The prognostic value of age for invasive lobular breast cancer depending on estrogen receptor and progesterone receptor-defined subtypes: A NCDB analysis

Quantifying hormone receptor status in lobular breast cancer in an institutional series: the relationship between estrogen and progesterone receptor status and outcomes

PURPOSE

Recent guidelines defined a new reporting category of ER-low-positive breast cancer based on immunohistochemistry (IHC). While low positivity of either hormone receptor is uncommon in invasive lobular carcinoma (ILC), we sought to investigate whether relatively low hormone receptor positivity was associated with tumor characteristics and patient outcomes in a single institutional cohort.

METHODS

We searched an institutional database for cases of stage I-III ILC with available IHC reports. Based on prior published categories in ILC, ER was classified as low, medium, or high as defined by ER staining of 10-69%, 70-89%, and ≥ 90% respectively. PR low and high tumors were defined by < 20%, or ≥ 20% staining respectively. We used chi-squared tests, t-tests, and Cox proportional hazards models to evaluate associations between ER/PR categories and tumor characteristics or disease-free survival (DFS).

RESULTS

The cohort consisted of 707 ILC cases, with 11% of cases categorized as ER low, 15.1% as medium, and 73.8% as high. The majority (67.6%) were PR high. Patients with ER low/medium expression were significantly younger, and more likely to also have PR low and/or HER2 positive tumors compared to those that were ER high. In a Cox proportional hazards model adjusting for age, stage, grade, pleomorphic histology, and treatment, ER category was not prognostic for DFS, but PR negative and PR low status each had significantly worse DFS compared to PR high status (HR 3.5, 95% CI 1.8-6.7, p < 0.001; and HR 2.0, 95% CI 1.1-3.5, p = 0.015, respectively).

CONCLUSION

These findings highlight the relevance of quantifying ER and PR within ILC.

Pathogenesis and Potential Therapeutic Targets for Triple-Negative Breast Cancer

Triple negative breast cancer (TNBC) is a heterogeneous tumor characterized by early recurrence, high invasion, and poor prognosis. Currently, its treatment includes chemotherapy, which shows a suboptimal efficacy. However, with the increasing studies on TNBC subtypes and tumor molecular biology, great progress has been made in targeted therapy for TNBC. The new developments in the treatment of breast cancer include targeted therapy, which has the advantages of accurate positioning, high efficiency, and low toxicity, as compared to surgery, radiotherapy, and chemotherapy. Given its importance as cancer treatment, we review the latest research on the subtypes of TNBC and relevant targeted therapies.

Adolescents and Young Adults with Breast Cancer have More Aggressive Disease and Treatment Than Patients in Their Forties

BACKGROUND

Adolescents and young adults (AYAs; age < 40 years) account for less than 2% of breast cancer patients. Therefore, little is known about the tumor characteristics and care provided to AYA patients. This study sought to describe demographic, tumor, and treatment variables among AYA patients.

METHODS

The study identified patients ages 15 to 49 years with breast cancer between 2010 and 2015 from the National Cancer Database. Patient and tumor factors were compared using Chi-square tests. Multivariable logistic regression was used to model the effect of age group on treatment while adjusting for confounding variables.

RESULTS

The study identified 46,265 AYA patients with stages 0 to 3 breast cancer and compared them with 169,423 breast cancer patients ages 40 to 49 years. A greater proportion of the AYA patients presented with clinical stage 2 or 3 disease than the adult patients 40 to 49 years old (stage 2 disease: 44.3% vs 29.9%, respectively; stage 3 disease: 14.0% vs 7.7%, respectively; both p < 0.001). A greater proportion of the AYA patients had triple-negative breast cancer (TNBC) or human epidermal growth factor receptor 2-positive (HER2+) cancer than the adult patients (TNBC: 21.2% vs 13.8%, respectively; HER2+: 26.0% vs 18.6%, respectively; both p < 0.001). Among the AYA patients, the very young (ages 15-29 years) had more advanced disease and TNBC or HER2+ disease than the older youth (ages 30 to 39 years). The multivariable analysis showed that the AYA patients were more likely to undergo mastectomy (odds ratio [OR] 2.1) and receive chemotherapy (OR 1.9) than patients in their forties (both p < 0.001).

CONCLUSION

A greater proportion of the AYA breast cancer patients had more advanced disease and TNBC and HER2+ disease. The AYA patients had higher rates of mastectomy and use of chemotherapy than the adult breast cancer patients, reflecting that more aggressive therapy is recommended or chosen for women in this age group.

Molecular features in young vs elderly breast cancer patients and the impacts on survival disparities by age at diagnosis

Young and elderly breast cancer patients are more likely to have a poorer outcome than middle‐aged patients. The intrinsic molecular features for this disparity are unclear. We obtained data from the Cancer Genome Atlas (TCGA) on May 15, 2017 to test the potential mediation effects of the molecular features on the association between age and prognosis with a four‐step approach. The relative contributions of the molecular features (PAM50 subtype, risk stratification, DNAm age, and mutations in TP53,PIK3CA,MLL3,CDH1,GATA3, and MAP3K1) to age disparities in survival were estimated by Cox proportional hazard models with or without the features. Young patients were significantly more likely to have basal‐like subtype, GATA3 mutations, and younger DNA methylation (DNAm) age than middle‐aged patients (P < .05). Both the young and elderly patients had a significantly increased risk of breast cancer recurrence after adjusted by race, tumor size, and node status (Hazard ratio [HR] (95% confidence interval [CI]): 2.81 [1.44, 5.45], 2.37 [1.45, 3.89], respectively). This increased risk was weakened in the young patients after further adjustments in the molecular features, particularly basal‐like subtype, GATA3 mutations, and DNAm age (HR [95%CI]: 1.87 [0.81, 4.32]), resulting in 33.5% decreased risk of recurrence. Meanwhile, the adjustments of the molecular features did not alter the recurrence risk for the elderly patients. Compared with middle‐aged patients of breast cancer, poorer prognosis of elderly patients may be caused by aging, while poorer prognosis of young patients was probably mediated through intrinsic characteristics, such as basal‐like subtype, GATA3 mutations, and DNAm age of the cancerous tissues.

Cumulative receiver operating characteristics for analyzing interaction between tissue visfatin and clinicopathologic factors in breast cancer progression

Background

Visfatin has been reported to be associated with breast cancer progression, but the interaction between the visfatin and clinicopathologic factors in breast cancer progression status requires further investigation. To address this problem, it is better to simultaneously consider multiple factors in sensitivity and specificity assays.

Methods

In this study, a dataset for 105 breast cancer patients (84 disease-free and 21 progressing) were chosen. Individual and cumulative receiver operating characteristics (ROC) were used to analyze the impact of each factor along with interaction effects.

Results

In individual ROC analysis, only 3 of 13 factors showed better performance for area under curve (AUC), i.e., AUC > 7 for hormone therapy (HT), tissue visfatin, and lymph node (LN) metastasis. Under our proposed scoring system, the cumulative ROC analysis provides higher AUC performance (0.746–0.886) than individual ROC analysis in predicting breast cancer progression. Considering the interaction between these factors, a minimum of six factors, including HT, tissue visfatin, LN metastasis, tumor stage, age, and tumor size, were identified as being highly interactive and associated with breast cancer progression, providing potential and optimal discriminators for predicting breast cancer progression.

Conclusion

Taken together, the cumulative ROC analysis provides better prediction for breast cancer progression than individual ROC analysis.

Electronic supplementary material

The online version of this article (10.1186/s12935-018-0517-z) contains supplementary material, which is available to authorized users.

The burden of metastatic disease of the femur on the Medicare system

Background

In the United States, over 1,650,000 new cases of cancer are being diagnosed yearly with almost 50 % of them being the top five bone-seeking cancers. Since cancer risk increases with age, this suggests that orthopedic oncology services may be a strain on the Medicare system. The femur is the most common site of long bone metastases. Prophylactic fixation techniques prevent pathologic fractures, reduce morbidities, and enhance the quality of life of patients with femoral metastases. This study aims to assess the rate of metastatic disease to the skeleton and evaluate the use and financial burden of femoral prophylactic fixation techniques on the Medicare system.

Questions/purposes

(1) In the Medicare population, has the number of skeletal metastases increased? (2) In the Medicare population, has the use of prophylactic fixation techniques increased? (3) How has the financial burden of prophylactic fixation changed over the study period?

Methods

The Medicare database was searched between 2005 and 2014 with the assistance of PearlDiver Technologies Inc. and the RBRVS DataManager Online from the American Medical Association. Searches were completed by using International Classification of Disease-9 (ICD-9) and current procedural terminology (CPT) codes for secondary malignant neoplasms and prophylactic fixation techniques. Facility charges, Medicare reimbursement and length of hospital stay were extracted from the Medicare database. Simple linear regression was performed to test the significance of yearly changes and the coefficient of determination was used to assess the strength of the correlation.

Results

(1) In the Medicare population, has the number of skeletal metastases increased? While the number of Medicare patients with skeletal metastases has increased from 132,452 in 2005 to 155,819 in 2012 (p = 0.01, r² = 0.72), the prevalence of skeletal metastases in this population remained constant at 30.66 cases per 10,000 Medicare patients in 2012 (p = 0.56, r² = 0.06). (2) In the Medicare population, has the use of prophylactic fixation techniques increased? The number of prophylactic fixation techniques has not increased from 2005 to 2014 (p = 0.68, r² = 0.02); however, the rate of prophylactic fixation among those diagnosed with skeletal metastases has significantly decreased from 94.6 per 10,000 in 2005 to 82.72 per 10,000 in 2012 (p = 0.006, r² = 0.74). (3) How has the financial burden of prophylactic fixation changed over the study period? Both total and average hospital charges increased after adjusting for inflation in the total Medicare population; however, only the average Medicare reimbursement changed to reflect this. The total amount Medicare spent on prophylactic fixation techniques in 2012 was $20,245,957 after adjusting to 2014. Despite the increase in hospital charges and average Medicare reimbursement, the average length of hospital stay in the total Medicare population showed a significant decreased trend—down from 7.51 days in 2005 to 5.86 days in 2012 (p = 0.02, r² = 0.81).

Conclusions

Although the prevalence of metastatic disease to the skeleton remained stable between 2005 and 2012 in the Medicare population, prophylactic femoral fixation techniques declined in elderly adults between 2005 and 2014. This most likely signifies an increase in other treatment modalities that can prevent pathologic fractures such as prophylactic hemiarthroplasty, bisphosphonates, and/or radiation therapy.

Level of evidence

Level IV, Cross-sectional Study.