Uptake of screening and risk-reducing recommendations among women with hereditary breast and ovarian cancer syndrome due to pathogenic BRCA1/2 variants evaluated at a large urban comprehensive cancer center

PURPOSE

Carriers of pathogenic variants in BRCA1/2 have an elevated lifetime cancer risk warranting high-risk screening and risk-reducing procedures for early detection and prevention. We report on prevention practices among women with pathogenic BRCA variants in order to document follow through with NCCN recommendations and to identify barriers to guideline-recommended care.

METHODS

Our cohort included women who had genetic testing through a cancer genetic clinic and completed a 54-item questionnaire to measure socio-demographics, medical history, rates of cancer screening and risk-reducing surgery, disclosure of test results, and cancer worry. Outcomes included rates of completion of risk-reducing salpingo-oophorectomy (RRSO), risk-reducing mastectomy (RRM), and NCCN risk-reducing and age-dependent screening guidelines (version 3.2019). Multivariable logistic regression analyses were used to evaluate potential predictors of these outcomes.

RESULTS

Of 129 evaluable women with pathogenic BRCA1/2 variants, 95 (74%) underwent RRSO and 77 (60%) had RRM, respectively, and 107 (83%) were considered adherent to NCCN guidelines. Women with a history of breast or ovarian cancer were more likely to have RRM (OR = 4.38; 95% CI 1.80-11.51; p = 0.002). Increasing age was associated with an increased likelihood of RRSO (OR = 1.05; 95% CI 1.01-1.09; p = 0.019) and decreased likelihood for RRM (OR = 0.95; 95% CI 0.92-0.99; p = 0.013). Women who had RRM were 3 times more likely to undergo RRSO (OR = 2.81; 95% CI 1.10-7.44; p = 0.025). Women who had genetic testing after June 2013 were less likely to have RRM than those tested before June 2013 (OR = 0.42; 95% CI 0.18-0.95; p = 0.040. None of the other measured factors were associated with rates of RRSO, RRM or follow through with NCCN recommendations. There was near universal (127/129) reported disclosure of genetic test results to family members, resulting in the discovery of a median of 1 relative with a pathogenic variant (range = 0-8).

CONCLUSION

An evaluation of follow up practice in a cohort of women with pathogenic variants in BRCA1/2 revealed high rates of reported completion of screening and surgical risk-reducing recommendations. Educational efforts should continue to reinforce the importance of follow-through with guideline recommended care among this high-risk group.

Low physical function Post-Cancer diagnosis is associated with higher mortality risk in postmenopausal women

BACKGROUND

Postmenopausal women with cancer experience an accelerated physical dysfunction beyond that expected through aging alone due to cancer and its treatments. The aim of this study is to determine whether declines in physical function after cancer diagnosis are associated with all-cause mortality and cancer-specific mortality.

METHODS

This prospective cohort study included 8,068 postmenopausal women enrolled in the Women's Health Initiative (WHI) who were diagnosed with cancer and had physical function assessed within 1-year of cancer diagnosis. Self-reported physical function was measured using the 10-item physical function subscale of the RAND 36-Item Health Survey. Cause of death was determined by medical record review with central adjudication and linkage to the National Death Index. Death was adjudicated through February 2022.

RESULTS

Over a median follow-up of 7.7 years from cancer diagnosis 3,316 (41.1%) women died. Our results showed that for every 10% decline in the physical function score after cancer diagnosis, all-cause mortality and cancer-specific mortality were significantly reduced by 12% (HR, 0.88; 95% CI, 0.87 to 0.89) and (HR, 0.88; 95%CI, 0.86 to 0.91), respectively. Further categorical analyses showed a significant dose-response relationship between post-diagnosis physical function categories and mortality outcomes (trend test P < .001), where the median survival time for women in the lowest physical function quartile was 9.1 (8.6, 10.6) years compared to 18.4 (15.8, 22.0) years for women in the highest physical function quartile.

CONCLUSION

Postmenopausal women with low physical function after cancer diagnosis may be at higher risk of mortality from all causes and cancer-related mortality.

The impact of high intensity interval training in a diverse group of cancer survivors: CAPABLE, a pilot study

Purpose

Given the well-documented benefits of regular exercise to cancer survivors, current American Cancer Society guidelines recommend that patients engage in a minimum of 150 min per week of moderate-to-vigorous physical activity with a minimum of two days of strength training. However, few survivors meet this goal, particularly among minorities.

Methods

The CAPABLE study is a single-arm, pilot exercise intervention that introduced 48 cancer survivors to a high intensity interval and strength training program three days a week for 12 weeks. We evaluated the impact of this unique training method on bodyweight, % body fat, serum markers correlated with an adverse cardiometabolic profile and health-related quality of life (HRQoL). Measures were summarized at baseline and program exit. Paired t-tests were used to assess change in each of these measures over time.

Results

We observed losses in weight, body mass index, and % body fat, and glycosylated hemoglobin (HbA1c) levels over 12-weeks. There were also clinically meaningful improvements in reported overall HRQoL (FACTG total change +9.5 (95% CI, 4.6, 14.4)) and in each one of the individual domains (physical, social, emotional, and functional well-being).

Conclusions

We observed meaningful improvements in body composition, HbA1c and quality of life over 12 weeks among cancer survivors participating in a high-intensity interval training program. Future work will include a control arm for comparison and address barriers to participation and adherence which will be important in using this intervention and others like it to improve outcomes and reduce cancer health disparities.

The impact of preexisting comorbidities on receipt of cancer therapy among women with Stage I-III breast cancer in the Detroit Research on Cancer Survivors cohort

PURPOSE

Pre-existing comorbidities play an important role in choice of cancer treatment. We retrospectively evaluated the relationship between pre-existing comorbidities and receipt of local and systemic therapy in a cohort of Black women with Stage I-III breast cancer.

METHODS

The study population for analysis included 1169 women with Stage I-III disease enrolled in the Detroit Research on Cancer Survivors (ROCS) cohort. Information on comorbidities, socio-demographic, and clinical variables were obtained from self-reported questionnaires and the cancer registry. Comorbidities were analyzed individually, and comorbidity burden was categorized as low (0-1), moderate (2-3) or high (≥4). We used logistic regression analysis to evaluate factors associated with receipt of local treatment (surgery ± radiation; N = 1156), hormonal (N = 848), and chemotherapy (N = 680). Adjusted models included variables selected a priori that were significant predictors in univariate analysis.

RESULTS

Receipt of treatment was categorized into local (82.6%), hormonal (73.7%), and/or chemotherapy (79.9%). Prior history of arthritis and depression were both associated with a lower likelihood to receive local treatment, [odds ratio (OR), 95% confidence interval (CI), 0.66, 0.47-0.93, and 0.53, 0.36-0.78], respectively. Obesity was associated with higher likelihood of receiving hormonal therapy (OR: 1.64, 95% CI: 1.19, 2.26), and heart failure a lower likelihood (OR: 0.46, 95% CI: 0.23, 0.90). Older age (Ptrend  <0.01) and increasing co-morbidity burden (Ptrend  = 0.02) were associated with lower likelihood of receiving chemotherapy.

CONCLUSION

History of prior co-morbidities has a potentially detrimental influence on receipt of recommended cancer-directed treatment among women with Stage I-III breast cancer.

[Weight gain and treatment with psychotropic drugs : Background and management]

Psychotropic drug-induced weight gain (PIWG) is a well-known and frequent side effect which is relevant for the prognosis of patients. Individual medications have varying risks for the occurrence of PIWG, and at the same time there are individual risk factors on the part of patients, such as age, gender, metabolic and genetic factors. As the metabolic changes in the context of PIWG result in increased mortality in the long term, it is important to prevent PIWG by appropriate prevention and to intervene in a targeted manner if PIWG has already occurred. Appropriate monitoring is therefore essential. This article provides an overview of underlying mechanisms, risk constellations and possible countermeasures.

Sugar-Sweetened and Artificially Sweetened Beverages and Risk of Liver Cancer and Chronic Liver Disease Mortality

Importance

Approximately 65% of adults in the US consume sugar-sweetened beverages daily.

Objective

To study the associations between intake of sugar-sweetened beverages, artificially sweetened beverages, and incidence of liver cancer and chronic liver disease mortality.

Design, Setting, and Participants

A prospective cohort with 98 786 postmenopausal women aged 50 to 79 years enrolled in the Women's Health Initiative from 1993 to 1998 at 40 clinical centers in the US and were followed up to March 1, 2020.

Exposures

Sugar-sweetened beverage intake was assessed based on a food frequency questionnaire administered at baseline and defined as the sum of regular soft drinks and fruit drinks (not including fruit juice); artificially sweetened beverage intake was measured at 3-year follow-up.

Main Outcomes and Measures

The primary outcomes were (1) liver cancer incidence, and (2) mortality due to chronic liver disease, defined as death from nonalcoholic fatty liver disease, liver fibrosis, cirrhosis, alcoholic liver diseases, and chronic hepatitis. Cox proportional hazards regression models were used to estimate multivariable hazard ratios (HRs) and 95% CIs for liver cancer incidence and for chronic liver disease mortality, adjusting for potential confounders including demographics and lifestyle factors.

Results

During a median follow-up of 20.9 years, 207 women developed liver cancer and 148 died from chronic liver disease. At baseline, 6.8% of women consumed 1 or more sugar-sweetened beverage servings per day, and 13.1% consumed 1 or more artificially sweetened beverage servings per day at 3-year follow-up. Compared with intake of 3 or fewer servings of sugar-sweetened beverages per month, those who consumed 1 or more servings per day had a significantly higher risk of liver cancer (18.0 vs 10.3 per 100 000 person-years [P value for trend = .02]; adjusted HR, 1.85 [95% CI, 1.16-2.96]; P = .01) and chronic liver disease mortality (17.7 vs 7.1 per 100 000 person-years [P value for trend <.001]; adjusted HR, 1.68 [95% CI, 1.03-2.75]; P = .04). Compared with intake of 3 or fewer artificially sweetened beverages per month, individuals who consumed 1 or more artificially sweetened beverages per day did not have significantly increased incidence of liver cancer (11.8 vs 10.2 per 100 000 person-years [P value for trend = .70]; adjusted HR, 1.17 [95% CI, 0.70-1.94]; P = .55) or chronic liver disease mortality (7.1 vs 5.3 per 100 000 person-years [P value for trend = .32]; adjusted HR, 0.95 [95% CI, 0.49-1.84]; P = .88).

Conclusions and Relevance

In postmenopausal women, compared with consuming 3 or fewer servings of sugar-sweetened beverages per month, those who consumed 1 or more sugar-sweetened beverages per day had a higher incidence of liver cancer and death from chronic liver disease. Future studies should confirm these findings and identify the biological pathways of these associations.

Pre-diagnosis lipid levels and mortality after obesity-related cancer diagnosis in the Women's Health Initiative cardiovascular disease biomarker cohort

BACKGROUND

Published studies have demonstrated inconclusive relationships between serum lipid levels and mortality after cancer.

METHODS

The primary objective was to evaluate the relationship between fasting lipid levels and mortality after cancer. Data were obtained on baseline lipids and outcomes after cancer from 1263 postmenopausal women diagnosed with 13 obesity-related cancers who were part of the Women's Health Initiative (WHI) lipid biomarkers cohort. Obesity-related cancers included incident invasive cancers of the breast, colorectum, endometrium, esophagus (adenocarcinoma), kidney, liver, gallbladder, pancreas, ovaries, small intestine, thyroid, stomach, as well as multiple myeloma. Baseline lipid measurements included high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, and non-HDL-cholesterol. Outcomes were all cause, cancer-specific, and CVD mortality. Multivariable Cox proportional hazards models were used to measure associations between lipid levels and mortality (all cause, cancer, and CVD) after a cancer diagnosis, with lipids analyzed as continuous variables.

RESULTS

Among women with obesity-related cancer, there were 707 deaths, of which 379 (54%) were due to cancer and 113 (16%) were due to CVD. Mean time from blood draw to cancer diagnosis was 5.1 years (range: 0.05-10 years). LDL-C values above the 95th percentile were associated with higher risk of all-cause mortality (p < 0.001), and cancer-specific mortality (p < 0.001), but not mortality due to CVD. Non-HDL-C values above the 65th percentile were associated with higher risk of all-cause mortality (p = 0.01) and mortality due to CVD (p = 0.003), but not cancer-specific mortality (p = 0.37). HDL-C values above the 95th percentile were associated with lower all-cause mortality (p = 0.002), and above the 65th percentile with lower cancer-specific mortality (p = 0.003), but no significant relationship with mortality due to CVD was observed.

CONCLUSIONS

The relationship between pre-diagnosis fasting lipid levels and mortality after cancer diagnosis is complex. These results suggest that improved lipid control through lifestyle and anti-lipid medications could have a meaningful impact on outcomes after cancer.

Predictors of nonadherence to breast cancer screening guidelines in a United States urban comprehensive cancer center

BACKGROUND

This study aimed to identify predictors of nonadherence to breast cancer screening guidelines in an urban screening clinic among high- and average-risk women in the United States.

METHODS

We reviewed records of 6090 women who received ≥2 screening mammograms over 2 years at the Karmanos Cancer Institute to examine how breast cancer risk and breast density were associated with guideline-concordant screening. Incongruent screening was defined as receiving supplemental imaging between screening mammograms for average-risk women, and as not receiving recommended supplemental imaging for high-risk women. We used t-tests and chi-square tests to examine bivariate associations with guideline-congruent screening, and probit regression to regress guideline-congruence unto breast cancer risk, breast density, and their interaction, controlling for age and race.

RESULTS

Incongruent screening was more likely among high- versus average-risk women (97.7% vs. 0.9%, p < 0.01). Among average-risk women, incongruent screening was more likely among those with dense versus nondense breasts (2.0% vs. 0.1%, p < 0.01). Among high-risk women, incongruent screening was more likely among those with nondense versus dense breasts (99.5% vs. 95.2%, p < 0.01). The significant main effects of density and high-risk on increased incongruent screening were qualified by a density by high-risk interaction, showing a weaker association between risk and incongruent screening among women with dense breasts (simple slope = 3.71, p < 0.01) versus nondense breasts (simple slope = 5.79, p < 0.01). Age and race were not associated with incongruent screening.

CONCLUSIONS

Lack of adherence to evidence-based screening guidelines has led to underutilization of supplementary imaging for high-risk women and potential overutilization for women with dense breasts without other risk factors.

A narrative review of heart failure with preserved ejection fraction in breast cancer survivors

Advances in breast cancer (BC) treatment have contributed to improved survival, but BC survivors experience significant short-term and long-term cardiovascular mortality and morbidity, including an elevated risk of heart failure with preserved ejection fraction (HFpEF). Most research has focused on HF with reduced ejection fraction (HFrEF) after BC; however, recent studies suggest HFpEF is the more prevalent subtype after BC and is associated with substantial health burden. The increased HFpEF risk observed in BC survivors may be explained by treatment-related toxicity and by shared risk factors that heighten risk for both BC and HFpEF. Beyond risk factors with physiological impacts that drive HFpEF risk, such as hypertension and obesity, social determinants of health (SDOH) likely contribute to HFpEF risk after BC, impacting diagnosis, management and prognosis.Increasing clinical awareness of HFpEF after BC and screening for cardiovascular (CV) risk factors, in particular hypertension, may be beneficial in this high-risk population. When BC survivors develop HFpEF, treatment focuses on initiating guideline-directed medical therapy and addressing underlying comorbidities with pharmacotherapy or behavioural intervention. HFpEF in BC survivors is understudied. Future directions should focus on improving HFpEF prevention and treatment by building a deeper understanding of HFpEF aetiology and elucidating contributing risk factors and their pathogenesis in HFpEF in BC survivors, in particular the association with different BC treatment modalities, including radiation therapy, chemotherapy, biological therapy and endocrine therapy, for example, aromatase inhibitors. In addition, characterising how SDOH intersect with these therapies is of paramount importance to develop future prevention and management strategies.

A Review of Endocrine Therapy in Early-stage Breast Cancer: The Journey From Crudeness to Precision

Endocrine therapy (ET) is the standard of care for hormone receptor-positive early-stage breast cancer in the adjuvant setting. However, response to ET can vary across patient subgroups. Historically, hormone receptor expression and clinical stage are the main predictors of the benefit of ET. A "window of opportunity" trials has raised significant interest in recent years as a means of assessing the sensitivity of a patient's cancer to short-term neoadjuvant ET, which provides important prognostic information, and helps in decision-making regarding treatment options in a time-efficient and cost-efficient manner. In the era of genomics, molecular profiling has led to the discovery and evaluation of the prognostic and predictive abilities of new molecular profiles. To realize the goal of personalized medicine, we are in urgent need to explore reliable biomarkers or genomic signatures to accurately predict the clinical response and long-term outcomes associated with ET. Validation of these biomarkers as reliable surrogate endpoints can also lead to a revolution in the clinical trial designs, and potentially avoid the need for repeated tissue biopsies in the surveillance of disease response. The clinical potential of tumor genomic profiling marks the beginning of a new era of precision medicine in breast cancer treatment.

Chemotherapy-induced peripheral neuropathy in the detroit research on cancer survivors (ROCS) cohort

PURPOSE

Improved life expectancy has increased the likelihood for long-term complications from chemotherapy among cancer survivors. One burdensome complication is chemotherapy-induced peripheral neuropathy (CIPN). We evaluated rates of CIPN outcomes in the Detroit Research on Cancer Survivorship (ROCS) cohort.

METHODS

The population included 1,034 African American (AA) survivors who received chemotherapy for breast, colorectal, lung or prostate cancer. CIPN prevalence was based on initial occurrence of worsening of self-reported pain, numbness or tingling after chemotherapy. Current CIPN included symptoms still present at the time of the survey, and persistent CIPN symptoms were present 12 or more months post-chemotherapy. CIPN severity was ranked as mild, moderate or severe. Logistic regression was utilized to evaluate sociodemographic and clinical factors associated with the various categories of CIPN.

RESULTS

CIPN prevalence was 68%, with 53% current and 52% persistent. The symptom severity distribution based on prevalent CIPN included 32.2% mild, 30.8% moderate, and 36.9% severe. Factors associated with prevalent CIPN (odds ratio, 95% confidence interval) included primary cancer site (breast: 3.88, 2.02-7.46); and (colorectal: 5.37, 2.69-10.73), lower risk for older age at diagnosis (0.66, 0.53-0.83) and divorced/separated marital status (2.13, 1.42-3.21). Current CIPN was in addition, associated with more advanced stage disease trend (1.34, 1.08-1.66) and greater number of co-morbid medical conditions trend (1.23, 1.09-1.40), as was persistent CIPN. Severity of prevalent CIPN was associated with history of arthritis (1.55, 1.06-2.26) and severity of persistent CIPN with higher BMI (1.58, 1.07-2.35).

CONCLUSIONS

CIPN is a common and persistent complication in AA cancer survivors. Further research is needed to improve our understanding of CIPN predictors in all groups of cancer survivors.

Racial and ethnic variation in BRCA1 and BRCA2 genetic test results among individuals referred for genetic counseling at a large urban comprehensive cancer center

PURPOSE

The prevalence of pathogenic variants in BRCA1 and BRCA2 in populations other than Ashkenazi Jewish (AJ) is not well defined. We describe the racial and ethnic-specific prevalence of BRCA1/2 pathogenic variants and variants of uncertain significance (VUS) among individuals referred for genetic testing in a large urban comprehensive cancer center over a 20-year period.

METHODS

The population included 3,537 unrelated individuals who underwent genetic testing from January 1999 to October 2019 at the Karmanos Cancer Institute. We estimated the prevalence of pathogenic variants and VUS and evaluated associations with race and ethnicity for African American (AA), Arab, AJ and Hispanic individuals compared to Non-Hispanic Whites (NHW). We used multivariable models to adjust for other predictors of pathogenic variants. We also reported the most common pathogenic variants by racial and ethnic group.

RESULTS

The racial and ethnic breakdown of our population was: NHW (68.9%), AA (20.3%), AJ (2.5%), Arab (2.2%), Hispanic (1.0%), Asian Pacific Islander, Native American/Alaskan Native (4.7%), and < 1% unknown. The overall prevalence of pathogenic variants in BRCA1/2 was 8.9% and the prevalence of VUS was 5.6%. Compared to NHW, there were no racial or ethnic differences in the rate of pathogenic variants. However, AA individuals were more likely to have VUS in BRCA1 (adjusted OR 2.43, 95% CI 1.38-4.28) and AJ were more likely to have VUS in BRCA2 (adjusted OR 3.50, 95% CI 1.61-6.58).

CONCLUSION

These results suggest the continued need for genetic testing and variant reclassification for individuals of all racial and ethnic groups.

Diet-Driven Inflammation and Insulinemia and Risk of Interval Breast Cancer

Interval breast cancers (IBCs) emerge after a non-suspicious mammogram and before the patient's next scheduled screen. Risk factors associated with IBC have not been identified. This study evaluated if the empirical dietary inflammatory pattern (EDIP) or empirical dietary index for hyperinsulinemia (EDIH) scores are associated with IBC compared to screen-detected breast cancer. Data were from women 50-79 years-old in the Women's Health Initiative cohort who completed food frequency questionnaires at baseline (1993-98) and were followed through March 31, 2019 for breast cancer detection. Women were identified as having either IBC diagnosed within 1-year after their last negative screening mammogram (N = 317) or screen-detected breast cancer (N = 1,928). Multivariable-adjusted logistic regression analyses were used to estimate odds ratios for risk of IBC compared to screen-detected cancer in dietary index tertiles. No associations were observed between EDIP or EDIH and IBC. Odds ratios comparing the highest to the lowest dietary index tertile were 1.08; 95%CI, 0.78-1.48 for EDIP and 0.92; 95%CI, 0.67-1.27 for EDIH. The null associations persisted when stratified by BMI categories. Findings suggest that diet-driven inflammation or insulinemia may not be substantially associated with IBC risk among postmenopausal women. Future studies are warranted to identify modifiable factors for IBC prevention.

Uptake of genetic counseling and testing in a clinic-based population of women with breast cancer

Background

The study was conducted to evaluate racial differences in referral and uptake of genetic counseling (GC) in a clinic‐based population of women with breast cancer.

Methods

Medical records of 150 breast cancer patients at the Karmanos Cancer Institute were reviewed to determine eligibility for GC according to National Comprehensive Cancer Network guidelines, GC referral rates, and appointment completion rates. Logistic regression was used to assess the relationship between demographic and clinical factors and GC eligibility and referral.

Results

The mean age at diagnosis was 57.1 (SD 12.6) and 66% of the women were Black. There were 91 women (60.7%) eligible for GC and of those, 54 (61.4%) were referred. After multivariable analyses, factors associated with reduced eligibility were older age at diagnosis (OR = 0.91, 95% CI [0.87,0.95]) and Black race (OR = 0.37, 95% CI [0.15, 0.96]). After additional multivariable analysis, eligibility was associated with an increased likelihood of referral (OR = 5.97, 95% CI [2.29, 15.56]), however, Medicare versus private insurance was associated with a lower likelihood for referral (OR = 0.32, 95% CI [0.12–0.80]. Of those referred, 49 (76.6%) completed an appointment, and 47 had genetic testing. Women with Medicare were also less likely to complete an appointment. Race had no impact on referral or appointment completion.

Conclusions

There were no racial differences in GC referral or appointment completion in a clinic‐based sample of women with breast cancer. Further interventions are needed to promote increased referral and appointment completion for women with breast cancer who are eligible for GC.

Lifestyle and Cardiovascular Risk Factors Associated With Heart Failure Subtypes in Postmenopausal Breast Cancer Survivors

Background

Breast cancer (BC) survivors experience an increased burden of long-term comorbidities, including heart failure (HF). However, there is limited understanding of the risk for the development of HF subtypes, such as HF with preserved ejection fraction (HFpEF), in BC survivors.

Objectives

This study sought to estimate the incidence of HFpEF and HF with reduced ejection fraction (HFrEF) in postmenopausal BC survivors and to identify lifestyle and cardiovascular risk factors associated with HF subtypes.

Methods

Within the Women’s Health Initiative, participants with an adjudicated diagnosis of invasive BC were followed to determine the incidence of hospitalized HF, for which adjudication procedures determined left ventricular ejection fraction. We calculated cumulative incidences of HF, HFpEF, and HFrEF. We estimated HRs for risk factors in relation to HF, HFpEF, and HFrEF using Cox proportional hazards survival models.

Results

In 2,272 BC survivors (28.6% Black and 64.9% White), the cumulative incidences of hospitalized HFpEF and HFrEF were 6.68% and 3.96%, respectively, over a median of 7.2 years (IQR: 3.6-12.3 years). For HFpEF, prior myocardial infarction (HR: 2.83; 95% CI: 1.28-6.28), greater waist circumference (HR: 1.99; 95% CI: 1.14-3.49), and smoking history (HR: 1.65; 95% CI: 1.01-2.67) were the strongest risk factors in multivariable models. With the exception of waist circumference, similar patterns were observed for HFrEF, although none were significant. In relation to those without HF, the risk of overall mortality in BC survivors with hospitalized HFpEF was 5.65 (95% CI: 4.11-7.76), and in those with hospitalized HFrEF, it was 3.77 (95% CI: 2.51-5.66).

Conclusions

In this population of older, racially diverse BC survivors, the incidence of HFpEF, as defined by HF hospitalizations, was higher than HFrEF. HF was also associated with an increased mortality risk. Risk factors for HF were largely similar to the general population with the exception of prior myocardial infarction for HFpEF. Notably, both waist circumference and smoking represent potentially modifiable factors.

Cardiometabolic risk factors, physical activity, and postmenopausal breast cancer mortality: results from the Women's Health Initiative

BACKGROUND

Higher physical activity levels are associated with lower breast cancer-specific mortality. In addition, the metabolic syndrome is associated with higher breast cancer-specific mortality. Whether the physical activity association with breast cancer mortality is modified by number of metabolic syndrome components (cardiometabolic risk factors) in postmenopausal women with early-stage breast cancer remains unknown.

METHODS

Cardiovascular risk factors included high waist circumference, hypertension, high cholesterol, and diabetes. Breast cancers were verified by medical record review. Mortality finding were enhanced by serial National Death Index queries. Cox proportional hazards regression models were used to estimate associations between baseline physical activity and subsequent breast cancer-specific and overall mortality following breast cancer diagnosis in Women's Health Initiative participants. These associations were examined after stratifying by cardiometabolic risk factor group.

RESULTS

Among 161,308 Women's Health Initiative (WHI) participants, 8543 breast cancers occurred after 9.5 years (median) follow-up in women, additionally with information on cardiometabolic risk factors and physical activity at entry. In multi-variable analyses, as measured from cancer diagnosis, higher physical activity levels were associated with lower all-cause mortality risk (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.78-0.95, trend P < 0.001) but not with breast cancer-specific mortality (HR 0.85, 95% CI 0.70 to 1.04, trend P = 0.09). The physical activity and all-cause mortality association was not significantly modified by cardiometabolic risk factor number.

CONCLUSIONS

Among women with early-stage breast cancer, although higher antecedent physical activity was associated with lower risk of all-cause mortality, the association did not differ by cardiometabolic risk factor number.

Racial and ethnic variation in multigene panel testing in a cohort of BRCA1/2-negative individuals who had genetic testing in a large urban comprehensive cancer center

Background

There is sparse clinical information on the racial and ethnic distribution of results of multigene panel testing among individuals at high risk for hereditary cancer.

Methods

We evaluated the results of multigene panel testing across eight clinical sites across the state of Michigan for individuals seen for genetic counseling from May 13, 2013 to October 31, 2019 at the Karmanos Cancer Institute's cancer genetics clinic. We estimated the prevalence of pathogenic variants and variants of uncertain significance (VUS) from genes other than BRCA1/2 among individuals of non‐Hispanic White (NHW), Black or African American (AA), Ashkenazi Jewish (AJ), Arab, Hispanic, and other ancestry.

Results

The racial and ethnic distribution of 2419 individuals who had panel testing included 68.8% NHW, 22.1% AA, 2.3% Arab, 2.2% AJ, 1.0% Hispanic, and 3.6% other. Of these, 11.2% had pathogenic variants and 17.5% had VUS. After multivariable analyses, compared to NHW, AA were less likely to have pathogenic variants (OR 95% CI, 0.38, 0.24–0.59, p < 0.001). Both AA and Arabs were more likely to have VUS (OR 95% CI, 1.53, 1.18–1.98, p = 0.001 and OR 95% CI, 2.28, 1.17–4.43, p = 0.015, respectively). There were no significant differences for other groups. The most common pathogenic variants were CHEK2 (n = 65), MUTYH (n = 45), ATM (n = 28), and MSH2 (n = 22); the most common pathogenic variants by race and ethnicity were CHEK2 (NHW), MSH2 and MUTYH (AA), MSH2 (Arab), MSH6 and CHEK2 (AJ), and MLH1 (Hispanic); the most common pathogenic variants by primary cancer site were CHEK2 (breast), MSH2 (colon), BRIP1 and MUTYH (ovarian), and MSH2 and MSH6 (endometrial).

Conclusions

Understanding the racial and ethnic distribution of pathogenic variants in multi‐gene panels has the potential to lead to better identification of individuals at risk for hereditary cancer.

A review of research on the intersection between breast cancer and cardiovascular research in the Women's Health Initiative (WHI)

Both obesity and metabolic syndrome are linked to increased incidence of type 2 diabetes, cardiovascular disease (CVD), and cancers of the breast (post-menopausal), and other obesity-related cancers. Over the past 50 years, the worldwide prevalence of obesity and metabolic syndrome has increased, with a concomitant higher incidence of associated co-morbidities and mortality. The precise mechanism linking metabolic syndrome to increased cancer incidence is incompletely understood, however, individual components of metabolic syndrome have been linked to increased breast cancer incidence and worse survival. There is a bidirectional relationship between the risk of CVD and cancer due to a high burden of shared risk factors and higher rates of CVD among cancer survivors, which may be impacted by the pro-inflammatory microenvironment associated with metabolic syndrome and cancer-directed therapies. The Women's Health Initiative (WHI) is an excellent resource to study a dual relationship between cancer and CVD (cardio-oncology) with extensive information on risk factors and long-term outcomes. The purpose of this review is to provide an overview of research on cardio-oncology conducted utilizing WHI data with focus on studies evaluating both breast cancer and CVD including shared risk factors and outcomes after cancer. The review also includes results on other obesity related cancers which were included in the analyses of breast cancer, articles looking at cancer after heart disease (reverse cardio-oncology) and the role of Clonal Hematopoiesis of Indeterminate Potential (CHIP) as a shared risk factor between CVD and cancer. A summary of pertinent WHI literature helps to delineate the direction of future research evaluating the relationship between CVD and other cancer sites, and provides information on the opportunity for other novel analyses within the WHI.

Chemotherapy-induced peripheral neuropathy in African American cancer survivors: Risk factors and quality of life outcomes

Background

Epidemiological studies of chemotherapy‐induced peripheral neuropathy (CIPN) have predominantly focused on non‐Hispanic White patients, despite the observation that African Americans are more likely to experience CIPN. To address this health disparities gap, we sought to identify non‐genetic risk factors and comorbidities associated with CIPN in African American cancer survivors using the Detroit Research on Cancer Survivors study.

Methods

Logistic regression was used to evaluate relationships between presence of self‐reported CIPN and relevant clinical characteristics in 1045 chemotherapy‐treated African American cancer survivors. Linear regression was used to evaluate risk factors for CIPN and quality of life outcomes that reflect physical, social, emotional, and functional domains of health.

Results

Patients with CIPN were more likely to report hypertension (OR = 1.28, 95% CI: 0.98–1.67, p = 0.07), hypercholesterolemia (OR = 1.32, 95% CI: 1.001–1.73, p = 0.05), history of depression (OR = 1.62, 95% CI: 1.18–2.25, p = 0.003), and diabetes (OR = 1.33, 95% CI: 0.98–1.82, p = 0.06) after adjustment for age at diagnosis, sex, and cancer site. BMI (OR = 1.02 kg/m², 95% CI: 1.006–1.04 kg/m², p = 0.008) was also positively associated with CIPN. In addition, CIPN status was significantly associated with quality of life (FACT‐G total: β = −8.60, 95% CI: −10.88, −6.32) p < 0.0001) and mood (PROMIS^® Anxiety: β = 4.18, 95% CI: 2.92–5.45, p < 0.0001; PROMIS^® Depression: β = 2.69, 95% CI: 1.53–3.84, p < 0.0001) after adjustment for age at diagnosis, sex, cancer site, and comorbidities. Neither alcohol consumption (OR = 0.88, 95% CI: 0.68–1.14, p = 0.32) nor tobacco use (ever smoked: OR = 1.04, 95% CI: 0.80–1.35, p = 0.76; currently smoke: OR = 1.28, 95% CI: 0.90–1.82, p = 0.18) was associated with increased CIPN risk.

Conclusion

Risk factor profiles in African Americans are not entirely consistent with those previously reported for non‐Hispanic White patients. Neglecting to understand the correlates of common chemotherapy‐induced toxicities for this patient population may further contribute to the health disparities these individuals face in receiving adequate healthcare.

Prevalence and predictors of peripheral neuropathy after breast cancer treatment

Background

Many of the 3.8 million breast cancer survivors in the United States experience long‐term side effects of cancer therapy including peripheral neuropathy (PN). We assessed the prevalence and predictors of PN among women with breast cancer followed in the Women's Health Initiative's Life and Longevity After Cancer survivorship cohort.

Methods

The study population included 2420 women with local (79%) or regional (21%) stage disease. Presence of PN was based on the reports of “nerve problems and/or tingling sensations” after treatment and PN severity was assessed using the Functional Assessment of Cancer Therapy‐Gynecologic Oncology Group/Neurotoxicity instrument. Logistic regression analysis was used to evaluate the socio‐demographic and clinical factors associated with PN prevalence and severity.

Results

Initial breast cancer treatment included surgery‐only (21%), surgery and radiation (53%), or surgery and chemotherapy (±radiation) (26%). Overall, 17% of women reported PN occurring within days (30%), months (46%), or years (24%) after treatment and 74% reported ongoing symptoms at a median of 6.5 years since diagnosis. PN was reported by a larger proportion of chemotherapy recipients (33%) compared to those who had surgery alone (12%) or surgery+radiation (11%) (p < 0.0001). PN was reported more commonly by women treated with paclitaxel (52%) and docetaxel (39%), versus other chemotherapy (17%) (p < 0.0001). In multivariable analyses, treatment type (chemotherapy vs. none; OR, 95% CI: 3.31, 2.4–4.6), chemotherapy type (taxane vs. no‐taxane; 4.74, 3.1–7.3), and taxane type (paclitaxel vs. docetaxel; 1.59, 1.0–2.5) were associated with higher odds of PN.

Conclusion

PN is an important long‐term consequence of taxane‐based chemotherapy in breast cancer survivors.

Low-fat dietary pattern and breast cancer mortality by metabolic syndrome components: a secondary analysis of the Women's Health Initiative (WHI) randomised trial

BACKGROUND

In the Women's Health Initiative (WHI) dietary modification (DM) randomised trial, the low-fat dietary intervention reduced deaths from breast cancer (P = 0.02). Extending these findings, secondary analysis examined dietary intervention influence on breast cancer mortality by metabolic syndrome (MS) components.

METHODS

In total, 48,835 postmenopausal women with no prior breast cancer were randomised to a low-fat dietary intervention or comparison groups. Four MS components were determined at entry in 45,833 participants: (1) high waist circumference, (2) high blood pressure, (3) high cholesterol and (4) diabetes history. Forest plots of hazard ratios (HRs) were generated with P-values for interaction between randomisation groups and MS component score. Primary outcome was death from breast cancer by metabolic syndrome score.

RESULTS

HRs and 95% confidence intervals (CI) for dietary intervention influence on death from breast cancer were with no MS components (n = 10,639), HR 1.09, 95% CI 0.63-1.87; with 1-2 MS components (n = 30,948), HR 0.80, 95% CI 0.62-1.02; with 3-4 MS components (n = 4,246), HR 0.31, 95% CI 0.14-0.69 (interaction P = 0.01).

CONCLUSIONS

While postmenopausal women with 3-4 MS components were at higher risk of death from breast cancer, those randomised to a low-fat dietary intervention more likely had reduction in this risk.

REGISTRY

ClinicalTrials.gov (NCT00000611).

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

Uptake of genetic counseling and testing in a clinic based population of women with breast cancer

10524

Background: Carriers of pathogenic variants in cancer susceptibility genes have an elevated risk of developing breast, ovarian, and other cancers.We conducted a medical record review to determine the uptake of genetic counseling and testing in a clinic-based population of women with breast cancer. Methods: Medical records of 150 women with breast cancer seen at the Karmanos Cancer Institute between January-December 2018 were reviewed to determine the proportion eligible for genetic testing according to National Comprehensive Cancer Network guidelines. We also assessed genetics referral rates, appointment completion and results of genetic testing. Using chi-square and ANOVA tests, we analyzed the association of demographic and clinical factors with eligibility and referral to genetic counseling. Results: The average age of diagnosis was 57.1 years old, with 68.7% of women diagnosed with stage I-III disease, and 31.3% diagnosed with stage IV disease. There were 91 (60.7%) women who met NCCN criteria for genetic testing, of which 46.2% ultimately underwent genetic testing. Eligible women were more likely to be younger (52.6 vs. 64.0 years old), White (75.0% vs. 54.5%), and have Medicaid (75.0%) or private insurance (72.9%) vs. Medicare (44.8%). Women who met NCCN criteria were 3.5 times more likely to be referred for genetic counseling than those that did not meet eligibility criteria. Women were also more likely to be referred if they had early-stage disease compared to stage IV (67.8% vs. 48.3%), and Medicaid or private insurance compared to Medicare (71.4%, 72.0% and 40.0%, respectively). Of eligible women, 59.3% had a genetic counseling appointment scheduled, and of those, 78.0% attended their appointment. There were no apparent differences in appointment completion based on race with similar percentages of Black and White women completing their appointments (74.0% and 77.0% respectively). Women with stage IV disease were more likely to complete their appointments (83.0%) compared to women with stages I-III (74.0%) and fewer women with Medicare completed their genetic counseling appointment (56.0%) compared to women with Medicaid (83.0%) and women with private insurance (83.0%). Among women who attended their appointment, 95.9% underwent genetic testing. Of women who had genetic testing, 8.5% had a pathogenic variant and 30.4% had a variant of unknown significance. Conclusions: The results of this study indicate that lack of genetic counseling referrals contribute to a gap between the need for and completion of genetic testing. By understanding barriers to genetic counseling and testing, future clinical initiatives could effectively improve accessibility to genetic counseling services.

Prevalence and predictors of peripheral neuropathy after chemotherapy: Outcomes from the Detroit Research on Cancer Survivorship (ROCS) cohort

12069

Background: Increased life expectancy for cancer survivors following advances in treatment has led to a greater likelihood of developing long-term complications. Among them is chemotherapy-induced peripheral neuropathy (CIPN), which adversely impacts the functional capacity of survivors. We assessed prevalence and predictors of CIPN in a cohort of African-American (AA) cancer survivors. Methods: The study population included 633 breast, colorectal, prostate and lung cancer survivors who received chemotherapy and participated in the Detroit Research on Cancer Survivorship (ROCS) study. Presence of CIPN was based on self-reported pain, numbness or tingling in the hands or feet, occurring either for the first time or worsening after chemotherapy. If participants reported continued CIPN at the time of survey, their symptoms were reported as persistent. CIPN severity was self-reported as mild, moderate or severe. Logistic regression analysis was used to evaluate socio-demographic and clinical factors (including 12 common comorbid conditions) associated with CIPN prevalence, persistence and severity. Results: Overall, 67% of the cohort reported CIPN at a mean time of 25.3 months (range 2-74 months) after cancer diagnosis, and 51% reported persistent CIPN. The distribution of CIPN severity consisted of 32.2% with mild, 30.8% with moderate, and 36.9% with moderate to severe symptoms. Diagnosis of primary breast (OR 3.99, 95% CI 1.52-10.46) or colorectal cancers (OR 5.24, 95% CI 2.17-12.69) conferred greater CIPN prevalence relative to a diagnosis of prostate cancer. The presence of each additional comorbid condition among those outlined in the survey also conferred a 20% greater prevalence of CIPN (OR 1.2, 95% CI 1.03-1.39). Similar trends were seen among those who reported persistent CIPN. Using age > 65 at diagnosis as the reference group, age < 50 (OR 2.64, 95% CI 1.43-4.88) and age 51-64 (OR 1.96, 95% CI 1.14-3.35) resulted in an increased risk of moderate or severe compared to mild CIPN. Conclusions: In the Detroit ROCS cohort, CIPN was reported in two-thirds of cancer survivors receiving chemotherapy. Out of them, more than one-third reported moderate to severe symptoms, more commonly seen among those age < 65. Consideration of CIPN as a prominent long-term complication of cancer treatment should play a role in treatment decisions and development of new chemotherapy regimens.

Comorbidities at time of diagnosis as a predictor of more or less aggressive treatment modalities in early-invasive breast cancer

e12591

Background: Comorbidities and advanced age have been shown to play important roles in breast cancer treatment and outcomes. Reduced doses of chemotherapy, worse treatment-related side-effects, poor performance status in patients with significant comorbidities, and the biological interplay between other diseases and cancer may also play roles. We evaluated the relationship between age and pre-existing comorbidities and receipt of local and systemic therapy in a cohort of African American (AA) women with early invasive breast cancer. Methods: The study population included 1,169 AJCC stage I-III invasive breast cancer survivors from the Detroit Research on Cancer Survivors (ROCS) study, a large cohort of AA cancer survivors. Comorbidities (both individual diseases and a combined count that was categorized as low/medium/high comorbidity burden), age at diagnosis, and other demographic variables were obtained from self-reported standardized questionnaires. Cancer-related variables including treatment were obtained from the Metropolitan Detroit Cancer Surveillance System registry. Recommended treatment was subdivided into localized (surgery ± radiation; N = 1,156), hormonal (N = 848) and chemotherapy (N = 680). Logistic regression estimated the associations between age and pre-existing comorbid conditions and the receipt of recommended treatments. Adjusted models included variables that were selected a priori and were significant predictors in univariate analysis. Results: Most women received recommended localized treatment (82.6%), hormone treatment (73.7%), and chemotherapy (79.9%). There were no differences in receipt of localized treatment based on age or comorbidity burden in adjusted analyses. However, arthritis and depression were significantly associated with not receiving recommended localized treatment (Odds ratio (OR): 0.66, 95% CI: 0.47, 0.93 and OR: 0.53, 95% CI: 0.36, 0.78, respectively). Women with a history of obesity (BMI ≥30) were more likely to receive recommended hormone therapy (OR: 1.64, 95% CI: 1.19, 2.26), while women with congestive heart failure were less likely (OR: 0.46, 95% CI: 0.23, 0.90). Receipt of recommended chemotherapy was less likely for those with increasing age (Ptrend< 0.01) and increasing comorbidity burden (Ptrend= 0.02). Those with a history of arthritis (OR: 0.66, 95% CI: 0.44, 0.99) and hypercholesterolemia (OR: 0.62, 95% CI: 0.41, 0.95) were also less likely to receive recommended chemotherapy. Conclusions: Advanced age and presence of pre-existing co-morbid medical conditions appears to influence the receipt of chemotherapy, while individual conditions were associated with receipt of local treatment or hormone therapy in a cohort of AA survivors, suggesting the importance of providing comprehensive medical care for all women with early invasive breast cancer.

Healthy Lifestyle and Clonal Hematopoiesis of Indeterminate Potential: Results From the Women's Health Initiative

Background

Presence of clonal hematopoiesis of indeterminate potential (CHIP) is associated with a higher risk of atherosclerotic cardiovascular disease, cancer, and mortality. The relationship between a healthy lifestyle and CHIP is unknown.

Methods and Results

This analysis included 8709 postmenopausal women (mean age, 66.5 years) enrolled in the WHI (Women's Health Initiative), free of cancer or cardiovascular disease, with deep‐coverage whole genome sequencing data available. Information on lifestyle factors (body mass index, smoking, physical activity, and diet quality) was obtained, and a healthy lifestyle score was created on the basis of healthy criteria met (0 point [least healthy] to 4 points [most healthy]). CHIP was derived on the basis of a prespecified list of leukemogenic driver mutations. The prevalence of CHIP was 8.6%. A higher healthy lifestyle score was not associated with CHIP (multivariable‐adjusted odds ratio [OR] [95% CI], 0.99 [0.80–1.23] and 1.13 [0.93–1.37]) for the upper (3 or 4 points) and middle category (2 points), respectively, versus referent (0 or 1 point). Across score components, a normal and overweight body mass index compared with obese was significantly associated with a lower odds for CHIP (OR, 0.71 [95% CI, 0.57–0.88] and 0.83 [95% CI, 0.68–1.01], respectively; P‐trend 0.0015). Having never smoked compared with being a current smoker tended to be associated with lower odds for CHIP.

Conclusions

A healthy lifestyle, based on a composite score, was not related to CHIP among postmenopausal women. However, across individual lifestyle factors, having a normal body mass index was strongly associated with a lower prevalence of CHIP. These findings support the idea that certain healthy lifestyle factors are associated with a lower frequency of CHIP.

Cardiometabolic risk factors and survival after cancer in the Women's Health Initiative

BACKGROUND

Cardiometabolic abnormalities are a leading cause of death among women, including women with cancer.

METHODS

This study examined the association between prediagnosis cardiovascular health and total and cause-specific mortality among 12,076 postmenopausal women who developed local- or regional-stage invasive cancer in the Women's Health Initiative (WHI). Cardiovascular risk factors included waist circumference, hypertension, high cholesterol, and type 2 diabetes. Obesity-related cancers included breast cancer, colorectal cancer, endometrial cancer, kidney cancer, pancreatic cancer, ovarian cancer, stomach cancer, liver cancer, and non-Hodgkin lymphoma. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for important predictors of survival.

RESULTS

After a median follow-up of 10.0 years from the date of the cancer diagnosis, there were 3607 total deaths, with 1546 (43%) due to cancer. Most participants (62.9%) had 1 or 2 cardiometabolic risk factors, and 8.1% had 3 or 4. In adjusted models, women with 3 to 4 risk factors (vs none) had a higher risk of all-cause mortality (HR, 1.99; 95% CI, 1.73-2.30), death due to cardiovascular disease (CVD) (HR, 4.01; 95% CI, 2.88-5.57), cancer-specific mortality (HR, 1.37; 95% CI, 1.1-1.72), and other-cause mortality (HR, 2.14; 95% CI, 1.70-2.69). A higher waist circumference was associated with greater all-cause mortality (HR, 1.17; 95% CI, 1.06-1.30) and cancer-specific mortality (HR, 1.22; 95% CI, 1.04-1.42).

CONCLUSIONS

Among postmenopausal women diagnosed with cancer in the WHI, cardiometabolic risk factors before the cancer diagnosis were associated with greater all-cause, CVD, cancer-specific, and other-cause mortality. These results raise hypotheses regarding potential clinical intervention strategies targeting cardiometabolic abnormalities that require future prospective studies for confirmation.

LAY SUMMARY

This study uses information from the Women's Health Initiative (WHI) to find out whether cardiac risk factors are related to a greater risk of dying among older women with cancer. The WHI is the largest study of medical problems faced by older women in this country. The results show that women who have 3 or 4 risk factors are more likely to die of any cause, heart disease, or cancer in comparison with women with no risk factors. It is concluded that interventions to help to lower the burden of cardiac risk factors can have an important impact on survivorship among women with cancer.

Patterns of cancer family history and genetic counseling eligibility among African Americans with breast, prostate, lung, and colorectal cancers: A Detroit Research on Cancer Survivors cohort study

BACKGROUND

Family history (FH) remains one of the strongest risk factors for many common cancers and is used to determine cancer genetic counseling (CGC) eligibility, but the understanding of familial cancer patterns in African Americans is limited.

METHODS

This study evaluated cancer FH among African Americans with invasive breast cancer, prostate cancer, lung cancer, or colorectal cancer (CRC) in the Detroit Research on Cancer Survivors (ROCS) cohort. Associations between participant cancer type, site-specific FH, and meeting national guidelines for CGC were evaluated via logistic regression. Cancer FH patterns were evaluating via hierarchical clustering.

RESULTS

Among 1500 ROCS participants, 71% reported at least 1 first-degree relative or grandparent with cancer. FHs of breast cancer, CRC, lung cancer, and prostate cancer were most common among participants with the same diagnosis (odds ratio [OR] for breast cancer, 1.14; P < .001; OR for CRC, 1.08; P = .003; OR for lung cancer, 1.09; P = .008; OR for prostate cancer, 1.14; P < .001). Nearly half of the participants (47%) met national CGC guidelines, and 24.4% of these participants met CGC criteria on the basis of their cancer FH alone. FH was particularly important in determining CGC eligibility for participants with prostate cancer versus breast cancer (OR for FH vs personal history alone, 2.91; 95% confidence interval, 1.94-4.35; P < .001). In clustering analyses, breast and prostate cancer FH-defined clusters were common across all participants. Clustering of CRC and breast cancer FHs was also observed.

CONCLUSIONS

ROCS participants reported high rates of cancer FH. The high rate of eligibility for CGC among ROCS participants supports the need for interventions to increase referrals and uptake of CGC among African Americans.

Rural-Urban Residence and Stroke Risk and Severity in Postmenopausal Women: The Women's Health Initiative

Background: The impact of rural–urban residence on stroke risk and poor stroke outcomes among postmenopausal women is unknown.

Methods: We used data from the Women's Health Initiative (WHI) (1993–2014; n = 155,186) to test the hypothesis that women who live in rural compared with urban areas have higher stroke risk and worse stroke outcomes than urban women. We used rural–urban commuting area codes to categorize geocoded participant addresses into urban, large rural, or small rural areas. Incident strokes during follow-up were adjudicated by neurologists who used standardized criteria for reviewing brain imaging reports and other medical records and determining stroke subtype. Stroke functional recovery was measured with the Glasgow Stroke Outcomes Scale ascertained from the hospital record. We used univariable and multivariable-adjusted Cox proportional hazards models as well as logistic regression models to test whether rural–urban residence predicted stroke risk and odds of poor stroke outcome.

Results: Among the 155,186 women in our cohort, 2.3% (n = 3514) had an incident stroke. We observed a modest reduction in risk of incident stroke among women who lived in urban (adjusted hazard ratio [aHR]: 0.86, confidence interval [95% CI]: 0.71–1.05) and large rural areas (aHR: 0.79, 95% CI: 0.60–1.04) compared with women who lived in small rural areas. In contrast, women who lived in urban compared with large rural areas had a similarly modest increased risk of stroke (aHR: 1.09, 95% CI: 0.89–1.32). Women who lived in urban compared with large rural areas were more likely to have poor stroke outcome (odds ratio [OR]: 1.41, 95% CI: 1.06–1.88), but the association was attenuated after adjustment for covariates (adjusted OR [aOR]: 1.27, 0.93–1.74).

Conclusions: Future studies should confirm and examine the potential pathways of the reported associations among postmenopausal women.

Heritable Susceptibility to Breast Cancer among African-American Women in the Detroit Research on Cancer Survivors Study

BACKGROUND

African-American women have high rates of breast cancer associated with hereditary features. However, no studies have reported the prevalence of inherited variation across all genes known to be breast cancer risk factors among African-American patients with breast cancer not selected for high-risk characteristics.

METHODS

We evaluated 182 African-American women diagnosed with invasive breast cancer in metropolitan Detroit via targeted capture and multiplex sequencing of 13 well-established breast cancer risk genes and five suggested breast cancer risk genes.

RESULTS

We identified 24 pathogenic variants in 23 women [12.6%; 95% confidence interval (CI), 8.2%-18.4%] and five genes (BRCA2, BRCA1, ATM, RAD50, CDH1). BRCA1 and BRCA2 accounted for 58.3% of all pathogenic variants. An additional six pathogenic variants were found in suggested breast cancer risk genes (MSH6, MUTYH, NF1, BRIP1).

CONCLUSIONS

The prevalence of germline pathogenic variants is relatively high among African-American patients with breast cancer unselected for high-risk characteristics across a broad spectrum of genes.

IMPACT

This study helps to define the genomic landscape of breast cancer susceptibility in African-American women who could benefit from enhanced surveillance and screening.

Abstract 4630: Eleven specific comorbidities and mortality risk in women diagnosed with invasive breast cancer between the ages of 35 and 64 years

Purpose: To evaluate the impact of 11 specific comorbidities on mortality risk in women diagnosed with breast cancer between the ages of 35 and 64 years.

Methods: We followed 4,485 women, ages 35 to 64 years when diagnosed with first primary invasive breast cancer between 7/1/94 and 4/30/98, to determine if subsequent mortality risk was affected by self-reported history of 11 comorbidities diagnosed before their breast cancer (previous cancer; diabetes; rheumatoid arthritis; myocardial infarction; other types of heart disease; hypertension; stroke; phlebitis, pulmonary embolism, or blood clots in legs or lungs; gallbladder disease; peptic, stomach, gastric, or duodenal ulcer; liver disease). During follow up (average 10.1 years), 1,234 women died (904 breast cancer deaths). Multivariable Cox proportional hazards regression models were fit to data to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for breast cancer-specific mortality and mortality due to other causes.

Results: Approximately 50% of women reported a history of having at least one of the 11 comorbidities. The total number of comorbidities a woman had was not associated with breast cancer-specific mortality risk (p-trend=0.43), but it was positively associated with risk of mortality due to other causes (p-trend&lt;0.0001). The positive association was not modified by race, education, household income, menopausal status, body mass index, history of alcohol consumption or cigarette smoking history (all p-heterogeneity ≥ 0.13). No individual comorbidity was associated with breast cancer-specific mortality whereas a history of previous cancer, diabetes, or myocardial infarction was associated with increased risk of mortality due to other causes (HRs: 1.73, 2.13, and 2.11, respectively). Women with a history of diabetes who also had a history of previous cancer or a history of myocardial infarction experienced an 8-fold greater risk of mortality due to other causes than women without any comorbidity (HR=8.01, 95% CI=4.50-14.26).

Conclusions: Our findings among women diagnosed with invasive breast cancer between the ages of 35 and 64 years suggest that the total number of comorbidities and specifically history of previous cancer, diabetes, or myocardial infarction increased the risk of dying from causes other than breast cancer, especially when having a history of diabetes as well as previous cancer or myocardial infarction. These results indicate the importance of interventions to reduce the impact of comorbidities among breast cancer survivors.

Citation Format: Huiyan Ma, Giske Ursin, Kathleen E. Malone, Michael S. Simon, Jill A. McDonald, Brian L. Strom, Michael F. Press, Leslie Bernstein, Yani Lu. Eleven specific comorbidities and mortality risk in women diagnosed with invasive breast cancer between the ages of 35 and 64 years [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4630.

Abstract 5805: Treatment-associated endocrine symptoms and change in ultrasound tomography measures of breast density after tamoxifen therapy

Background: Tamoxifen therapy has been shown to have greater therapeutic benefit among women whose breast density declines subsequent to treatment than among women whose density does not decline. Although limited data suggests that endocrine symptoms after tamoxifen initiation may be associated with improved breast cancer outcomes, it is unknown whether these symptoms are associated with reductions in breast density. We therefore evaluated endocrine symptoms and change in breast density in a 12-month longitudinal study of women undergoing tamoxifen therapy for clinical indications.

Methods: Cohort members (N=74) were aged 30-74 years in the Ultrasound Study of Tamoxifen at Karmanos Cancer Institute and Henry Ford Health Systems (Detroit, MI). Endocrine symptoms and breast density were both assessed prior to tamoxifen initiation (T0) and at 1-3 months (T1), 4-6 months (T2), and approximately 12 months (T3) post-tamoxifen initiation. Treatment-associated endocrine symptoms included treatment-emergent or increasing vasomotor and/or joint symptoms. Endocrine symptom severity was also assessed with a Likert scale for symptom frequency and categorized as no symptoms (score=0), low/moderate symptoms (score=1-5), and high symptoms (score=6+). Sound speed (m/s), a surrogate of volumetric breast density, was measured with whole breast ultrasound tomography. Change in breast density was calculated as density at T1-T3 minus density at T0. We used multivariable linear regression to estimate mean change in density by endocrine symptoms adjusting for age, race, menopausal status, body mass index, and baseline sound speed. Generalized estimating equations were used to account for within-subject correlations over time.

Results: Women with treatment-associated endocrine symptoms had an overall greater mean reduction in breast density compared with women without symptoms (mean change [95% CI]: -1.97 m/s [-3.80, -0.13]; -0.27 m/s [- 3.50, 2.95], respectively; p=0.22). Longitudinal trends in breast density significantly differed for women with versus without treatment-associated endocrine symptoms (p-interaction=0.02). Significant declines in breast density over time were observed among women with treatment-associated endocrine symptoms (p-trend=0.005), but not among women without symptoms (p-trend=0.16). Similar trends in breast density decline were observed among women with higher symptom severity (p-trends for no symptoms=0.53; low/moderate symptoms=0.04; high symptoms=0.008).

Conclusions: These findings suggest that treatment-associated endocrine symptoms may be associated with a significant decline in breast density after tamoxifen initiation. Further studies are needed to assess whether these observations can predict clinical outcome, and if confirmed, both treatment-associated endocrine symptoms and observed reductions in breast density may be useful for patients and providers to improve adherence.

Citation Format: Cody Ramin, Ruth Pfeiffer, Shaoqi Fan, Maeve Mullooly, Roni T. Falk, Mark A. Sak, Michael S. Simon, David H. Gorski, Haythem Ali, Peter Littrup, Nebojsa Duric, Mark E. Sherman, Gretchen L. Gierach. Treatment-associated endocrine symptoms and change in ultrasound tomography measures of breast density after tamoxifen therapy [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5805.

Association of Menopausal Hormone Therapy With Breast Cancer Incidence and Mortality During Long-term Follow-up of the Women's Health Initiative Randomized Clinical Trials

IMPORTANCE

The influence of menopausal hormone therapy on breast cancer remains unsettled with discordant findings from observational studies and randomized clinical trials.

OBJECTIVE

To assess the association of prior randomized use of estrogen plus progestin or prior randomized use of estrogen alone with breast cancer incidence and mortality in the Women's Health Initiative clinical trials.

DESIGN, SETTING, AND PARTICIPANTS

Long-term follow-up of 2 placebo-controlled randomized clinical trials that involved 27 347 postmenopausal women aged 50 through 79 years with no prior breast cancer and negative baseline screening mammogram. Women were enrolled at 40 US centers from 1993 to 1998 with follow-up through December 31, 2017.

INTERVENTIONS

In the trial involving 16 608 women with a uterus, 8506 were randomized to receive 0.625 mg/d of conjugated equine estrogen (CEE) plus 2.5 mg/d of medroxyprogesterone acetate (MPA) and 8102, placebo. In the trial involving 10 739 women with prior hysterectomy, 5310 were randomized to receive 0.625 mg/d of CEE alone and 5429, placebo. The CEE-plus-MPA trial was stopped in 2002 after 5.6 years' median intervention duration, and the CEE-only trial was stopped in 2004 after 7.2 years' median intervention duration.

MAIN OUTCOMES AND MEASURES

The primary outcome was breast cancer incidence (protocol prespecified primary monitoring outcome for harm) and secondary outcomes were deaths from breast cancer and deaths after breast cancer.

RESULTS

Among 27 347 postmenopausal women who were randomized in both trials (baseline mean [SD] age, 63.4 years [7.2 years]), after more than 20 years of median cumulative follow-up, mortality information was available for more than 98%. CEE alone compared with placebo among 10 739 women with a prior hysterectomy was associated with statistically significantly lower breast cancer incidence with 238 cases (annualized rate, 0.30%) vs 296 cases (annualized rate, 0.37%; hazard ratio [HR], 0.78; 95% CI, 0.65-0.93; P = .005) and was associated with statistically significantly lower breast cancer mortality with 30 deaths (annualized mortality rate, 0.031%) vs 46 deaths (annualized mortality rate, 0.046%; HR, 0.60; 95% CI, 0.37-0.97; P = .04). In contrast, CEE plus MPA compared with placebo among 16 608 women with a uterus was associated with statistically significantly higher breast cancer incidence with 584 cases (annualized rate, 0.45%) vs 447 cases (annualized rate, 0.36%; HR, 1.28; 95% CI, 1.13-1.45; P < .001) and no significant difference in breast cancer mortality with 71 deaths (annualized mortality rate, 0.045%) vs 53 deaths (annualized mortality rate, 0.035%; HR, 1.35; 95% CI, 0.94-1.95; P= .11).

CONCLUSIONS AND RELEVANCE

In this long-term follow-up study of 2 randomized trials, prior randomized use of CEE alone, compared with placebo, among women who had a previous hysterectomy, was significantly associated with lower breast cancer incidence and lower breast cancer mortality, whereas prior randomized use of CEE plus MPA, compared with placebo, among women who had an intact uterus, was significantly associated with a higher breast cancer incidence but no significant difference in breast cancer mortality.

Comparison of Mortality Among Participants of Women's Health Initiative Trials With Screening-Detected Breast Cancers vs Interval Breast Cancers

IMPORTANCE

Interval breast cancers (IBCs) are cancers that emerge after a mammogram with negative results but before the patient's next scheduled screening. Interval breast cancer has a worse prognosis than cancers detected by screening; however, it is unknown whether the length of the interscreening period is associated with prognostic features and mortality.

OBJECTIVE

To compare the prognostic features and mortality rate of women with IBCs diagnosed within 1 year or between 1 and 2.5 years of a mammogram with negative results with the prognostic features and mortality rate of women with breast cancers detected by screening.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used mammography data, tumor characteristics, and patient demographic data from the Women's Health Initiative study, which recruited participants from 1993 to 1998 and followed up with participants for a median of 19 years. The present study sample for these analyses included women aged 50 to 79 years who participated in the Women's Health Initiative study and includes data collected through March 31, 2018. There were 5455 incidents of breast cancer; only 3019 women compliant with screening were retained in analyses. Statistical analysis was performed from October 25, 2018, to November 24, 2019. Breast cancers detected by screening and IBCs were defined based on mammogram history, date of last mammogram, type of visit, and results of examination. Interval breast cancers were subdivided into those occurring within 1 year or between 1 and 2.5 years after the last protocol-mandated mammogram with negative results.

MAIN OUTCOMES AND MEASURES

The primary outcome of this study was breast cancer-specific mortality for each case of breast cancer detected by screening and IBCs detected within 1 year or between 1 and 2.5 years from a mammogram with negative results. Secondary outcomes included prognostic and tumor characteristics for each group. Comparisons between groups were made using the t test, the χ2 test, and Fine-Gray multivariable cumulative incidence regression analyses.

RESULTS

Among the 3019 participants in this analysis, all were women with a mean (SD) age of 63.1 (6.8) years at enrollment and 68.5 (7.1) years at diagnosis. A total of 1050 cases of IBC were identified, with 324 (30.9%) diagnosed within 1 year from a mammogram with negative results and 726 (69.1%) diagnosed between 1 and 2.5 years after last mammogram with negative results. The remaining 1969 cases were breast cancers detected by screening. Interval breast cancers diagnosed within 1 year from a mammogram with negative results had significantly more lobular histologic characteristics (13.0% vs. 8.1%), a larger tumor size (1.97 cm vs 1.43 cm), a higher clinical stage (28.4% vs 17.3% regional and 3.7% vs 0.6% distant), and more lymph node involvement (27.1% vs 17.0%) than cancers detected by screening. Unadjusted breast cancer-specific mortality hazard ratios were significantly higher for IBCs diagnosed within 1 year from a mammogram with negative results compared with breast cancers detected by screening (hazard ratio, 1.92; 95% CI, 1.39-2.65). Higher breast cancer-specific mortality remained statistically significant for IBCs diagnosed within 1 year after adjusting for trial group, molecular subtype, waist to hip ratio, histologic characteristics, and either tumor size (hazard ratio, 1.46; 95% CI, 1.03-2.08) or lymph node involvement (hazard ratio, 1.44; 95% CI, 1.03-2.01). However, significance was lost when tumor size and lymph node involvement were both included in the model (hazard ratio, 1.34; 95% CI, 0.96-1.88). Interval breast cancers diagnosed between 1 and 2.5 years from a mammogram with negative results were not different from breast cancers detected by screening based on prognostic factors or mortality.

CONCLUSIONS AND RELEVANCE

Women with IBCs diagnosed within 1 year of negative mammogram results overall were associated with worse survival than women with breast cancers detected by screening. These differences in survival may be due to a uniquely aggressive biology among IBC cases.

Abstract C042: Family history of cancer among African Americans with breast, prostate, lung, and colorectal cancers in the Detroit Research on Cancer Survivors cohort

Individuals with familial cancers are at increased risk of second primary cancers, and there are clear clinical guidelines for treatment and follow-up. However, the literature on the patterns of cancer family history (FH) in African Americans (AAs) is sparse. Detroit Research on Cancer Survivors (ROCS) is a population-based cohort study of AAs residing in metropolitan Detroit diagnosed with a primary invasive cancer of the breast, colon/rectum, lung or prostate after January 1, 2013. ROCS participants complete baseline and yearly follow-up questionnaires that include assessment of participants’ family history of cancer. We examined the distribution of breast, prostate, colorectal, lung, kidney, liver, ovarian, pancreatic cancers among first degree relatives and grandparents of Detroit ROCS participants (i.e, probands). We also estimated the distribution of cancers involved in known hereditary cancer syndromes (hereditary breast and ovarian cancer (HBOC), Lynch, Peutz-Jeghers, Cowden, Li-Fraumeni) within these families. Associations between probands’ age of onset and cancer family history were evaluated using logistic regression. Among the first 1,500 ROCS participants recruited into the cohort (674 breast, 138 colorectal, 174 lung, 514 prostate), 71% reported at least one relative with a cancer of any type, which did not vary substantially by proband cancer site. FH of breast (p&lt;0.001), colorectal (p=0.010), lung (p=0.022), prostate (p&lt;0.001), and ovarian (p=0.044) cancers significantly varied by proband cancer site, where probands were most likely to report a FH of their index cancer site (breast: 30%, colorectal: 17%, lung: 25%, prostate: 28%). When restricted to older family members (parents + grandparents), a FH of cancer matching the probands’ cancer site increased the odds of being diagnosed under the age of 50 (Breast: Odds ratio (OR)=1.73, 95% confidence interval (CI) 1.01-2.96; colorectal: OR=3.71, 95% CI 0.71-19.41; prostate: OR=1.86, 95% CI 0.91-3.79). FH of HBOC cancers was most common among probands with breast (47%) and prostate (43%) cancer compared to other sites (28-34%, p&lt;0.001), while FH of Li-Fraumeni cancers was most common among probands with breast cancers (31% vs. 17-22%, p&lt;0.001). Probands with breast and colorectal cancers were more likely to report FH of Cowden cancers (36-38% vs. 24-25%, p&lt;0.001). FH of Lynch and Peutz-Jeghers cancers were less commonly reported among probands with lung (23% vs. 32-38%, p=0.004) and prostate (39% vs. 48-53%, p&lt;0.001) cancers, respectively. AAs with breast, prostate, lung, and colorectal cancers frequently report FH of cancer, and patterns of FH differ by index cancer site. A better understanding of cancer family history among AAs could provide insights into cancer etiology in this population.

Citation Format: Kristen S Purrington, Julie J Ruterbusch, Mark Manning, Michael S Simon, Jennifer Beebe-Dimmer, Ann G Schwartz. Family history of cancer among African Americans with breast, prostate, lung, and colorectal cancers in the Detroit Research on Cancer Survivors cohort [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 C042.

Lipid levels and survival after obesity-related cancer in the Women’s Health Initiative CVD biomarker cohort

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Background: Previous investigations have demonstrated an inconclusive relationship between lipid biomarkers and mortality after cancer. Methods: We used data from 2,279 postmenopausal women diagnosed with 13 obesity-related cancers, who were part of the Women’s Health Initiative (WHI) lipid biomarkers cohort, to evaluate the relationship between lipid levels measured at study entry prior to cancer diagnosis, and mortality after cancer. Baseline lipid measurements consisted of HDL-Cholesterol, LDL-Cholesterol, and non-HDL-Cholesterol with ranges of measurement listed in the table. Obesity-related cancers included: meningioma, thyroid, adenocarcinoma of esophagus, breast, multiple myeloma, liver, kidney, gallbladder, stomach, uterus, pancreas, ovaries, and colorectal. The age adjusted relationship between baseline lipids and all-cause mortality as well as mortality due to cancer were estimated using Cox proportional hazards models and Fine-Gray models, respectively. Results: The majority of women in the cohort had either desirable or acceptable lipid levels (86% HDL-C, 30% LDL-C and 61% non-HDL-C. Low vs. desirable HDL-C levels were associated with higher risk of all-cause mortality (hazard ratio (HR) 1.54, 95% confidence interval [CI] [1.48, 1.60], p <.001) and higher cancer mortality (sub-distribution hazard ratio (SHR)1.9, 95% CI [1.51, 2.3], p <.001). High non-HDL-C vs desirable, was associated with higher all-cause mortality (HR 1.13, 95% CI [1.06, 1.21], p = .001) however no significant impact on cancer mortality (SHR 1.06, 95% CI [0.87, 1.30], p = 0.563). LDL-C levels demonstrated a more complex relationship with mortality, nevertheless, very high LDL-C levels were associated with higher risk of all-cause mortality (HR 1.63, 95% CI,1.21-2.2, p = ,0.001) and cancer-specific mortality (HR 1.78, 95% CI 1.22-2.63, p = 0.003). Conclusions: Elevated LDL-C and lower HDL-C may be associated with a lower risk of all-cause and cancer specific mortality in women diagnosed with obesity related cancers in the WHI. Results of multivariable adjustment for important predictors of mortality including race/ethnicity, medication use and other socio-demographic and clinical factors will be presented. [Table: see text]

Family cancer patterns and variation by race and ethnicity among individuals with pathogenic variants in multi-gene cancer predisposition panels at a large urban comprehensive cancer center

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Background: The identification of pathogenic variants and variants of unknown significance (VUS) in multi-gene cancer predisposition testing raises new questions regarding cancer risk and management. We evaluated the personal and family cancer patterns and variation by race and ethnicity, among individuals positive for pathogenic variants in non-BRCA1/ 2 cancer predisposing genes. Methods: The Karmanos Cancer Institute (KCI) Cancer Genetics database was queried from May 13, 2013 through December 31, 2018. There were 3,544 unrelated individuals evaluated for hereditary cancer predisposition of whom 1,868 had 18-gene panel testing at 6 sites across Michigan. Data was collected on personal and family cancer history including ages at diagnosis utilizing a 3-generation pedigree, self-identified race and ethnicity and results of genetic testing. We describe the prevalence of pathogenic variants by proband cancer diagnosis, family history, race, and ethnicity. Results: The race/ethnic distribution of the tested cohort included 67.5% non-Hispanic White (NHW), 24.4% African American (AA), 2.1% Arab, 1.8% Ashkenazi Jewish (AJ), 1.0% Hispanic, and 3.4% other. The distribution of cancer diagnoses included 40.6% breast, 5.5% ovarian, 4.1% colon, 3.5% endometrial, 2.0% pancreas and 39.7% unaffected. Pathogenic variants were seen in 151 (8.1%) individuals and VUS in 309 (16.5%). The five most common pathogenic variants were CHEK2 (40), MUTYH (22), ATM (20), and PALB2 (18). The most common pathogenic variants by race and ethnicity were CHEK2 (NHW), RAD51C (AA), PALB2 (Arab), CHEK2, MSH6 (AJ), and none in Hispanics. Variants associated with the four most common cancer types were breast ( CHEK2 ), ovarian ( CHEK2, MUTYH, BRIP1), colon ( ATM), and endometrial ( MSH6, PALB2). Of 40 individuals with CHEK2 variants, 92.5% were NHW, and 34 (85%), 31 (78%), 10 (25%), 1 (2.5%) had family history of breast cancer, breast cancer before age 50, ovarian, and colon cancer, respectively. Of 20 with ATM variants, 95% were NHW, 13 had family history data and 10 (76.9%), 8 (61.5%), 2 (15.4%), 1 (7.7%) had family history of breast, breast cancer before age 50, ovarian, and colon cancer, respectively. Conclusions: Pathogenic variants seen using multigene panel testing differ by race, ethnicity and personal/family history of cancer. This data will inform genetic counseling strategies in regards to cancer risk and management. Data on additional genes updated through 2019 will be presented.

The impact of high intensity interval training on functional performance, body composition and quality of life in a diverse group of cancer survivors

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Background: Given the well-documented benefits of regular exercise to cancer survivors, in 2012, an expert panel assembled by the American Cancer Society recommended that patients engage in at least 150 minutes per week of moderate-to-vigorous physical activity. However, few patients meet this goal. We have also observed racial differences in reported participation in regular exercise among cancer survivors living in Metropolitan Detroit, Michigan. Methods: The CAPABLE study is a 12- week pilot exercise intervention that introduces cancer survivors to the sport of CrossFit. We evaluated the impact of this unique, high-intensity interval training method on functional performance, cardiovascular endurance, body composition and health-related quality of life (HRQOL) as measured by the Functional Assessment of Cancer Therapy (FACT) instrument. All measures were summarized at baseline and program exit. Paired signed rank tests were used to assess change in each of these measures over time. Results: Of the 48 participants enrolled in the pilot, 37 (77%) were considered adherent to the program (attending at least 75% of sessions over the 12-week period). The mean age of participants was 58.5 years, 73% identified as African American and the majority of participants were breast cancer survivors (N = 20). The mean body mass index (BMI) at baseline was 32.8 kg/m2 decreasing to a mean of 31.7 kg/m2 at exit (BMI change -1.1, p < 0.001). Similar changes were observed in % body fat measured by bioelectrical impedance. There were significant improvements in all measures of functional performance over 12-weeks (all p < 0.001). We observed significant and meaningful improvements in reported HRQOL measured by the FACT survey, overall (FACTG total change +9.5 (p < 0.001)) and in each one of the individual domains (physical, social, emotional, and functional well-being). Conclusions: We observed significant improvements in performance, body composition and quality of life among cancer survivors introduced to a high-intensity interval training program. Understanding and eliminating barriers to programs like these are critical to improving outcomes and reducing cancer health disparities. Clinical trial information: NCT03750981 .

Peripheral neuropathy after breast cancer: An analysis of data from the Women’s Health Initiative Life and Longevity After Cancer cohort

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Background: There are over 3.8 million breast cancer survivors in the United States, and many experience long-term side effects from chemotherapy. Factors associated with peripheral neuropathy (PN), one troubling side effect, following breast cancer among women are unknown. Methods: We included 2,420 women enrolled in the Women’s Health Initiative and diagnosed prospectively with local or regional stage breast cancer and followed in the Life and Longevity After Cancer (LILAC) study. PN was assessed by response to the baseline LILAC questionnaire regarding the presence of “nerve problems, tingling sensations” after treatment. Data were collected on initial course of therapy (surgery, radiation, and chemotherapy) through Medicare linkage or the LILAC staging and treatment form. Chi-square and Wilcoxon rank-sum tests were used for univariate comparison of socio-demographics, clinical and diagnosis characteristics associated with the presence or absence of PN. Results: The sample included 1,913 women (79%) with local and 507 women (21%) with regional stage disease. Initial course of therapy included either surgery alone (21%), surgery and radiation (53%), or surgery and chemotherapy (+/- radiation) (26%). Seventeen percent of women reported experiencing PN days (30%), months (46%) or years (24%) following treatment. Three-quarters (74%) reported ongoing symptoms at the time of the LILAC survey. PN was reported by 33% of chemotherapy recipients, compared to 12% in the surgery alone group, and 11% in the group that received surgery and radiation (p<0.0001). The prevalence of PN was higher among women receiving regimens containing paclitaxel (52%) and docetaxel (39%), compared to those receiving other chemotherapy (17%) (p<0.0001). Conclusions: PN is an important complication of taxane-based chemotherapy. Further analysis will explore the relationship between socio-demographic, clinical and treatment on the development, timing of, and severity of PN after cancer directed therapy.

Racial differences in estrogen receptor staining levels and implications for treatment and survival among estrogen receptor positive, HER2-negative invasive breast cancers

BACKGROUND

African American women (AAW) die more frequently from estrogen receptor (ER) positive breast cancer than European American women (EAW). We investigated the relationship between race, percent ER staining, treatment, and clinical outcomes.

METHODS

Percent ER staining (weakly ER+: 1-10%, moderately ER+: 11-50%, strongly ER+: > 50%) was abstracted from pathology reports for 1573 women with ER+/HER2- invasive breast cancer treated at a single cancer center in Detroit, MI from 2010 to 2017. Clinical outcomes and tumor characteristics were obtained from the Metropolitan Detroit Cancer Surveillance System. Associations of ER levels with demographic and clinical characteristics were evaluated using logistic regression. Overall and breast cancer-specific (BCS) survival were evaluated using Cox proportional hazards models.

RESULTS

AAW were more likely to have tumors with lower ER staining levels than EAW (weakly ER+: Odds ratio (OR) 2.19, p = 0.019; moderately ER+: OR 2.80, p = 0.005). Women with weakly compared to strongly ER+ tumors were less likely to receive endocrine therapy (ET) regardless of race (OR 0.79, p < 0.001). Mortality was predicted by both AA race (Overall hazard ratio (HR) = 1.72, p < 0.001; BCS HR 1.45, p = 0.08) and low (1-50%) ER (Overall HR 1.57, p = 0.083; BCS HR 2.11, p = 0.017) adjusting for clinic-pathologic characteristics. ET was associated with improved BCS survival in all women (1-50%: HR 0.11, p < 0.001; > 50%: HR 0.24, p < 0.001).

CONCLUSION

The biology of ER+/HER2- tumors varies by race, although this does not appear to account for racial differences in survival. Although ET substantially reduces mortality among women with weakly ER+ tumors, these women are less likely to be treated with ET and have poorer outcomes.

Physical activity and quality of life in African American cancer survivors: The Detroit Research on Cancer Survivors study

BACKGROUND

The benefit of regular exercise in improving cancer outcomes is well established. The American Cancer Society (ACS) released a recommendation that cancer survivors should engage in at least 150 minutes of moderate to vigorous physical activity (PA) per week; however, few report meeting this recommendation. This study examined the patterns and correlates of meeting ACS PA recommendations in the Detroit Research on Cancer Survivors (ROCS) cohort of African American cancer survivors.

METHODS

Detroit ROCS participants completed baseline and yearly follow-up surveys to update their health and health behaviors, including PA. This study examined participation in PA by select characteristics and reported health-related quality of life (HRQOL) as measured with the Functional Assessment of Cancer Therapy and Patient-Reported Outcomes Measurement Information System instruments.

RESULTS

Among the first 1500 ROCS participants, 60% reported participating in regular PA, with 24% reporting ≥150 min/wk. Although there were no differences by sex, prostate cancer survivors were the most likely to report participating in regular PA, whereas lung cancer survivors were the least likely (P = .022). Survivors who reported participating in regular PA reported higher HRQOL (P < .001) and lower depression (P = .040).

CONCLUSIONS

Just 24% of African American cancer survivors reported meeting the ACS guidelines for PA at the baseline, but it was encouraging to see increases in activity over time. Because of the established benefits of regular exercise observed in this study and others, identifying and reducing barriers to regular PA among African American cancer survivors are critical for improving outcomes and minimizing disparities.

Abstract GS5-00: Long-term influence of estrogen plus progestin and estrogen alone use on breast cancer incidence: The Women's Health Initiative randomized trials

Background: Breast cancer outcomes from the Women’s Health Initiative (WHI) Estrogen plus Progestin and Estrogen-alone trials have been reported but issues remain regarding long- term, post-intervention influence on breast cancer incidence and the influence of time from menopause to hormone therapy initiation (gap time) on breast cancer findings.

Design and methods: Postmenopausal women aged 50 to 79 years with no prior breast cancer and with mammogram clearance enrolled in one of two randomized clinical trials at 40 US centers from 1993 to1998, with follow up through September, 2016. The randomized, placebo-controlled trial interventions were: conjugated equine estrogens (CEE, 0.625 mg/d) plus medroxyprogesterone acetate (MPA, 2.5 mg/d) (n = 8,506) vs placebo (n = 8,102) for 5.6 years (median) for women with a uterus or CEE-alone (n = 5,310) vs placebo (n = 5,429) for 7.2 years (median) for women with prior hysterectomy. Annual mammography was mandated through the originally specified completion date in both trials (March 31, 2005). Incident breast cancers were verified by medical record review. Hazard ratios (HRs) were estimated using multi-variable Cox proportional hazards models. The primary outcome for these analyses was time-specific invasive breast cancer incidence rates. In each trial, participants were instructed to stop all study pills coincident with the publication of each trial’s results, in 2002 and 2004, respectively.

Results: During the intervention period, with 238 incident breast cancers, CEE-alone significantly reduced breast cancer incidence (hazard ratio [HR] 0.76 95% confidence interval [CI] 0.58, 0.98, P = 0.04). As previously reported, subgroup analyses indicated CEE-alone was particularly beneficial for women with no prior HT use (interaction P = 0.04) and women with gap time &gt;= 5 years (interaction P = 0.01). Post-intervention, through 16.1 years of cumulative follow-up, with 520 incident breast cancers, CEE-alone use continued to significantly reduce breast cancer incidence (HR 0.77 95% CI

0.65-0.92, P = 0.005) while subgroup differences were attenuated and were no longer statistically significant. During the intervention period, with 360 incident breast cancers, CEE plus MPA use significantly increased breast cancer incidence (HR 1.26 95% CI 1.02, 1.56, P = 0.04) with increase in breast cancer incidence greater in women with prior HT use (interaction P = 0.02) and women with gap time &lt; 5 years (interaction P = 0.002). Post-intervention, through 18.3 years cumulative follow-up, with 1,003 incident breast cancers, CEE plus MPA continued to significantly increase breast cancer incidence (HR 1.29 95% CI 1.14, 1.47, P &lt; 0.001) while subgroup differences were attenuated and were no longer statistically significant.

Conclusions: CEE-alone and CEE plus MPA use have opposite effects on breast cancer incidence. CEE alone significantly decreases breast cancer incidence which is long term and persists over a decade after discontinuing use. CEE plus MPA use significantly increases breast cancer incidence which is long term and persists over a decade after discontinuing use. As a result of the attenuation of subgroup interactions: all postmenopausal women with prior hysterectomy using CEE-alone have the potential benefit of experiencing a reduction in breast cancer incidence while all postmenopausal women using CEE plus MPA have the potential risk of experiencing an increase in breast cancer incidence.

Citation Format: Rowan T Chlebowski, Garnet L Anderson, Aaron K Aragaki, JoAnn E Manson, Marcia Stefanick, Kathy Pan, Wendy Barrington, Lewis H Kuller, Michael S. Simon, Dorothy Lane, Karen C Johnson, Thomas E. Rohan, Margery L.S. Gass, Jane A Cauley, Electra D. Paskett, Maryam Sattari, Ross L Prentice. Long-term influence of estrogen plus progestin and estrogen alone use on breast cancer incidence: The Women's Health Initiative randomized trials [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr GS5-00.

The association of delay in curative intent treatment with survival among breast cancer patients: findings from the Women's Health Initiative

PURPOSE

Delays in adjuvant breast cancer (BC) therapy have been shown to worsen outcomes. However, thus far studies have only evaluated delays to initial treatment, or a particular modality, such as chemotherapy, leaving uncertainty about the role of delay to subsequent therapy and the effects of cumulative delay, on outcomes. We investigated the associations of delays across treatment modalities with survival.

METHODS

We included 3368 women with incident stage I-III BC in the Women's Health Initiative (WHI) enrolled in fee-for-service Medicare who underwent definitive surgery. This prospective analysis characterized treatment delays by linking WHI study records to Medicare claims. Delays were defined as > 8 weeks to surgery, chemotherapy, and radiation from diagnosis or prior treatment. We used Cox proportional hazards models to estimate BC-specific mortality (BCSM) and all-cause mortality (ACM) in relation to treatment delays.

RESULTS

We found 21.8% of women experienced delay to at least one therapy modality. In adjusted analysis, delay to chemotherapy was associated with a higher risk of BCSM (HR = 1.71; 95% CI 1.07-2.75) and ACM (HR = 1.39; 95% CI 1.02-1.90); delay in radiation increased BCSM risk (HR = 1.49; 95% CI 1.00-2.21) but not ACM risk (HR = 1.19; 95% CI 0.99-1.42). Delays across multiple treatment modalities increased BCSM risk threefold (95% CI 1.51-6.12) and ACM risk 2.3-fold (95% CI 1.50-3.50).

CONCLUSIONS

A delay to a single treatment modality and delay to a greater extent an accumulation of delays were associated with higher BCSM and ACM after BC. Timely care throughout the continuum of breast cancer treatment is important for optimal outcomes.

Abstract P2-10-04: Racial differences in estrogen receptor expression, treatment, and survival among estrogen receptor positive, HER2-negative invasive breast cancers

Background: African American women (AAW) are more likely to die from hormone receptor positive, HER2-negative breast cancer than European American women (EAW), even when accounting for factors including tumor stage and other clinical characteristics, although the mechanisms underlying this disparity are unclear. We recently showed that AAW with this breast cancer subtype are 75% more likely to have high predicted risk of distant recurrence than EAW using a 21-gene recurrence score, providing evidence for underlying racial differences in tumor biology. Estrogen receptor (ER) positive tumors can vary widely in the percentage of cells staining positive for ER (1-100%), and tumors with lower percent ER staining are more likely to display basal-like features typically associated with triple negative disease, a subtype that is more common among AAW. The relationship between race, ER staining levels, and clinical treatment and outcomes remains unknown. Methods: We identified 1,625 women with ER+, HER2- invasive breast cancer who received treatment at the Karmanos Cancer Institute in Detroit, MI from 2010-2017 via the Metropolitan Detroit Cancer Surveillance System (MDCSS) registry. Percentage of cells staining positive for ER (weakly ER+ = 1-10%, moderately ER+ = 11-50%, strongly ER+ = &gt;50%) was abstracted from pathology reports. Clinical outcomes and tumor characteristics were linked via the MDCSS registry. Associations between ER levels and demographic/clinical characteristics were evaluated using logistic regression models and breast cancer-specific survival was evaluated using Cox proportional hazards models. Results: Weakly, moderately, and strongly ER+ tumors accounted for 3.2%, 2.7%, and 94.1% of the sample, respectively. AAW were more than twice as likely to have weakly ER+ tumors (Odds ratio (OR)=2.39, 95% confidence interval (CI) 1.28-4.49, p=6.4 × 10−3) and moderately ER+ tumors (OR=2.79, 95% CI 1.40-5.58, p=3.7 × 10−3) than EAW. AAW with weakly ER+ tumors were 4-fold more likely to be node positive than EAW (OR=4.35, p=0.045) and AAW with moderately ER+ tumors were 3-fold more likely to be node positive than EAW (OR=3.01, p=0.28). Adjustment for tumor size at surgery did not affect the relationship between race and node status. In a multivariable logistic model predicting whether a women received endocrine therapy, women with weakly ER+ tumors were 20% less likely to receive endocrine therapy compared to those with strongly ER+ tumors (OR=0.77, p=9.4 × 10−8), and lymph node positive tumors were 15% less likely to receive endocrine therapy (OR=0.85, p=7.2 × 10−11). In contrast, receiving chemotherapy and having later stage tumors were each associated with a 10% increase in receiving endocrine therapy (chemo: OR=1.08, p=1.9 × 10−5; stage: OR=1.13. p=6.1 × 10−5). In a multivariable Cox regression analysis, race (Hazard ratio (HR)=1.70, 95% CI 1.15-2.51, p=0.0074), ER staining levels (1-10%: HR=2.72, p=0.0029; 11-50%: HR+2.41, p=0.062), node positivity (HR=3.36, p=0.0017), distant stage (HR=18.6, p=6.0 × 10−14), and endocrine therapy (HR=0.26, p=4.1 × 10−9) were significantly associated with breast cancer specific survival. While not statistically significant, the effects of both race (HR=3.94, 95% CI 0.62-25.2, p=0.15) and endocrine therapy (HR=0.11, 95% CI 0.01-1.06, p=0.056) were strongest among the weakly HR+ tumor group. Conclusions: The biology of ER+, HER2- tumors varies by race, and AAW are more likely to have weakly ER+, node-positive tumors- which are less likely to be treated with beneficial endocrine therapy- and predict poorer outcomes. A better understanding of the role of hormone signaling in these tumors would substantially affect racial differences in survival among with ER+/HER2- tumors.

Citation Format: Kristen S. Purrington, David Gorski, Michael S. Simon, Seongho Kim, Rayna Rosati, Ann Schwartz, Manohar Ratnam. Racial differences in estrogen receptor expression, treatment, and survival among estrogen receptor positive, HER2-negative invasive breast cancers [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-10-04.

COPD and lung cancer incidence in the Women's Health Initiative Observational Study: A brief report

OBJECTIVES

Lung cancer is the leading cause of cancer mortality in both men and women in the United States. COPD is associated with lung cancer independently of cigarette smoking, but remains understudied in women. Utilizing data from the Women's Health Initiative Observational Study (WHI-OS), this report investigates the association between COPD and development of lung cancer, with a focus on ethnicity and cancer subtype.

MATERIALS AND METHODS

The WHI-OS, part of the larger Women's Health Initiative (WHI), is comprised of postmenopausal women between ages 50 and 79 years old at enrollment. Self-administered questionnaires were utilized to gather baseline demographic, socioeconomic, and behavioral information from participants. For this analysis, COPD status was determined at study entry (baseline) and on annual survey (incident). Information on the primary outcome of interest, diagnosis of lung cancer, was also collected annually.

RESULTS AND CONCLUSION

Of the 92,789 women examined, 1,536 developed lung cancer. Overall, women with COPD were 1.64 times more likely to develop lung cancer than those without COPD, after adjusting for smoking status and intensity, ethnicity, education, body mass index, and income (HR = 1.64, 95 % CI: 1.43, 1.89). The relationship between COPD and lung cancer was not found to be significantly different between ethnic groups (p-value = 0.697). The associations between COPD and lung cancer was similar across subtypes (HR range 1.31-2.16), after adjusting for smoking status and intensity. COPD increases risk of lung cancer in women, thus they may benefit from more intensive surveillance compared to similar women without COPD.

The association between statins and colorectal cancer stage in the Women's Health Initiative

The anticarcinogenic effect of statins may reduce the metastatic potential of cancer cells leading to ‘stage migration’, with users more likely diagnosed with early rather than late stage cancer. The association between prior statin use and colorectal cancer (CRC) stage at diagnosis in the Women's Health Initiative (WHI) was investigated. The study population included 132,322 post-menopausal women, among which there were 2,628 pathologically confirmed cases of in situ (3.3%), localized (43.6%), regional (40.4%) and distant (12.7%) stage CRC, after an average of 13.9 (SD=4.7) years of follow-up. To reduce the possibility of detection bias among women more likely to be prescribed statins, women who did not report a mammogram within 5 years of study entry and who had no health insurance or medical care provider (n=28,237) were excluded from the study. Stage was coded using SEER criteria into early (in situ and local) vs. late (regional and distant) stage disease. Hazards ratios (HR) and 95% confidence intervals (CIs) evaluating the association between statin use and diagnosis of late-stage CRC both at baseline and in a time-dependent manner were computed from multivariable-adjusted Cox proportional hazards analyses. In the multivariable time-dependent analysis, there was a lower hazard of late stage CRC among users of lipophilic statins compared with non-users (HR=0.80, 95% CI 0.66-0.98, P=0.029) and a marginally lower hazard of late stage CRC among users of lipophilic vs. hydrophilic statins (HR=0.70, 95% CI 0.49-1.01, P=0.058). The use of lipophilic statins was associated with a reduction in the proportion of CRC cases that were late stage at the time of diagnosis.

Pre-diagnosis alcohol consumption and mortality risk among black women and white women with invasive breast cancer

Background

Alcohol consumption is associated with increased risk of breast cancer; however, its association with subsequent risk of breast cancer death is unclear.

Methods

We followed 4523 women with complete information on relevant risk factors for mortality; these women were 35 to 64 years of age when diagnosed with incident invasive breast cancer between 1994 and 1998. During follow up (median, 8.6 years), 1055 women died; 824 died from breast cancer. The information on alcohol consumption before diagnosis was collected shortly after breast cancer diagnosis (average: 5.1 months) during an in-person interview which used a structured questionnaire. Multivariable Cox proportional hazards regression models provided hazard ratios (HRs) and 95% confidence intervals (CIs) for breast cancer-specific mortality, mortality due to causes other than breast cancer, and all-cause mortality associated with alcohol consumption from age 15 years until breast cancer diagnosis and during recent periods of time prior to breast cancer diagnosis.

Results

Average weekly alcohol consumption from age 15 years until breast cancer diagnosis was inversely associated with breast cancer-specific mortality (P_trend = 0.01). Compared to non-drinkers, women in the highest average weekly alcohol consumption category (≥7 drinks/week) had 25% lower risk of breast cancer-specific mortality (HR = 0.75, 95% CI = 0.56–1.00). Breast cancer mortality risk was also reduced among women in the highest average weekly alcohol consumption category in two recent time periods (5-year period ending 2-years prior to breast cancer diagnosis, HR = 0.74, 95% CI = 0.57–0.95; 2-year period immediately prior to breast cancer diagnosis: HR = 0.73, 95% CI = 0.56–0.95). Furthermore, analyses of average weekly alcohol consumption by beverage type from age 15 years until breast cancer diagnosis suggested that wine consumption was inversely associated with breast cancer-specific mortality risk (wine P_trend = 0.06, beer P_trend = 0.24, liquor P_trend = 0.74). No association with any of these alcohol consumption variables was observed for mortality risk due to causes other than breast cancer.

Conclusions

Overall, we found no evidence that alcohol consumption before breast cancer diagnosis increases subsequent risk of death from breast cancer.

Phase II clinical trial using anti-CD3 x anti-HER2 bispecific antibody armed activated T cells (HER2 BATs) for HER2-negative (0-2+) metastatic breast cancer

1080

Background: This study presents a phase II cell therapy trial in 32 women with metastatic or locally advanced HER2- breast cancer (BrCa) who received infusions of anti-CD3 x anti-HER2 bispecific antibody armed activated T cells (BATs). This phase II study (NCT 01022138) was conducted to determine if BATs infusions could improve time to progression (TTP) and overall survival (OS), as well as to confirm the toxicity profile of BATs. Methods: The phase II included 32 patients with a median of 4 lines of therapy (7 TNBC and 25 HR/PR+ HER2- patients) with an average age of 52.5 years (range 28-75 years). Twenty-one patients had ≥3 lines of prior therapy and 11 patients had 1-2 lines. Peripheral blood mononuclear cells (PBMC) were stimulated with anti-CD3 antibody and expanded in IL-2, armed with HER2Bi, and aliquoted for the clinical trial. Patients received oncologist’s choice of chemotherapy (4 cycles/4 months) followed by 3 infusions of BATs given once per week for 3 weeks and a boost given 12 weeks after the 3rd infusion. Results: Fifteen of 32 (ORR of 46.8%) who had received any cells had stable disease (SD) at 1 month after the last infusion, and 8 of 15 (25%) had SD > 4 months. For patients who completed 3 or 4 infusions (17-83 x 109 BATs), 8 of 31 patients had TTP > 4 months. One patient completed 2 infusions (17 x 109 BATs). There were no dose limiting toxicities (DLTs). Tumor markers decreased in 13 of 23 (56.5%) patients with evaluable markers. The median OS was 13.8, 16.5, and 12.4 months for all, ER/PR+, and TNBC, respectively. OS for all patients with chemosensitive (chemoS) and chemoresistant (chemoR) disease was 14.6 and 8.6 months (NS), respectively. OS for chemoS and chemoR disease in HER2- ER/PR+ patients was 16.5 and 8.6 months (NS), respectively. OS for chemoS and chemoR disease in TNBC patients was 12.4 and 22.6 months, respectively (NS). The median TTP for all, HER2- ER/PR+, and TNBC patients was 2.7, 2.9, and 1.4 months, respectively. Increases in serum IL-2 and IL-12 were associated with BATs infusions. Conclusions: Targeting HER2- tumors was safe. There were trends toward improved survival in patients who were HER2-/ER/PR+ TNBC, patients who were chemoS, was associated with increased TTP and OS in all groups, and was associated with decreased tumor markers in those who received 4 infusions. Immune studies showed evidence for induction of adaptive immunity directed at breast cancer antigens. Targeting metastatic HER2- BrCa with BATs shows promise. Clinical trial information: NCT 01022138.