Concomitant medication, comorbidity and survival in patients with breast cancer

Between 30% and 70% of patients with breast cancer have pre-existing chronic conditions, and more than half are on long-term non-cancer medication at the time of diagnosis. Preliminary epidemiological evidence suggests that some non-cancer medications may affect breast cancer risk, recurrence, and survival. In this nationwide cohort study, we assessed the association between medication use at breast cancer diagnosis and survival. We included 235,368 French women with newly diagnosed non-metastatic breast cancer. In analyzes of 288 medications, we identified eight medications positively associated with either overall survival or disease-free survival: rabeprazole, alverine, atenolol, simvastatin, rosuvastatin, estriol (vaginal or transmucosal), nomegestrol, and hypromellose; and eight medications negatively associated with overall survival or disease-free survival: ferrous fumarate, prednisolone, carbimazole, pristinamycin, oxazepam, alprazolam, hydroxyzine, and mianserin. Full results are available online from an interactive platform ( https://adrenaline.curie.fr ). This resource provides hypotheses for drugs that may naturally influence breast cancer evolution.

Expressions of HuR, Methyl-HuR and Phospho-HuR in Endometrial Endometrioid Adenocarcinoma Are Associated with Clinical Features

HuR regulates cytoplasmic mRNA stability and translatability, with its expression correlating with adverse outcomes in various cancers. This study aimed to assess the prognostic value and pro-oncogenic properties of HuR and its post-translational isoforms methyl-HuR and phospho-HuR in endometrial adenocarcinoma. Examining 89 endometrioid adenocarcinomas, we analyzed the relationship between HuR nuclear or cytoplasmic immunostaining, tumor-cell proliferation, and patient survival. HuR cytoplasmic expression was significantly increased in grade 3 vs. grade 1 adenocarcinomas (p < 0.001), correlating with worse overall survival (OS) (p = 0.02). Methyl-HuR cytoplasmic expression significantly decreased in grade 3 vs. grade 1 adenocarcinomas (p < 0.001) and correlated with better OS (p = 0.002). Phospho-HuR nuclear expression significantly decreased in grade 3 vs. grade 1 adenocarcinomas (p < 0.001) and non-significantly correlated with increased OS (p = 0.06). Cytoplasmic HuR expression strongly correlated with proliferation markers MCM6 (rho = 0.59 and p < 0.001) and Ki67 (rho = 0.49 and p < 0.001). Conversely, these latter inversely correlated with cytoplasmic methyl-HuR and nuclear phospho-HuR. Cytoplasmic HuR expression is a poor prognosis marker in endometrioid endometrial adenocarcinoma, while cytoplasmic methyl-HuR and nuclear phosphoHuR expressions are markers of better prognosis. This study highlights HuR as a promising potential therapeutic target, especially in treatment-resistant tumors, though further research is needed to understand the mechanisms regulating HuR subcellular localization and post-translational modifications.

Impact of ERAS in breast reconstruction with a latissimus dorsi flap, compared to conventional management

BACKGROUND

Enhanced recovery after surgery (ERAS) programs are associated with improved management, reduced hospital stays, and lower complication rates.

OBJECTIVE

To evaluate the impact of ERAS on mean length of stay (LOS) and postoperative morbidity in breast reconstruction with latissimus dorsi flap (LDF) compared with conventional recovery program.

PATIENTS AND METHOD

All patients operated by LDF between December 2014 and October 2020: those managed before April 2018, when the ERAS protocol was introduced, were included in the "no ERAS" group, and beyond in the "ERAS" group.

RESULTS

Out of 193 patients, 129 were included in the "ERAS" group and 64 in the "no ERAS" group. There was a significant difference between the two groups in LOS (4.2 ± 1.5 days in the "ERAS" group vs. 5.4 ± 1.9 days in the "no ERAS" group; p < 0.001), high-grade complications at 30 days (9.3% in the "ERAS" group vs. 25% in the "no ERAS" group; p = 0.01), reintervention rate (13.9% vs. 26.6%, respectively; p = 0.02), and 30-day rehospitalization rate (6.2% in the "ERAS" group vs. 15.6% in the "no ERAS" group; p = 0.03).

CONCLUSION

The ERAS protocol has a positive impact on breast reconstruction with LDF without generating additional adverse effects. These results support the democratization of these programs for breast reconstruction surgery.

Ergonomic Assessment of the Surgeon's Physical Workload During Robot-Assisted Versus Standard Laparoscopy in a French Multicenter Randomized Trial (ROBOGYN-1004 Trial)

BACKGROUND

Standard laparoscopy (SL) is responsible for musculoskeletal disorders in surgeons because of poor ergonomic positions, which could be reduced by robot-assisted laparoscopy (RAL) owing to the surgeons' seated position. One of the aims of the ROBOGYN-1004 study (NCT01247779) was to evaluate surgeons' workloads during real-time procedures of gynecological oncological surgery.

METHODS

Patients with gynecological cancer eligible for minimally invasive surgery were recruited from 13 French centers between December 2010 and December 2015. Physical workload was evaluated using the Borg scale every hour over the surgery duration and the perception of workload evaluated using NASA-TLX at the end of surgery.

RESULTS

A total of 369 patients were recruited, of whom 176 underwent RAL and 193 underwent SL (per-protocol analysis). Posture during SL was significantly more challenging for all body parts except the back. There was an increase in discomfort over time (up to 4 h) for the hands and arms, neck, and legs in SL compared with RAL. Perceived physical activity and abilities were rated higher in SL than in RAL (p < 0.01), whereas perceived personal performance was higher in SL (p < 0.01). Perceived physical effort during surgery was lower in RAL than in SL.

CONCLUSIONS

RAL improves the perception of physical workload. Compared with SL, the perceived effort is lower in RAL regardless of the complexity of the surgery.

Contraception in breast cancer survivors from the FEERIC case-control study (performed on behalf of the Seintinelles research network)

OBJECTIVE

To compare the prevalence of contraception in breast cancer (BC) patients at risk of unintentional pregnancy (i.e. not currently pregnant or trying to get pregnant) and matched controls.

STUDY DESIGN

The FEERIC study (Fertility, Pregnancy, Contraception after BC in France) is a prospective, multicenter case-control study, including localized BC patients aged 18-43 years, matched for age and parity to cancer-free volunteer controls in a 1:2 ratio. Data were collected through online questionnaires completed on the Seintinelles research platform.

RESULTS

In a population of 1278 women at risk of unintentional pregnancy, the prevalence of contraception at study inclusion did not differ significantly between cases (340/431, 78.9%) and controls (666/847, 78.6%, p = 0.97). Contrarily, the contraceptive methods used were significantly different, with a higher proportion of copper IUD use in BC survivors (59.5% versus 25.0% in controls p < 0.001). For patients at risk of unintentional pregnancy, receiving information about chemotherapy-induced ovary damage at BC diagnosis (OR = 2.47 95%CI [ 1.39-4.37] and anti-HER2 treatment (OR = 2.46, 95% CI [ 1.14-6.16]) were significantly associated with the use of a contraception in multivariate analysis.

CONCLUSION

In this large French study, BC survivors had a prevalence of contraception use similar to that for matched controls, though almost one in five women at risk of unintentional pregnancy did not use contraception. Dedicated consultations at cancer care centers could further improve access to information and contraception counseling.

No Impact of Seasonality of Diagnoses on Baseline Tumor Immune Infiltration, Response to Treatment, and Prognosis in BC Patients Treated with NAC

Simple Summary

High tumor-infiltrating lymphocyte (TIL) levels are associated with an increased response to neoadjuvant chemotherapy (NAC) in breast cancer (BC). The seasonal fluctuation of TILs in breast cancer is poorly documented. In this study, we compared pre- and post-treatment immune infiltration, the treatment response as assessed by means of pathological complete response (pCR) rates, and survival according to the seasonality of BC diagnoses in a clinical cohort of patients treated with NAC. We found no association between seasonality and baseline TIL levels or pCR rates. We found that post-NAC stromal lymphocyte infiltration was lower when cancer was diagnosed in the summer, especially in the subgroup of patients with TNBC. Our data do not support the hypothesis that the seasonality of diagnoses has a major impact on the natural history of BC treated with NAC.

Abstract

Breast cancer (BC) is the most common cancer in women worldwide. Neoadjuvant chemotherapy (NAC) makes it possible to monitor in vivo response to treatment. Several studies have investigated the impact of the seasons on the incidence and detection of BC, on tumor composition, and on the prognosis of BC. However, no evidence is available on their association with immune infiltration and the response to treatment. The objective of this study was to analyze pre- and post-NAC immune infiltration as assessed by TIL levels, the response to treatment as assessed by pathological complete response (pCR) rates, and oncological outcomes as assessed by relapse-free survival (RFS) or overall survival (OS) according to the seasonality of BC diagnoses in a clinical cohort of patients treated with neoadjuvant chemotherapy. Out of 1199 patients, the repartition of the season at BC diagnosis showed that 27.2% were diagnosed in fall, 25.4% in winter, 24% in spring, and 23.4% in summer. Baseline patient and tumor characteristics, including notable pre-NAC TIL levels, were not significantly different in terms of the season of BC diagnosis. Similarly, the pCR rates were not different. No association for oncological outcome was identified. Our data do not support the idea that the seasonality of diagnoses has a major impact on the natural history of BC treated with NAC.

Breast reconstruction with silicone prosthesis and acellular dermal matrix of porcine origin: Retrospective study of 84 cases

INTRODUCTION

Breast reconstruction (BR) using a prosthesis implant (PI) associated with an acellular dermal matrix (ADM) is a known method that has been the subject of discussion in recent years. The objective of this study was to quantify the rate of PI removal after BR using prosthesis combined with ADM, and to identify the risk factors in the event of removal.

METHODS

This was a retrospective study conducted between 2010 and 2015. Inclusion criteria were patients who had undergone immediate (IBR) or delayed (DBR) breast reconstruction with placement of a PI associated with porcine ADM. The primary endpoint was the postoperative removal of the PI.

RESULTS

In all, 84 reconstructions were performed. The mean age of the population was 57.5 years. 25.9% of the patients were active smokers at the time of surgery. 89.5% of patients had previously benefited from ipsilateral breast radiation therapy (IBRT) in DBR, 10.5% in IBR. The PI deposition rate, all BR combined, was 21.4%. It was 52.17% in smokers and 9.84% in non-smokers (P<0.0001), making smoking an independent risk factor for reconstruction failure (hazard ratio (HR)=7.4, 95%CI [2.64-20.9]). IBRT was also a risk factor for PI removal, especially when performed after IBR (HR=8.1, 95%CI [1.1-62.1]).

CONCLUSION

Smoking and adjuvant IBRT are risk factors for failure of reconstruction by PI associated with ADM. This type of reconstruction should be selected for non-smokers who have not undergone IBRT and therefore could be a therapeutic alternative in the BR panel.

The French Early Breast Cancer Cohort (FRESH): A Resource for Breast Cancer Research and Evaluations of Oncology Practices Based on the French National Healthcare System Database (SNDS)

Simple Summary

Because of an important disparity of care pathways and quality of care among women diagnosed with an early-stage breast cancer, we aimed to create a unique cohort of patients including all French women aged 18 years or over, treated by surgery and registered in the general health insurance coverage plan. After aggregating and annotating medico-administrative data on 235,368 early breast cancer patients, we open up perspectives for research on adverse effects, morbidity, mortality, the monitoring of care consumption, or medical-economic studies. We describe data sources, inclusion, and exclusion criteria, basic descriptive analyses, and longitudinal trends over time.

Abstract

Background: Breast cancer (BC) is the most frequent cancer and the leading cause of cancer-related death in women. The French National Cancer Institute has created a national cancer cohort to promote cancer research and improve our understanding of cancer using the National Health Data System (SNDS) and amalgamating all cancer sites. So far, no detailed separate data are available for early BC. Objectives: To describe the creation of the French Early Breast Cancer Cohort (FRESH). Methods: All French women aged 18 years or over, with early-stage BC newly diagnosed between 1 January 2011 and 31 December 2017, treated by surgery, and registered in the general health insurance coverage plan were included in the cohort. Patients with suspected locoregional or distant metastases at diagnosis were excluded. BC treatments (surgery, chemotherapy, targeted therapy, radiotherapy, and endocrine therapy), and diagnostic procedures (biopsy, cytology, and imaging) were extracted from hospital discharge reports, outpatient care notes, or pharmacy drug delivery data. The BC subtype was inferred from the treatments received. Results: We included 235,368 patients with early BC in the cohort (median age: 60 years). The BC subtype distribution was as follows: luminal (80.2%), triple-negative (TNBC, 9.5%); HER2⁺ (10.3%), or unidentifiable (n = 44,388, 18.9% of the cohort). Most patients underwent radiotherapy (n = 200,685, 85.3%) and endocrine therapy (n = 165,655, 70.4%), and 38.3% (n = 90,252) received chemotherapy. Treatments and care pathways are described. Conclusions: The FRESH Cohort is an unprecedented population-based resource facilitating future large-scale real-life studies aiming to improve care pathways and quality of care for BC patients.

Abstract P2-14-20: Early locoregional breast surgery improves overall and progression-free survival in oligometastatic breast cancer

Background

Four percent of patients have Metastatic Breast Cancer (MBC) at the time of diagnosis. Surgery in this context is generally not recommended. However, tumour resection may have an effect on tumour load influencing metastatic growth. Some studies have suggested an advantage of locoregional surgery in MBC. The objective was to evaluate the effectiveness of surgery in the year following diagnosis of metastatic disease.

Methods

Data were collected within the ESME breast cancer data platform. Stage IV patients diagnosed between 2008 and 2014 without further personal cancer were included. Patients who died or progressed in 1-year post-diagnosis were excluded. We compared patients operated within the first 12 months after diagnosis with the others.

Results

Among 1977 patients with MBC at diagnosis, alive and progression-free at 12 months, 530 (26.8%) had surgery within this interval. Patients operated in the year of diagnosis had less oligometastatic disease (less than 3 metastases; 9.2% vs 21.8%, p&lt;0.01) compared to patients with no surgery. They had less bone metastasis (57.7% vs 74.4%, p&lt;0.01), more lymph node (33.2% vs 27.8%, p=0.02), lung (19.8%, p&lt;0.01) and less liver metastasis (17.9% vs 26.8%, p&lt;0.01) sites. Other treatments included more chemotherapy and HER2-targeted therapy (89.1% vs 69.6%, p&lt;0.01), locoregional radiotherapy (81.7% vs 32.5%, p&lt;0.01) and the same frequency of hormone therapy (79.8% vs 78.6%, p=0.57). Multivariate survival analysis based on Cox model showed that surgery of primary breast lesion performed within 12 months (Hazard Ratio(HR)=0.75, p&lt;0.01), HER2 positive status (HR=0.42, p&lt;0.01) and the non-visceral metastases (HR=0.80, p=0.02) improved overall survival (OS) whereas an older age than 50 (HR=1.50, p&lt;0.01) and 3 or more metastases (HR=1.45, p&lt;0.01) were associated with poorer survival. Progression-Free Survival (PFS) was also improved for locoregional surgery (HR=0.70, p&lt;0.001) after adjustment on HER2 positive status (HR=0.70, p&lt;0.01), age greater than 50 (HR=1.18, p&lt;0.01) and 3 or more metastases (HR=1.27, p&lt;0.01). Propensity score matching analyses confirmed these results.

Discussion

We demonstrated that surgery of primary breast lesion had a benefit on OS (HR=0.75, p&lt;0.01), and PFS (HR=0.70, p&lt;0.01) in metastatic patient. Metastasis number less than 3 was a complementary protective factor to surgery. Studies have sought to evaluate the population that could benefit from surgery of primary breast lesion in the event of metastatic disease. They showed an increasing morbimortality in plurimetastatic patients. In our study, patients with more than 3 metastases had poorer OS and PFS (HR=1.45, p=0.01 and HR=1.27, p=0.03 respectively).

Conclusion

Results of our study show that surgical control of primary breast lesion could be considered as an option in the locoregional treatment of MBC, particularly in non-visceral oligometastastic breast cancer.

Citation Format: Hotton J, Lusque A, Rauch P, Leufflen L, Buhler J, Pierret M, Salleron J, Marchal F. Early locoregional breast surgery improves overall and progression-free survival in oligometastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-20.

Abstract P1-07-30: Predictive factors of sentinel lymph node biopsy invasion in extended ductal carcinoma in situ treated by radical mastectomy

Introduction: The incidence of ductal carcinoma in situ (DCIS) increased with the practice of organized breast cancer screening to reach 14 % in France in 2010. The incidence of positive sentinel lymph node biopsy (SLNB) ranged from 0 to 16.7 %. The main hypothesis would be the presence of an invasive contingent on the definitive analyze not identified preoperatively. The objective was to identify predictive factors of SLNB positivity in the management of extended DCIS treated by radical mastectomy.

Method: This study was retrospective, longitudinal, descriptive conducted at the Cancer Institute of Lorraine from January 2000 to July 2015. All patients whose management consisted of a radical mastectomy for an extended DCIS, associated with a sentinel lymph node procedure were included.

Results: 161 patients were included. The mean age at diagnosis was 56 years; 15 had a clinical nodule. The diagnosis was made in 63.3 % with macrobiopsies. Preoperatively, 16 patients (9.9 %) had DCIS associated with microinvasion (DCIS-MI) and the others were pure DCIS. An average of 3.9 ± 2.7 SLNB were sampled. Twelve patients (7.4 %) had a SLNB invasion. Eleven of them had axillary lymph node dissection (ALND) of which only 1 was positive. The final histological analysis found 104 pure DCIS (64.6 %), 23 DCIS-MI (14.3 %) and 34 occult invasive ductal carcinomas (IDC) (21.1 %). Mean follow-up was 41.1 months. There were 2 recurrences and 2 deaths.

N°Final histologyPreoperative histologyDCIS size (mm)PalpabilitySLNB typeSLNB positivityALND positivity1DCISDCIS60NoMacrometastase542DCISDCIS50NoMicrometastase203DCISDCIS10NoIsolated Tumor Cells1-4DCIS-MIDCIS90YesIsolated Tumor Cells105DCIS-MIDCIS-MI75YesIsolated Tumor Cells106IDCDCIS110YesMicrometastase107IDCDCIS70NoIsolated Tumor Cells108IDCDCIS80YesMicrometastase109IDCDCIS-MI100NoMicrometastase1010IDCDCIS-MI50NoMicrometastase1011IDCDCIS-MI60NoMicrometastase1012IDCDCIS-MI40YesMacrometastase10

Predictive factors were size of palpated mass (mean: 46 mm, p = 0.04) and microinvasion on biopsy (p = 0.02). Positivity of the SLNB was an overstaging risk factor on the final histology (p &lt; 0.001). Postoperative histological results were significantly different from preoperative (p = 0.001) with poor concordance (kappa = 0.15).

Discussion: After SLNB, the rate of secondary lymphedema in the literature was 5%. Our study included 7.4 % (12 cases) of axillary lesions, majority of which were unique micrometastases or isolated tumor cells (ITC). All predictive factors were identified in literature. In our study, mean size of palpated mass was 46 mm whereas it was 30 mm in literature. Of the 9.9 % of DCIS-MI, 4 patients had a positive SLNB. In cases of pure DCIS, the percentage of positive SLNB was reduced to 5.5 %. The rate of occult invasive ductal carcinoma was 21,1%, similarly like in literature where rate was in mean 23%.

Conclusion: The low rate of SLNB invasion in pure DCIS suggests that ALND is carried out in the presence of predictive factors. New techniques for identification of SLNB could report axillary staging after obtaining the definitive histologic results.

Citation Format: Hotton J, Salleron J, Rauch P, Buhler J, Leufflen L, Ameloot S, Marchal F. Predictive factors of sentinel lymph node biopsy invasion in extended ductal carcinoma in situ treated by radical mastectomy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-30.

[Risks acceptability related to obstetrical epidural analgesia]

OBJECTIVES

Evaluation of the acceptability of complications related to obstetrical epidural analgesia in two populations, parturients and anesthesiologists.

STUDY DESIGN

Prospective, transversal, single center study.

MATERIALS AND METHODS

Evaluation of the acceptability of complications associated with obstetric epidural analgesia performed using a questionnaire of six clinical scenarii in two populations: parturients cared at the University maternity of Nancy and anesthesiologists of Lorraine. Patients were interviewed by an anesthesiologist, physicians via Internet. Acceptability was assessed using two tools, the absolute acceptability with a visual analog scale and the relative acceptability obtained by classifying clinical scenario against each other, in ascending order of acceptability.

RESULTS

One hundred and forty-six parturients and 87 anesthetists assessed the acceptability of the different scenarios. The three less serious scenarios (hypotension, failure, dural tap) were acceptable for both populations. One case (spinal hematoma) was unacceptable for parturients. Three cases of varying severity (failure, dural tap, plexus injury with sequelae) were judged significantly less acceptable by patients than physicians (5.9 vs. 7.9 [P<0.001], 5.75 vs. 8.1 [P<0.01], 4.1 vs. 5.1 [P=0.035]). Multivariate analysis did not show any predictive factor of acceptability in both populations.

CONCLUSION

In this study, the overall acceptability of the inherent complications of epidural analgesia was good in the two populations. It was essentially based on the notion of severity and preventability. A large interindividual variability was observed and a better acceptance by the anesthesiologists.

[Anesthetic apparatus: failure of fresh gas delivery to the auxiliary circuit]

A case of sudden loss of fresh gas delivery to a manual auxiliary anaesthetic circuit is reported. The corresponding fresh gas outlet was disunited from the anaesthesia machine and had been inadvertently rotated in its housing, allowing the rubber tubing linking the fresh gas delivery unit to the gas outlet to be twisted.