Abstract P3-08-05: The use of chemoprevention increases significantly with oncology trained providers and with application of a risk assessment model

BACKGROUND

Large clinical trials have proven the efficacy of selective estrogen receptor modulators in reducing the risk of breast cancer in high risk women. However, despite these studies the use of chemoprevention in high risk women remains low. The goal of this study was to determine in a clearly identified high risk population, the utilization rate of chemoprevention and factors that affect its use, notably, surgeon training and the Gail model.

METHODS

This was a retrospective chart review of all women diagnosed with Atypical Ductal Hyperplasia (ADH) at our institution from 2008 to 2013. We examined the use of chemoprevention and screening recommendations after diagnosis. Other factors evaluated included family history, Gail model, surgeon specialty and menopausal status.

RESULTS

Ninety-four women with ADH were treated at our facility in the study time frame. The overall use of chemoprevention in our study population was 41.5%. Of those who were not on chemoprevention, 56.4 % were offered chemoprevention and declined. In addition, after the diagnosis of ADH, annual mammography was recommended for 75% of women. However, this was preferentially seen in women on chemoprevention (95% vs. 65%). Menopausal status and use of the Gail model were statistically significant in predicting annual screening after a diagnosis of ADH. The Gail score was calculated preferentially in women who chose chemoprevention. Prior breast biopsy, family history of cancer, first degree relative with cancer, age and menopausal status were not found to be statistically significant in the use of chemoprevention. Oncology training and use of the Gail model were found to be statistically significant in chemoprevention use.

CONCLUSION

The use of chemoprevention in high risk women is significantly improved with oncology training and the use of the Gail model. Concern regarding side effects continues to result in low utilization of selective estrogen receptor modulators. Education regarding newer agents for chemoprevention with minimal side effects may result in increased utilization of chemoprevention.

Table 1: Patient CharacteristicsFactorsChemoprevention n (%)No Chemoprevention n (%)p valueMedian age (range)58 (37-78)52 (30-77)0.07Race  0.790Caucasian18 (46.1 %)33 (60.0 %) Asian/PCI6 (15.4 %)5 (9.1 %) African American2 (5.1 %)2 (3.6 %) Hispanic2 (5.1 %)1 (1.8 %) Family history10 (25.6 %)18 (32.7 %)0.358First degree26 (66.7 %)32 (58.1 %)1.000Gail score calculated29 (74.3 %)20 (36.3 %)<0.001Gail score median (range)3.4 % (0.8-17.7)2.7% (0.2-8.6)0.169Menopausal status17 (43.6 %)19 (34.5 %)0.796Specialty provider37 (94.9 %)38 (69.1 %)0.002Prior breast biopsy13 (33.3 %)16 (29.1 %)0.438

The views expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.

Citation Format: Oseni T, Perkins S, Deutsch E, Soballe P. The use of chemoprevention increases significantly with oncology trained providers and with application of a risk assessment model. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-08-05.

P4-12-08: Five Year Preliminary Outcomes of a Prospective Surveillance Model To Reduce Upper Extremity Morbidity Related to Breast Cancer Treatment

Background

Early detection and management of physical impairments after breast cancer treatment contribute to successful functional outcomes and improved quality of life throughout disease treatment and survivorship. Assessment of upper extremity (UE) morbidity including; shoulder dysfunction, scarring, pain, fatigue and lymphedema should be conducted through a prospective surveillance model of care to promote early identification of impairments and provide intervention while functional limitations are minimal, thereby preventing long term loss of function. This report highlights 5-year findings related to physical function in patients participating in a prospective surveillance model of care.

Methods: A prospective, observational study enrolled women with breast cancer at the point of disease diagnosis (n=196) and measured UE morbidity, impairments and functional disability over a 5 year period. Patient demographics, cancer characteristics, measures of UE strength, range of motion (ROM) and limb volume were taken pre-operatively and repeated at 1, 3, 6, 9, 12 and 60 months post-operatively. Subjective assessment of physical activity, health status and quality of life were assessed by questionnaire at 12 and 60 months. 166 subjects completed visits at 1 year and 95 completed visits at 5 years. All subjects received education regarding exercise, risk reduction and advice on return to activity. If physical impairments were detected during the study, immediate physical therapy intervention was initiated to alleviate the impairment.

Results: The incidence of objective UE impairments at five years after treatment was 9% with loss of shoulder ROM, 25% with subclinical lymphedema (defined as a ≥ 3% change in limb volume from baseline), 5.6% with advanced lymphedema (Stage I or II) and 27.8% with clinically significant fatigue (defined as ≥ 3 on a visual analog scale). Subjectively 8.4% reported feeling moderately or severely disabled with their affected arm, 11.1% reported moderate to severe difficulty carrying heavy objects, 4.2% reported moderate to severe limitations with heavy household chores.

Discussion: This is the first prospective cohort study in the United States to specifically monitor physical and functional outcomes to 5-years post breast cancer treatment. The prospective surveillance model of care, conducted by the physical therapist, enabled early detection and treatment of breast cancer treatment-related impairments resulting in improved long-term function. Long-term incidence of UE morbidity after breast cancer treatment has been documented in the literature as high as 40–60% with lymphedema and up to 60% with fatigue. This study clearly demonstrates the potential for substantial reduction in UE dysfunction related to breast cancer treatment when using an early identification and intervention model. Morbidity such as pain, reduced range of motion, decreased strength and sub-clinical lymphedema were detected early and managed through the prospective model. These results strongly suggest that prospective surveillance monitoring for functional impairments is an optimal construct to assure long-term function in women after breast cancer treatment.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-08.

Abstract P1-10-06: Racial Disparities in Physical and Functional Domains in Women with Early Breast Cancer

Background. There is limited research on the racial/ethnic disparities in breast cancer survivors’ (BCS) physical functioning and quality of life (QOL). Previous studies note that African American (AA) women are typically diagnosed with larger, more aggressive tumors and require more intensitve surgical and adjuvant treatment potentiating higher levels of functional morbidity. Reasons given for these disparities include; genetic predisposition, poor access to screening and cultural norms that may impact a patients willingness to seek screening and early treatment. This analysis compared the QOL and prevalence of physical impairments (including lymphedema, seroma, cording) of white and African-American BCS from a US Military hospital where all patients have coverage and access to health care services. Methods. Data was analyzed from 166 women (130 white and 28 African-American). Participants were assessed preoperatively and examined at 1, 3, 6, 9, 12-24 months post surgery for impairments by a physical therapist. QOL was assessed at 12-24 months post-operation through the Short Form Health Survey (SF36v2). Analysis of variance estimated differences in QOL and occurrences of impairments between white and African-American BCS. Results. African-American BCS: were premenopausal(P<.05), had ER/PR negative tumors(P<.001, P<.05), and received radiation(P<.05). No significant differences were found in type, stage, grade, or size of BC tumor, surgery type, lymph node dissection, or number of lymph nodes sampled. More AA BCS were employed(P<.05) and socially active(P<.05), but less recreationally active(P<.05); there were no significant differences in marital status. More AA BCS had axillary web syndrome(P <.05) and lymphedema(P <.05). No significant differences were found in seroma, fatigue, chestwall pain, shoulder pain, numbness, and self-reported QOL. Conclusions. Results suggest a difference in physical effects of BC treatment on white and AA women; however, contrary to other studies, no differences in QOL were noted. Our cohort demonstrates an interesting trend, in that only ER/PR status differed and other characteristics of the tumor were not different between racial groups. This differs from past reports and may suggest that access to care plays a role in promoting earlier stage diagnosis. However, despite the homogeneity of our cohorts tumor status we found that AA BCS may be at a higher risk for common impairments associated with BC treatment and should be monitored prospectively to mitigate the potential for impairments. Further research should examine effects of BC treatments on women of various ethnicities.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-06.

Correlates of clinically significant fatigue in women with newly diagnosed breast cancer

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Background: Cancer related fatigue (CRF) is common in cancer survivors. CRF has been reported to be one of the most distressing symptoms associated with cancer and its treatment. Activity and biological profiles of those who suffer from CRF, have been poorly characterized. This IRB approved prospective, natural history study reports fatigue and associated findings in women newly diagnosed with breast cancer (BrCa), receiving standard treatment. Methods: All women were evaluated pre-operatively and at >9 months after diagnosis. Variables measured: Age, height, marital status, presence of children, menopausal status, tumor size, node status, estrogen receptor (ER+), hemoglobin, white blood cell count, fasting blood glucose, and BMI. Patient reported outcomes included visual analog scale (VAS) of fatigue (F), SF-36 version2, Physical Activity Questionnaire (PAQ, Harvard Alumni Health Study) and Sleep Questionnaire. Some variables were dichotomized to maximize the statistical power for the relatively small sample size. Bivariate correlations, and logistic regression analyses were performed using two fatigue conditions: presence of any F, or presence of clinically significant fatigue (CSF) defined as >=4 on the VAS. Results: 61 women, mean age of 51y, 39% had BMI >=25, 85% had >= 1 child, 52% were post-menopause, 92% ER+. Increased F at follow-up was statistically significant when compared to baseline (p=<0.0001, using paired t-test). Significant correlations (p<0.1) are reported between CSF and the following: node+, BMI>=25; inverse correlations with amount of vigorous activity (PAQ), physical function and vitality on SF-36. Physical function (SF-36) had significant inverse correlations with: age, menopause, and BMI. Low vitality was associated with: large tumor size, high WBC, longer time sleeping. Node+, BMI>=25, low physical function and vitality levels retained statistically significant relationships to CSF in the regression analyses. Conclusions: Node+ BrCa, BMI>=25, low level of physical activity and vitality (SF-36) are correlated with CSF. Except node status, each is treatable and may reduce CSF

No significant financial relationships to disclose.

Functional recovery after surgery in patients with breast cancer

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Background: Upper extremity dysfunction and decreased quality of life are frequently reported sequelae of the treatment for early stage breast cancer (BC). Surgical trauma and/or radiation therapy may lead to upper extremity (UE) impairments, functional limitations and disabilities including pain, stiffness, lymphedema, decreased strength and range of motion (ROM) and decreased activity tolerance. In this study we examined specific functional characteristics of shoulder impairments and associated limitations. Methods: Women (n=88, mean age = 53y [SD=11.81]) newly diagnosed with unilateral, Stage I to III BC were screened pre-operatively for this prospective trial. Patient data and physical therapy based assessments were recorded at the pre-operative visit (baseline) and at 1, 3, and 12+ months (BA, M1, M3, M12) after surgical treatment including pain (VAS on 10 point scale), bilateral shoulder ROM and strength (MMT). Volumes for upper extremities were taken using an optoelectric device (Perometer®). During post BC treatment visits, appropriate physical therapy was provided, and if there was a diagnosis of lymphedema, a light-grade compression garment was fitted. ROMs (shoulder Abd, ER, Flex, IR), a composite MMT value, and volume were analyzed with one-way repeated ANOVA including Greenhouse-Geisser correction for non-normal data where necessary. Post hoc testing was done using Within-Subjects Contrasts. Limited range of values for pain resulted in a highly skewed distribution, inappropriate for statistical testing. Results: For the variables Abd, ER, Flex, and sumMMT there was a decrease in function from BA to M1, improvement from M1 to M3, and further improvement from M3 to M12 (all p < 0.0001). For IR there was a decrease from BA to M1, no difference between M1 and M3, and an improvement from M1 and M3 to M12 (p < 0.3). Pain remained relatively low with 60–80% of the women reporting ≤2/10. Conclusions: After surgery for breast cancer, a decrement in shoulder function may be expected around 1 month after the procedure. Most subjects demonstrated significant improvement in function by 3 months after the procedure, and by 12 months, subjects achieved near complete recovery of shoulder impairment.

No significant financial relationships to disclose.

Biomarker assays in nipple aspirate fluid

The noninvasive technique of nipple aspiration as a potential source of biomarkers of breast cancer risk was evaluated. The feasibility of performing mutagenesis assays, amplifying DNA, and performing protein electrophoresis on nipple aspirate fluid was explored. A tool was developed to measure the level of discomfort, if any, from this procedure. Twenty-five healthy women (20 premenopausal and 5 postmenopausal) were enrolled. Fluid was obtained using a modified breast pump. Premenopausal women were scheduled for four to six weekly aspirations, and postmenopausal women were scheduled for one to two weekly aspirations. Mutagenesis assays were performed using the Salmonella (Ames) assay. DNA amplification of several microsatellite regions was carried out using polymerase chain reaction. Protein was quantified, and two-dimensional protein electrophoresis was performed. Overall, fluid was obtained from 80% of the women, and the level of discomfort was minimal. Acid hydrolysis of one sample resulted in mutagenicity; all six nonhydrolyzed samples were not mutagenic. The ability to amplify DNA ranged from 34% to 96%, depending on length of the microsatellite region examined. The average protein concentration was 71 microg/mL. Two-dimensional protein electrophoresis was successfully performed on samples from two subjects. Nipple aspiration is a simple technique and is easily learned and well tolerated, which yields a reagent useful for a variety of investigations. This technique may facilitate the identification and application of biomarkers for future breast cancer risk assessment and chemopreventive protocols.

Spleen-preserving pancreatectomy for cystic pancreatic neoplasms

Cystic neoplasms of the pancreas are an uncommon entity comprising fewer than 1 per cent of all pancreatic neoplasms. The guidelines for management of these tumors, specifically, the extent of resection, are unclear. Formerly, a distal pancreatectomy including the spleen was performed for tumors in the tail of the pancreas. The importance of preserving the spleen has been well documented; however, there are few reports of spleen-preserving pancreatectomy for cystic neoplasms of the distal pancreas. We report two patients who underwent spleen-preserving pancreatectomy for mucinous cystic neoplasms in the tail of the pancreas. Both patients were female, ages 39 and 65 years. Preoperative preparation included administration of vaccinations and subcutaneous somatostatin. Operative technique emphasized division of the splenic artery and vein beyond the tip of the distal pancreas without mobilization of the spleen. The pancreas was transected with a vascular stapler. Fibrin glue was applied to the margin of the pancreas. The operative blood loss, duration of operation, and postoperative hospital stay were 150 and 250 mL, 150 and 180 minutes, and 7 and 9 days, respectively. The pathology revealed both lesions to be mucinous cystic neoplasms. The patients recovered and at 6-month follow-up were without complaints and in good health. Spleen-preserving pancreatectomy is rapid and associated with minimal morbidity. This procedure should be considered in the surgical management of cystic neoplasms in the tail of the pancreas.