Axillary lymph node dissection can be omitted in patients with limited clinically node-positive breast cancer: a National Cancer Database analysis

BACKGROUND

De-escalation of axillary surgery in breast cancer has progressively taken place when appropriate. Data supporting surgical de-escalation in patients with clinically node-positive (cN+) disease remains scarce. Here, survival among patients with cN+ T1-2 tumours undergoing sentinel lymph node biopsy (SLNB) and regional nodal irradiation (RNI) was investigated and compared with that among patients undergoing axillary lymph node dissection (ALND) with or without RNI.

METHODS

The National Cancer Data Base was used to identify three groups of patients with cN+ tumours according to axillary management among those treated between 2010 and 2016: patients who underwent SLNB and RNI (cN+ SLNB/RNI group); those who had ALND and RNI (cN+ ALND/RNI group); and those who had ALND alone (cN+ ALND/no RNI group). Patients who underwent neoadjuvant chemotherapy, and those who had stage IV breast cancer or pN2-3 disease were excluded.

RESULTS

A total of 12 560 patients met the inclusion criteria: 3030 in the cN+ SLNB/RNI, 5446 in the cN+ ALND/RNI, and 4084 in the cN+ ALND/no RNI group. The sizes of cN + SLNB/RNI and cN+ ALND/RNI groups increased over the study interval, whereas the cN+ ALND/no RNI group decreased in size (P < 0.001). There was a median of one positive node in the cN+ SLNB/RNI group and two nodes in the cN+ ALND/RNI and cN+ ALND/no RNI groups. The median number of nodes examined was three, 14, and 14, respectively (P < 0.001). Median follow-up was 57.9 (range 0.8-114) months. The overall survival rate was 97, 97, and 92 per cent respectively at two years, and 88, 86, and 78 per cent at five years (P < 0.001).

CONCLUSION

Patients with limited cN+ T1-2 breast cancer undergoing upfront SLNB and RNI have favourable survival outcomes that are not inferior to those of patients undergoing ALND with or without RNI. Prospective studies are warranted to assess locoregional control and long-term outcomes.

Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer

Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.

1186 Developing And Testing A Web-based Provider Training For Cognitive Behavioral Therapy Of Insomnia

Introduction

Chronic insomnia is a common, debilitating disorder and a risk factor for significant medical morbidity, mental health problems, and workplace difficulties. Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard treatment for insomnia. However, few providers are trained in CBT-I, in part due to a bottleneck in training availability and the time and cost associated with current training platforms. To address this training deficit, our team developed and evaluated CBTIweb.org, a web-based provider training course for CBT-I.

Methods

Feedback from alpha- and beta-testing of CBTIweb.org was collected and used to optimize course content and functionality. Then, a comparison study was conducted in which licensed providers were randomized to complete either the online CBTIweb.org course (n=21) or an in-person CBT-I training (n=23). During all phases of development, providers completed a Computer System Usability Questionnaire (CSUQ), investigator-developed website usability and content questionnaires, and pre/post-training competency assessments.

Results

Independent samples t-tests indicated significant improvements in CSUQ, and website usability and content questionnaires responses from alpha- to beta-testing (all ps &lt; .05). Linear mixed-effects modeling revealed significant within-subject increases in knowledge acquisition (F(34.7) = 65.4, p &lt; 0.001; baseline = 69% correct, post-training = 92% correct) when collapsed across in-person and web-based groups. The interaction group by time interaction was non-significant (F(34.7) = 1.7, p = 0.204), indicating similar gains in knowledge (i.e., equivalence) between the in-person and the CBTIweb.org training formats.

Conclusion

Alpha and beta testers of CBTIweb.org reported high levels of satisfaction while also noting areas for improvement, which were used to update the site. Findings suggest the final CBTIweb.org product successfully trained clinicians compared to an in-person workshop, given knowledge acquisition improvements. CBTIweb.org is an efficient and effective training platform for clinicians to gain knowledge and competence in the most effective treatment for insomnia.

Support

W81XWH-17-1-0165

0483 Predictors of Cognitive Behavioral Therapy for Insomnia (CBT) Outcomes in Active Duty U.S. Army Personnel

Introduction

Cognitive behavioral therapy for insomnia (CBTi) is well established as the first-line treatment for the management of chronic insomnia. Identifying predictors of response to CBTi should enable the field to efficiently utilize resources to treat those who are likely to respond and to personalize treatment approaches to optimize outcomes for those who are less likely to respond to traditional CBTi. Although a range of studies have been conducted, no clear pattern of predictors of response to CBTi has emerged.

Methods

The purpose of this study was to examine the impact and relative importance of a comprehensive group of pretreatment predictors of insomnia outcomes in 99 active duty service members who received in-person CBTi in a randomized clinical trial.

Results

Results indicated that higher levels of baseline insomnia severity and total sleep time predicted greater improvements on the Insomnia Severity Index (ISI) following treatment. Higher depression symptoms and a history of head injury predicted a worse response to treatment (i.e., smaller improvements on the ISI).

Conclusion

Clinically meaningful improvements, as measured by the reliable change index (RCI), were found in 59% of the sample. Over and above baseline insomnia severity, only depressive symptoms predicted this outcome. Future studies should examine if modifications to CBTi based on these predictors of response can improve outcomes.

Support

This study was conducted with support from the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program award W81XWH-10-1-0828 (PI: Dr Taylor).

0945 Adolescent Sleep Mediates Maternal Depression and Harsh Parenting

Introduction

Mothers dealing with depressive problems often report using more harsh parenting practices. This occurs, in part, due to a scarcity of effective coping mechanisms and increased irritability. In addition, depressed mothers are less likely to set consistent rules and expectations within the home, which may result in children who stay up late. Children who get inadequate levels of sleep also are more likely to have behavior problems, irritability, and defiance toward their parents, particularly in adolescence. However, no studies have examined the potential of adolescent sleep as a contributor to the association between maternal depression and the use of harsh parenting. The current study examined whether mothers’ perceptions of inadequate adolescent sleep duration mediated the relationship between maternal depression and harsh parenting, with child gender as a moderator.

Methods

The sample (N=318) consisted of mothers reporting on adolescents aged 16-18 (M=16.89, SD = .429; 53.4% female) from the 10th wave of the Schools and Families Educating Children Study (SAFE). The SAFE study was a randomized control trial conducted from 1997-2008 designed to investigate children and families living in inner-city Chicago, Il. Measures included the Child Behavior Checklist (CBCL), Center for Epidemiologic Studies Depression Scale (CESD), and the Parenting Practices Questionnaire (PPQ).

Results

Too little adolescent sleep mediated (β = .15) the relation between maternal depression and her reported use of harsh parenting. Mediation was further moderated by child gender, such that the mediation occurred for sons (β = .12) but not daughters.

Conclusion

These results suggest that too little adolescent sleep is the process through which mothers experiencing depressive problems engage in more harsh parenting. In addition, important child gender differences were apparent, such that sons’ lack of sleep may be more related to maternal depression and the use of harsh discipline.

Support

United States Department of Health and Human Services. National Institutes of Health. National Institute on Drug Abuse (5 R01 DA020829)

Nanoparticle Systems Modulating Myeloid-Derived Suppressor Cells for Cancer Immunotherapy

Myeloid-derived suppressor cells (MDSCs) are a heterogeneous population of immature myeloid cells that are preferentially expanded in cancer. They arise from myeloid progenitor cells that do not differentiate into mature dendritic cells (DCs), granulocytes, or macrophages, and are rather thought to play a pivotal role in immune escape and cancer progression. MDSCs are characterized by the ability to suppress T cell proliferation and cytotoxicity, inhibit natural killer T (NKT) cell activation, and induce the differentiation and expansion of regulatory T cells (Treg). MDSC levels have been shown to correlate negatively with prognosis and overall survival of patients with cancers of various types and stages. The role of MDSCs in cancer progression represents a promising target for effective cancer immunotherapy. In this review, we discuss the mechanisms of MDSC functions, their influence on tumor progression and metastasis, and finally focus on up to date nanoparticle approaches that target and antagonize MDSCs in tumor-bearing hosts. The development of multifunctional nanoparticle systems for effective imaging, assessment and manipulation of MDSCs will represent strategic theranostic innovations that may improve cancer staging, therapeutic outcomes, and overall patient survival.

Disability and Depression

Here, Ann Cvetkovich, interviewed by Abby Wilkerson, brings Cvetkovich's influential cultural studies analysis of depression explicitly into conversation with disability studies. Cvetkovich understands "feeling bad" (a term she prefers to "depression") as a defining affective state under neoliberalism. Drawing on a distinctive historical/cultural archive, she challenges the atomism of the neoliberal medical model that frames depression and affective distress more generally as the result of faulty brain chemistry-individual organisms gone awry. Instead, she traces these common experiences to sociopolitical phenomena ranging from current neoliberal demands for productivity as exemplified in university life, to histories of colonization, slavery, and displacement. The conversation considers the value of disability frameworks for understanding mental health diagnoses and the intersections of social institutions, bodily practices, and everyday affective life.

Ventral hippocampal dopamine D1 and D2 systems and spatial working memory in rats

The hippocampus has long been known to be important for memory function. However, the involvement of hippocampal dopamine systems with memory has received little attention. In the current study, dopamine D1 and D2 hippocampal receptor system involvement with memory was assessed in female Sprague-Dawley rats by local infusion of D1 and D2 agonists and antagonists into the ventral hippocampus. Working memory performance was assessed on the radial-arm maze. Neither the D1 agonist dihydrexidine (1.1-10 microg/side) nor the D1 antagonist SCH 23390 (0.19-1.67 microg/side) was effective in significantly altering radial-arm maze choice accuracy. In contrast, there were significant and opposite effects of D2 agonist and antagonist treatments. The D2 agonist quinpirole caused a significant (P<0.05) dose-related improvement in choice accuracy over a dose range of 1.1-10 microg/side. In a complementary fashion, the D2 antagonist raclopride caused a significant (P<0.05) dose-related choice accuracy deficit over a range of 0.19-1.67 microg/side. This study provides clear evidence that hippocampal D2 activity is positively related to working memory performance, while evidence for D1 systems is less compelling. Dopamine D2 receptors in the ventral hippocampus were shown to have important influences on spatial working memory. In a consistent pattern of effects ventral hippocampal infusion of the D2 agonist quinpirole improved working memory performance in the radial-arm maze, while ventral hippocampal infusion of the D2 antagonist raclopride impaired performance.

The MMPI-2 Gender-role scales as measures of sex-typing

The validity of the MMPI-2 Gender-role GM/GF scales as measures of sex-typing was examined relative to gender classification using the Personality Attributes Questionnaires. Although mean differences by sex were in the expected direction, the scales did not distinguish sex-typed, androgynous, and undifferentiated subjects. Correlations with the PAQ gender scales provided some support for the criterion validity of Gender-role GM scale for both men and women and the Gender-role GF scale for women.

Prenatal nicotine effects on memory in rats: pharmacological and behavioral challenges

Cigarette smoking during pregnancy has been shown in a variety of studies to be associated with cognitive deficits in the children. Nicotine administration to rats during gestation has been found to cause subtle cognitive effects in the offspring. Some individual differences in cognitive impairment may be related to prenatal nicotine effects on noradrenergic (NE) systems. In the current study, 10 Sprague-Dawley rat dams were infused with approximately 2 mg/kg/day of nicotine ditartrate via osmotic minipumps and 10 control dams were exposed to vehicle-containing minipumps from gestational day (GD) 4-20. Starting on postnatal day (PND) 50, the offspring were tested for T-maze rewarded spatial alternation with intertrial intervals of 0, 10, 20, or 40 s. There was a sex- and delay-dependent effect of prenatal nicotine exposure on T-maze alternation. Nicotine-exposed males showed a significant deficit at the 0 s delay. In radial-arm maze (RAM) acquisition training there were no significant nicotine effects. However, significant nicotine-related effects were seen with subsequent behavioral and pharmacological challenges in the RAM. Changing the RAM testing location to an identical maze in a different room elicited a significant choice accuracy deficit in the prenatal nicotine-exposed rats compared with controls. Acute nicotine challenge did not cause any differential effects in the prenatal nicotine and control groups. During the isoproterenol (beta-NE agonist) challenge phase there appeared a significant facilitation of choice accuracy and speeding of response in the prenatal nicotine exposure group which was not seen in the control group. The alpha-NE agonist phenylpropanolamine caused a significant deficit in control females but not in the females prenatally exposed to nicotine. No differential effects of the alpha-NE antagonist phenoxybenzamine were seen in the prenatal nicotine and control groups. Throughout RAM testing there was a significant sex effect with males having better choice accuracy than females. These results demonstrate that the persisting cognitive effects of prenatal exposure to 2 mg/kg/day cause subtle effects in cognitive performance which can be elicited with behavioral and pharmacological challenge. These results also support previous studies suggesting the involvement of NE systems in persisting effects of prenatal nicotine exposure.

Biodegradation of radioactive animals

The two most common disposal alternatives for animals contaminated with radioactive materials are incineration and burial. For most of the country burial has entailed shipping the carcasses to a commercial disposal facility at Barnwell, South Carolina, where it was landfilled along with other solid radioactive waste. Unfortunately, since 30 June 1994, this facility accepts waste generated by the states of the Southeast Compact only. Therefore, burial is no longer an option for most of the country's generators and incineration is an option only for those institutions which have, or have access to, an incinerator that is permitted to burn radioactive materials and that accepts animal carcasses with de minimis levels of radioactive contaminants. Many institutions, especially those in congested urban areas where the public does not support incineration, do not have viable outlets for radioactive animal carcasses. Interim, on-site storage poses problems of its own. Biodegradation of animal carcasses with dermestid beetles is an inexpensive approach to this waste management problem.

Homophobia and the moral authority of medicine

This essay identifies ways in which medicine expresses and legitimizes homophobic values. Examples of such homophobia are identified in the treatment of people with HIV, moralistic interpretations of people with AIDS, certain conceptions about ways in which HIV is transmitted, media representations of AIDS, and even in the way in which medicine's "objectivity" reinforces a moral view inimical to gay men, lesbians, and bisexuals. It is concluded that the notion of medical objectivity and traditional conceptions of the ethics of health care hinder an appreciation of the ways in which medicine presumes and perpetuates homophobic values.