Abstract 5318: High-grade serous ovarian cancer DNA methylation and survival in African-American women

Ovarian cancer is the most lethal gynecologic cancer in the United States, and African-American (AA) women have the poorest outcomes compared to other racial/ethnic groups. Although several biomarkers have been proposed to establish prognosis in European ancestry (EA) patients, including some DNA methylation markers (FGF4, FGF21, MYLK2, MYLK3, MYL7, and ITGAE) (Phelps et al., 2017), it is unknown if these or other markers are applicable to AA patients. Using data from the African-American Cancer Epidemiology Study (AACES), we evaluated 1) if DNA methylation is associated with residual disease and survival, and 2) if previously reported CpG biomarkers for EA women are related to survival in AA women. 121 AA women with high-grade serous ovarian cancer (HGSOC) were randomly selected from 600 women enrolled in AACES. Clinical records and formalin-fixed, paraffin-embedded (FFPE) tumor tissue were retrieved, and a pathologist reviewed histopathologic slides to confirm diagnosis. 92 HGSOC had complete clinical information. DNA methylation was measured using Illlumina HumanMethylationEPIC. Beta-values were preprocessed (RELIC, Tost+BMIQ and ComBat). Low quality probes were filtered. Tumor purity was estimated using InfiniumPurify; <30% was considered low purity. Four cell estimates (RefFreecellmix) were used as a proxy of cell composition. To evaluate DNA methylation alterations, we used the top 100K most variable CpG sites and a semisupervised recursively partitioned mixture model (ssRPMM) approach to delineate the patients into RPMM classes. We also evaluated the six candidate CpGs from Phelps et al. The dataset was divided into training and validation subsets (50% each); if findings were consistent, a pooled statistic is reported. We used logistic regression to evaluate the association between DNA methylation and residual disease; Cox proportional hazard models were used for survival. Models were adjusted for age at diagnosis, low purity, cell types, neoadjuvant therapy, tissue source (adnexa vs. peritoneum), histology (serous vs. mixed), and residual disease. The RPMM classes were not associated with residual disease. For survival, four RPMM classes were delineated, which we collapsed into two classes. A lower risk of mortality was observed for one of the RPMM classes, HR: 0. 03[95% CI: 0.01-0.12]. This “low risk” RPMM class grouped five CpGs in genes PLEC1, AP5B1, DNAH7 and MAPK15. These genes have been associated with cell motility and ovarian cancer ascites. Among the candidate CpGs, we only observed a trend to better survival per every 10% increase in MYLK3 CpG methylation, HR: 0.51 [95%CI: 0.24-1.10]. These preliminary results suggest that some DNA methylation modifications may identify subgroups of AA women with better survival. Previously reported biomarkers in EA may not be as useful in AA women. Future studies with increased sample size may help to disentangle these associations.

Citation Format: Lucas A. Salas, Lauren C. Peres, Sarah E. Abbott, Casey S. Greene, Jeffrey R. Marks, Anthony J. Alberg, Elisa V. Bandera, Jill S. Barnholtz-Sloan, Ann G. Schwartz, Michele L. Cote, Patricia G. Moorman, Ellen M. Funkhouser, Edward S. Peters, Melissa L. Bondy, Paul D. Terry, Jennifer A. Doherty, Brock C. Christensen, Joellen M. Schildkraut. High-grade serous ovarian cancer DNA methylation and survival in African-American women [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5318.

Values and worries of ovarian cancer patients

INTRODUCTION

Older women with ovarian cancer (OC) are less likely to receive guideline concordant treatment. Differences in values and worries about treatment may explain why.

METHODS

Women with OC in 2013-2015 were surveyed about values and worries at the time of initial treatment. Existing values (11 item, e.g., maintaining quality of life) and worries (12 items, e.g., treatment side effects) scales were adapted based on OC literature. Responses were very/somewhat/a little/not at all important or worried. Principal Component Analyses (PCA) identified groups of values and worries that best explained scales' variation. We examined proportions reporting very/somewhat important/worried on ≥1 item in each component by age (older ≥65years, younger <65years).

RESULTS

Of 170 respondents, 42.3% were older. PCA components for values were: functional well-being (3 survey items, proportion of variance explained [PoVE] 26.3%), length of life and sexual functioning (3 items, PoVE 20.1%), attitudes (3 items, PoVE 14.2%), and not becoming a burden (2 items, PoVE 13.7%). PCA components for worries were: economic (4 items, PoVE 27.2%), uncertainty (6 items, PoVE 26.0%), and family impact (2 items, PoVE 16.3%). Older women were less likely to indicate very/somewhat worried to ≥1 item in the economic (51.4% vs 72.4%, p=0.006), uncertainty (80.6% vs. 98.0%, p=0.001), and family impact component (55.6% vs. 70.4%, p=0.03). No other age differences were found.

CONCLUSIONS

While worry during OC treatment decision-making may differ across age groups, values do not. Research should assess how differences in worry might affect OC medical decision-making for older and younger women.

Nutritional risk and body mass index predict hospitalization, nursing home admissions, and mortality in community-dwelling older adults: results from the UAB Study of Aging with 8.5 years of follow-up

BACKGROUND

Nutritional risk and low BMI are common among community-dwelling older adults, but it is unclear what associations these factors have with health services utilization and mortality over long-term follow-up. The aim of this study was to assess prospective associations of nutritional risk and BMI with all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality over 8.5 years.

METHODS

Data are from 1,000 participants in the University of Alabama at Birmingham Study of Aging, a longitudinal, observational study of older black and white residents of Alabama aged 65 and older. Nutritional risk was assessed using questions associated with the DETERMINE checklist. BMI was categorized as underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), class I obese (30.0-34.9), and classes II and III obese (≥35.0). Cox proportional hazards models were fit to assess risk of all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality. Covariates included social support, social isolation, comorbidities, and demographic measures.

RESULTS

In adjusted models, persons with high nutritional risk had 51% greater risk of all-cause hospitalization (95% confidence interval: 1.14-2.00) and 50% greater risk of nonsurgical hospitalizations (95% confidence interval: 1.11-2.01; referent: low nutritional risk). Persons with moderate nutritional risk had 54% greater risk of death (95% confidence interval: 1.19-1.99). BMI was not associated with any outcomes in adjusted models.

CONCLUSIONS

Nutritional risk was associated with all-cause hospitalizations, nonsurgical hospitalizations, and mortality. Nutritional risk may affect the disablement process that leads to health services utilization and death. These findings point to the need for more attention on nutritional assessment, interventions, and services for community-dwelling older adults.

Disparities in use of gynecologic oncologists for women with ovarian cancer in the United States

OBJECTIVE

To examine disparities in utilization of gynecologic oncologists (GOs) across race and other sociodemographic factors for women with ovarian cancer.

DATA SOURCES

Obtained SEER-Medicare linked dataset for 4,233 non-Hispanic White, non-Hispanic African American, Hispanic of any race, and Non-Hispanic Asian women aged ≥ 66 years old diagnosed with ovarian cancer during 2000-2002 from 17 SEER registries. Physician specialty was identified by linking data to the AMA master file using Unique Physician Identification Numbers.

STUDY DESIGN

Retrospective claims data analysis for 1999-2006. Logistic regression models were used to analyze the association between GO utilization and race/ethnicity in the initial, continuing, and final phases of care.

PRINCIPAL FINDINGS

GO use decreased from the initial to final phase of care (51.4-28.8 percent). No racial/ethnic differences were found overall and by phase of cancer care. Women >70 years old and those with unstaged disease were less likely to receive GO care compared to their counterparts. GO use was lower in some SEER registries compared to the Atlanta registry.

CONCLUSIONS

GO use for the initial ovarian cancer treatment or for longer term care was low but not different across racial/ethnic groups. Future research should identify factors that affect GO utilization and understand why use of these specialists remains low.

Caries treatment in a dental practice-based research network: movement toward stated evidence-based treatment

OBJECTIVES

Practice-based research networks (PBRNs) provide a venue to foster evidence-based care. We tested the hypothesis that a higher level of participation in a dental PBRN is associated with greater stated change toward evidence-based practice.

METHODS

A total of 565 dental PBRN practitioner-investigators completed a baseline questionnaire entitled 'Assessment of Caries Diagnosis and Treatment'; 405 of these also completed a follow-up questionnaire about treatment of caries and existing restorations. Certain questions (six treatment scenarios) were repeated at follow-up a mean (SD) of 36.0 (3.8) months later. A total of 224 were 'full participants' (enrolled in clinical studies and attended at least one network meeting); 181 were 'partial participants' (did not meet 'full' criteria).

RESULTS

From 10% to 62% of practitioners were 'surgically invasive' at baseline, depending on the clinical scenario. Stated treatment approach was significantly less invasive at follow-up for four of six items. Change was greater among full participants and those with a more-invasive approach at baseline, with an overall pattern of movement away from the extremes.

CONCLUSIONS

These results are consistent with a preliminary conclusion that network participation fostered movement of scientific evidence into routine practice. PBRNs may foster movement of evidence into everyday practice as practitioners become engaged in the scientific process.

Improving care after myocardial infarction using a 2-year internet-delivered intervention: the Department of Veterans Affairs myocardial infarction-plus cluster-randomized trial

BACKGROUND

Cardiovascular risk reduction in ambulatory patients who survive myocardial infarction (MI) is effective but underused. We sought to evaluate a provider-directed, Internet-delivered intervention to improve cardiovascular management for post-MI outpatients.

METHODS

The Department of Veterans Affairs (VA) MI-Plus study was a cluster-randomized trial involving 168 community-based primary care clinics and 847 providers in 26 states, the Virgin Islands, and Puerto Rico, from January 1, 2002, through December 31, 2008, with the clinic as the randomization unit. We collected administrative data for 15,847 post-MI patients and medical record data for 10,452 of these. A multicomponent, Internet-delivered intervention included quarterly educational modules, practice guidelines, monthly literature summaries, and automated e-mail reminders delivered to providers for 27 months. Main outcome measures included percentage of patients who achieved each of 7 clinical indicators, a composite score of the 7 clinical indicators, and mean low-density lipoprotein cholesterol and hemoglobin A(1c) levels.

RESULTS

Clinics had a median of 3 providers (interquartile range, 2-6), with a median of 50.0% of providers (33.3%-66.7%) participating in the study. Patients in intervention clinics had greater improvements (from 70.0% to 85.5%) in the percentages prescribed β-blockers than patients in control clinics (71.9% to 84.0%; adjusted improvement gain for intervention vs control, 2.6%; 95% CI, 0.1%-4.1%). We found nonsignificant differences in improvements favoring patients in intervention clinics for 5 of 6 remaining clinical indicators and levels of low-density lipoprotein cholesterol and hemoglobin A(1c).

CONCLUSION

A longitudinal, Internet-delivered intervention improved only 1 of 7 clinical indicators of cardiovascular management in ambulatory post-MI patients.

Using single-item health literacy screening questions to identify patients who read written nonsteroidal anti-inflammatory medicine information provided at pharmacies

Our goal was to assess the relationships between single-item health literacy screening questions and reading prescription nonsteroidal anti-inflammatory drug (NSAID) written medicine information (WMI) provided at pharmacies. The health literacy of 382 patients from primary care physician practices in Alabama was estimated using validated health literacy screening questions related to understanding written medical information (SQ1); confidence in completing medical forms alone (SQ2); and need for assistance in reading hospital materials (SQ3). Reading WMI was measured by a "Yes" response to the question, "Often the drug store gives you written information such as pamphlets or handouts along with your prescription. Have you read about the risks of NSAIDs in this written material provided by the drug store?" Relationships were assessed using generalized linear latent and mixed models. Two-thirds (67.6%) of patients read WMI. Higher estimated health literacy was associated with increased odds of reading WMI. Adjusted odds ratios (95% CI) were 2.08 (1.08-4.03); 2.09 (1.12-3.91); and 1.98 (1.04-3.77) using SQ1-SQ3. Current WMI may be unable to meet the needs of those with inadequate health literacy. Health literacy screening questions can be used to triage patients at risk for not reading WMI so they can be assisted with supplemental educational strategies.

Comorbidity independently predicted death in older prostate cancer patients, more of whom died with than from their disease

OBJECTIVE

The purpose of this study was to examine the proportion of men who died from prostate cancer (PrCa) vs. with PrCa and assess the comorbid conditions associated with other-cause deaths.

STUDY DESIGN AND SETTING

We identified all male decedents aged >/=65 years in Jefferson County, AL, in 1993-1995. By crosslinking three databases (death certificate, Medicare, and Veteran's Administration), we identified men whose deaths might have been caused by PrCa. We abstracted and reviewed medical records to rate comorbid conditions and determine whether or not death was due to PrCa.

RESULTS

Of 561 men with a premortem diagnosis of PrCa, 42% died from PrCa and 53% died with PrCA; 50.2% of blacks died from PrCa vs. 36.9% of Whites. Other factors related to dying with PrCa included older age at death and a serious, or very serious, comorbid condition. Treatment did not have an independent effect on cause of death (i.e., death with vs. from PrCa).

CONCLUSIONS

Comorbidity was an independent predictor of dying with PrCa, even after adjustment for ethnicity, age, and treatment. Given the as yet unproven benefit of PrCa screening, our results extend the body of information relevant to the screening decision; among men dying with a diagnosis of PrCa, only about 1/3 to 1/2 died from the disease.

Longitudinal study of elbow and shoulder pain in youth baseball pitchers

PURPOSE

Previous studies among young pitchers have focused on the frequency and description of elbow injuries. The purpose of this study was to evaluate the frequency of elbow and shoulder complaints in young pitchers and to identify the associations between pitch types, pitch volume, and other risk factors for these conditions.

METHODS

A prospective cohort study of 298 youth pitchers was conducted over two seasons. Each participant was contacted via telephone after each game pitched to identify arm complaints. Generalized estimating equations were used to assess associations between arm complaints and independent variables.

RESULTS

The frequency of elbow pain was 26%; that of shoulder pain, 32%. Risk factors for elbow pain were increased age, increased weight, decreased height, lifting weights during the season, playing baseball outside the league, decreased self-satisfaction, arm fatigue during the game pitched, and throwing fewer than 300 or more than 600 pitches during the season. Risk factors for shoulder pain included decreased satisfaction, arm fatigue during the game pitched, throwing more than 75 pitches in a game, and throwing fewer than 300 pitches during the season.

CONCLUSION

Arm complaints are common, with nearly half of the subjects reporting pain. The factors associated with elbow and shoulder pain were different, suggesting differing etiologies. Developmental factors may be important in both. To lower the risk of pain at both locations, young pitchers probably should not throw more than 75 pitches in a game. Other recommendations are to remove pitchers from a game if they demonstrate arm fatigue and limit pitching in nonleague games.

Prevention of mother-to-child transmission of HIV in Thailand: physicians' attitudes on zidovudine use, pregnancy termination, and willingness to provide care

We administered a survey to Thai physicians, using regular mail, on their attitudes and practices regarding zidovudine (ZDV) use and pregnancy termination in HIV-infected pregnant women. We surveyed their willingness to care for these patients as well. In 1997, 79.5% of 480 respondents reported that they did not routinely use perinatal ZDV prophylaxis. Predictors of failure to use ZDV found to be significant in our logistic regression model included practice outside of Bangkok (odds ratio [OR] = 2.0), belief that ZDV is not cost effective (OR = 2.5), unfamiliarity with AIDS Clinical Trials Group (ACTG) 076 results (OR = 2.5), and failure to screen for HIV routinely (OR = 4.9). Elective abortion for HIV-infected women was advocated by 45.3% of respondents. Factors associated in multivariable analysis with this preference included specialty training in obstetrics/gynecology (OR = 1.8), practice inside Bangkok (OR = 2.0), male gender (OR = 1.9), and treatment of < or =2 HIV-infected patients yearly (OR = 1.8). A significant proportion of respondents described themselves as unwilling to perform pelvic examinations (19.2%), vaginal deliveries (30.7%), or cesarean deliveries (39.5%) on women who were known to be infected with HIV. We conclude that many Thai obstetric providers are reluctant to care for HIV-infected women, do not routinely use perinatal ZDV prophylaxis, and prefer to terminate pregnancies among HIV-infected patients. Physician education concerning the value of HIV screening and antiretroviral therapy in HIV-infected pregnant women is needed urgently in Thailand.

Aspirin and reduced risk of esophageal carcinoma

BACKGROUND

Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) have been shown experimentally to inhibit chemically induced esophageal cancers. An epidemiologic study of more than 600,000 adults in the United States followed for 6 years found that aspirin use was associated with a reduced risk of death from esophageal cancer.

METHODS

The relation of aspirin use and esophageal cancer was examined using data from the National Health and Nutrition Examination Survey (NHANES I) and the National Epidemiologic Follow-up Studies (NEFS). Of the 14,407 United States residents followed for 12-16 years, esophageal cancer developed in 15. Persons were classified as nonusers, occasional users, or regular users of aspirin based on their response to two questions at the baseline examination: whether they had taken aspirin in the past 30 days and whether they had used pain medications regularly during the prior 6 months.

RESULTS

Occasional use was associated with a 90% decreased risk (95% confidence interval, 0.01-0.76) of developing esophageal cancer, and no person classified as a regular user developed the disease. Adjusting for cigarette smoking (ever vs. never) and alcohol intake (at least monthly vs. not) did not explain the finding.

CONCLUSION

Aspirin use was associated with a 90% decreased risk of developing esophageal carcinoma. Further studies to determine whether aspirin is protective against both squamous cell esophageal carcinoma and adenocarcinoma of the esophagus are indicated.

Aspirin and reduced risk of esophageal carcinoma

BACKGROUND

Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) have been shown experimentally to inhibit chemically induced esophageal cancers. An epidemiologic study of more than 600,000 adults in the United States followed for 6 years found that aspirin use was associated with a reduced risk of death from esophageal cancer.

METHODS

The relation of aspirin use and esophageal cancer was examined using data from the National Health and Nutrition Examination Survey (NHANES I) and the National Epidemiologic Follow-up Studies (NEFS). Of the 14,407 United States residents followed for 12-16 years, esophageal cancer developed in 15. Persons were classified as nonusers, occasional users, or regular users of aspirin based on their response to two questions at the baseline examination: whether they had taken aspirin in the past 30 days and whether they had used pain medications regularly during the prior 6 months.

RESULTS

Occasional use was associated with a 90% decreased risk (95% confidence interval, 0.01-0.76) of developing esophageal cancer, and no person classified as a regular user developed the disease. Adjusting for cigarette smoking (ever vs. never) and alcohol intake (at least monthly vs. not) did not explain the finding.

CONCLUSION

Aspirin use was associated with a 90% decreased risk of developing esophageal carcinoma. Further studies to determine whether aspirin is protective against both squamous cell esophageal carcinoma and adenocarcinoma of the esophagus are indicated.

Aspirin and reduced risk of esophageal carcinoma

BACKGROUND

Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) have been shown experimentally to inhibit chemically induced esophageal cancers. An epidemiologic study of more than 600,000 adults in the United States followed for 6 years found that aspirin use was associated with a reduced risk of death from esophageal cancer.

METHODS

The relation of aspirin use and esophageal cancer was examined using data from the National Health and Nutrition Examination Survey (NHANES I) and the National Epidemiologic Follow-up Studies (NEFS). Of the 14,407 United States residents followed for 12-16 years, esophageal cancer developed in 15. Persons were classified as nonusers, occasional users, or regular users of aspirin based on their response to two questions at the baseline examination: whether they had taken aspirin in the past 30 days and whether they had used pain medications regularly during the prior 6 months.

RESULTS

Occasional use was associated with a 90% decreased risk (95% confidence interval, 0.01-0.76) of developing esophageal cancer, and no person classified as a regular user developed the disease. Adjusting for cigarette smoking (ever vs. never) and alcohol intake (at least monthly vs. not) did not explain the finding.

CONCLUSION

Aspirin use was associated with a 90% decreased risk of developing esophageal carcinoma. Further studies to determine whether aspirin is protective against both squamous cell esophageal carcinoma and adenocarcinoma of the esophagus are indicated.