Symposium highlights and synopses of the scientific program: the Sixth Annual Mid-Atlantic Healthcare Informatics Symposium

As the bar to actively participate in one's own health is consistently lowered through technology, patients are helping to evolve traditional workflows to make data more accessible at the point of care. This growing trend of patient engagement and personalized medicine was the focus of the 2013 Mid-Atlantic Healthcare Informatics Symposium in Philadelphia, PA on April 26, 2013. The conference, presented annually by the Center for Bio-medical Informatics (CBMi) at The Children's Hospital of Philadelphia, featured plenary sessions, panel discussions, and paper presentations on a range of topics, including patient engagement and personalized medicine; using data and analytics to optimize patient care; nursing informatics; and the future of biomedical informatics.

Alcohol consumption in relation to aberrant DNA methylation in breast tumors

The mechanism for the observed association of alcohol consumption breast cancer risk is not known; understanding that mechanism could improve understanding of breast carcinogenesis and optimize prevention strategies. Alcohol may impact breast malignancies or tumor progression by altering DNA methylation. We examined promoter methylation of three genes, the E-cadherin, p16, and retinoic acid-binding receptor-β2 (RAR-β2) genes in archived breast tumor tissues from participants in a population-based case-control study. Real time methylation-specific PCR was performed on 803 paraffin-embedded samples, and lifetime alcohol consumption was queried. Unordered polytomous and unconditional logistic regression were used to derive adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RAR-β2 methylation was not associated with drinking. Among premenopausal women, alcohol consumption was also not associated with promoter methylation for E-cadherin and p16 genes. In case-case comparisons of postmenopausal breast cancer, compared with lifetime never drinkers, promoter methylation likelihood was increased for higher alcohol intake for E-cadherin (OR=2.39; 95% CI, 1.15-4.96), in particular for those with estrogen receptor-negative tumors (OR=4.13; 95% CI, 1.16-14.72), and decreased for p16 (OR=0.52; 95% CI, 0.29-0.92). There were indications that the association with p16 was stronger for drinking at younger ages. Methylation was also associated with drinking intensity independent of total consumption for both genes. We found alcohol consumption was associated with DNA methylation in postmenopausal breast tumors, suggesting that the association of alcohol and breast cancer may be related, at least in part, to altered methylation, and may differ by drinking pattern.

Association of Rad51 polymorphism with DNA repair in BRCA1 mutation carriers and sporadic breast cancer risk

BACKGROUND

Inter-individual variation in DNA repair capacity is thought to modulate breast cancer risk. The phenotypic mutagen sensitivity assay (MSA) measures DNA strand breaks in lymphocytes; women with familial and sporadic breast cancers have a higher mean number of breaks per cell (MBPC) than women without breast cancer. Here, we explore the relationships between the MSA and the Rad51 gene, which encodes a DNA repair enzyme that interacts with BRCA1 and BRCA2, in BRCA1 mutation carriers and women with sporadic breast cancer.

METHODS

Peripheral blood lymphoblasts from women with known BRCA1 mutations underwent the MSA (n = 138 among 20 families). BRCA1 and Rad51 genotyping and sequencing were performed to identify SNPs and haplotypes associated with the MSA. Positive associations from the study in high-risk families were subsequently examined in a population-based case-control study of breast cancer (n = 1170 cases and 2115 controls).

RESULTS

Breast cancer diagnosis was significantly associated with the MSA among women from BRCA1 families (OR = 3.2 95%CI: 1.5-6.7; p = 0.004). The Rad51 5'UTR 135 C>G genotype (OR = 3.64; 95% CI: 1.38, 9.54; p = 0.02), one BRCA1 haplotype (p = 0.03) and in a polygenic model, the E1038G and Q356R BRCA1 SNPs were significantly associated with MBPC (p = 0.009 and 0.002, respectively). The Rad51 5'UTR 135C genotype was not associated with breast cancer risk in the population-based study.

CONCLUSIONS

Mutagen sensitivity might be a useful biomarker of penetrance among women with BRCA1 mutations because the MSA phenotype is partially explained by genetic variants in BRCA1 and Rad51.

DNA promoter methylation in breast tumors: no association with genetic polymorphisms in MTHFR and MTR

Aberrant promoter methylation is recognized as an important feature of breast carcinogenesis. We hypothesized that genetic variation of genes for methylenetetrahydrofolate reductase (MTHFR) and methionine synthase (MTR), two critical enzymes in the one-carbon metabolism, may alter DNA methylation levels and thus influence DNA methylation in breast cancer. We evaluated case-control association of MTHFR C677T, A1298C, and MTR A2756G polymorphisms for cases strata-defined by promoter methylation status for each of three genes, E-cadherin, p16, and RAR-beta2 in breast cancer; in addition, we evaluated case-case comparisons of the likelihood of promoter methylation in relation to genotypes using a population-based case-control study conducted in Western New York State. Methylation was evaluated with real-time methylation-specific PCRs for 803 paraffin-embedded breast tumor tissues from women with primary, incident breast cancer. We applied unordered polytomous regression and unconditional logistic regression to derive adjusted odds ratios and 95% confidence intervals. We did not find any association of MTHFR and MTR polymorphisms with breast cancer risk stratified by methylation status nor between polymorphisms and likelihood of promoter methylation of any of the genes. There was no evidence of difference within strata defined by menopausal status, estrogen receptor status, folate intake, and lifetime alcohol consumption. Overall, we found no evidence that these common polymorphisms of the MTHFR and MTR genes are associated with promoter methylation of E-cadherin, p16, and RAR-beta2 genes in breast cancer.

Effect modification by catalase genotype suggests a role for oxidative stress in the association of hormone replacement therapy with postmenopausal breast cancer risk

Catalase, a ubiquitous heme enzyme, catalyzes conversion of hydrogen peroxide to water and molecular oxygen, protecting cells from oxidative stress. A C/T polymorphism in the promoter region of the CAT gene (rs1001179) affects transcriptional activity and RBC catalase levels. Oxidative stress may explain the observed increased postmenopausal breast cancer risk associated with hormone replacement therapy (HRT). We examined CAT genotype, HRT, and postmenopausal breast cancer risk in the Western New York Exposures and Breast Cancer case-control study. Cases (n = 616) were women with primary, incident, pathologically confirmed breast cancer. Randomly selected controls (n = 1,082) were frequency matched to cases on age and race. Genotype was assayed by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Unconditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) adjusted for potential confounders. CAT genotype alone was not associated with breast cancer risk. Ever use of HRT was associated with increased risk (OR, 1.39; 95% CI, 1.11-1.75). The increase with ever use was more pronounced among those with variant CT or TT CAT genotype (OR, 1.88; 95% CI, 1.29-2.75) than among those with CC (OR, 1.15; 95% CI, 0.86-1.54). Similarly, risk associated with >or=5 years of HRT use was greater among those with at least one variant T allele (OR, 2.32; 95% CI, 1.50-3.59). Increased risk was limited to estrogen receptor-positive tumors. Our findings suggest that CAT genotype modifies the effect of HRT use on breast cancer risk and that HRT may affect risk by affecting oxidative stress.

Abstract 5814: Association between ADH1B and ADH1C haplotype tag SNPs and breast cancer risk, and the interaction with alcohol drinking

Alcohol consumption has been found to be associated with breast cancer with some consistency. Alcohol dehydrogenase is rate limiting in alcohol metabolism. We investigated the association of haplotype tag SNPs in ADH1B and ADH1C with breast cancer risk and the interaction with alcohol drinking in a population-based case control study (the WEB Study) conducted in western New York between 1996 and 2001. Genomic DNA and SNP genotyping was performed by allelic discrimination real time PCR for 991 cases and 1698 controls. Haplotype tag SNPs were selected from the Caucasian HapMap data. Lifetime alcohol consumption was queried by interview. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). Backwards selection was employed to obtain the most parsimonious model starting with the full model with interactions. Two tag SNPs, rs1042026 in ADH1B and rs1614972 in ADH1C, were associated with risk for postmenopausal women. The ADH1B SNP rs1042026 located in the 3’UTR is in LD with several functional SNPs from ADH6, ADH1A, ADH1B and ADH1C. This SNP was in Hardy Weinberg equilibrium in the postmenopausal control and not in postmenopausal cases, which strengthens the evidence of association. This SNP showed evidence of significant interaction with alcohol consumption. The OR for postmenopausal breast cancer in women with both CC genotype and who consume alcohol versus without the AA genotype and who abstain was 1.94, 95%CI 1.13-3.30. In addition, we found evidence of a trend for dose response depending on the amount of alcohol consumption when alcohol consumption was examined in three categories of abstainers, low and high consumption (p=0.08). The ADH1C SNP rs1614972 located in intron 8 is in LD with other six nonsynonymous exonic SNPs including the functional I350V (rs698). There was an interaction with alcohol consumption with the presence of the CC genotype and risk conferring a protective effect varying inversely proportional with the drinking level (p=0.0092). Moreover, the CC genotype decreased the odds of breast cancer in women who consume alcohol versus those that abstain regardless of the menopausal status (OR=0.56, 95%CI 0.35-0.90). In conclusion, haplotype tag SNPs in ADH1B and ADH1C were associated with breast cancer risk especially in postmenopausal women, and showed evidence of significant interaction with alcohol consumption.

Supported by the following grants: DAMD-17-03-1-0446, DAMD-17-00-1-0417 and NCI-RO1CA92040

Marian C. was supported by an AVON-AACR International Scholar in Breast Cancer Research award

DNA hypermethylation and clinicopathological features in breast cancer: the Western New York Exposures and Breast Cancer (WEB) Study

Aberrant DNA hypermethylation of gene promoter regions has been increasingly recognized as a common molecular alteration in carcinogenesis. We evaluated the association between major clinicopathological features and hypermethylation of genes in tumors among 803 incidence breast cancer cases from a large population-based case-control study conducted in Western New York State. DNA samples were isolated from archive paraffin embedded tumor tissue and were analyzed for hypermethylation status of the E-cadherin, p16, and RAR-beta(2) genes using real time methylation-specific polymerase chain reaction. The frequencies of hypermethylation were 20.0% for E-cadherin, 25.9% for p16, and 27.5% for RAR-beta(2) genes. For postmenopausal women, hypermethylation of E-cadherin tended to be more likely in progesterone receptor (PR) negative than in PR-positive tumors (odds ratio (OR), 1.41; 95% confidence interval (CI), 0.91-2.18). Hypermethylation of p16 tended to be more frequent among estrogen receptor (ER) negative cases than ER-positive cases (OR, 1.51; 95% CI, 1.01-2.32). Hypermethylation of RAR-beta(2) gene was inversely associated with histological and nuclear grade of breast cancer.

Exposure to traffic emissions throughout life and risk of breast cancer: the Western New York Exposures and Breast Cancer (WEB) study

OBJECTIVE

We previously reported that total suspended particulates exposure (a measure of air pollution) at the time of birth was related to increased postmenopausal breast cancer risk. In this study, we examined breast cancer risk in relation to exposure to air pollution from traffic emissions throughout life.

METHODS

We conducted a case-control study of breast cancer. Participants were women, aged 35-79, residents of Erie and Niagara Counties. Cases had incident, primary, histologically confirmed breast cancer. Controls were randomly selected from the population, frequency-matched on age and race. Using lifetime residential histories, exposure to traffic emissions was modeled for each woman using her residence as a proxy. Estimates were calculated for residence at menarche, her first birth, and 20 and 10 years before interview. Unconditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Higher exposure to traffic emissions at the time of menarche was associated with increased risk of premenopausal breast cancer (OR 2.05, 95% CI 0.92-4.54, p for trend 0.03); and at the time of a woman's first birth for postmenopausal breast cancer (OR 2.57, 95% CI 1.16-5.69, p for trend 0.19). Statistically significant associations were limited to lifetime non-smokers; there was a significant interaction between exposure at time of menarche and smoking for premenopausal women.

CONCLUSION

Our findings add to accumulating evidence that early life exposures impact breast cancer risk and provide indication of potential importance of traffic emissions in risk of breast cancer.

Lifetime adult weight gain, central adiposity, and the risk of pre- and postmenopausal breast cancer in the Western New York exposures and breast cancer study

While there are quite consistent data regarding associations of body weight and postmenopausal breast cancer, there are now accumulating data that would indicate that weight gain in adult life is more predictive of risk than absolute body weight. There is, however, little known about the relative impact of timing of weight gain in adult life as well as other characteristics of the weight and breast cancer association that might provide insight into the mechanism of the observation. We conducted a population-based case control study of breast cancer (1996-2001), the Western New York Exposures and Breast Cancer Study. Included were 1,166 women with primary, histologically confirmed, incident breast cancer and 2,105 controls frequency-matched on age, race and county of residence. Unconditional logistic regression was used to estimate odds ratios and 95% confidence intervals. We found increased risk of breast cancer associated with lifetime adult weight gain among post- but not premenopausal women, and there was a 4% increase in risk for each 5 kg increase in adult weight. Further there was a tendency toward a stronger association for those with higher waist circumference and those with positive estrogen or progesterone status, and who had never used HRT. We also found an association with risk for weight gain since first pregnancy and for weight gain between the time of the first pregnancy and menopause, independent of body mass index and lifetime adult weight gain. Our results suggest that there are time periods of weight gain that have greater impact on risk, and that central body fat, receptor status and hormone replacement therapy may all affect the observed association.

Dietary lignan intakes and risk of breast cancer by tumor estrogen receptor status

We examined the association of dietary lignan intake with estrogen receptor negative (ER-) and ER positive (ER+) breast cancer risk in a breast cancer case-control study. Among premenopausal women only, there was a reduced risk of ER- breast cancer for those in the highest compared to the lowest quartile of lignan intake suggesting that the observed negative association of lignans with breast cancer may be limited to ER- tumors.

Geographic clustering of residence in early life and subsequent risk of breast cancer (United States)

OBJECTIVE

This study focused on geographic clustering of breast cancer based on residence in early life and identified spatio-temporal clustering of cases and controls.

METHODS

Data were drawn from the WEB study (Western New York Exposures and Breast Cancer Study), a population-based case-control study of incident, pathologically confirmed breast cancer (1996-2001) in Erie and Niagara counties. Controls were frequency-matched to cases on age, race, and county of residence. All cases and controls used in the study provided lifetime residential histories. The k-function difference between cases and controls was used to identify spatial clustering patterns of residence in early life.

RESULTS

We found that the evidence for clustered residences at birth and at menarche was stronger than that for first birth or other time periods in adult life. Residences for pre-menopausal cases were more clustered than for controls at the time of birth and menarche. We also identified the size and geographic location of birth and menarche clusters in the study area, and found increased breast cancer risk for pre-menopausal women whose residence was within the cluster compared to those living elsewhere at the time of birth.

CONCLUSION

This study provides evidence that early environmental exposures may be related to breast cancer risk, especially for pre-menopausal women.

Lung cancer in humans is not associated with lifetime total alcohol consumption or with genetic variation in alcohol dehydrogenase 3 (ADH3)

Although there is clear evidence that smoking is the primary risk factor for lung cancer, not all variation in disease risk is understood. There is some evidence that alcohol may contribute to risk. We examined lifetime and recent (12-24 mo previous) alcohol consumption in relation to risk of lung cancer in a case-control study in western New York. In addition we examined the alcohol dehydrogenase 3 (ADH3) genotype in relation to lung cancer risk; ADH3 is rate limiting in alcohol metabolism and has a functional polymorphism. We interviewed incident, primary, histologically confirmed lung cancer cases (n = 111) in two counties. Controls were randomly selected from among those residing in the counties, frequency-matched to cases for age and race (n = 1546). Lifetime and recent total alcohol and beverage-specific alcohol consumption as well as relevant confounders were assessed by interview. ADH3 genotype was evaluated by a PCR-restriction fragment length polymorphism assay. Because of the small sample size, power was limited and CI were wide. Residual confounding by smoking remains a concern. Although we found a significant trend for increased risk for beer consumption in the recent period (odds ratio 1.67, 95% CI 0.96-2.92, P for trend = 0.05), chance cannot be ruled out as an explanation. We found no evidence of risk related to lifetime alcohol consumption nor evidence that alcohol dehydrogenase genotype modifies risk related to alcohol and lung cancer.

Dietary lignan intakes and risk of pre- and postmenopausal breast cancer

Lignans are plant compounds metabolized in the mammalian gut to produce the phytoestrogens enterolactone and enterodiol. Because estrogens have been linked to breast cancer etiology, lignans could affect breast cancer risk through modulation of endogenous estrogen metabolism or competitive inhibition with estrogen receptors. We examined breast cancer risk and dietary lignan intake in a population-based case-control study of 1,122 women with primary, incident, histologically confirmed breast cancer and 2,036 controls frequency matched to cases on age and county of residence as part of the Western New York Exposures and Breast Cancer (WEB) Study. Diet was assessed with a self-administered 104-item food frequency questionnaire and other relevant data were collected by detailed in-person interviews. Lignans were expressed as the sum of the dietary precursors secoisolariciresinol and matairesinol. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by unconditional logistic regression, adjusting for age, total energy and other breast cancer risk factors. Premenopausal women in the highest quartile of dietary lignan intake had reduced breast cancer risk (OR = 0.66; 95% CI = 0.44-0.98). No association was observed between lignan intakes and postmenopausal breast cancer. Our results suggest that dietary lignans may be important in the etiology of breast cancer, particularly among premenopausal women.

Quid pro quo: fee for services delivered in a psychology training clinic

The present study evaluated the use of a sliding-fee scale at a training clinic for doctoral students in clinical psychology. A chart review of 209 individual therapy clients and a follow-up telephone interview of 87 of these clients were conducted. Results of the chart review revealed a client group of relatively low income, with only a very small number receiving social assistance or a disability pension. The follow-up survey found that the large majority of clients were satisfied with the fees charged. Service use (i.e., frequency and number of sessions), client satisfaction with services, and treatment outcome did not vary with out-of-pocket costs incurred by clients. Overall, findings suggest that training clinics can charge fees without affecting services, although future research needs to examine the extent that fee charging by training clinics may be an obstacle to service access for the poorest segments of the population.

Effects of decreasing sedentary behaviors on activity choice in obese children

In this study, methods of decreasing highly preferred sedentary behaviors were compared and the consequent effects on activity choice were examined. Following free choice of sedentary and physical activities, 34 obese children either were positively reinforced for decreases in high-preference sedentary activity, were punished for high-preference sedentary activity, had access to high-preference sedentary activity restricted, or had no contingencies on activity (control group). Children randomized to reinforcement and punishment were more physically active on intervention days than the control group. Liking for targeted sedentary activity decreased in the reinforcement group, but increased in the restriction and control groups. Results suggest that reinforcing decreases in high-preference sedentary activity can increase physical activity and decrease liking for targeted sedentary activities.

Effects of decreasing sedentary behaviors on activity choice in obese children

In this study, methods of decreasing highly preferred sedentary behaviors were compared and the consequent effects on activity choice were examined. Following free choice of sedentary and physical activities, 34 obese children either were positively reinforced for decreases in high-preference sedentary activity, were punished for high-preference sedentary activity, had access to high-preference sedentary activity restricted, or had no contingencies on activity (control group). Children randomized to reinforcement and punishment were more physically active on intervention days than the control group. Liking for targeted sedentary activity decreased in the reinforcement group, but increased in the restriction and control groups. Results suggest that reinforcing decreases in high-preference sedentary activity can increase physical activity and decrease liking for targeted sedentary activities.

Determinants of physical activity in obese children assessed by accelerometer and self-report

Previous research has shown that predictors of activity in adults depend upon the method of measurement. This study is designed to assess the predictors of activity in a sample of 59 obese children. Activity was measured using self-reported and TriTrac accelerometer METs. Self-report and TriTrac accelerometer measures were moderately correlated, r = 0.46, with the self-reported activity (2.3 METs) significantly greater than TriTrac (1.6 METs). Hierarchical regression analysis examined the influence of socioeconomic level, body composition, fitness, hedonics of child and adult activity behaviors, and decisional balance on self-reported and accelerometer-measured activity, controlling for child and parent psychopathology. Child and parent psychological symptoms accounted for 8.3% and 3.4% of the variance in accelerometer and self-reported METs, respectively. The model for accelerometer-measured activity showed socioeconomic level and parent self-report of activity accounted for 14.8% of the incremental variance in child activity. The model for self-report of child activity found that child fitness accounted for 23.5% of the incremental variance in child activity. These results suggest that the predictors of activity level are different based upon the method of measurement, consistent with research in adults.

Tobacco, alcohol, and other drug use behaviors among adolescents in Erie County, New York

This article provides estimates of the prevalence of tobacco, alcohol, and other drug use behaviors of ninth-grade students enrolled in public and parochial schools in Erie County, New York. A computer-scannable survey consisting of 50 questions was completed by 7,891 students in the fall of 1992. Survey findings show that tobacco and alcohol are the drugs used most often by ninth-grade students. Results also indicate that cigarette use is strongly associated with other drug use behaviors such as getting drunk, using marijuana, and other illegal drugs. A report detailing findings from the survey has been widely disseminated to school officials and community leaders throughout Erie County. Our experience in conducting this survey suggests that collecting information on the drug use behaviors of adolescents at the local level is both feasible and worthwhile.