Use of the Decipher genomic classifier among men with prostate cancer in the United States

BACKGROUND

Management of localized or recurrent prostate cancer since the 1990s has been based on risk stratification using clinicopathological variables, including Gleason score, T stage (based on digital rectal exam), and prostate-specific antigen (PSA). In this study a novel prognostic test, the Decipher Prostate Genomic Classifier (GC), was used to stratify risk of prostate cancer progression in a US national database of men with prostate cancer.

METHODS

Records of prostate cancer cases from participating SEER (Surveillance, Epidemiology, and End Results) program registries, diagnosed during the period from 2010 through 2018, were linked to records of testing with the GC prognostic test. Multivariable analysis was used to quantify the association between GC scores or risk groups and use of definitive local therapy after diagnosis in the GC biopsy-tested cohort and postoperative radiotherapy in the GC-tested cohort as well as adverse pathological findings after prostatectomy.

RESULTS

A total of 572 545 patients were included in the analysis, of whom 8927 patients underwent GC testing. GC biopsy-tested patients were more likely to undergo active active surveillance or watchful waiting than untested patients (odds ratio [OR] =2.21, 95% confidence interval [CI] = 2.04 to 2.38, P < .001). The highest use of active surveillance or watchful waiting was for patients with a low-risk GC classification (41%) compared with those with an intermediate- (27%) or high-risk (11%) GC classification (P < .001). Among National Comprehensive Cancer Network patients with low and favorable-intermediate risk, higher GC risk class was associated with greater use of local therapy (OR = 4.79, 95% CI = 3.51 to 6.55, P < .001). Within this subset of patients who were subsequently treated with prostatectomy, high GC risk was associated with harboring adverse pathological findings (OR = 2.94, 95% CI = 1.38 to 6.27, P = .005). Use of radiation after prostatectomy was statistically significantly associated with higher GC risk groups (OR = 2.69, 95% CI = 1.89 to 3.84).

CONCLUSIONS

There is a strong association between use of the biopsy GC test and likelihood of conservative management. Higher genomic classifier scores are associated with higher rates of adverse pathology at time of surgery and greater use of postoperative radiotherapy.In this study the Decipher Prostate Genomic Classifier (GC) was used to analyze a US national database of men with prostate cancer. Use of the GC was associated with conservative management (ie, active surveillance). Among men who had high-risk GC scores and then had surgery, there was a 3-fold higher chance of having worrisome findings in surgical specimens.

An Expandable Informatics Framework for Enhancing Central Cancer Registries with Digital Pathology Specimens, Computational Imaging Tools, and Advanced Mining Capabilities

BACKGROUND

Population-based state cancer registries are an authoritative source for cancer statistics in the United States. They routinely collect a variety of data, including patient demographics, primary tumor site, stage at diagnosis, first course of treatment, and survival, on every cancer case that is reported across all U.S. states and territories. The goal of our project is to enrich NCI's Surveillance, Epidemiology, and End Results (SEER) registry data with high-quality population-based biospecimen data in the form of digital pathology, machine-learning-based classifications, and quantitative histopathology imaging feature sets (referred to here as Pathomics features).

MATERIALS AND METHODS

As part of the project, the underlying informatics infrastructure was designed, tested, and implemented through close collaboration with several participating SEER registries to ensure consistency with registry processes, computational scalability, and ability to support creation of population cohorts that span multiple sites. Utilizing computational imaging algorithms and methods to both generate indices and search for matches makes it possible to reduce inter- and intra-observer inconsistencies and to improve the objectivity with which large image repositories are interrogated.

RESULTS

Our team has created and continues to expand a well-curated repository of high-quality digitized pathology images corresponding to subjects whose data are routinely collected by the collaborating registries. Our team has systematically deployed and tested key, visual analytic methods to facilitate automated creation of population cohorts for epidemiological studies and tools to support visualization of feature clusters and evaluation of whole-slide images. As part of these efforts, we are developing and optimizing advanced search and matching algorithms to facilitate automated, content-based retrieval of digitized specimens based on their underlying image features and staining characteristics.

CONCLUSION

To meet the challenges of this project, we established the analytic pipelines, methods, and workflows to support the expansion and management of a growing repository of high-quality digitized pathology and information-rich, population cohorts containing objective imaging and clinical attributes to facilitate studies that seek to discriminate among different subtypes of disease, stratify patient populations, and perform comparisons of tumor characteristics within and across patient cohorts. We have also successfully developed a suite of tools based on a deep-learning method to perform quantitative characterizations of tumor regions, assess infiltrating lymphocyte distributions, and generate objective nuclear feature measurements. As part of these efforts, our team has implemented reliable methods that enable investigators to systematically search through large repositories to automatically retrieve digitized pathology specimens and correlated clinical data based on their computational signatures.

Ovarian Cancer Epidemiology, Healthcare Access and Disparities (ORCHiD): methodology for a population-based study of black, Hispanic and white patients with ovarian cancer

INTRODUCTION

Less than 40% of patients with ovarian cancer (OC) in the USA receive stage-appropriate guideline-adherent surgery and chemotherapy. Black patients with cancer report greater depression, pain and fatigue than white patients. Lack of access to healthcare likely contributes to low treatment rates and racial differences in outcomes. The Ovarian Cancer Epidemiology, Healthcare Access and Disparities study aims to characterise healthcare access (HCA) across five specific dimensions-Availability, Affordability, Accessibility, Accommodation and Acceptability-among black, Hispanic and white patients with OC, evaluate the impact of HCA on quality of treatment, supportive care and survival, and explore biological mechanisms that may contribute to OC disparities.

METHODS AND ANALYSIS

We will use the Surveillance Epidemiology and Ends Results dataset linked with Medicare claims data from 9744 patients with OC ages 65 years and older. We will recruit 1641 patients with OC (413 black, 299 Hispanic and 929 white) from cancer registries in nine US states. We will examine HCA dimensions in relation to three main outcomes: (1) receipt of quality, guideline adherent initial treatment and supportive care, (2) quality of life based on patient-reported outcomes and (3) survival. We will obtain saliva and vaginal microbiome samples to examine prognostic biomarkers. We will use hierarchical regression models to estimate the impact of HCA dimensions across patient, neighbourhood, provider and hospital levels, with random effects to account for clustering. Multilevel structural equation models will estimate the total, direct and indirect effects of race on treatment mediated through HCA dimensions.

ETHICS AND DISSEMINATION

Result dissemination will occur through presentations at national meetings and in collaboration with collaborators, community partners and colleagues across othercancer centres. We will disclose findings to key stakeholders, including scientists, providers and community members. This study has been approved by the Duke Institutional Review Board (Pro00101872). Safety considerations include protection of patient privacy. All disseminated data will be deidentified and summarised.

Endometrial Cancer Type 2 Incidence and Survival Disparities Within Subsets of the US Black Population

Introduction

Endometrial cancer type 2 (EC2) carries a worse prognosis compared to EC type 1. EC2 disproportionately affects Black women among whom incidence is higher and survival is poorer compared to Whites. Here we assessed EC2 incidence and survival patterns among US Black ethnic groups: US-born Blacks (UBB), Caribbean-born Blacks (CBB), and Black Hispanics (BH).

Methods

We analyzed population-based data (n=24,387) for the entire states of Florida and New York (2005–2016). Hysterectomy-corrected EC2 incidence rates were computed by racial-ethnic group, and survival disparities were examined using Cox regression adjusting for tumor characteristics, poverty level, and insurance status.

Results

EC2 incidence rates were highest among UBB (24.4 per 100,000), followed by CBB (18.2), Whites (11.1), and Hispanics of all races (10.1). Compared to Whites, the age-adjusted cause-specific survival was worse for non-Hispanic Blacks (aHR: 1.61; 95%CI 1.52–1.71) and Hispanics of all races (aHR:1.09; 95% CI:1.01–1.18). In relation to Whites, survival was worse for non-Hispanic Blacks: UBB (aHR:1.62; 95%CI 1.52–1.74) and CBB (aHR:1.59; 95% CI:1.44–1.76) than for BH (aHR:1.30; 95% CI:1.05–1.61). Surgical resection was associated with a lower risk of death, while carcinosarcoma subtype and advanced stage at diagnosis were associated with a greater risk.

Conclusions

Although higher EC2 incidence and lower survival are observed among all African-descent groups, there are significant intra-racial differences among UBB, CBB, and BH. This heterogeneity in EC2 patterns among Black populations suggests an interplay between genetic and socioenvironmental factors.

Abstract A106: Preexisting mental illness on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer

Background: Research suggests mental illness contributes to poor survival among cancer patients. In New York State (NYS), Medicaid is the largest single insurer for individuals with mental illness. We investigated the influence of preexisting mental illness on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer. Methods: 9,479 women aged &lt;65 years diagnosed with breast cancer and reported to the NYS Cancer Registry from 2004-2016 were linked with NYS Medicaid claims. Women were grouped as having depression or severe mental illness if they had at least three diagnosis claims for mental illness with at least one claim within three years prior to breast cancer diagnosis. Severe mental illness included schizophrenia, bipolar disorder, and other psychotic disorders. Hazard ratios (HR) and 95% confidence intervals (95% CI) were calculated with Cox regression, adjusting for potential confounders. Results: Women with severe mental illness had greater risks of all-cause (HR 1.49; 95% CI 1.25, 1.78), cancer (HR 1.36; 95% CI 1.09, 1.68), and cardiovascular (HR 2.14; 95% CI 1.22, 3.74) mortality compared to women without mental illness. No association was observed for depression. The association between severe mental illness and all-cause mortality was strongest among Asians (HR 3.85; 95% CI 1.55, 9.60) but also observed in White (HR 1.50; 95% CI 1.17, 1.93) and Black (HR 1.36; 95% CI 1.02, 1.80) women. Additionally, associations were also observed among obese (HR 1.83; 95% CI 1.42, 2.36) and postmenopausal (HR 1.64; 95% CI 1.35, 2.01) women with preexisting severe mental illness, but no association was observed for premenopausal women. Conclusion: Women with preexisting severe mental illness diagnosed with breast cancer have an elevated mortality risk and should be monitored and treated by a coordinated cross-functional clinical team.

Citation Format: Wayne R Lawrence, Akiko Hosler, Margaret Gates, Matthew Leinung, Xiuling Zhang, Wangjian Zhang, Maria Schymura, Francis Boscoe. Preexisting mental illness on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A106.

Lower serum testosterone associated with elevated polychlorinated biphenyl concentrations in Native American men

BACKGROUND

Polychlorinated biphenyls (PCBs) and chlorinated pesticides are endocrine disruptors, altering both thyroid and estrogen hormonal systems. Less is known of action on androgenic systems.

OBJECTIVE

We studied the relationship between serum concentrations of testosterone in relation to levels of PCBs and three chlorinated pesticides in an adult Native American (Mohawk) population.

METHODS

We collected fasting serum samples from 703 adult Mohawks (257 men and 436 women) and analyzed samples for 101 PCB congeners, hexachlorobenzene (HCB), dichlorodiphenyldichloroethylene (DDE), and mirex, as well as testosterone, cholesterol, and triglycerides. The associations between testosterone and tertiles of serum organochlorine levels (both wet weight and lipid adjusted) were assessed using a logistic regression model while controlling for age, body mass index (BMI), and other analytes, with the lowest tertile being considered the referent. Males and females were considered separately.

RESULTS

Testosterone concentrations in males were inversely correlated with total PCB concentration, whether using wet-weight or lipid-adjusted values. The odds ratio (OR) of having a testosterone concentration above the median was 0.17 [95% confidence interval (CI), 0.05-0.69] for total wet-weight PCBs (highest vs. lowest tertile) after adjustment for age, BMI, total serum lipids, and three pesticides. The OR for lipid-adjusted total PCB concentration was 0.23 (95% CI, 0.06-0.78) after adjustment for other analytes. Testosterone levels were significantly and inversely related to concentrations of PCBs 74, 99, 153, and 206, but not PCBs 52, 105, 118, 138, 170, 180, 201, or 203. Testosterone concentrations in females are much lower than in males, and not significantly related to serum PCBs. HCB, DDE, and mirex were not associated with testosterone concentration in either men or women.

CONCLUSIONS

Elevation in serum PCB levels is associated with a lower concentration of serum testosterone in Native American men.

Mortality Among Semiconductor and Storage Device-Manufacturing Workers

PROBLEM

We evaluated mortality during 1965 to 1999 among 126,836 workers at two semiconductor facilities and one storage device facility.

METHOD

We compared employees' cause-specific mortality rates with general population rates and examined mortality patterns by facility, duration of employment, time since first employment, and work activity.

RESULTS

Employees had lower-than-expected mortality overall (6579 observed deaths, standardized mortality ratio [SMR] = 65; 95% confidence interval [CI] = 64-67), for all cancers combined (2159 observed, SMR = 78, 95% CI = 75-81) and for other major diseases. Central nervous system cancer was associated with process equipment maintenance at one of the semiconductor facilities (10 observed, SMR = 247, 95% CI = 118-454). Prostate cancer was associated with facilities/laboratories at the storage device facility (18 observed, SMR = 198, (5% CI = 117-313).

CONCLUSIONS

Further evaluation of workplace exposures or independent investigations of similar occupational groups may clarify the interpretation of associations observed in this study.

Risk of cancer among women with AIDS in New York City

To evaluate the risk of cancer among women with AIDS in New York City (NYC), we compared the cancer experience of AIDS-infected women in NYC with that of the general population of women in NYC by matching the population-based New York State Cancer Registry with the New York City AIDS Registry. A probabilistic algorithm was used to match names, birth dates, and, where available, Social Security numbers between 15,146 women with AIDS and 232,902 women with cancer. Standardized incidence ratios (SIR) were calculated as the ratio of observed to expected cancer cases in the population of NYC women matched for age, race, and calendar period of cancer diagnosis. Period-specific relative risks (RR) of cancer prevalence prior to AIDS, and incidence at or after AIDS were calculated to determine which cancers increased in proximity to an AIDS diagnosis, a surrogate marker of increasing immunodeficiency. Analysis was limited to women between the ages of 15 to 69 who were diagnosed with AIDS between 1981 and 1994. Among 15,146 women diagnosed with AIDS, we found 1,194 matches with the Cancer Registry. For cancers included in the 1993 AIDS case definition, the SIR was 178.49 for Kaposi's sarcoma, 48.97 for non-Hodgkin's lymphoma, and 9.20 for invasive cervical cancer. The overall SIR for all non-AIDS-defining cancers was 2.20. Among non-AIDS-defining cancers, elevated SIRs were found for cancers of the lung (7.95), esophagus (7.69), multiple myeloma (7.37), oral cavity and pharynx (6.55), Hodgkin's disease (5.65), leukemias (4.52), and rectal/anal cancers (3.23). Statistically significant increases in period-specific risks were found for all non-AIDS-defining cancers combined, but not for individual cancers. Dual screening by two registries and unknown behavioral factors complicate the ascertainment of cancer risk. Our results show significantly elevated risks for several non-AIDS-defining cancers; these results are consistent with other studies of cancers among persons with AIDS. Extension of the time period of analysis is required to test for the effects of new anti-viral treatments and their association with cancer development among HIV-infected women.

Birth characteristics and subsequent risk for breast cancer in very young women

There is growing evidence that prenatal exposures may influence later breast cancer risk. This matched case-control study used linked New York State birth and tumor registry data to examine the association between birth characteristics and breast cancer risk among women aged 14-37 years. Cases were women diagnosed with breast cancer between 1978 and 1995 who were also born in New York after 1957 (n = 484). For each case, selected controls were the next six liveborn females with the same maternal county of residence. The authors found a J-shaped association between birth weight and breast cancer risk, and very high birth weight (> or =4,500 g) was associated with the greatest elevation in risk (adjusted odds ratio (OR) = 3.10, 95% confidence interval (CI): 1.18, 7.97). The association of maternal age with breast cancer risk was also J-shaped, with maternal age of more than 24 years showing a positive, linear association (adjusted OR = 1.94, 95% CI: 1.18, 3.18 for maternal age > or =35 vs. 20-24 years; p for trend = 0.02). In contrast, women born very preterm had a lower risk (adjusted OR = 0.11, 95% CI: 0.02, 0.79 for gestational age <33 vs. > or =37 weeks). These findings support a role for early life factors in the development of breast cancer in very young women.

Comparison of active and cancer registry-based follow-up for breast cancer in a prospective cohort study

The authors compared the relative effectiveness of two distinct follow-up designs in prospective cohort studies--the active approach, based on direct contact with study subjects, and the passive approach, based on record linkages with population-based cancer registries--utilizing available information from the New York University Women's Health Study (WHS) and the New York State Cancer Registry (NYSCR). The analyses were limited to breast cancer cases identified during the period 1985-1992, for which follow-up was considered reasonably complete by both the WHS and the NYSCR. Among 12,947 cohort members who reported a New York State address, 303 pathologically confirmed cases were identified through active follow-up and 284 through record linkage. Sixty-three percent of cancers were identified by both sources, 21% by the WHS only, and 16% by the NYSCR only. The agreement was appreciably better for invasive cancers. The percentage of cases identified only by the NYSCR was increased among subjects whose active follow-up was incomplete, as well as among nonwhites, obese patients, and parous patients. This suggests that relying on either type of follow-up alone may introduce certain biases in evaluating risk factors for breast cancer. Combining both approaches appears to be a better strategy in prospective cohort studies.

A categorical data analysis of contacts with the Family Health Clinic, Calabar, Nigeria

The relationships of population, environmental and accessibility variables to registration and attendance by mothers of children under 6 at the Family Health Clinic in Calabar, Nigeria are investigated. The technique used to analyze the data collected is categorical data analysis which proceeds in two stages, variable selection to reduce the variable set and fitting a log-linear model to the reduced set. Details of the statistical procedures used are provided to indicate how categorical data analysis can be used as a valuable tool of analysis in medical geographical studies that employ count or frequency data. It was found that younger mothers and Ibibio women registered more often at the clinic than did their counterparts. However, if the relatively sparse data on fathers is accepted, the association between age and registration is found to be spurious and a model can be substituted which shows younger fathers and fathers who spoke a non-Efik/Ibibio language to be associated with higher clinic registration of mothers. It was further found that for registered mothers the probability of a clinic visit was decreased by mother's age, increased by distance given no travel cost, unaffected by distance given some travel cost, increased by travel cost given a short distance to the clinic and decreased by travel cost given a longer distance from the clinic. These results are discussed in relation to population characteristics such as socio-economic status, clinic procedures such as health worker activities, transportation availability in Calabar, the spatial ecology of the city and local environmental conditions.