The Role of Axillary Lymph Node Dissection versus Sentinel Lymph Node Dissection in Breast Cancer Patients with Clinical N2b-N3c Disease Who Receive Adjuvant Radiotherapy

BACKGROUND

For breast cancer with advanced regional lymph node involvement, axillary lymph node dissection (ALND) remains the standard of care for staging and treating the axilla despite the presence of undissected lymph nodes. The benefit of ALND in this setting is unknown.

OBJECTIVES

We sought to describe national patterns of care of axillary surgery and its association with overall survival (OS) among women with cN2b-N3c breast cancer who receive adjuvant radiotherapy.

PATIENTS AND METHODS

We identified female patients with cN2b-N3c breast cancer from 2012 to 2017 from the National Cancer Database. Clinical and demographic information were analyzed using Wilcoxon rank sum and χ2 tests. Predictors of receipt of ALND and predictors of death were identified with multivariable logistic regression modeling. Inverse probability of treatment weighting was implemented to adjust for differences in treatment cohorts. The Kaplan-Meier method was used to evaluate OS.

RESULTS

We identified 7167 patients. Of these, 922 (13%) received SLNB and 6254 (87%) received ALND; 7% were cN2b, 19% cN3a, 24% cN3b, 19% cN3c, and 31% cN3, not otherwise specified. Predictors of receipt of ALND were age 50-69 years [odds ratio (OR) 1.3, p < 0.01], cN3a (OR 7.6, p < 0.01), cN3b (OR 2.8, p < 0.01), and cN3c (OR 4.2, p < 0.01). Predictors of death included cN3c (OR 1.9, p < 0.01), age 70-90 years (OR 1.5, p = 0.01), and positive surgical margins (OR 1.5, p < 0.01). After cohort balancing, ALND was not associated with improved OS when compared with SLNB (HR 0.99, p = 0.91).

CONCLUSIONS

ALND in patients with advanced nodal disease was not associated with improved survival compared with SLNB for women who receive adjuvant radiotherapy.

The Development of an Infrastructure to Facilitate the Use of Whole Genome Sequencing for Population Health

The clinical use of genomic analysis has expanded rapidly resulting in an increased availability and utility of genomic information in clinical care. We have developed an infrastructure utilizing informatics tools and clinical processes to facilitate the use of whole genome sequencing data for population health management across the healthcare system. Our resulting framework scaled well to multiple clinical domains in both pediatric and adult care, although there were domain specific challenges that arose. Our infrastructure was complementary to existing clinical processes and well-received by care providers and patients. Informatics solutions were critical to the successful deployment and scaling of this program. Implementation of genomics at the scale of population health utilizes complicated technologies and processes that for many health systems are not supported by current information systems or in existing clinical workflows. To scale such a system requires a substantial clinical framework backed by informatics tools to facilitate the flow and management of data. Our work represents an early model that has been successful in scaling to 29 different genes with associated genetic conditions in four clinical domains. Work is ongoing to optimize informatics tools; and to identify best practices for translation to smaller healthcare systems.

Body Mass Index and Mammographic Density in a Multiracial and Multiethnic Population-Based Study

BACKGROUND

Mammographic density (MD) is strongly associated with breast cancer risk. We examined whether body mass index (BMI) partially explains racial and ethnic variation in MD.

METHODS

We used multivariable Poisson regression to estimate associations between BMI and binary MD [Breast Imaging Reporting and Database System (BI-RADS) A&B versus BI-RADS C&D] among 160,804 women in the Utah mammography cohort. We estimated associations overall and within racial and ethnic subgroups and calculated population attributable risk percents (PAR%).

RESULTS

We observed the lowest BMI and highest MD among Asian women, the highest BMI among Native Hawaiian and Pacific Islander women, and the lowest MD among American Indian and Alaska Native (AIAN) and Black women. BMI was inversely associated with MD [RRBMI≥30 vs. BMI<25 = 0.43; 95% confidence interval (CI), 0.42-0.44] in the full cohort, and estimates in all racial and ethnic subgroups were consistent with this strong inverse association. For women less than 45 years of age, although there was statistical evidence of heterogeneity in associations between BMI and MD by race and ethnicity (P = 0.009), magnitudes of association were similar across groups. PAR%s for BMI and MD among women less than 45 years were considerably higher in White women (PAR% = 29.2, 95% CI = 28.4-29.9) compared with all other groups with estimates ranging from PAR%Asain = 17.2%; 95% CI, 8.5 to 25.8 to PAR%Hispanic = 21.5%; 95% CI, 19.4 to 23.6. For women ≥55 years, PAR%s for BMI and MD were highest among AIAN women (PAR% = 37.5; 95% CI, 28.1-46.9).

CONCLUSIONS

While we observed substantial differences in the distributions of BMI and MD by race and ethnicity, associations between BMI and MD were generally similar across groups.

IMPACT

Distributions of BMI and MD may be important contributors to breast cancer disparities.

Association of the neutrophil-to-lymphocyte ratio prior to checkpoint blockade immunotherapy (CBI) or radiation plus CBI with overall survival in melanoma patients

200

Background: Studies in certain cancer types have indicated that radiation therapy prior to the use of CBI provides a survival benefit. This benefit has not been clearly defined for patients with metastatic melanoma. Additionally, the neutrophil-to-lymphocyte ratio (NLR) may be a potential biomarker. Methods: This retrospective study was performed in patients diagnosed with melanoma between January 2007 and August 2016 who received CBI with or without previous radiation treatment at Intermountain Healthcare (Utah, USA). Cases were identified from electronic medical records and data was manually extracted through August of 2017. The neutrophil-to-lymphocyte ratio (NLR) was calculated from the absolute neutrophil and lymphocyte counts of a complete blood cell count with differentials performed as a routine standard of care procedure in melanoma patients prior to therapy initiation. Overall survival was defined as the length of time (d) from start of CBI to death as of August, 2017. Results: Forty-six melanoma patients were initially identified. Of these, thirteen patients were excluded due to lack of follow-up data (n = 9), radiation performed after CBI (n = 3), or concurrent radiation and CBI (n = 1). The final analysis consisted of 33 subjects separated below (NLR < 3.12, n = 16) and above (NLR ≥ 3.12, n = 17) the NLR median. Age, height, body mass, and body mass index were not significantly different between groups (p-range: 0.11-0.60). Results from the Kaplan-Meier curve indicate that a NLR above the median associates with lower overall survival (Mantel, p = 0.04) in melanoma patients receiving CBI with or without previous radiation treatment. In a separate analysis of this cohort, overall survival was not significantly influenced by radiation therapy prior to CBI. Conclusions: Although prior radiation therapy offered no survival advantage for patients receiving CBI, NLR less than 3.12 was associated with an increase in overall survival. Further studies are need to explore NLR as a biomarker.