value in a multivariate analysis and accordingly these factors can categorize breast-cancer patients into prognostic groups after several years of follow-up. In contrast, mitotic frequency loses its prognostic power within 2 postoperative years, while morphometric nuclear factors and histological grade have no practical prognostic value after 1 year of follow-up.

Demographic prognostic factors in breast cancer

The aim of this study was to assess the prognostic influence of the month of treatment, the year of treatment, and the patient's age at diagnosis of breast cancer in comparison with clinical and histopathological prognostic factors. This retrospective analysis from the years 1968-1990 at one university hospital in a rural area in Eastern Finland included 688 patients with invasive breast cancer followed up for more than 12 years. The breast tumours diagnosed in September and in October were larger, had distant metastases more often and, accordingly, had a worse prognosis than the tumours diagnosed during the rest of the year. The prognosis of breast tumours improved during the study period whereas the patient's age was inversely related to prognosis. The histopathological characteristics of breast tumours were not related to the month of treatment. The tumours were histologically more atypical and smaller in size, and the patients were older at diagnosis in the 1990's than in the 1980's. In conclusion, the month of treatment, the year of treatment, and the patient's age were found to be independent prognostic predictors in breast cancer, acting as confounders in survival analyses based on the biological prognostic factors.