Weight, physical activity, diet, and prognosis in breast and gynecologic cancers

Outcomes of older adults with early-stage triple-negative breast cancer (TNBC) receiving chemotherapy: a single-institution experience

BACKGROUND

Despite lower chemotherapy use in older triple-negative breast cancer (TNBC) patients, their outcomes match younger counterparts. We compared outcomes in early-stage TNBC patients by age receiving chemotherapy at a major cancer center with a national TNBC database.

METHODS

Retrospective study using institutional data on stage I-III TNBC (ER/PR < 10%) women with neoadjuvant/adjuvant chemotherapy. Based on their ages at diagnosis, patients were stratified into four categories: ≤40, 41-59, 60-69, and ≥ 70 years. Demographic and clinical characteristics recorded included race, disease stage, ER/PR positivity, treatment regimen, lymphatic or vascular invasion (LVI), histologic grade, Ki-67 level, body mass index (BMI), and pathologic complete response (pCR) following neoadjuvant treatment and are summarized using descriptive statistics. The primary endpoints were overall survival (OS), disease-free survival (DFS), and distant disease-free survival (DDFS); all were estimated using the Kaplan-Meier method. Both univariate and multivariate (MV) Cox regressions were applied to evaluate the impact of important covariates on these time-to-event endpoints.

RESULTS

Of the 2336 patients studied, 492 (21.1%) were ≤ 40 years old, 1239 (53.1%) were 41-59, 461 (19.7%) were 60-69, and 144 (6.2%) were ≥ 70. In the univariate regression model of OS/DFS/DDFS, age ≥ 70 was significantly associated with worse OS (p = 0.0217); other factors associated with worse OS were non-anthracycline-based chemotherapy, higher tumor stage, and neoadjuvant chemotherapy. The multivariate Cox regression model, adjusted for race and stage, showed no significant effects of age on OS; however, patients ≥ 70 years old who received non-anthracycline treatment combinations had worse DFS (hazard ratio = 0.349 vs. 1.049, p = 0.0293) and DDFS (hazard ratio = 0.317 vs. 1.016, p = 0.0251) than patients ≤ 40 years old. DFS from MV model after adjusting for age, race, and disease stage, the hazard ratio between anthracycline + taxane treatments and anthracycline + other treatments in patients ≥ 70 years old was statistically significantly lower than in patients ≤ 40 years old (hazard ratios [HRs] = 0.349 vs. 1.049, p = 0.0293).

CONCLUSIONS

Our findings indicate that outcomes such as DFS are less favorable in older compared to younger patients with early-stage TNBC, primarily in those who did not receive an anthracycline based chemotherapy regimen.

WLCD: a dataset of lifestyle in relation with women's cancer

OBJECTIVES

Social media text mining has been widely used to extract information about the experiences and needs of patients regarding various diseases, especially cancer. Understanding these issues is necessary for further management in primary care. Researchers have identified that lifestyle factors such as diet, exercise, alcohol, and Smoking are associated with cancer risks, particularly women's cancer. Considering the growing trend in the global burden of women's cancer, it is essential to monitor up-to-date data sources using text mining.

DATA DESCRIPTION

We have prepared six independent datasets regarding lifestyle components and women's cancer: (1) a dataset of nutrition containing 10,161 tweets; (2) a dataset of exercise containing 9412 tweets; (3) a dataset of alcohol containing 2132 tweets; (4) a dataset of Smoking containing 4316 tweets; and (5) a dataset of lifestyle (term) containing 1861 tweets. We also construct an additional dataset: (6) a dataset by summing other components containing 27,882 tweets. These data are provided to discover people's perspectives, knowledge, and experiences regarding lifestyle and women's cancer. Hence, it should be valuable for healthcare providers to develop more efficient patient management approaches.

Associations of Post-Diagnosis Lifestyle with Prognosis in Women with Invasive Breast Cancer

BACKGROUND

Lifestyle habits can impact breast cancer development, but its impact on breast cancer prognosis remains unclear. We investigated associations of post-diagnosis lifestyle with mortality and recurrence in 1,964 women with invasive breast cancer enrolled in the Kaiser Permanente Northern California Pathways Study shortly after diagnosis with lifestyle information at baseline (2005-2013) and the 2-year follow-up.

METHODS

We calculated a post-diagnosis lifestyle score (range, 0-18) based on 9 diet, physical activity, and body weight recommendations from the American Cancer Society/American Society of Clinical Oncology (ACS/ASCO) using follow-up data (body weight also included baseline data); higher scores indicate greater guideline concordance. Similarly, we calculated a pre-diagnosis lifestyle score using baseline data to investigate pre- to post-diagnosis changes. We estimated hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional hazard models, with follow-up through December 2018 (observing 290 deaths and 176 recurrences).

RESULTS

The 2-year post-diagnosis lifestyle score was inversely associated with all-cause mortality (ACM; HR per 2-point increase = 0.90; 95% CI, 0.82-0.98), and breast cancer-related mortality (HR, 0.79; 95% CI, 0.67-0.95), but not recurrence. Relative to women who maintained low concordance with recommendations at both time points, women who maintained high concordance had a lower risk of ACM (HR, 0.61, 95% CI, 0.37-1.03). Improved concordance with some specific recommendations (particularly PA) may be associated with a lower hazard of ACM (HRPA, 0.52; 95% CI, 0.35-0.78).

CONCLUSIONS

Results suggest that women with breast cancer may benefit from a post-diagnosis lifestyle aligned with ACS/ASCO guidelines.

IMPACT

This information may potentially guide lifestyle recommendations for breast cancer survivors to reduce mortality risk.

Measuring the Impact of the COVID-19 Pandemic on Health Behaviors and Health Care Utilization in Rural and Urban Patients with Cancer and Cancer Survivors

Healthcare access and health behaviors differ between those living in urban and rural communities and contribute to inequitable cancer health outcomes. The COVID-19 pandemic led to significant disruptions in daily life and healthcare delivery. This cross-sectional survey aimed to measure the impact of the COVID-19 pandemic on the health behaviors of cancer patients and survivors, comparing outcomes for urban and rural respondents. Survey was administered from January 2021-June 2021 to cancer patients or survivors (treated within the last 5 years) at one of six cancer centers in Washington and Idaho. Respondent ZIP code was used to assess rurality using Rural-Urban Commuting Area designation. 515 rural (43.5% of those contacted) and 146 urban (40% of those contacted) cancer patients and survivors participated. Few differences between urban and rural cancer patients and cancer survivors were noted. Rural residents were older (69.2 years vs. 66.9 years). Rural respondents had higher mean alcohol consumption than urban respondents (4.4 drinks per week vs. 2.7 drinks per week). 12.2% of those who reported drinking in the last 30 days also reported increased alcohol consumption since the start of the pandemic, with no difference in reported increased alcohol consumption in rural vs. urban respondents. 38.5% reported decreased physical activity. 20.5% reported cancelling or delaying cancer care due to the COVID-19 pandemic. Delays in cancer healthcare services and worsening health behaviors due to the COVID-19 pandemic may contribute to poorer health outcomes, with few differences between rural and urban cancer patients and cancer survivors.

[Impact of adapted physical activity on joint pain induced under adjuvant hormone therapy for breast cancer: A review of the literature]

Hormone therapy provides an excellent survival rate after cancer but has many side effects, including joint pain in one out of two women. This leads about 13 % of women to stop their treatment within the first 6 months, impacting on its effectiveness, survival and the risk of recurrence. In order to better manage pain and quality of life, physical activity is highly recommended. In this context, the present review proposes a state of the art on the effects of adapted physical activity, based on the works referenced in PubMed. These studies show that physical activity has proved its worth in the primary prevention of cancer and is being evaluated in secondary prevention, particularly in the reduction of adverse effects. Overall, there is a reduction in joint pain, an improvement in quality of life and fatigue. Physical activity also plays a role in tertiary prevention. Paradoxically, oncologists and educators often note a reduction in the practice of physical activity due to fear of the onset of pain. It seems necessary to reinforce communication with patients and health professionals and to recommend the practice of physical activity in an appropriate setting.

Impacts of nutritive and bioactive compounds on cancer development and therapy

For persons who survive with progressive cancer, nutritional therapy and exercise may be significant factors to improve the health condition and life quality of cancer patients. Nutritional therapy and medications are essential to managing progressive cancer. Cancer survivors, as well as cancer patients, are mostly extremely encouraged to search for knowledge about the selection of diet, exercise, and dietary supplements to recover as well as maintain their treatment consequences, living quality, and survival of patients. A healthy diet plays an important role in cancer treatment. Different articles are studied to collect information and knowledge about the use of nutrients in cancer treatment as well as cancer prevention. The report deliberates nutrition and exercise strategies during the range of cancer care, emphasizing significant concerns during treatment of cancer and for patients of advanced cancer, but concentrating mostly on the requirements of the population of persons who are healthy or who have constant disease following their repossession from management. It also deliberates choice nutrition and exercise problems such as dietary supplements, food care, food selections, and weight; problems interrelated to designated cancer sites, and common questions about diet, and cancer survival. Decrease the side effects of medicines both during and after treatment.

Significant Physical and Exercise-Related Variables for Exercise-Centred Lifestyle: Big Data Analysis for Gynaecological Cancer Patients

This study investigated the characteristics of gynaecological cancers and is aimed at identifying significant risk variables using the National Health Insurance Sharing Service database to develop practical interventions for affected patients. Data regarding patients with uterine and ovarian cancer from the National Health Insurance Sharing Service database were collected and analysed using Student's t-test, logistic regression, and receiver operating characteristic curve analyses. Student's t-test analyses revealed that age, body mass index, blood pressure, and waist variables differed significantly among patients with uterine cancer. Gamma-glutamyl transpeptidase levels were higher in patients with ovarian cancer than in patients with uterine cancer. Physical fitness function tests reflected the status of patients with cancer. Moreover, physical disability was associated with an increased incidence of ovarian cancer. Intensive exercise for 20 min more than 1 time per week must be avoided to prevent uterine cancer. Receiver operating characteristic curve analyses showed that the optimal cutoff value for one-leg standing time, a prognostic and preventive factor in ovarian cancer, was 9.50 s (sensitivity, 94.9%; specificity, 96.9%). Controlling significant variables for each gynaecological cancer type in an individualised and optimised manner is recommended, including by maintenance of an adjusted exercise-centred lifestyle.

Quantity of Resistance Exercise for Breast Cancer Patients: Does the Dose Match the Objective?

ABSTRACT

Rosenberg, J, Hyde, PN, Yancy, WS, Ford, KM, and Champ, CE. Quantity of resistance exercise for breast cancer patients: does the dose match the objective? J Strength Cond Res 35(5): 1467-1476, 2021-There is currently a lack of consensus as to what defines exercise and resistance training in the cancer setting and whether current studies comply with exercise guidelines. This study aimed to quantify the available research studies using resistance training exercise interventions in the breast cancer setting for future clinical trial utilization. We systemically reviewed all available resistance exercise studies during and after breast cancer treatment in an attempt to quantify to the prescribed dose and whether regimens aligned with general exercise guidelines to improve functional mobility, body composition, and metabolic function. They were then compared with recommendations set forth by the national committees that create evidence-based exercise guidelines. Fifty studies met the initial criteria, with 35 meeting analysis criteria for evaluation. Fifteen studies evaluated an exercise regimen during cancer treatment, and 20 evaluated a regimen after treatment. The average adherence rates were 84% for all studies. Only 23 studies listed specific exercises used within the protocol. Most exercise regimens relied on open chain movements and machine exercises. Around half of studies met criteria to achieve hypertrophy, and 66% met American College of Sports Medicine exercise guidelines for cancer patients. A minority of breast cancer studies implementing a resistance training exercise regimen prescribed a regimen or specific dose that follows general exercise guidelines. This study highlights a potential deficiency in exercise programs designed for patients with breast cancer, and these findings should be considered in future study design.

A Narrative Review of the Role of Diet and Lifestyle Factors in the Development and Prevention of Endometrial Cancer

Simple Summary

The incidence and prevalence of endometrial cancer is increasing globally. The main factors involved in this increase have been the way women live today and what they eat and drink. In fact, the obesity pandemic that is sweeping across the planet is considered to be the main contributory feature. This review aims to introduce to a new audience, those that are not experts in the field, what is known about the different types of endometrial cancer and the mechanisms for their induction and protection. We also seek to summarise the existing knowledge on dietary and lifestyle factors that prevent endometrial development in susceptible populations and identify the main problem in this arena; the paucity of research studies and clinical trials that investigate the interaction(s) between diet, lifestyle and endometrial cancer risk whilst highlighting those areas of promise that should be further investigated.

Abstract

Endometrial cancer is the most common cancer affecting the reproductive organs of women living in higher-income countries. Apart from hormonal influences and genetic predisposition, obesity and metabolic syndrome are increasingly recognised as major factors in endometrial cancer risk, due to changes in lifestyle and diet, whereby high glycaemic index and lipid deposition are prevalent. This is especially true in countries where micronutrients, such as vitamins and minerals are exchanged for high calorific diets and a sedentary lifestyle. In this review, we will survey the currently known lifestyle factors, dietary requirements and hormonal changes that increase an individual’s risk for endometrial cancer and discuss their relevance for clinical management. We also examine the evidence that everyday factors and clinical interventions have on reducing that risk, such that informed healthy choices can be made. In this narrative review, we thus summarise the dietary and lifestyle factors that promote and prevent the incidence of endometrial cancer.

Effects of Adiposity and Exercise on Breast Tissue and Systemic Metabo-Inflammatory Factors in Women at High Risk or Diagnosed with Breast Cancer

Excess body fat and sedentary behavior are associated with increased breast cancer risk and mortality, including in normal weight women. To investigate underlying mechanisms, we examined whether adiposity and exercise impact the breast microenvironment (e.g., inflammation and aromatase expression) and circulating metabo-inflammatory factors. In a cross-sectional cohort study, breast white adipose tissue (WAT) and blood were collected from 100 women undergoing mastectomy for breast cancer risk reduction or treatment. Self-reported exercise behavior, body composition measured by dual-energy x-ray absorptiometry (DXA), and waist:hip ratio were obtained prior to surgery. Breast WAT inflammation (B-WATi) was assessed by IHC and aromatase expression was assessed by quantitative PCR. Metabolic and inflammatory blood biomarkers that are predictive of breast cancer risk and progression were measured. B-WATi was present in 56 of 100 patients and was associated with older age, elevated BMI, postmenopausal status, decreased exercise, hypertension and dyslipidemia (Ps < 0.001). Total body fat and trunk fat correlated with B-WATi and breast aromatase levels (Ps < 0.001). Circulating C-reactive protein, IL6, insulin, and leptin positively correlated with body fat and breast aromatase levels, while negative correlations were observed for adiponectin and sex hormone binding globulin (P < 0.001). Inverse relationships were observed with exercise (Ps < 0.05). In a subgroup of 39 women with normal BMI, body fat levels positively correlated with B-WATi and aromatase expression (Ps < 0.05). In conclusion, elevated body fat levels and decreased exercise are associated with protumorigenic micro- and host environments in normal, overweight, and obese individuals. These findings support the development of BMI-agnostic lifestyle interventions that target adiposity. PREVENTION RELEVANCE: We report that individuals with high body fat and low exercise levels have breast inflammation, higher breast aromatase expression, and levels of circulating metabo-inflammatory factors that have been associated with increased breast cancer risk. These findings support interventions to lower adiposity, even among normal weight individuals, to prevent tumor growth.

Optimizing Cardiovascular Health in Patients With Cancer: A Practical Review of Risk Assessment, Monitoring, and Prevention of Cancer Treatment-Related Cardiovascular Toxicity

Advances in cancer screening and improved treatment approaches have led to an increase in survivorship and, consequently, recognition of an association between cancer treatments and the development of cardiovascular complications. In addition, as the population becomes proportionally older, comorbid cardiovascular risk factors are more prevalent in the population and compound the risk of developing cancer treatment-related cardiovascular toxicity. Cardio-oncology has emerged as a new subspecialty of medicine that provides a multidisciplinary approach, bringing together oncologists, cardiologists, and allied health care providers who are tasked with optimizing the cardiovascular health of patients exposed to potentially cardiotoxic cancer therapy. Using a case-based approach, practical advice on how to identify, monitor, and treat patients with cancer who are at risk for developing cancer treatment-related cardiovascular dysfunction is discussed. Cardiovascular risk factors (e.g., age, hypertension, diabetes) and cancer therapies (chemotherapy, targeted therapy, radiation) associated with cardiovascular toxicity are presented. Current cardiac monitoring strategies such as two- and three-dimensional echocardiography, cardiac MRI, and biomarkers (troponin and brain natriuretic peptide [BNP]) are discussed. Last, the current literature on pharmacologic (e.g., angiotensin-converting enzyme inhibitors, β-blockers, statins) and lifestyle (diet and exercise) strategies to mitigate cardiovascular toxicity during and following completion of cancer therapy are reviewed.

Knowledge and self-efficacy for caring for breast and colon cancer survivors among safety net primary care providers

BACKGROUND

Primary care providers (PCPs) are critical to the provision of comprehensive care for cancer survivors, yet there is very little data on the practices and quality of survivorship care occurring in safety net primary care settings. This study aimed to assess the knowledge and attitudes of PCPs and preferences for care models for breast and colon cancer survivors in a safety net health network.

METHODS

A modified National Cancer Institute Survey of Physician Attitudes Regarding the Care of Cancer Survivors was sent electronically to 220 PCPs in 12 primary care clinics in the San Francisco Health Network affiliated with Zuckerberg San Francisco General Hospital and Trauma Center.

RESULTS

The response rate was 50% (110/220). About half of PCPs strongly/somewhat agreed (vs. strongly/somewhat disagreed) that PCPs have the knowledge needed to provide follow-up care related to breast (50%) and colon cancer (54%). Most providers (93%) correctly reported recommended frequency of mammography, however, frequency of blood tests and other imaging surveillance were not as well recognized for breast or colon cancer. Recognition of long-term side effects of chemotherapy drugs ranged from 12% for oxaliplatin to 44% for doxorubicin. Only 33% of providers reported receiving any survivorship training. The most preferred model for survivorship care was shared care model (40%).

CONCLUSIONS

Safety net PCPs prefer a shared care model for care of cancer survivors but are limited by lack of training, poor communication, and poor delineation of roles. Patient-centered survivorship care can be improved through effective oncologist-PCP-patient partnerships and coordination.

Clinical value of selected markers of angiogenesis, inflammation, insulin resistance and obesity in type 1 endometrial cancer

Background

It is a well-known fact show that the risk of developing endometrial cancer (type 1 EC) is strongly associated with obesity. In this study, selected markers, such as obesity, insulin resistance, angiogenesis and inflammation markers related to EC type 1 progression and patients’ survival data were analyzed.

Methods

To measure levels of adiponectin, C-reactive protein (CRP), vascular endothelial growth factor-A (VEGF-A), angiopoietin-2 (Ang-2), insulin-like growth factor-1 (IGF-1), insulin and C-peptide in 176 preoperative serum samples, the immunoassay technique (EMIT) has been applied.

Results

Angiopoietin-2 levels increase with age (P = 0.005), FIGO stage (p = 0.042), myometrial invasion (P = 0.009) and LVSI (P < 0.001). The CRP levels increase with age (P = 0.01), as well as the advancement of the FIGO stage (P < 0.001), higher tumor grade (P = 0.012), and myometrial invasion (P < 0.001). A positive correlation between serum Ang-2 and CRP levels was demonstrated (r = 0.44; p < 0.001). Kaplan-Meier survival analysis showed that patients with high CRP levels in serum and Ang-2 presented a worse outcome (P = 0.03 and P = 0.015, respectively). Cox regression analysis of individual predictors revealed that high serum levels of Ang-2, CRP, advanced clinical FIGO stage (P < 0.001, respectively), old age (P = 0.013) were all significant overall survival predictors. By means of multivariate analysis, their predictive significance was confirmed.

Conclusion

Our study provides evidence that serum levels of Ang-2 and CRP may serve as predictors for assessment of the clinical stage of type 1 EC and are significantly associated with poor prognosis. It is likely that angiogenesis and inflammation associated with obesity have a significant impact on EC type 1 progression and survival rate of patients.

Barriers to physical activity participation in colorectal cancer patients during chemotherapy treatment: A qualitative study

PURPOSE

To explore the barriers that colorectal cancer patients (stage II and III) perceive to participate in physical activity (PA) when involved in adjuvant chemotherapy. Views of relatives and physicians concerning this issue were also included.

METHOD

Qualitative data from ten patients, ten relatives, and ten health professionals were obtained through semi-structured interviews (n = 30).

RESULTS

Two main themes were identified after data analysis: (a) barriers to PA related to ostomy and adjuvant chemotherapy and (b) barriers related to perceived lack of support for PA. In regard to the first theme, participants reported difficulties associated with the ostomy, limitations of the intravenous chemotherapy device, fatigue and reduced physical fitness, and focusing on cancer and restructuring priorities. Concerning the perceived lack of support for PA, participants referred to their families' overprotection, the health professionals' lack of knowledge and time to prescribe PA, and the lack of PA services in health centres.

CONCLUSIONS

Further information from health professionals about the recommendations of PA and its benefits during adjuvant chemotherapy could palliate these PA barriers. The offer of specific PA programmes for these patients is also recommended.

Discrepancy between perceived diet quality and actual diet quality among US adult cancer survivors

OBJECTIVES

Little is known about cancer survivors' self-perception of their dietary quality compared with their measured diet quality and how those perceptions may influence their actual diet. This study aimed to fill this gap using national large datasets.

METHODS

National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2014 were used. The healthy eating index (HEI) based on 24-h dietary recall was used to measure diet quality. Logistic regression models were fit to examine the influence of the misperception of eating healthiness on diet quality.

RESULTS

The agreement between self-perceived and actual diet quality was low (Kappa = 0.06, 95% CI: 0.02, 0.09) among cancer survivors. Over-rating diet quality was associated with a 5.39 lower total HEI score (P < 0.0001), 1.00 lower HEI score for empty calorie intake (P = 0.0028), 0.15 lower score for vegetable intake (P = 0.108), and 0.29 lower score for fruit intake; under-rating one's diet quality was associated with a 7.12 higher total HEI score (P < 0.0001), 2.57 higher HEI score for empty calorie intake (P < 0.0001), 0.02 higher score for vegetable intake (P = 0.904), and 0.84 higher score for fruit intake (P = 0.001). Our multinomial regression estimates suggested that each 10-year increase in age was associated with an increase in the odds of being an over-rater vs. a correct-rater (OR: 11.4, 95% CI: 10.01, 10.2). Hispanics were more likely than non-Hispanic whites to over-rate their diet quality (OR: 1.792, 95% CI: 1.062, 3.024).

CONCLUSIONS

Tailored nutrition interventions and guidance aimed at reducing the divergence between self-assessed and actual diet quality have the potential to improve cancer survivorship and narrow racial/ethnic and socioeconomic disparities.

The impact of breast cancer on physical activity from midlife to early older adulthood and predictors of change post-diagnosis

PURPOSE

To examine physical activity (PA) patterns from pre- to post-diagnosis, and compare these changes to women without breast cancer. To determine pre-diagnosis predictors of PA change, post-diagnosis, in breast cancer survivors (BCS).

METHODS

Data were from 2314 Study of Women's Health Across the Nation (SWAN) participants, average age of 46.4 ± 2.7 years at baseline (1996-1997). In Pink SWAN, 151 women who reported an incident breast cancer diagnosis over 20 years were classified as BCS; the remaining 2163 women were controls. LOESS plots and linear mixed models were used to illustrate and compare PA changes (sports/exercise [primary measure] and total PA) from pre- to post-diagnosis (or corresponding period) in BCS versus controls. Adjusted linear regression models were used to determine pre-diagnosis predictors of at-risk post-diagnosis PA change patterns (consistently low and decreased PA).

RESULTS

No differences in pre- to post-diagnosis PA (or corresponding period) were observed in BCS versus controls. Among BCS, the odds of at-risk post-diagnosis PA change patterns was 2.50 (95% CI 0.96-6.48) times higher for those who reported sleep problems at ≥ 50% (compared to 0%) of pre-diagnosis visits and 3.49 (95% CI 1.26-9.65) times higher for those who were overweight or obese at all (compared to no) pre-diagnosis visits. No other statistically significant predictors were noted.

CONCLUSIONS

Age-related declines in PA were not amplified by a breast cancer diagnosis. Given the beneficial role of PA across the cancer control continuum, efforts to increase or maintain adequate PA, post-diagnosis, should be continued.

IMPLICATIONS FOR CANCER SURVIVORS

While age-related physical activity declines were not amplified breast cancer diagnosis, efforts to identify breast cancer survivors at increased risk for post-diagnosis physical activity declines (or maintenance of low activity) may be a high-yield strategy to improve prognosis and quality of life.

Sphingosine Kinase 1 in Breast Cancer-A New Molecular Marker and a Therapy Target

It is now well-established that sphingosine kinase 1 (SK1) plays a significant role in breast cancer development, progression, and spread, whereas SK1 knockdown can reverse these processes. In breast cancer cells and tumors, SK1 was shown to interact with various pathways involved in cell survival and chemoresistance, such as nuclear factor-kappa B (NFκB), Notch, Ras/MAPK, PKC, and PI3K. SK1 is upregulated by estrogen signaling, which, in turn, confers cancer cells with resistance to tamoxifen. Sphingosine-1-phosphate (S1P) produced by SK1 has been linked to tumor invasion and metastasis. Both SK1 and S1P are closely linked to inflammation and adipokine signaling in breast cancer. In human tumors, high SK1 expression has been linked with poorer survival and prognosis. SK1 is upregulated in triple negative tumors and basal-like subtypes. It is often associated with high phosphorylation levels of ERK1/2, SFK, LYN, AKT, and NFκB. Higher tumor SK1 mRNA levels were correlated with poor response to chemotherapy. This review summarizes the up-to-date evidence and discusses the therapeutic potential for the SK1 inhibition in breast cancer, with emphasis on the mechanisms of chemoresistance and combination with other therapies such as gefitinib or docetaxel. We have outlined four key areas for future development, including tumor microenvironment, combination therapies, and nanomedicine. We conclude that SK1 may have a potential as a target for precision medicine, its high expression being a negative prognostic marker in ER-negative breast cancer, as well as a target for chemosensitization therapy.

Factors Affecting Long-Survival of Patients with Breast Cancer by Non-Mixture and Mixture Cure Models Using the Weibull, Log-logistic and Dagum Distributions: A Bayesian Approach

BACKGROUND

Breast cancer is a top biomedical research priority, and it is a major health problem. Therefore, the present study aimed to determine the prognostic factors of breast cancer survival using cure models.

METHODS

In this retrospective cohort analytic study, data of 140 breast cancer patients were collected from Ali Ibn Abi Taleb hospital, Rafsanjan, Southeastern Iran. Since in this study, a part of the population had long-term survival, cure models were used and evaluated using DIC index. The data were analyzed using Openbugs Software.

RESULTS

In this study, of 140 breast cancer patients, 23 (16.4%) cases died of breast cancer. Based on the findings, the Bayesian nonmixture cure model, with type I Dagum distribution, was the best fitted model. The variables of BMI, number of children, number of natural deliveries, tumor size, metastasis, consumption of canned food, tobacco use, and breastfeeding affected patients' survival based on type I Dagum distribution.

CONCLUSION

The results of the present study demonstrated that the Bayesian nonmixture cure model, with type I Dagum distribution, can be a good model to determine factors affecting the survival of patients when there is the possibility of a fraction of cure. In this study, it was found that adapting a healthy lifestyle (eg, avoiding canned foods and smoking) can improve the survival of breast cancer patients.

Physical Activity: Impact on Survival in Gynecologic Cancer

Importance

Physical activity has many important health benefits. There is also growing evidence that physical activity plays a role in the prevention and prognosis of multiple cancers, including gynecologic malignancies. Despite the many benefits of physical activity, the number of individuals meeting physical activity recommendations remains low.

Objective

To examine the role that physical activity plays in the prevention, treatment, and prognosis of gynecologic malignancies and to review the feasibility of physical activity interventions among gynecologic cancer survivors.

Evidence Acquisition

A PubMed search was performed using relevant terms to identify journal articles related to the proposed subject. The websites of multiple national and international organizations were also used to obtain up-to-date guidelines and recommendations.

Results

Physical activity appears to decrease the risk of ovarian, endometrial, and cervical cancer, with the strongest evidence of this association seen in endometrial cancer. Although the literature is scarce, participation in physical activity is feasible during active treatment for gynecologic cancers and may decrease symptom burden and increase chemotherapy completion rates. Gynecologic cancer survivors are motivated to increase physical activity, and lifestyle intervention programs are feasible and well received among this population.

Conclusions and Relevance

Health care providers caring for women with gynecologic malignancies must counsel patients regarding the importance of physical activity. This should include a discussion of the health benefits and, specifically, the cancer-related benefits. A personalized approach to physical activity intervention is essential.

Are cancer survivors following the national comprehensive cancer network health behavior guidelines? An assessment of patients attending a cancer survivorship clinic

PURPOSE

Engaging in positive health behaviors post-treatment is important for cancer survivors' health. However, little is known about whether survivors are practicing health promoting behaviors. We aimed to explore whether survivors are meeting the recent health behavior guidelines set forth by the National Comprehensive Cancer Network (NCCN) and to examine associations between health behaviors and distress.

METHODS

Sixty-six survivors completed a cross-sectional questionnaire assessing health behaviors prior to an initial appointment at a survivorship care clinic. Information about sociodemographic, clinical, and psychosocial variables and six health behavior recommendations, including physical activity, sunscreen use, tobacco use, alcohol consumption, weight management, and annual primary care provider visits, was collected.

FINDINGS

Only 7.6% of survivors met all six NCCN health behavior guidelines. One in ten (10.6%) survivors had smoked a cigarette in the previous 30 days, and half did not use sunscreen regularly (50%), had an unhealthy body mass index (53%), and did not engage in >10 MET-h/week of physical activity (50%). Approximately 1 in 6 (15.1%) survivors reported drinking beyond the recommended limit, and a similar proportion had not seen a PCP in the previous year (27.3%). Clinically significant levels of distress (>5; range 0-10) on the NCCN distress scale were reported by 64.6% of survivors. Participants with clinical levels of distress were less likely to adhere to health behavior guidelines than those who were not distressed (p = .002).

CONCLUSIONS

Overall, survivors engaged at a survivorship clinic did not meet the NCCN recommended health behavior guidelines. Implications for Psychosocial Providers or Policy: Survivors' health behaviors and distress should be assessed and intervened upon during survivorship care. Survivorship clinics may provide a unique forum in which to provide ongoing behavioral health counseling and psychosocial support for these patients.

Changes in dietary intake, plasma carotenoids and erythrocyte membrane fatty acids in breast cancer survivors after a lifestyle intervention: results from a single-arm trial

BACKGROUND

The influence of nutrition on breast cancer prognosis is still inconclusive and therefore dietary interventions incorporating dietary biomarkers are needed to confirm compliance with dietary goals and clarify biological mechanisms. The present study assessed whether a lifestyle intervention in breast cancer survivors could affect dietary biomarkers of fruit and vegetables and fatty acids.

METHODS

In this phase II single-arm trial, 37 overweight/obese early stage breast cancer patients completed a 12-week diet and exercise intervention. The intervention involved 1-h weekly diet sessions delivered by a dietician and 75-min bi-weekly physical activity sessions of moderate-to-high intensity led by trained monitors. Before and after the intervention, three 24-h dietary recalls were carried out to calculate nutrient intakes and, in addition, blood samples were taken to measure plasma carotenoids, vitamin E and retinol concentrations and erythrocyte membrane fatty acid (EFA) composition. Wilcoxon signed rank tests were used to assess changes in dietary and biomarkers measurements over the intervention period.

RESULTS

After the intervention, there was a significant increase in the intake of dietary carotenoids (+15.1% compared to baseline) but not plasma carotenoids levels (+6.3%). Regarding the EFA levels, we observed a significant decrease in percentage of saturated fatty acids (-1.4%) and n-6 polyunsaturated fatty acids (-2.9%) and an increase in monounsaturated fatty acids (1.7%) and total and long-chain n-3 polyunsaturated fatty acids (by 13.1% and 13.7%, respectively). A favourable decrease in the ratio of long-chain n-6 to n-3 polyunsaturated fatty acids (-9.1%) was also observed.

CONCLUSIONS

After a short-term diet and exercise intervention in overweight/obese breast cancer survivors, we observed significant changes in dietary nutrients and fatty acid biomarkers, suggesting positive dietary changes that could be relevant for breast cancer prognosis.

Breast Cancer Survivors' Experiences With an Activity Tracker Integrated Into a Supervised Exercise Program: Qualitative Study

Background

There is growing evidence that physical activity is related to a better prognosis after a breast cancer diagnosis, whereas sedentary behavior is associated with worse outcomes. It is therefore important to stimulate physical activity and reduce sedentary time among patients with breast cancer. Activity trackers offer a new opportunity for interventions directed at stimulating physical activity behavior change.

Objective

This study aimed to explore the experience of patients with breast cancer who used an activity tracker in addition to a supervised exercise intervention in the randomized UMBRELLA Fit trial.

Methods

A total of 10 patients with breast cancer who completed cancer treatment participated in semistructured in-depth interviews about their experience with and suggestions for improvements for the Jawbone UP2 activity tracker.

Results

The activity tracker motivated women to be physically active and created more awareness of their (sedentary) lifestyles. The women indicated that the automatically generated advice (received via the Jawbone UP app) lacked individualization and was not applicable to their personal situations (ie, having been treated for cancer). Furthermore, women felt that the daily step goal was one-dimensional, and they preferred to incorporate other physical activity goals. The activity tracker’s inability to measure strength exercises was a noted shortcoming. Finally, women valued personal feedback about the activity tracker from the physiotherapist.

Conclusions

Wearing an activity tracker raised lifestyle awareness in patients with breast cancer. The women also reported additional needs not addressed by the system. Potential improvements include a more realistic total daily physical activity representation, personalized advice, and personalized goals.

Health Behaviors and Lifestyle Interventions in African American Breast Cancer Survivors: A Review

Background: African American breast cancer survivors have a higher incidence of estrogen receptor negative and basal-like (e.g., triple negative) tumors, placing them at greater risk for poorer survival when compared to women of other racial and ethnic groups. While access to equitable care, late disease stage at diagnosis, tumor biology, and sociodemographic characteristics contribute to health disparities, poor lifestyle characteristics (i.e., inactivity, obesity, and poor diet) contribute equally to these disparities. Lifestyle interventions hold promise in shielding African American survivors from second cancers, comorbidities, and premature mortality, but they are often underrepresented in studies promoting positive behaviors. This review examined the available literature to document health behaviors and lifestyle intervention (i.e., obesity, physical activity, and sedentary behavior) studies in African American breast cancer survivors. Methods: We used PubMed, Academic Search Premier, and Scopus to identify cross-sectional and intervention studies examining the lifestyle behaviors of African American breast cancer survivors. Identified intervention studies were assessed for risk of bias. Other articles were identified and described to provide context for the review. Results: Our systematic review identified 226 relevant articles. The cross-sectional articles indicated poor adherence to physical activity and dietary intake and high rates of overweight and obesity. The 16 identified intervention studies indicated reasonable to modest study adherence rates (>70%), significant reductions in weight (range -1.9 to -3.6%), sedentary behavior (-18%), and dietary fat intake (range -13 to -33%) and improvements in fruit and vegetable intake (range +25 to +55%) and physical activity (range +13 to +544%). The risk of bias for most studies were rated as high (44%) or moderate (44%). Conclusions: The available literature suggests that African American breast cancer survivors adhere to interventions of various modalities and are capable of making modest to significant changes. Future studies should consider examining (a) mediators and moderators of lifestyle behaviors and interventions, (b) biological outcomes, and (c) determinants of enhanced survival in this population.

Pre-diagnostic sex hormone levels and survival among breast cancer patients

PURPOSE

Higher levels of circulating sex steroid hormones are associated with increased breast cancer risk, though their association with prognosis remains unclear. We evaluated the association between circulating sex hormone levels and breast cancer survival in two large cohorts.

METHODS

We evaluated this association among 2073 breast cancer cases from the Nurses' Health Study (NHS) and Nurses' Health Study II (NHSII) cohorts. Women in this analysis provided a blood sample in 1989-1990 (NHS) or in 1996-1999 (NHSII) and were subsequently diagnosed with breast cancer. Levels of estradiol (postmenopausal women only), testosterone, dehydroepiandrosterone-sulfate (DHEAS), and sex hormone-binding globulin (SHBG) were measured in plasma. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for survival, adjusting for patient and tumor characteristics.

RESULTS

A total of 639 deaths and 160 breast cancer deaths occurred over follow-up through 2015. Compared to women in the lowest quartile, postmenopausal women in the highest quartile of estradiol experienced a 1.43-fold overall mortality rate (HR 1.43, 95% CI 1.03-1.97, P-trend = 0.04) and a nonsignificantly higher breast cancer mortality rate (HR 1.50, 95% CI 0.75-2.98, P-trend = 0.12). Higher DHEAS levels were nonsignificantly associated with better overall survival (HR_Q4vsQ1=0.79, 95% CI 0.57-1.10, P-trend = 0.05), though not with breast cancer survival. No associations were observed between testosterone or SHBG and survival.

CONCLUSIONS

Pre-diagnostic postmenopausal circulating estradiol levels were modestly associated with worse survival among breast cancer patients. Further studies should evaluate whether circulating hormone levels at diagnosis predict cancer prognosis or treatment response.

Causal effect of obesity on gynecologic malignancies

INTRODUCTION

Gynecologic malignancies are estimated to affect 110,070 women and will be the cause of death in approximately 32,120 in 2018. Endometrial cancer is among the most prevalent with 63,320 estimated new cases and approximately 11,350 deaths, followed by ovarian cancer with an estimate of 22,000 new cases and 14,000 deaths annually. Obesity is one of the most modifiable risk factors. Providers should engage in a multifaceted approach to patient education and healthcare to decrease the projected cases of obesity-related cancers.

BACKGROUND

The literature demonstrates a significant link between obesity and the development of certain malignancies such as endometrial, pancreatic, and renal cancer. Specific mechanisms found to play a role in the development of these malignancies include alterations of the metabolic pathway attributed to lipid accumulation as well as a chronic inflammatory process. Obesity also predisposes patients to other medical comorbidities as well as a poorer prognosis once a diagnosis of cancer is established. Factors contributing to poorer prognosis include challenges with treatment planning, specifically pertaining to inappropriate chemotherapy dosing and delivery of radiation therapy. Surgical approach and perioperative management are similarly challenging in obese patients and are associated with increased risk of complications.

CONCLUSION

Obesity is a modifiable factor which is associated with an increased risk of cancer and poorer outcomes. Providers should educate patients on all health hazards of obesity, including increased risk of cancer, and encourage them to participate in a structured weight loss plan.

Body Mass Index is Negatively Associated with Endometrial Cancer Stage, Regardless of Subtype and Menopausal Status

Objective: Obesity is one of the common risk factors for developing of endometrial cancer and is negatively associated with its survival, although this result is controversial. Endometrial cancer stages range from stage I, which has better clinical outcomes to stage IV, which has poorer clinical outcomes. Endometrial cancer traditionally divides into type 1 and type 2 dependent on histology which has different clinical outcomes. In this study we investigated whether obesity is associated with the stages of endometrial cancer taking into account subtypes of cancer and menopausal status.

Methods: Data on 1,104 women with endometrial cancer were retrospectively collected from the largest women's hospital in China and analysed. Data included age at diagnosis, body mass index (BMI), histology of cancer and menopausal status.

Results: The BMI in patients with stage I endometrial cancer was significantly higher than that in patients with stage II or III or IV (p=0.0001). However, there was no statistical difference in BMI between patients with stage II, and stage III endometrial cancer. This negative association was persisted with type 1 and type 2 endometrial cancer (p=0.1989) and premenopausal and post-menopausal status (p=0.4342). In addition, the proportion of over-weight or obese women in type1 endometrial cancer with stage I was not different to type 2 endometrial cancer with stage I.

Conclusion: Our data demonstrate that BMI is negatively associated with endometrial cancer in early stage regardless of subtypes of cancer, menopausal status and obesity may be also a potential risk factor for developing type 2 endometrial cancer.

Alcohol and Tobacco Use in an Ethnically Diverse Sample of Breast Cancer Patients, Including Sea Island African Americans: Implications for Survivorship

Background/Objective: Data suggest that modifiable risk factors such as alcohol and tobacco use may increase the risk of breast cancer (BC) recurrence and reduce survival. Female BC mortality in South Carolina is 40% higher among African Americans (AAs) than European Americans (EAs). Given this substantial racial disparity, using a cross-sectional survey design we examined alcohol and tobacco use in an ethnically diverse statewide study of women with recently diagnosed invasive breast cancer. This included a unique South Carolina AA subpopulation, the Sea Islanders (SI), culturally isolated and with the lowest European American genetic admixture of any AA group.

Methods: Participants (42 EAs, 66 non-SI AAs, 29 SIs), diagnosed between August 2011 and December 2012, were identified through the South Carolina Central Cancer Registry and interviewed by telephone within 21 months of diagnosis. Self-reported educational status, alcohol consumption and tobacco use were obtained using elements of the Behavior and Risk Factor Surveillance System questionnaire.

Results:Alcohol: EAs were approximately twice as likely to consume alcohol (40%) and to be moderate drinkers (29%) than either AA group (consumers: 24% of non-SI AAs, 21% of SIs; moderate drinkers 15 and 10% respectively). Users tended to be younger, significantly among EAs and non-SI AAs, but not SIs, and to have attained more education. Heavy drinking was rare (≤1%) and binge drinking uncommon (≤10%) with no differences by race/ethnicity. Among both AA subgroups but not EAs, alcohol users were six to nine times more likely to have late stage disease (Regional or Distant), statistically significant but with wide confidence intervals. Tobacco: Current cigarette smoking (daily or occasional) was reported by 14% of EAs, 14% of non-SI AAs and 7% of SIs. Smoking was inversely associated with educational attainment. Use of both alcohol and cigarettes was reported by 3–6% of cases.

Conclusions: Prevalences of alcohol and cigarette use were similar to those in the general population, with alcohol consumption more common among EAs. Up to half of cases used alcohol and/or tobacco. Given the risks from alcohol for disease recurrence, and implications of smoking for various health outcomes, these utilization rates are of concern.

Lifestyle and Breast Cancer Recurrences: The DIANA-5 Trial

Aims and Background

The DIANA (Diet and Androgens)-5 study is a multi-institutional randomized controlled trial of the effectiveness of a diet based on Mediterranean and macrobiotic recipes and principles, associated with moderate physical activity, in reducing additional breast cancer events in women with early stage invasive breast cancer at high risk of recurrence because of metabolic or endocrine milieu. The intervention is expected to reduce serum insulin and sex hormones, which were associated with breast prognosis in previous studies.

Methods

Between 2008 and 2010, the study randomly assigned 1208 patients to an intensive diet and exercise intervention or to a comparison group, to be followed-up through 2015. General lifestyle recommendations for the prevention of cancer are given to both groups, and the intervention group is being offered a comprehensive lifestyle intervention, including cooking classes, conferences, common meals and exercise sessions. Adherence assessments occurred at baseline and at 12 months and are planned at 36 and 60 months. They include food frequency diaries, anthropometric measures, body fat distribution assessed with impedance scale, one week registration of physical activity with a multisensor arm-band monitor, metabolic and endocrine blood parameters. Outcome breast cancer events are assessed through self report at semi annual meetings or telephone interview and are validated through medical record verification.

Results

The randomized groups were comparable for age (51.8 years), proportion of ER-negative tumors (22%), axillary node metastasis (42%), reproductive variables, tobacco smoking, blood pressure, anthropometric measurements and hormonal and metabolic parameters.

Conclusions

DIANA-5 has the potential to establish whether a Mediterranean-macrobiotic lifestyle may reduce breast cancer recurrences. We will assess evidence of effectiveness, first by comparing the incidence of additional breast cancer events (local or distant recurrence, second ipsilateral or contralateral cancer) in the intervention and in the control group, by an intention-to-treat analysis, and second by analyzing the incidence of breast cancer events in the total study population by compliance assessment score.

Perceived barriers and preferred components for physical activity interventions in African-American survivors of breast or endometrial cancer with type 2 diabetes: the S.U.C.C.E.S.S. framework

PURPOSE

African-American (AA) female cancer survivors share a disproportionate burden of diabetes compared to their white counterparts. Our objectives were to explore the perspectives of AA survivors with type 2 diabetes on perceived barriers to physical activity (PA) and preferences for a PA intervention and develop a framework for a PA program after cancer treatment.

METHODS

Trained interviewers conducted semi-structured interviews with AA survivors of breast or endometrial cancer with diabetes (total n = 20; 16 breast, 4 endometrial). Thirteen open-ended questions were posed to stimulate discussions, which were audio recorded and transcribed verbatim. Two investigators independently reviewed transcriptions and extracted coded quotations to identify major themes.

RESULTS

Median age of participants was 63 years. Nine themes were identified that focused on post-treatment physical symptoms (e.g., lymphedema, bone/joint pain, depression symptoms and self-motivation as barriers to PA, exercise routines tailored to physical limitations and peer partners and program leaders who understand their emotional health needs). The S.U.C.C.E.S.S. framework summarizes the survivors' preferences for an effective lifestyle intervention: Support efforts to maintain PA, Understand physical and depression symptoms, Collaborate with multi-disciplinary provider, Coordinate in-person intervention activities, Encourage partnerships among survivors for comorbidity risk reduction, develop Sustainable coping strategies for side effects of treatment, and Share local community resources.

CONCLUSIONS

Survivors verbalized the need for a multi-disciplinary team to assist with their psychosocial needs and physical limitations to achieve their PA goals, as integrated into the S.U.C.C.E.S.S.

FRAMEWORK

IMPLICATIONS FOR CANCER SURVIVORS

The S.U.C.C.E.S.S. framework reflects the perspectives of survivors with type 2 diabetes and may help to inform post-treatment programs.

Effect of Aromatase Inhibitor Therapy on Sleep and Activity Patterns in Early-stage Breast Cancer

INTRODUCTION

Adherence to aromatase inhibitor (AI) therapy is poor, often because of treatment-emergent side effects, including musculoskeletal symptoms, fatigue, and insomnia. In the present analysis, we examined the sleep patterns and daytime function both objectively using actigraphy and subjectively using validated questionnaires in women initiating AI therapy.

PATIENTS AND METHODS

Postmenopausal women with stage 0-III hormone receptor-positive breast cancer who were initiating AI therapy were eligible. The patients wore actigraphy devices for 10 consecutive days and completed questionnaires at baseline before the initiation of AI and after 3 months of AI therapy. Associations between the baseline demographics and symptoms, changes in patient-reported outcomes and actigraphy measures from baseline to 3 months of AI therapy and discontinuation of AI therapy were examined using sign tests, logistic regression models, Spearman's correlation, and linear mixed models.

RESULTS

Forty-two patients (86%) completed the baseline assessments and 23 patients (47%) completed both the baseline and the 3-month assessments. Objectively measured daytime function as measured by total daytime activity decreased during the 3 months after starting AI (232,566 activity count vs. 204,205 activity count; P = .023), and the decrease was more evident in women with higher baseline physical function. Reduced daytime activity correlated with increased fatigue (ρ = -0.49; P = .017).

CONCLUSION

Daytime function decreased after initiation of AI therapy and correlated moderately with increased fatigue, although no association was identified with changes in pain or sleep quality. Additional studies are required to understand why function is reduced, which could have implications for interventions to improve patient tolerance of, and persistence with, AI therapy.

Future perspectives in melanoma research "Melanoma Bridge", Napoli, November 30th-3rd December 2016

Major advances have been made in the treatment of cancer with targeted therapy and immunotherapy; several FDA-approved agents with associated improvement of 1-year survival rates became available for stage IV melanoma patients. Before 2010, the 1-year survival were quite low, at 30%; in 2011, the rise to nearly 50% in the setting of treatment with Ipilimumab, and rise to 70% with BRAF inhibitor monotherapy in 2013 was observed. Even more impressive are 1-year survival rates considering combination strategies with both targeted therapy and immunotherapy, now exceeding 80%. Can we improve response rates even further, and bring these therapies to more patients? In fact, despite these advances, responses are heterogeneous and are not always durable. There is a critical need to better understand who will benefit from therapy, as well as proper timing, sequence and combination of different therapeutic agents. How can we better understand responses to therapy and optimize treatment regimens? The key to better understanding therapy and to optimizing responses is with insights gained from responses to targeted therapy and immunotherapy through translational research in human samples. Combination therapies including chemotherapy, radiotherapy, targeted therapy, electrochemotherapy with immunotherapy agents such as Immune Checkpoint Blockers are under investigation but there is much room for improvement. Adoptive T cell therapy including tumor infiltrating lymphocytes and chimeric antigen receptor modified T cells therapy is also efficacious in metastatic melanoma and outcome enhancement seem likely by improved homing capacity of chemokine receptor transduced T cells. Tumor infiltrating lymphocytes therapy is also efficacious in metastatic melanoma and outcome enhancement seem likely by improved homing capacity of chemokine receptor transduced T cells. Understanding the mechanisms behind the development of acquired resistance and tests for biomarkers for treatment decisions are also under study and will offer new opportunities for more efficient combination therapies. Knowledge of immunologic features of the tumor microenvironment associated with response and resistance will improve the identification of patients who will derive the most benefit from monotherapy and might reveal additional immunologic determinants that could be targeted in combination with checkpoint blockade. The future of advanced melanoma needs to involve education and trials, biobanks with a focus on primary tumors, bioinformatics and empowerment of patients and clinicians.

Prevalence of Smoking and Obesity Among U.S. Cancer Survivors: Estimates From the National Health Interview Survey, 2008-2012

PURPOSE/OBJECTIVES

To describe smoking and obesity prevalence among male and female cancer survivors in the United States.
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DESIGN

Cross-sectional survey.
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SETTING

Household interviews.
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SAMPLE

9,753 survey respondents who reported ever having a malignancy, excluding nonmelanoma skin cancers. 
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METHODS

Data from the National Health Interview Survey (2008-2012) were used to calculate weighted smoking status prevalence estimates. Cross-tabulations of smoking and weight status were produced, along with Wald chi-square tests and linear contrasts.
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MAIN RESEARCH VARIABLES

Cancer history, smoking status, obesity status, gender, age, and age at diagnosis.
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FINDINGS

Seventeen percent of cancer survivors reported current smoking. Female survivors had higher rates of current smoking than males, particularly in the youngest age category. Male survivors who currently smoked had lower obesity prevalence rates than males who previously smoked or never smoked. Among female survivors, 31% were obese and no significant differences were seen in obesity prevalence by smoking status for all ages combined. 
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CONCLUSIONS

The findings highlight the variation in smoking status and weight by age and gender. Smoking interventions may need to be targeted to address barriers specific to subgroups of cancer survivors.
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IMPLICATIONS FOR NURSING

Nurses can be instrumental in ensuring that survivors receive comprehensive approaches to address both weight and tobacco use to avoid trading one risk for another.

Association between MGMT Promoter Methylation and Risk of Breast and Gynecologic Cancers: A Systematic Review and Meta-Analysis

The role of the promoter methylation of O⁶-methylguanine-DNA methyltransferase (MGMT) remains controversial for breast and gynecologic cancers. We conducted a meta-analysis to assess the association between hypermethylation of MGMT promoter and the risk of breast and gynecologic cancers. A comprehensive search was conducted in PubMed and Embase electronic databases up to 19th August 2017 for studies about the association between MGMT promoter hypermethylation and breast and gynecologic cancers. A total of 28 articles including 2,171 tumor tissues and 1,191 controls were involved in the meta-analysis. The pooled results showed that MGMT promoter methylation status was significantly associated with an increased risk of breast and gynecologic cancers (OR = 4.37, 95% CI: 2.68–7.13, P < 0.05). The associations were robust in subgroup analysis based on ethnicity, cancer type, methylation detection method, and control source. This meta-analysis indicated that MGMT hypermethylation was significantly associated with the risk of breast and gynecological cancers, and it may be utilized as a valuable biomarker in early diagnostics and prognostication of these cancers. Further efforts are needed to identify and validate this finding in prospective studies, especially in situation with new methylation testing methods and samples from plasma circulating DNA.

Association of 15-hydroxyprostaglandin dehydrogenate and poor prognosis of obese breast cancer patients

In order to explore the new mechanism that obesity worsens the prognosis of breast cancer, we reanalyzed the data about gene expression of normal, overweight, and obese breast cancer patients to explore potential genes and validate its function by clinical and experimental data. The fold change of 15-hydroxyprostaglandin dehydrogenate (HPGD) gene which displayed declining trend with BMI increase was 0.46 in obese versus normal weight patients. HPGD protein was highest expressed in normal weight group and lowest expressed in obese group. The rate of positive lymph nodes was 67% in low expression of HPGD group and 35% in high expression of HPGD group. The recurrence-free survival (RFS) rate and overall survival (OS) rate of 5 years had significant difference between low expression of HPGD group and high expression of HPGD group. Obesity dramatically decreased the RFS rate and OS rate of 5 years. Down regulation of HPGD expression could increase the migration and proliferation ability of breast cancer cell line MCF-7. Taken together, our results indicate that low expression of HPGD may be a reason for poor prognosis of obese breast cancer patients.

Risk factors and a prediction model for lower limb lymphedema following lymphadenectomy in gynecologic cancer: a hospital-based retrospective cohort study

Background

Lower limb lymphedema (LLL) is a chronic and incapacitating condition afflicting patients who undergo lymphadenectomy for gynecologic cancer. This study aimed to identify risk factors for LLL and to develop a prediction model for its occurrence.

Methods

Pelvic lymphadenectomy (PLA) with or without para-aortic lymphadenectomy (PALA) was performed on 366 patients with gynecologic malignancies at Yaizu City Hospital between April 2002 and July 2014; we retrospectively analyzed 264 eligible patients. The intervals between surgery and diagnosis of LLL were calculated; the prevalence and risk factors were evaluated using the Kaplan-Meier and Cox proportional hazards methods. We developed a prediction model with which patients were scored and classified as low-risk or high-risk.

Results

The cumulative incidence of LLL was 23.1% at 1 year, 32.8% at 3 years, and 47.7% at 10 years post-surgery. LLL developed after a median 13.5 months. Using regression analysis, body mass index (BMI) ≥25 kg/m² (hazard ratio [HR], 1.616; 95% confidence interval [CI], 1.030–2.535), PLA + PALA (HR, 2.323; 95% CI, 1.126–4.794), postoperative radiation therapy (HR, 2.469; 95% CI, 1.148–5.310), and lymphocyst formation (HR, 1.718; 95% CI, 1.120–2.635) were found to be independently associated with LLL; age, type of cancer, number of lymph nodes, retroperitoneal suture, chemotherapy, lymph node metastasis, herbal medicine, self-management education, or infection were not associated with LLL. The predictive score was based on the 4 associated variables; patients were classified as high-risk (scores 3–6) and low-risk (scores 0–2). LLL incidence was significantly greater in the high-risk group than in the low-risk group (HR, 2.19; 95% CI, 1.440–3.324). The cumulative incidence at 5 years was 52.1% [95% CI, 42.9–62.1%] for the high-risk group and 28.9% [95% CI, 21.1–38.7%] for the low-risk group. The area under the receiver operator characteristics curve for the prediction model was 0.631 at 1 year, 0.632 at 3 years, 0.640 at 5 years, and 0.637 at 10 years.

Conclusion

BMI ≥25 kg/m², PLA + PALA, lymphocyst formation, and postoperative radiation therapy are significant predictive factors for LLL. Our prediction model may be useful for identifying patients at risk of LLL following lymphadenectomy. Providing an intensive therapeutic strategy for high-risk patients may help reduce the incidence of LLL and conserve the quality of life.

HRT for women with premature ovarian insufficiency: a comprehensive review

BACKGROUND

Premature ovarian insufficiency (POI), often and misleadingly referred to as ‘premature menopause’, is defined as a loss of ovarian activity before the age of 40 years and is characterized by irregular or absent periods and reduced fertility. Symptoms include those associated with the natural menopause (night sweats and vaginal dryness), and with the long-term adverse effects of estrogen deficiency (osteoporosis and cardiovascular disease): the latter is believed to explain the shorter life expectancy associated with POI.

OBJECTIVE AND RATIONALE

The objective of the current review was to collect all relevant studies supporting recommendations on the indications, treatment options, and risks of hormone replacement therapy (HRT) (estrogen, progestogens and androgens) for women with POI.

SEARCH METHODS

The current review was written based on the best available evidence on the topic collected for the recently published ESHRE guideline on the management of women with POI. PUBMED/MEDLINE and the Cochrane library were searched in a stepwise approach. Relevant references were summarized in evidence tables, with assessment of the quality.

OUTCOMES

HRT is strongly recommended for women with POI, mainly for vasomotor and genito-urinary symptom relief. In addition, HRT has been shown to have a role in bone protection and probably also in primary prevention of cardiovascular disease. There is little evidence on the optimal type, regimen and dose of HRT; patient preference for route and method of administration of each component of HRT must be considered when prescribing, as should contraceptive needs. In women with POI, physiological replacement of estrogen (and progesterone) is essential for their health, and the controversies that surround the use of HRT in postmenopausal women do not apply.

LIMITATIONS, REASONS FOR CAUTION

N/A.

WIDER IMPLICATIONS

New areas of study on HRT for women with POI should focus on life expectancy, quality of life and neurological function. Furthermore, randomized controlled trials comparing transdermal estradiol with oral estrogens with regard to efficacy, patient satisfaction and side effects are urgently needed.

STUDY FUNDING/COMPETING INTERESTS

The authors received no funding for the review. The costs for the development of the ESHRE guideline were covered by ESHRE. The authors have no conflicts of interest to disclose.

Sociodemographic and economic factors are associated with weight gain between before and after cancer diagnosis: results from the prospective population-based NutriNet-Santé cohort

Purpose

While many cancer patients are affected by weight loss, others tend to gain weight, which may impact prognosis and risk of recurrence and of second cancer. The aim of this prospective study was to investigate weight variation between before and after cancer diagnosis and socio-demographic, economic, lifestyle and clinical factors associated with moderate-to-severe weight gain.

Methods

1051 incident cases of first primary cancer were diagnosed in the NutriNet-Santé cohort between 2009 and 2015. Weight was prospectively collected every 6 months since subjects’ inclusion (i.e. an average of 2y before diagnosis). Mean weights before and after cancer diagnosis were compared with paired Student's t-test. Factors associated with moderate-to-severe weight gain (≥5% of initial weight) were investigated by age and sex-adjusted logistic regression.

Results

Weight loss was observed in men (-3.54±4.39kg in those who lost weight, p=0.0002) and in colorectal cancer patients (-3.94±4.40kg, p=0.001). Weight gain was observed in breast and skin cancers (2.83±3.21kg, p=0.04, and 2.96±2.75kg, p=0.04 respectively). Women (OR=1.75[1.06-2.87],p=0.03), younger patients (2.44[1.51-3.70],p<0.0001), those with lower income (OR=1.30[1.01-1.72],p-trend=0.007), lower education (OR=1.32[1.03-2.70],p-trend=0.03), excess weight before diagnosis (OR=1.64[1.12-2.42],p=0.01), lower physical activity (OR=1.28[1.01-1.64],p=0.04) and those who stopped smoking (OR=4.31[1.99-9.35],p=0.005]) were more likely to gain weight. In breast cancer patients, induced menopause was associated with weight gain (OR=4.12[1.76-9.67]), but no association was detected for tumor characteristics or treatments.

Conclusion

This large prospective cohort provided original results on weight variation between before and after cancer diagnosis, highlighting different weight trajectories. Socio-demographic and economic factors appeared to influence the risk of weight gain, illustrating social inequalities in health.

Fruit and vegetable intake and breast cancer prognosis: a meta-analysis of prospective cohort studies

The effect of fruit and vegetable intake on breast cancer prognosis is controversial. Thus, a meta-analysis was carried out to explore their associations. A comprehensive search was conducted in PubMed, Web of Science, OVID, ProQuest and Chinese databases from inception to April 2016. The summary hazard ratios (HR) and 95 % CI were estimated using a random effects model if substantial heterogeneity existed and using a fixed effects model if not. Subgroup analyses and sensitivity analyses were also performed. In total, twelve studies comprising 41 185 participants were included in the meta-analysis. Comparing the highest with the lowest, the summary HR for all-cause mortality were 1·01 (95 % CI 0·72, 1·42) for fruits and vegetables combined, 0·96 (95 % CI 0·83, 1·12) for total vegetable intake, 0·99 (95 % CI 0·89, 1·11) for cruciferous vegetable intake and 0·88 (95 % CI 0·74, 1·05) for fruit intake; those for breast cancer-specific mortality were 1·05 (95 % CI 0·77, 1·43) for total vegetable intake and 0·94 (95 % CI 0·69, 1·26) for fruit intake; and those for breast cancer recurrence were 0·89 (95 % CI 0·53, 1·50) for total vegetable intake and 0·98 (95 % CI 0·76, 1·26) for cruciferous vegetable intake. This meta-analysis found no significant associations between fruit and vegetable intake and breast cancer prognosis.

Impact of Physical Inactivity on Risk of Developing Cancer of the Uterine Cervix: A Case-Control Study

OBJECTIVE

In this study, we investigated whether physical inactivity was associated with risk of cervical cancer in women treated at an American cancer hospital.

METHODS

This case-control study included 128 patients with cervical cancer and 512 controls matched on age. Controls were women suspected of having but not ultimately diagnosed with a neoplasm. Physical inactivity was defined in accordance with the 2008 Physical Activity Guidelines for Americans. Thus, participants reporting, on average, no moderate or vigorous recreational physical activity were classified as inactive. Unconditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Compared with noncancer controls, those with cervical cancer had significantly increased odds of reporting abstinence from recreational physical activity (OR, 2.43; 95% CI, 1.56-3.80). No association was noted between occupational-related physical inactivity and cervical cancer (OR, 0.88; 95% CI, 0.58-1.36).

CONCLUSIONS

Our findings suggest that abstinence from regular recreational physical activity is associated with increased odds of cervical cancer. To our knowledge, this is the first US-based study examining these associations. Given the 2008 Physical Activity Guidelines for Americans, this study has identified yet another potential public health benefit to regular physical activity. Further investigation is needed using a larger sample and prospectively collected data to characterize dose of activity to mitigate risk and the optimal window of susceptibility.

Women's interest in a personal breast cancer risk assessment and lifestyle advice at NHS mammography screening

Background

Although mortality from breast cancer is declining, incidence continues to increase and is often detected at routine NHS screening. Most middle aged and older women in England attend for screening every 3 years. Assessing their personal breast cancer risk and providing preventative lifestyle advice could help to further reduce breast cancer incidence.

Methods

A cross-sectional, self-complete postal survey measured attendees' interest in having a personal risk assessment, expected impact on screening attendance, knowledge of associations between lifestyle and breast cancer and preferred ways of accessing preventative lifestyle advice.

Results

A total of 1803/4948 (36.4%) completed questionnaires were returned. Most participants (93.7%) expressed interest in a personal risk assessment and 95% (1713/1803) believed it would make no difference or encourage re-attendance. Two-thirds (1208/1803) associated lifestyle with breast cancer, but many were unaware of specific risks such as weight gain, obesity, alcohol consumption and physical inactivity. NHS sourced advice was expected to be more credible than other sources, and booklets, brief counselling or an interactive website were most preferred for accessing this.

Conclusions

Attendees appear to welcome an intervention that would facilitate more proactive clinical and lifestyle prevention and address critical research gaps in breast cancer prevention and early detection.

A prospective evaluation of clinical and genetic predictors of weight changes in breast cancer survivors

BACKGROUND

Postdiagnosis weight gain in patients with breast cancer has been associated with increased cancer recurrence and mortality. This study was designed to identify risk factors for weight gain and create a predictive model to identify a high-risk population for targeted interventions.

METHODS

The weight of 393 patients with breast cancer from the Northwestern Robert H. Lurie Cancer Center was measured over a 2-year period from diagnosis, with body mass index (BMI) change over 18 months as the primary endpoint. Demographics, clinical factors, treatment methods, as well as tumor characteristics were also recorded; and a lifestyle questionnaire was conducted. Blood samples were genotyped for 16 single nucleotide polymorphisms in FTO, adiponectin pathway genes (ADIPOQ, ADIPOR1), and FNDC5. Serum leptin, adiponectin, and irisin levels also were measured.

RESULTS

Mean ± standard deviation 18-month BMI changes were 0.68 ± 1.42, 0.98 ± 1.62, 0.79 ± 1.74, and -0.44 ± 1.58 kg/m² for patients ages <40, 40 to 49, 50 to 59, and ≥60 years, respectively. The optimal multivariable model for 18-month BMI change contained the predictors age, height, and endocrine therapy, but only age was statistically significant, with a 0.04 kg/m² increase in 18-month BMI change per younger year of age. Single nucleotide polymorphisms in ADIPOR1, FTO, and FNDC5 were associated with 18-month BMI change, and the first 2 remained significant after adjusting for the optimal clinical model (all P < .05).

CONCLUSIONS

Women age 60 years and younger at the time of breast cancer diagnosis who have an obesity genetic risk model are at increased risk for weight gain after treatment and should be targeted for weight-maintenance interventions. Cancer 2017;123:2413-21. © 2017 American Cancer Society.

Weight Loss and Mortality in Overweight and Obese Cancer Survivors: A Systematic Review

Background

Excess adiposity is a risk factor for poorer cancer survival, but there is uncertainty over whether losing weight reduces the risk. We conducted a critical review of the literature examining weight loss and mortality in overweight or obese cancer survivors.

Methods

We systematically searched PubMed and EMBASE for articles reporting associations between weight loss and mortality (cancer-specific or all-cause) in overweight/obese patients with obesity-related cancers. Where available, data from the same studies on non-overweight patients were compared.

Results

Five articles describing observational studies in breast cancer survivors were included. Four studies reported a positive association between weight loss and mortality in overweight/obese survivors, and the remaining study observed no significant association. Results were similar for non-overweight survivors. Quality assessment indicated high risk of bias across studies.

Conclusions

There is currently a lack of observational evidence that weight loss improves survival for overweight and obese cancer survivors. However, the potential for bias in these studies is considerable and the results likely reflect the consequences of disease-related rather than intentional weight loss. There is a need for stronger study designs, incorporating measures of intentionality of weight loss, and extended to other cancers.