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Gkekos L, Johansson ALV, Rodriguez-Wallberg KA, Fredriksson I, Lundberg FE. Obstetric and perinatal outcomes in women with previous breast cancer: a nationwide study of singleton births 1973-2017. Hum Reprod Open 2024; 2024:hoae027. [PMID: 38784055 PMCID: PMC11112047 DOI: 10.1093/hropen/hoae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 04/15/2024] [Indexed: 05/25/2024] Open
Abstract
STUDY QUESTION What are the obstetric and perinatal outcomes in births to breast cancer survivors compared to women without previous breast cancer? SUMMARY ANSWER Women who conceived during the first 2 years following a breast cancer diagnosis had a higher risk for preterm birth, induced delivery, and cesarean section, while no increased risks were observed in births conceived later than 2 years after a breast cancer diagnosis. WHAT IS KNOWN ALREADY A recent meta-analysis found higher risks of cesarean section, preterm birth, low birthweight, and small for gestational age in pregnancies among breast cancer survivors. Less is known about rarer outcomes such as pre-eclampsia or congenital malformations. STUDY DESIGN SIZE DURATION We conducted a population-based matched cohort study including all breast cancer survivors who gave birth to singletons 1973-2017 in Sweden, identified through linkage between the Swedish Cancer Register, the Medical Birth Register, and the National Quality Register for Breast Cancer. PARTICIPANTS/MATERIALS SETTINGS METHODS Each birth following breast cancer (n = 926) was matched by maternal age at delivery, parity, and calendar year at delivery to 100 births in a comparator cohort of women (n = 92 490). Conditional logistic and multinomial regression models estimated relative risks (RR) with 95% CI. Subgroup analyses by time since diagnosis and type of treatment were performed. MAIN RESULTS AND THE ROLE OF CHANCE Previous breast cancer was associated with higher risks of induced delivery (RR; 1.3, 1.0-1.6), very preterm birth (RR; 1.8, 1.1-3.0), and planned preterm birth (RR; 1.6, 1.0-2.4). Women who conceived within 1 year after breast cancer diagnosis had higher risks of cesarean section (RR; 1.7, 1.0-2.7), very preterm birth (RR; 5.3, 1.9-14.8), and low birthweight (RR; 2.7, 1.4-5.2), while the risks of induced delivery (RR; 1.8, 1.1-2.9), moderately preterm birth (RR; 2.1, 1.2-3.7), and planned preterm birth (RR; 2.5, 1.1-5.7) were higher in women who conceived during the second year after diagnosis. Women who conceived later than 2 years after breast cancer diagnosis had similar obstetric risks to their comparators. LIMITATIONS REASONS FOR CAUTION As information on the end date of treatment was unavailable, the time between the date of diagnosis and conception was used as a proxy, which does not fully capture the effect of time since end of treatment. In addition, treatments and clinical recommendations have changed over the long study period, which may impact childbearing patterns in breast cancer survivors. WIDER IMPLICATIONS OF THE FINDINGS Risks of adverse obstetric outcomes in breast cancer survivors were confined to births conceived within 2 years of diagnosis. As family building holds significance for numerous young breast cancer patients, these findings are particularly important to inform both breast cancer survivors and clinicians about future reproductive outcomes. STUDY FUNDING/COMPETING INTERESTS This work was supported by the Swedish Cancer Society (grant number 22-2044 Pj A.L.V.J.), Karolinska Institutet Foundations (grant number: 2022-01696 F.E.L., 2022-01559 A.L.V.J.), and the Swedish Research Council (grant number: 2021-01657 A.L.V.J.). K.A.R.-W. is supported by grants from the Swedish Cancer Society (20 0170 F) and the Radiumhemmets Research Foundations for clinical researchers 2020-2026. The authors declare that they have no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Leo Gkekos
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anna L V Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Cancer Registry of Norway, Norwegian Institute of Public Health, Oslo, Norway
| | - Kenny A Rodriguez-Wallberg
- Department of Oncology-Pathology, Laboratory of Translational Fertility Preservation, Karolinska Institutet, Stockholm, Sweden
- Division of Gynecology and Reproduction, Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Irma Fredriksson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Frida E Lundberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology-Pathology, Laboratory of Translational Fertility Preservation, Karolinska Institutet, Stockholm, Sweden
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Kingsberg S, Banks V, Caetano C, Janssenswillen C, Moeller C, Schoof N, Lee L, Scott M, Nappi RE. Real-world clinical evaluation of natural and induced vasomotor symptoms in the USA and Europe. Climacteric 2024:1-9. [PMID: 38695491 DOI: 10.1080/13697137.2024.2340472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/03/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE This study aimed to examine physicians' and patients' perceptions regarding symptom burden and impact in women experiencing natural vasomotor symptoms (nVMS) or vasomotor symptoms induced by endocrine therapy for breast cancer (iVMS). METHODS The cross-sectional survey based on real-world clinical consultations was conducted in the USA and five European countries. Obstetrician-gynecologists, primary-care physicians and oncologists provided demographic and symptom data for patients experiencing VMS; patients optionally self-reported their experiences via questionnaires, including their symptom profile and work/activity burden through the Menopause Quality of Life (MENQOL) and Work Productivity and Activity Impairment (WPAI) tools. RESULTS Physicians completed survey forms on 2451 consulting patients; patients completed 1029 questionnaires. nVMS and iVMS severity was significantly associated with the severity of mood symptoms and sleep disturbances (p < 0.0001). However, around half of the patients with mild nVMS/iVMS also experienced moderate-severe mood changes (55.4%/43.7%) or sleep disturbances (42.4%/40.4%). Presence of mood/sleep disturbances alongside nVMS increased MENQOL vasomotor scores (p = 0.004/p < 0.001). Presence of sleep disturbances increased WPAI activity impairment (p < 0.001) but mood changes did not. Similar findings were reported for iVMS patients. CONCLUSION Significant burden from the triad of natural or induced menopausal symptoms, sleep disturbances and mood changes affected women's daily activities, work and quality of life more than vasomotor symptoms alone.
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Affiliation(s)
- Sheryl Kingsberg
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Victoria Banks
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Reading, UK
| | - Cecilia Caetano
- Medical Affairs Women's Healthcare, Bayer Consumer Care, Basel, Switzerland
| | | | - Carsten Moeller
- IEG TA WHC, Immunology, Inflammation, Bayer AG, Berlin, Germany
| | - Nils Schoof
- IEG TA WHC, Immunology, Inflammation, Bayer AG, Berlin, Germany
| | - Lauren Lee
- Respiratory & Women's Health, Adelphi Real World, Bollington, UK
| | - Megan Scott
- Respiratory & Women's Health, Adelphi Real World, Bollington, UK
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy
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Kim S, Chen N, Reid P. Current and future advances in practice: aromatase inhibitor-induced arthralgia. Rheumatol Adv Pract 2024; 8:rkae024. [PMID: 38601139 PMCID: PMC11003819 DOI: 10.1093/rap/rkae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/19/2024] [Indexed: 04/12/2024] Open
Abstract
Aromatase inhibitors (AIs) have shown great success as adjuvant therapy for post-menopausal women with hormone receptor-positive breast cancers. AI-induced arthralgia (AIA) is a frequent AI toxicity contributing to non-adherence and discontinuation. This review aims to understand current knowledge of AIA. The mean incidence of AIA was 39.1% and the mean discontinuation of AI therapy due to AIA was 9.3%. Most of the AIAs were non-inflammatory. A shorter time since the last menstrual period and pre-existing joint pain were risk factors. Vitamin D3 supplementation may be a preventative measure and treatment with duloxetine, acupuncture and/or exercise is supported by large randomized controlled trials. There was consistent improvement in AIAs with switching to an alternate AI, and this could additionally allow continuation of cancer treatment with AI. Further research is needed to identify predictive biomarkers, better characterize AIA subcategories and study more reliable therapeutic options.
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Affiliation(s)
- Sara Kim
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nan Chen
- Division of Hematology and Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Pankti Reid
- Division of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA
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Woolpert KM, Schmidt JA, Ahern TP, Hjorth CF, Farkas DK, Ejlertsen B, Collin LJ, Lash TL, Cronin-Fenton DP. Clinical factors associated with patterns of endocrine therapy adherence in premenopausal breast cancer patients. Breast Cancer Res 2024; 26:59. [PMID: 38589932 PMCID: PMC11003111 DOI: 10.1186/s13058-024-01819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/02/2024] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION Patients with hormone receptor positive breast cancer are recommended at least five years of adjuvant endocrine therapy, but adherence to this treatment is often suboptimal. We investigated longitudinal trends in adjuvant endocrine therapy (AET) adherence among premenopausal breast cancer patients and identified clinical characteristics, including baseline comorbidities and non-cancer chronic medication use, associated with AET adherence. METHODS We included stage I-III premenopausal breast cancer patients diagnosed during 2002-2011 and registered in the Danish Breast Cancer Group clinical database who initiated AET. We used group-based trajectory modeling to describe AET adherence patterns. We also linked patients to Danish population-based registries and fit multinomial logistic models to compute odds ratios (ORs) and 95% confidence intervals (95% CIs) associating clinical characteristics with AET adherence patterns. RESULTS We identified three adherence patterns among 4,353 women-high adherers (57%), slow decliners (36%), and rapid decliners (6.9%). Women with stage I disease (vs. stage II; OR: 1.9, 95% CI 1.5, 2.5), without chemotherapy (vs. chemotherapy; OR: 4.3, 95% CI 3.0, 6.1), with prevalent comorbid disease (Charlson Comorbidity Index score ≥ 1 vs. 0; OR: 1.6, 95% CI 1.1, 2.3), and with a history of chronic non-cancer medication use (vs. none; OR: 1.3, 95% CI 1.0, 1.8) were more likely to be rapid decliners compared with high adherers. CONCLUSIONS Women with stage I cancer, no chemotherapy, higher comorbidity burden, and history of chronic non-cancer medication use were less likely to adhere to AET. Taking steps to promote adherence in these groups of women may reduce their risk of recurrence.
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Affiliation(s)
- Kirsten M Woolpert
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
| | - Julie A Schmidt
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Thomas P Ahern
- Department of Surgery, The Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Cathrine F Hjorth
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Dóra K Farkas
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Bent Ejlertsen
- On behalf of the Danish Breast Cancer Group, Rigshospitalet, Copenhagen, Denmark
- Department of Oncology, Department of Clinical Medicine, University of Copenhagen and Rigshospitalet, Copenhagen, Denmark
| | - Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Deirdre P Cronin-Fenton
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
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Pleasant V. A Public Health Emergency: Breast Cancer Among Black Communities in the United States. Obstet Gynecol Clin North Am 2024; 51:69-103. [PMID: 38267132 DOI: 10.1016/j.ogc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
While Black people have a similar incidence of breast cancer compared to White people, they have a 40% increased death rate. Black people are more likely to be diagnosed with aggressive subtypes such as triple-negative breast cancer. However, despite biological factors, systemic racism and social determinants of health create delays in care and barriers to treatment. While genetic testing holds incredible promise for Black people, uptake remains low and results may be challenging to interpret. There is a need for more robust, multidisciplinary, and antiracist interventions to reverse breast cancer-related racial disparities.
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Affiliation(s)
- Versha Pleasant
- Department of Obstetrics and Gynecology, Cancer Genetics & Breast Health Clinic, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Chen C, Tang WH, Wu CC, Lee TL, Tsai IT, Hsuan CF, Wang CP, Chung FM, Lee YJ, Yu TH, Wei CT. Pretreatment Circulating Albumin, Platelet, and RDW-SD Associated with Worse Disease-Free Survival in Patients with Breast Cancer. BREAST CANCER (DOVE MEDICAL PRESS) 2024; 16:23-39. [PMID: 38250195 PMCID: PMC10799625 DOI: 10.2147/bctt.s443292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024]
Abstract
Objective Breast cancer is the second most common malignancy globally and a leading cause of cancer death in women. Analysis of factors related to disease-free survival (DFS) has improved understanding of the disease and characteristics related to recurrence. The aim of this study was to investigate the predictors of DFS in patients with breast cancer to enable the identification of patients at high risk who may benefit from prevention interventions. Methods We retrospectively analyzed 559 women with breast cancer who underwent treatment between 2004 and 2022. The study endpoint was DFS. Recurrence was defined as local recurrence, regional recurrence, distant metastases, contralateral breast cancer, other second primary cancer, and death. Baseline tumor-related characteristics, treatment-related characteristics, sociodemographic and biochemical data were analyzed using Cox proportional hazards analysis. Results The median DFS was 45 months (range, 2 to 225 months). Breast cancer recurred in 86 patients (15.4%), of whom 10 had local recurrence, 10 had regional recurrence, 17 had contralateral breast cancer, 29 had distant metastases, 10 had second primary cancer, and 10 patients died. Multivariate forward stepwise Cox regression analysis showed that AJCC stage III, Ki67 ≥14%, albumin, platelet, and red cell distribution width-standard deviation (RDW-SD) were predictors of worse DFS. In addition, the effects of albumin, platelet, and RDW-SD on disease recurrence were confirmed by structural equation model (SEM) analysis. Conclusion In addition to the traditional predictors of worse DFS such as AJCC stage III and Ki67 ≥14%, lower pretreatment circulating albumin, higher pretreatment circulating platelet count and RDW-SD could significantly predict worse DFS in this study, and SEM delineated possible causal pathways and inter-relationships of albumin, platelet, and RDW-SD contributing to the disease recurrence among Chinese women with breast cancer.
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Affiliation(s)
- Chia‐Chi Chen
- Department of Pathology, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
- Department of Physical Therapy, I-Shou University, Kaohsiung, 82445, Taiwan
- The School of Chinese Medicine for Post Baccalaureate, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Wei-Hua Tang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Yuli Branch, Hualien, 98142, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 112304, Taiwan
| | - Cheng-Ching Wu
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Cancer Hospital, I-Shou, University, Kaohsiung, 82445, Taiwan
| | - Thung-Lip Lee
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
| | - I-Ting Tsai
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
- Department of Emergency, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Chin-Feng Hsuan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chao-Ping Wang
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Fu-Mei Chung
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Yau-Jiunn Lee
- Lee’s Endocrinologic Clinic, Pingtung, 90000, Taiwan
| | - Teng-Hung Yu
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
| | - Ching-Ting Wei
- The School of Chinese Medicine for Post Baccalaureate, College of Medicine, I-Shou University, Kaohsiung, 82445, Taiwan
- Division of General Surgery, Department of Surgery, E-Da Hospital, I-Shou University, Kaohsiung, 82445, Taiwan
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Saraf A, Tahir I, Hu B, Dietrich ASW, Tonnesen PE, Sharp GC, Tillman G, Roeland EJ, Nipp RD, Comander A, Peppercorn J, Fintelmann FJ, Jimenez RB. Association of Sarcopenia With Toxicity-Related Discontinuation of Adjuvant Endocrine Therapy in Women With Early-Stage Hormone Receptor-Positive Breast Cancer. Int J Radiat Oncol Biol Phys 2024; 118:94-103. [PMID: 37506979 DOI: 10.1016/j.ijrobp.2023.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/27/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE Sarcopenia, an age-related decline in muscle mass and physical function, is associated with increased toxicity and worse outcomes in women with breast cancer (BC). Sarcopenia may contribute to toxicity-related early discontinuation of adjuvant endocrine therapy (aET) in women with hormone receptor-positive (HR+) BC but remains poorly characterized. METHODS AND MATERIALS This multicenter, retrospective cohort study included consecutive women with stage 0-II HR+ BC who received breast conserving therapy (lumpectomy and radiation therapy) and aET from 2011 to 2017 with a 5-year follow-up. Skeletal muscle index (SMI, cm2/m2) was analyzed using a deep learning model on routine cross-sectional radiation simulation imaging; sarcopenia was dichotomized according to previously validated reports. The primary endpoint was toxicity-related aET discontinuation; logistic regression analysis evaluated associations between SMI/sarcopenia and aET discontinuation. Cox regression analysis evaluated associations with time to aET toxicity, ipsilateral breast tumor recurrence (IBTR), and disease-free survival (DFS). RESULTS A total of 305 women (median follow-up, 89 months) were included with a median age of 67 years and early-stage BC (12% stage 0, 65% stage I). A total of 60 (20%) women experienced toxicity-related aET discontinuation. Sarcopenia was associated with toxicity-related early discontinuation of aET (odds ratio, 2.18; P = .036) and shorter time to aET toxicity (hazard ratio [HR], 1.62; P = .031). SMI or sarcopenia were not independently associated with IBTR or DFS; toxicity-related aET discontinuation was associated with worse IBTR (HR, 9.47; P = .002) and worse DFS (HR, 4.53; P = .001). CONCLUSIONS Among women with early-stage HR+ BC who receive adjuvant radiation therapy and hormone therapy, sarcopenia is associated with toxicity-related early discontinuation of aET. Further studies should validate these findings in women who did not receive adjuvant radiation therapy. These high-risk patients may be candidates for aggressive symptom management and/or alternative treatment strategies to improve outcomes.
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Affiliation(s)
- Anurag Saraf
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Ismail Tahir
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Bonnie Hu
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - P Erik Tonnesen
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gayle Tillman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric J Roeland
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Ryan D Nipp
- Department of Medical Oncology, University of Oklahoma Stephenson Cancer Center, Oklahoma City, Oklahoma
| | - Amy Comander
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffery Peppercorn
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Zheng D, Thomas J. Adherence to and persistence with adjuvant hormone therapy, healthcare utilization, and healthcare costs among older women with breast cancer: A population-based longitudinal cohort study. J Geriatr Oncol 2023; 14:101599. [PMID: 37598659 DOI: 10.1016/j.jgo.2023.101599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION To assess associations between adherence to and persistence with adjuvant hormone therapy, healthcare utilization, and healthcare costs among older women with breast cancer. MATERIALS AND METHODS This study was a population-based longitudinal cohort study using the Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare claims. This study included older women diagnosed with stage I-III hormone receptor-positive breast cancer from 2009 through 2017. Participants were considered adherent with a proportion of days covered (PDC) of 0.80 or more and persistent if they had no hormone therapy discontinuation, i.e., a break of at least 180 continuous days. Length of persistence was calculated as time from therapy initiation to discontinuation. All participants were followed for up to five years after hormone therapy initiation. Generalized linear mixed models with repeated measures or hurdle generalized linear mixed models in the event of excess zeroes were used to assess associations between adherence to and persistence with annual healthcare utilization and costs. RESULTS This study included 25,796 women. Being adherent was associated with lower annual healthcare utilization, i.e., hospitalizations, hospital days, emergency room visits, and hospital outpatient visits. Persistence was associated with fewer annual hospitalizations, hospital days, emergency room visits, and hospital outpatient visits. Adherent participants had lower annual inpatient costs, outpatient costs, medical costs, and total healthcare costs despite higher prescription drug costs. Both being persistent and longer persistence were associated with lower inpatient costs, outpatient costs, medical costs, and total healthcare costs despite higher prescription drug costs. DISCUSSION This study underscores the economic benefits associated with adherence to and persistence with adjuvant hormone therapy based on comprehensive measures for healthcare utilization and costs. To our best knowledge, this was the first study that reported total healthcare cost savings associated with adherence to and persistence with adjuvant hormone therapy.
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Affiliation(s)
- Dandan Zheng
- Department of Pharmacy Practice, College of pharmacy, Purdue University, West Lafayette, IN, USA.
| | - Joseph Thomas
- Department of Pharmacy Practice, College of pharmacy, Purdue University, West Lafayette, IN, USA
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D'Onofrio R, Omarini C, Toss A, Sperduti I, Piacentini F, Barbolini M, Cortesi L, Barbieri E, Pettorelli E, Chiavelli C, Dominici M, Moscetti L. Adjuvant Endocrine Therapy in Premenopausal Women With Hormone Receptor-Positive Early-Stage Breast Cancer: Risk Stratification in a Real-World Setting. Clin Breast Cancer 2023; 23:712-720.e3. [PMID: 37507257 DOI: 10.1016/j.clbc.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Ovarian function suppression (OFS) and hormone therapy (HT) represent an adjuvant option in premenopausal hormone receptor-positive early breast cancer (HR+EBC). The SOFT-TEXT trials showed improved outcomes upon receiving aromatase inhibitors (AIs)/OFS. METHODS In order to estimate the magnitude of absolute improvements, we conducted a retrospective study applying composite risk (CR) to 237 premenopausal HR+EBC patients. RESULTS Overall, 119 of these received tamoxifen (T)/OFS and 118 received AIs/OFS. The median age was 45 years (ys). After a median follow up of 65 months, recurrence was 6.7% in T patients and 10.2% in AI ones. CR (cutoff: 2.67) and ET duration (five-year cutoff) was found to have a significant impact on DFS. Invasive disease-free survival (IDFS) at 5 ys amounted to 82.9% for a CR>2.67 and 95% with CR=2.67 (p 0.0046). Five-year IDFS was 98.3% in patients who had completed 5-year HT compared to 54.6% of those who had stopped before 5 years (P < .0001). Excluding patients who had discontinued therapy due to disease relapse, IDFS difference at 5 years remained statistically significant (p=0.03) between the two groups, with an iDFS rate of 86.5% at 5 years in the second group. Adverse events of different grades were reported in 116 and 112 patients in the T/OFS group and the AIs/OFS, respectively. Early discontinuation due to toxicity was 3.8%. Seven patients (19.4%) discontinued therapy due to pregnancy desire (6 in the T group, 1 in the AI one); of these, one patient relapsed. CONCLUSION In a real-world setting, treatment options for premenopausal patients who are candidates for HT and OFS should take risk status into account. Therefore, every effort should be made to maintain patient adherence to treatment in order to manage toxicities and improve outcomes.
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Affiliation(s)
- Raffaella D'Onofrio
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Claudia Omarini
- Division of Medical Oncology, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Parma, Italy
| | - Angela Toss
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy; Department of Oncology and Hematology, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Isabella Sperduti
- Biostatistics Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Federico Piacentini
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Parma, Italy
| | - Monica Barbolini
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Laura Cortesi
- Division of Medical Oncology, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Elena Barbieri
- Division of Medical Oncology, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Elisa Pettorelli
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Chiara Chiavelli
- Department of Oncology and Hematology, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy; Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Dominici
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy; Department of Oncology and Hematology, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Luca Moscetti
- Division of Medical Oncology, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Parma, Italy.
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10
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Eliassen FM, Blåfjelldal V, Helland T, Hjorth CF, Hølland K, Lode L, Bertelsen BE, Janssen EAM, Mellgren G, Kvaløy JT, Søiland H, Lende TH. Importance of endocrine treatment adherence and persistence in breast cancer survivorship: a systematic review. BMC Cancer 2023; 23:625. [PMID: 37403065 DOI: 10.1186/s12885-023-11122-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/28/2023] [Indexed: 07/06/2023] Open
Abstract
PURPOSE Adjuvant endocrine treatment is essential for treating luminal subtypes of breast cancer, which constitute 75% of all breast malignancies. However, the detrimental side effects of treatment make it difficult for many patients to complete the guideline-required treatment. Such non-adherence may jeopardize the lifesaving ability of anti-estrogen therapy. In this systematic review, we aimed to assess the consequences of non-adherence and non-persistence from available studies meeting strict statistical and clinical criteria. METHODS A systematic literature search was performed using several databases, yielding identification of 2,026 studies. After strict selection, 14 studies were eligible for systematic review. The review included studies that examined endocrine treatment non-adherence (patients not taking treatment as prescribed) or non-persistence (patients stopping treatment prematurely), in terms of the effects on event-free survival or overall survival among women with non-metastatic breast cancer. RESULTS We identified 10 studies measuring the effects of endocrine treatment non-adherence and non-persistence on event-free survival. Of these studies, seven showed significantly poorer survival for the non-adherent or non-persistent patient groups, with hazard ratios (HRs) ranging from 1.39 (95% CI, 1.07 to 1.53) to 2.44 (95% CI, 1.89 to 3.14). We identified nine studies measuring the effects of endocrine treatment non-adherence and non-persistence on overall survival. Of these studies, seven demonstrated significantly reduced overall survival in the groups with non-adherence and non-persistence, with HRs ranging from 1.26 (95% CI, 1.11 to 1.43) to 2.18 (95% CI, 1.99 to 2.39). CONCLUSION The present systematic review demonstrates that non-adherence and non-persistence to endocrine treatment negatively affect event-free and overall survival. Improved follow-up, with focus on adherence and persistence, is vital for improving health outcomes among patients with non-metastatic breast cancer.
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Affiliation(s)
- Finn Magnus Eliassen
- Department of Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway.
| | - Vibeke Blåfjelldal
- Department of Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
| | - Thomas Helland
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Cathrine Fonnesbech Hjorth
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Kari Hølland
- Division of Research, University of Stavanger, Stavanger, Norway
| | - Lise Lode
- Department of Gastrointestinal Surgery, Hvidovre Hospital, Copenhagen, Denmark
| | - Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Emiel A M Janssen
- Department of Pathology, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
- Department of Chemistry, Biosciences and Environmental Engineering, University of Stavanger, Stavanger, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jan Terje Kvaløy
- Department of Research, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - Håvard Søiland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Research, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
| | - Tone Hoel Lende
- Department of Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
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11
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Tseng J, Bazan JG, Minami CA, Schonberg MA. Not Too Little, Not Too Much: Optimizing More Versus Less Locoregional Treatment for Older Patients With Breast Cancer. Am Soc Clin Oncol Educ Book 2023; 43:e390450. [PMID: 37327467 DOI: 10.1200/edbk_390450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Although undertreatment of older women with aggressive breast cancers has been a concern for years, there is increasing recognition that some older women are overtreated, receiving therapies unlikely to improve survival or reduce morbidity. De-escalation of surgery may include breast-conserving surgery over mastectomy for appropriate candidates and omitting or reducing extent of axillary surgery. Appropriate patients to de-escalate surgery are those with early-stage breast cancer, favorable tumor characteristics, are clinically node-negative, and who may have other major health issues. De-escalation of radiation includes reducing treatment course length through hypofractionation and ultrahypofractionation regimens, reducing treatment volumes through partial breast irradiation, omission of radiation for select patients, and reducing radiation dose to normal tissues. Shared decision making, which aims to facilitate patients making decisions concordant with their values, can guide health care providers and patients through complicated decisions optimizing breast cancer care.
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Affiliation(s)
| | - Jose G Bazan
- City of Hope Comprehensive Cancer Center, Duarte, CA
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12
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Jang SH, Paek SH, Kim JK, Seong JK, Lim W. A New Culture Model for Enhancing Estrogen Responsiveness in HR+ Breast Cancer Cells through Medium Replacement: Presumed Involvement of Autocrine Factors in Estrogen Resistance. Int J Mol Sci 2023; 24:ijms24119474. [PMID: 37298425 DOI: 10.3390/ijms24119474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/20/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Hormone receptor-positive breast cancer (HR+ BC) cells depend on estrogen and its receptor, ER. Due to this dependence, endocrine therapy (ET) such as aromatase inhibitor (AI) treatment is now possible. However, ET resistance (ET-R) occurs frequently and is a priority in HR+ BC research. The effects of estrogen have typically been determined under a special culture condition, i.e., phenol red-free media supplemented with dextran-coated charcoal-stripped fetal bovine serum (CS-FBS). However, CS-FBS has some limitations, such as not being fully defined or ordinary. Therefore, we attempted to find new experimental conditions and related mechanisms to improve cellular estrogen responsiveness based on the standard culture medium supplemented with normal FBS and phenol red. The hypothesis of pleiotropic estrogen effects led to the discovery that T47D cells respond well to estrogen under low cell density and medium replacement. These conditions made ET less effective there. The fact that several BC cell culture supernatants reversed these findings implies that housekeeping autocrine factors regulate estrogen and ET responsiveness. Results reproduced in T47D subclone and MCF-7 cells highlight that these phenomena are general among HR+ BC cells. Our findings offer not only new insights into ET-R but also a new experimental model for future ET-R studies.
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Affiliation(s)
- Seok-Hoon Jang
- Department of Surgery, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Republic of Korea
- Laboratory of Developmental Biology and Genomics, College of Veterinary Medicine, Seoul National University, 1, Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Se Hyun Paek
- Department of Surgery, Ewha Womans University Seoul Hospital, 260, Gonghang-daero, Gangseo-gu, Seoul 07804, Republic of Korea
| | - Jong-Kyu Kim
- Department of Surgery, Ewha Womans University Seoul Hospital, 260, Gonghang-daero, Gangseo-gu, Seoul 07804, Republic of Korea
| | - Je Kyung Seong
- Laboratory of Developmental Biology and Genomics, College of Veterinary Medicine, Seoul National University, 1, Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea
| | - Woosung Lim
- Department of Surgery, Ewha Womans University Mokdong Hospital, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Republic of Korea
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13
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Chamalidou C, Nasic S, Linderholm B. Compliance to adjuvant endocrine therapy and survival in breast cancer patients. Cancer Treat Res Commun 2023; 35:100704. [PMID: 37031604 DOI: 10.1016/j.ctarc.2023.100704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Data on compliance to adjuvant endocrine treatment (ET) is mainly reported from prospective clinical trials or from smaller retrospective cohorts without correlation to outcome. AIMS To determine compliance to adjuvant ET and the impact on survival in a population-based series of patients with early breast cancer (BC) advised ET. PATIENTS AND METHODS 1090 consecutive patients with hormone receptor positive (HR+) stage I-III BC diagnosed from 1 January 1997 to 31 December 2003 from one health care region of Sweden were included. Data on tumour, type of ET, compliance, reason for termination and outcome were collected. Statistical analyses were calculated with patients in three groups. RESULTS 72 patients were excluded leaving 1018 patients with a HR+ stage I to III BC for analyses. The most common ET was tamoxifen (n = 751, 73.8%). At the last follow up (31 Dec 2019) with a median follow-up of 18 years (interquartile range 16-22) 228 (22.4%) patients had a relapse. 71.1% of the included patients were compliant to endocrine therapy. Older patients ≥74 years had lower compliance, 61% compared with 75% in the other age groups (≤50 years and 51-73 years) (p < 0001), other parameters including type of ET were not associated with compliance. Low compliance remained as an independent risk factor in multivariate analyses for lower relapse-free survival, HR=1.83, 95% Confidence Interval (CI) 1.52-2.19, p < 0.001 and for time to BC death, HR=2.69, 95%CI 1.82-3.98, p < 0.001. CONCLUSIONS Patients compliant to adjuvant ET have an improved survival.
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Affiliation(s)
- Chaido Chamalidou
- Institute of Clinical Sciences, Department of Oncology, Sahlgrenska Academy at Gothenburg University, Sweden; Skaraborg Hospital, Department of Oncology, Skövde, Sweden.
| | - Salmir Nasic
- Research and Development Centre, Skaraborgs Hospital, Skövde, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, the Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Barbro Linderholm
- Institute of Clinical Sciences, Department of Oncology, Sahlgrenska Academy at Gothenburg University, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
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14
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Ward KA, Muller DA, Dutta SW, Malhi J, Sanders JC, Luminais CK, Millard TA, Showalter TN, Showalter SL, Janowski EM. Long-Term Adherence to Adjuvant Endocrine Therapy Following Various Radiotherapy Modalities in Early Stage Hormone Receptor Positive Breast Cancer. Clin Breast Cancer 2023; 23:369-377. [PMID: 36868913 DOI: 10.1016/j.clbc.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/24/2022] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION We compared the rates of long-term adjuvant endocrine therapy (AET) adherence after various radiation therapy (RT) modalities among patients with early stage breast cancer. MATERIALS AND METHODS Medical records from patients with stage 0, I, or IIA (tumors ≤3 cm), hormone receptor (HR) positive breast cancer that received adjuvant radiation therapy (RT) from 2013 to 2015 at a single institution were retrospectively reviewed. All patients received breast conserving surgery (BCS) followed by adjuvant RT via one of the following modalities: whole breast radiotherapy (WBI), partial breast irradiation (PBI) with either external beam radiation therapy (EBRT) or fractionated intracavitary high-dose rate (HDR) brachytherapy, or single fraction HDR-brachytherapy intraoperative-radiation therapy (IORT). RESULTS One hundred fourteen patients were reviewed. Thirty patients received WBI, 41 PBI, and 43 IORT with a median follow up of 64.2, 72.0, and 58.6 months, respectively. For the entire cohort, AET adherence was approximately 64% at 2 years and 56% at 5 years. Among patients in the IORT clinical trial, adherence to AET was approximately 51% at 2 years and 40% at 5 years. After controlling for additional factors, DCIS histology (vs invasive disease) and IORT (compared to other radiation modalities) were associated with decreased endocrine therapy adherence (P < 0.05). CONCLUSION DCIS histology and receipt of IORT were associated with lower rates of adherence to AET at 5 years. Our findings suggest that examination of the efficacy of RT interventions such as PBI and IORT in patients who do not receive AET is warranted.
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Affiliation(s)
- Kristin A Ward
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA.
| | - Donald A Muller
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Sunil W Dutta
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Jasmine Malhi
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Jason C Sanders
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | | | - Trish A Millard
- Department of Hematology/Oncology, University of Virginia, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
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15
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Kuhn EP, Pirruccello J, Boothe JT, Li Z, Tosteson TD, Stahl JE, Schwartz GN, Chamberlin MD. Preventing metastatic recurrence in low-risk ER/PR + breast cancer patients-a retrospective clinical study exploring the evolving challenge of persistence with adjuvant endocrine therapy. Breast Cancer Res Treat 2023; 198:31-41. [PMID: 36592233 PMCID: PMC9883310 DOI: 10.1007/s10549-022-06849-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/30/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE In the genomic era, more women with low-risk breast cancer will forego chemotherapy and rely on adjuvant endocrine therapy (AET) to prevent metastatic recurrence. However, some of these patients will unfortunately relapse. We sought to understand this outcome. Preliminary work suggested that early discontinuation of AET, also known as non-persistence, may play an important role. A retrospective analysis exploring factors related to our breast cancer patients' non-persistence with AET was performed. METHODS Women who underwent Oncotype-DX® testing between 2011 and 2014 with minimum 5 years follow-up were included. 'Low risk' was defined as Oncotype score < 26. Outcomes of recurrence and persistence were determined by chart review. Patient, tumor and treatment factors were collected, and persistent versus non-persistent groups compared using multivariable ANOVA and Fisher Chi square exact test. RESULTS We identified six cases of distant recurrence among low-risk patients with a median follow-up of 7.7 years. Among them, five of six patients (83%) were non-persistent with AET. The non-persistence rate in our cohort regardless of recurrence was 57/228 (25%). Non-persistent patients reported more severe side effects compared with persistent patients (p = 0.002) and were more likely to be offered a switch in endocrine therapy, rather than symptom-relief (p = 0.006). In contrast, persistent patients were 10.3 times more likely to have been offered symptom-alleviating medications compared with non-persistent patients (p < 0.001). A subset analysis revealed that patients who persisted with therapy had a higher Oncotype-DX® score than patients who discontinued early (p = 0.028). CONCLUSION Metastatic recurrence in low-risk breast cancer patients may be primarily due to non-persistence with endocrine therapy. Further work is needed to optimize care for patients who struggle with side effects. To our knowledge, these are the first published data suggesting that Oncotype-DX® score may influence persistence with AET.
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Affiliation(s)
- Elaine P Kuhn
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Jonathan Pirruccello
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - James T Boothe
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Zhongze Li
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Biomedical Data Sciences, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Tor D Tosteson
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Biomedical Data Sciences, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - James E Stahl
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Gary N Schwartz
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mary D Chamberlin
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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16
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Rosenberg SM, Zheng Y, Gelber S, Ruddy KJ, Poorvu P, Sella T, Tamimi RM, Wassermann J, Schapira L, Borges VF, Come S, Peppercorn J, Sepucha KR, Partridge AH. Adjuvant endocrine therapy non-initiation and non-persistence in young women with early-stage breast cancer. Breast Cancer Res Treat 2023; 197:547-558. [PMID: 36436128 PMCID: PMC10233447 DOI: 10.1007/s10549-022-06810-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/09/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Characterizing oral adjuvant endocrine therapy (ET) non-initiation and non-persistence in young women with breast cancer can inform strategies to improve overall adherence in this population. METHODS We identified 693 women with hormone receptor-positive, stage I-III breast cancer enrolled in a cohort of women diagnosed with breast cancer at age ≤ 40 years. Women were classified as non-initiators if they did not report taking ET in the 18 months after diagnosis. Women who initiated but did not report taking ET subsequently (through 5-year post-diagnosis) were categorized as non-persistent. We assessed ET decision-making and used logistic regression to identify factors associated with non-initiation/non-persistence and to evaluate the association between non-persistence and recurrence. RESULTS By 18 months, 9% had not initiated ET. Black women had higher odds and women with a college degree had lower odds of non-initiation. Among 607 women who initiated, 20% were non-persistent. Younger age, being married/partnered, and reporting more weight problems were associated with higher odds of non-persistence; receipt of chemotherapy and greater hot flash and vaginal symptom burden were associated with lower odds of non-persistence. Adjusting for age and clinical characteristics, non-persistence was associated with lower odds of recurrence. Women who initiated were more likely to report shared decision-making than non-initiators (57% vs. 38%, p = 0.049), while women who were non-persistent were less likely to indicate high confidence with the decision than women who were persistent (40% vs. 63%, p < 0.001). CONCLUSION Interventions to improve ET decision-making may facilitate initiation and address barriers to adherence in young breast cancer survivors. TRIAL REGISTRATION www. CLINICALTRIALS gov , NCT01468246.
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Affiliation(s)
- Shoshana M Rosenberg
- Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67St LA-0005, New York, NY, 10065, USA.
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Yue Zheng
- Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Shari Gelber
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | | | - Philip Poorvu
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tal Sella
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rulla M Tamimi
- Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67St LA-0005, New York, NY, 10065, USA
| | - Johanna Wassermann
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Department of Medical Oncology, Sorbonne Université, IUC, Pitié-Salpêtrière University Hospital, Paris, AP-HP, France
| | - Lidia Schapira
- Department of Medicine, Division of Medical Oncology, Stanford University, Stanford, CA, USA
| | - Virginia F Borges
- Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Steven Come
- Harvard Medical School, Boston, MA, USA
- Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeffrey Peppercorn
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Karen R Sepucha
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ann H Partridge
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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17
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Joyce E, Carr G, Wang S, Brummett CM, Kidwell KM, Henry NL. Association between nociplastic pain and premature endocrine therapy discontinuation in breast cancer patients. Breast Cancer Res Treat 2023; 197:397-404. [PMID: 36371776 PMCID: PMC9825644 DOI: 10.1007/s10549-022-06806-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/03/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE At least 5 years of adjuvant endocrine therapy (ET) is recommended for patients with hormone receptor-positive invasive breast cancer to reduce cancer recurrence risk. Up to half of patients prematurely discontinue ET, often due to musculoskeletal pain. Nociplastic pain is abnormal central nervous system pain processing without evidence of tissue or neuronal damage. This study aimed to evaluate the relationship between baseline nociplastic pain and ET discontinuation. METHODS This was a retrospective, single center, cohort study. Included patients were female, had stage 0-III invasive breast cancer, did not receive neoadjuvant therapy, and completed quality of life questionnaires prior to breast surgery, including Fibromyalgia Survey for nociplastic pain. Clinical data including duration of ET were abstracted from the medical record. Patient characteristics were analyzed with t-tests and Chi-squared tests, as appropriate. Univariate and multivariable regressions were performed with Cox proportional hazard models. RESULTS Six hundred eighty-one patients diagnosed between 2012 and 2019 met inclusion criteria; 480 initiated ET and were included in the analysis. Of these 480 patients, 203 (42.3%) prematurely discontinued initial ET therapy. On univariate analysis, tamoxifen use (hazard ratio [HR] 0.70, p = 0.021) and premenopausal status (HR 0.73, p = 0.04) were inversely associated with ET discontinuation, while Fibromyalgia Score was positively associated (HR 1.04, p = 0.043). On multivariable analysis, baseline Fibromyalgia Score remained associated with ET discontinuation. CONCLUSION Nociplastic pain present prior to surgery was associated with premature ET discontinuation. Fibromyalgia Score screening may be useful for evaluating ET discontinuation risk. Treatments targeting nociplastic pain may be more effective for treating ET-emergent pain.
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Affiliation(s)
| | - Grant Carr
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Sidi Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - N Lynn Henry
- Department of Internal Medicine, University of Michigan Medical School, 1500 East Medical Center Dr. Room 7322, Ann Arbor, MI, 48109, USA.
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18
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Wang K, Shen L, Tian W, Zhang S. Comparison of changes in lipid profiles of premenopausal women with early-stage breast cancer treated with different endocrine therapies. Sci Rep 2022; 12:22650. [PMID: 36587111 PMCID: PMC9805421 DOI: 10.1038/s41598-022-27008-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023] Open
Abstract
Adjuvant endocrine therapy improves the prognosis of early breast cancer with hormone receptor positivity. However, there is no systematic report on the effect of endocrine therapy (particularly ovarian function suppression, OFS) on serum lipids in premenopausal women. This retrospective cohort study aimed to determine whether various endocrine treatments had different effects on blood lipids. This study enrolled 160 premenopausal patients with stage I-III breast cancer in eastern China. The initial diagnostic information was retrieved from patient's medical records, including age at the time of diagnosis, tumor characteristics, anticancer treatment and past medical history. The changes in blood lipids in patients receiving different types of endocrine therapy were compared at the 3rd, 6th, 12th, and 24th months after initiating endocrine therapy. Generalized linear mixed model was used in our analyses. Our data revealed that low-density lipoprotein cholesterol (LDL-C) levels in patients with tamoxifen (TAM) were significantly lower in the 6th, 12th, and 24th months than that in the 3rd month, while high-density lipoprotein cholesterol (HDL-C) levels in the 6th, 12th, and 24th months were significantly higher than that in the 3rd month, indicating that blood lipid levels generally improved with time. While in TAM plus OFS group, HDL-C levels were significantly higher in the 24th month than in the 3rd month, total cholesterol (TC) levels were significantly higher in the 24th month than in the 6th month. The lipid profiles of OFS plus aromatase inhibitor (AI) group did not show significant differences at any time point but were significantly higher than those of the other two groups especially in LDL and TC. TAM group tended to have lower serum lipid levels. With longer follow-up, no statistically significant difference in values was observed between TAM and TAM plus OFS groups at various time points. Compared with the other two groups, OFS plus AI group presented an increasing trend toward LDL-C and TC. The risk of dyslipidemia requires further investigation using a large sample size.
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Affiliation(s)
- Kaiyue Wang
- grid.13402.340000 0004 1759 700XDepartment of Breast Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 China
| | - Lu Shen
- grid.13402.340000 0004 1759 700XDepartment of Breast Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 China
| | - Wei Tian
- grid.13402.340000 0004 1759 700XDepartment of Breast Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 China
| | - Suzhan Zhang
- grid.13402.340000 0004 1759 700XCancer Institute (The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), Department of Surgical Oncology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009 China
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Long-Term Effects of Breast Cancer Therapy and Care: Calm after the Storm? J Clin Med 2022; 11:jcm11237239. [PMID: 36498813 PMCID: PMC9738151 DOI: 10.3390/jcm11237239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/01/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
Breast cancer is still a lethal disease and the leading cause of death in women, undermining patients' survival and quality of life. Modern techniques of surgery and radiotherapy allow for the obtaining of good results in terms of survival, however they cause long-term side effects that persist over time, such as lymphedema and neuropathy. Similarly, the advent of new therapies such as endocrine therapy revolutionized breast cancer outcomes, but side effects are still present even in years of follow-up after cure. Besides the side effects of medical and surgical therapy, breast cancer is a real disruption in patients' lives considering quality of life-related aspects such as the distortion of body image, the psychological consequences of the diagnosis, and the impact on family dynamics. Therefore, the doctor-patient relationship is central to providing the best support both during treatment and afterwards. The aim of this review is to summarize the consequences of medical and surgical treatment on breast cancer patients and to emphasize the importance of early prevention of side effects to improve patients' quality of life.
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Persistence with tamoxifen and aromatase inhibitors in Germany: a retrospective cohort study with 284,383 patients. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04376-5. [PMID: 36149512 DOI: 10.1007/s00432-022-04376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/20/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The aim of this study was to analyze the persistence of women on tamoxifen (TAM) and aromatase inhibitors (AIs) in Germany, and to investigate possible determinants of non-persistence. METHODS The present retrospective cohort study was based on the IQVIA longitudinal prescription database (LRx). The study included women with an initial prescription of TAM or AIs (anastrozole, letrozole, and exemestane) between January 2016 and December 2020 (index date). Kaplan-Meier analyses were performed to show the persistence for TAM and AI, using a therapy gap of 90 or 180 days, respectively. A multivariable Cox proportional hazards regression model was further used to estimate the relationship between non-persistence and drug prescription (AI versus TAM), age, and the specialty of the physician initiating therapy (gynecologist, oncologist, or general practitioner). RESULTS Up to 5 years after the index date, only 35.1% of AI and 32.5% of TAM patients were continuing therapy when therapy discontinuation was defined as at least 90 days without therapy. Using a 180-day therapy gap, 51.9% of AI and 50.4% of TAM patients remained on therapy after 5 years. Cox regression models reveal that initial therapy with TAM (HR 1.06, 95% CI 1.04-1.07), therapy initiation by oncologists (HR 1.09, 95% CI 1.07-1.11), or general practitioners (HR 1.24, 95% CI 1.21-1.27) and age ≤ 50 (HR 1.08, 95% CI 1.06-1.10) were significantly associated with an increased risk of therapy discontinuation. CONCLUSION Overall, the present study indicates that persistence rates are low in all age groups for both TAM and AI treatment. We found several factors (e.g., physician specialty, younger age, and type of endocrine therapy) to be associated with an increased risk for non-persistence.
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Hyder T, Marino CC, Ahmad S, Nasrazadani A, Brufsky AM. Aromatase Inhibitor-Associated Musculoskeletal Syndrome: Understanding Mechanisms and Management. Front Endocrinol (Lausanne) 2021; 12:713700. [PMID: 34385978 PMCID: PMC8353230 DOI: 10.3389/fendo.2021.713700] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/12/2021] [Indexed: 12/31/2022] Open
Abstract
Aromatase inhibitors (AIs) are a key component in the chemoprevention and treatment of hormone receptor-positive (HR+) breast cancer. While the addition of AI therapy has improved cancer-related outcomes in the management of HR+ breast cancer, AIs are associated with musculoskeletal adverse effects known as the aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) that limit its tolerability and use. AIMSS is mainly comprised of AI-associated bone loss and arthralgias that affect up to half of women on AI therapy and detrimentally impact patient quality of life and treatment adherence. The pathophysiology of AIMSS is not fully understood though has been proposed to be related to estrogen deprivation within the musculoskeletal and nervous systems. This review aims to characterize the prevalence, risk factors, and clinical features of AIMSS, and explore the syndrome's underlying mechanisms and management strategies.
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Affiliation(s)
- Tara Hyder
- University of Pittsburgh Physicians, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Christopher C Marino
- Mario Lemieux Center for Blood Cancers, University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, Pittsburgh, PA, United States
| | - Sasha Ahmad
- Department of Sciences, Sewickley Academy, Pittsburgh, PA, United States
| | - Azadeh Nasrazadani
- UPMC Hillman Cancer Center, Magee Women's Hospital, Pittsburgh, PA, United States
| | - Adam M Brufsky
- UPMC Hillman Cancer Center, Magee Women's Hospital, Pittsburgh, PA, United States
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