Sex exceptionalism and erasure in porn health protocols

Porn production, like all forms of labour, entails certain occupational health and safety (OHS) risks. Porn production has generally not been subject to state occupational health oversight, and porn workers have instead implemented self-regulatory OHS systems. However, in California, where the industry is most established, governmental and non-governmental bodies have made several paternalist attempts to legislate standardised OHS protocols. Their proposed legislation exceptionalises sex work as uniquely dangerous while failing to tailor guidance to the specific needs of and practices associated with porn work. This is largely because: 1) regulators are ignorant of porn's self-regulatory processes; 2) industry self-regulation conceptualises the occupational hazard on porn sets as infectious bodily fluids, whereas external regulators perceive the hazard as sex itself; and 3) regulators devalue porn work and so do not take the viability of the labour into account when evaluating protocol effectiveness. Using critical-interpretive medical anthropology involving fieldwork and interviews with porn workers and a critical analysis of porn OHS texts, I argue that porn health protocols should be left to industry self-determination, to be developed by porn workers rather than for them.

The impact of rurality on vulvodynia diagnosis and management: Primary care provider and patient perspectives

Objective

The objective of this study was to better understand how rurality impacts the knowledge, diagnosis and management of vulvodynia by primary care providers (PCPs) practising in the geographically disparate province of Newfoundland and Labrador, Canada.

Design

This was a qualitative case study using questionnaires and semi-structured interviews with PCPs, compared with semi-structured focus groups and interviews with vulvodynia patients conducted in a previous study phase.

Results

Ten family physicians and 6 nurse practitioners participated. Over half had baseline knowledge that vulvodynia has a relatively high prevalence, but most underestimated the likelihood they would see a patient with vulvodynia in their practice. Three barriers to discussing and managing vulvodynia emerged: (1) discomfort initiating sexual/vulvar health conversations; (2) concerns about protecting patient privacy and confidentiality; and (3) time constraints and building therapeutic relationships. These issues were largely corroborated by previous findings with vulvodynia patients. Rural-informed solutions might include: (1) supporting increased education in vulvodynia and sexual health more broadly, including funding to attend continuing professional education and developing more clinical tools; (2) following practice guidelines regarding standardised initiation of sexual health conversations; (3) incentivising retention of rural providers and extending appointment times by reconsidering fee-for-service structures; and (4) researching a tailored vulvodynia toolkit and the potential advantage of mobile health units.

Conclusion

Rurality exacerbates common concerns in the identification and management of vulvodynia. Acting on recommended solutions may address the impact of rurality on the provision of timely care for those experiencing vulvodynia and other sexual health concerns.

Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives

INTRODUCTION

Persons with vulvodynia (a chronic vulvar pain condition) suffer many barriers to diagnosis and treatment, several of which may be exacerbated by the sociocultural and geographical context in which they live.

AIM

We drew on the experiences of patients with vulvodynia who were living in small urban and rural communities to learn what they perceived as the major barriers to diagnosis and treatment as well as to probe for possible solutions.

METHODS

For this qualitative case study, we conducted 3 focus groups with a total of 10 participants, drawn from patients seen at our academic tertiary referral center, with a goal of understanding their lived experience with vulvodynia.

MAIN OUTCOME MEASURES

The patient dialogue was coded into themes and temporally grouped to illustrate struggles and victories in diagnosis and treatment.

RESULTS

Participants confirmed that healthcare provider knowledge and attitudes as well as system challenges (specialist and allied healthcare provider availability) are major barriers to timely diagnosis. Of novel interest are other factors that exacerbate distress and delay diagnosis such as patients' inadequate knowledge of sexual functioning and sociocultural messages regarding "normal" sexual activity. Our work suggests that a disease prevention framework that includes comprehensive sexual education before or at the onset of sexual activity may be of benefit in reducing the burden of vulvodynia when added to strategies to increase healthcare provider knowledge and improve access to effective treatments.

CONCLUSION

While healthcare provider knowledge and attitudes are often at the forefront of barriers to diagnosis, our study suggests that to minimize patient distress and expedite diagnosis, resources must also be directed to promoting comprehensive sexual health education. Webber V, Miller ME, Gustafson DL, et al. Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives. Sex Med 2020;8:757-766.

Abstract P3-10-26: Predicting benefit from HER2-targeted therapies in patients with ER+/HER2+ breast cancer

Background: ER+/HER2+ accounts for up to 10% of all breast cancers (BCs) and most are treated with endocrine therapy (ET) after surgery to reduce the recurrence risk. We developed and validated an immunohistochemistry (IHC) based test (EA2Clin) that incorporates baseline IL6ST, clinical variables and on-treatment measurement of MCM4. Responders (Rs) and non-responders (NRs) to ET are identified and it accurately estimates recurrence-free survival (RFS) and BC-specific overall survival (BCSS). The aim was to determine if EA2Clin could accurately predict ER+/HER2+ patients likely to benefit from ET and to determine if it can identify those for whom HER2-targeted therapies are required.

Methods: 3 cohorts were studied:

A: 32 post-menopausal women (PMW) with large ER+/HER2+ BC treated with neoadjuvant (3-6 months) then adjuvant letrozole. 5 also received adjuvant chemotherapy plus Herceptin. Neoadjuvant clinical response was assessed by changes in tumour volume. Tumour core biopsies were taken at 0, 14 days and 3 months. Gene expression analysis using Illumina HT12 whole-genome beadarrays was performed on a subset (n=17) where fresh tissue was available.

B: 13 PMW with ER+/HER2+ BC who were treated by surgery without neoadjuvant therapy. RNA was extracted from excision tissues and analysed using whole-genome Affymetrix U133A microarrays.

C: 15 PMW with ER+/HER2+ BC treated with 2-weeks of pre-operative letrozole (n=7) or anastrozole (n=8). All received adjuvant letrozole. Tissues were collected at pre-treatment and at surgery. None received Herceptin or chemotherapy.

All patients were followed-up after surgery (median follow-up = 6.4 years).

Results: In cohort A, half (16/32) of the patients responded to ET with tumour volume reductions of >70% with neoadjuvant treatment. Innate resistance was apparent in 3 patients with continued tumour growth on ET, whereas 13 patients developed resistance after a period of response. EAClin2 predicted neoadjuvant response with a 92% accuracy. There was increased expression of phospho-AKT and phospho-ERK in NRs, not seen in Rs. Half (8/16) of the NR cancers expressed phospho-ER; but was not seen in any responsive cancer. Gene expression analysis in 17 patients showed increased MAPK and PI3K pathway activity in the 9 NR compared with the 8 R tumours. These results were recapitulated in cohort B where MAPK and PI3K activity were associated with low levels of IL6ST.

In the 16/32 patients who responded well to neoadjuvant ET the actuarial recurrence rate was 0% at 5 and 10 years. The rate of recurrence in the NR was 30% at both 5 and 10 years. Of the 5 patients who received chemotherapy plus Herceptin, none recurred despite a poor response to neoadjuvant letrozole (median length to last follow-up was 6.1 years). Initial data suggest that in cohort B EA2Clin identifies a group of ER+/HER2+ cancers that can be managed by ET alone.

Conclusions:

· The EA2Clin test identifies ER+/HER2+ BCs who respond well to ET alone and those with a poor clinical response who have higher risk of recurrence.

· NR to ET have increased expression of PI3K and MAPK pathways, consistent with active HER2 signalling.

· There is potential role for EA2Clin in selecting ER+/HER2+ patients that require and benefit from HER2-targeted therapies.

Citation Format: Turnbull AK, Webber V, McStay D, Arthur L, Martinez-Perez C, Fernando A, Renshaw L, Keys J, Clarke R, Sims AH, Dixon JM. Predicting benefit from HER2-targeted therapies in patients with ER+/HER2+ breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-26.

Contemporary thoughts on the management of Spigelian hernia

BACKGROUND

Spigelian hernias are said to be a rare condition of the elderly population, usually arising below the arcuate line. Local experience has led us to challenge these commonly held beliefs.

METHODS

Operations for Spigelian hernia from 2006-2016 were identified from the Edinburgh Lothian Surgical Audit computerised database and case notes were reviewed.

RESULTS

One hundred and one patients underwent surgery for 107 Spigelian hernias in the 10-year period. The female-to-male ratio was 2:1. Ages ranged from 32 to 88 with a median of 64 years. Sixty-five operations were done open and 42 were laparoscopic. Twelve of the 27 for which the precise anatomic location was recorded were situated above the arcuate line. Twenty-nine hernias had small defects and comprised interstitial fat only with no peritoneal sac. Ages in this group ranged from 32 to 80 (median = 48 years). All presented with intermittent local pain and/or swelling, although in three patients the hernias were impalpable. Those three also underwent ultrasound, CT and/or laparoscopy, but the hernias were only identified after open surgical exploration. The remaining 78 cases had peritoneal sacs of varying size with defects up to 9 cm across, and all were identified on imaging and/or laparoscopy. Ages ranged from 38 to 88 (median = 67 years; p < 0.01). Eighteen patients presented as emergencies and all were in this group.

CONCLUSION

Spigelian hernias may be more common than we think and are probably under-diagnosed. They commonly arise above the arcuate line. We describe three clinical stages: Stage 1 hernias are those without peritoneal sacs and tend to arise in younger patients, can be difficult to diagnose and may not seen at laparoscopy. Stages 2 and 3 hernias arise in older patients, do have peritoneal sacs, are visible at laparoscopy and are more likely to present as emergencies. Stage three hernias are too large for laparoscopic repair. The differences between stages likely reflect the natural history of the condition, which begins as extraperitoneal fat protrusion and progresses over many years to develop a peritoneal sac.

Abstract P3-07-20: A validated test for neoadjuvant clinical response to endocrine therapy in breast cancer that estimates accurately recurrence-free and overall survival

Background: Aromatase inhibitors (AIs) have an established role in the treatment of estrogen receptor alpha positive post-menopausal breast cancer. Recently we have developed and validated a microarray-derived 4-gene test (Edinburgh EndoResponse4) to predict response to AIs in the neoadjuvant setting. We have also demonstrated the translational potential of this test in predicting accurately clinical response when mRNA is measured for these genes by polymerase chain reaction (PCR) or the gene protein is measured by immunohistochemistry (IHC). There is a major clinical need for biomarkers to predict which patients are likely to recur on adjuvant endocrine therapy so alternative or additional treatments can be provided to reduce recurrence and improve outcome. The aim of this study was to determine if Endoresponse4 and IHC of these gene proteins could do this.

Methods: The original microarray assay used pre- and on-treatment (14-days) biopsies from 73 post-menopausal women with ER-rich breast cancer receiving 3 months of neoadjuvant letrozole prior to surgery with 10 years follow-up after adjuvant letrozole. Matched formalin-fixed paraffin embedded (FFPE) tissue sections from 42 of these patients were used for IHC and antibodies were optimised against 3 of the 4 proteins (where validated antibodies were available) using Envision technology. The ability of our test to estimate recurrence-free (RFS) and breast cancer specific overall survival (OS) using both PCR and IHC was then tested in a unique validation cohort of 140 post-menopausal women with ER-rich breast cancer treated with 2 weeks of neoadjuvant letrozole or anastrozole prior to surgery followed by adjuvant endocrine therapy and 10 years of follow up..

Results: Within our training cohort (n=73) using Kaplan-Meier analysis our 4-gene test predicted neoadjuvant clinical response and demonstrated a significant association with both RFS (P=0.029) and OS (P=0.009). This approach predicts outcomes within 2-weeks rather than 4-months of treatment required in other studies such as P024. Using IHC in the training cohort (n=42), two gene markers in combination (IL6ST at diagnosis and MCM4 after 2-weeks treatment) predicted both RFS (P=0.017) and OS (P=0.009) with great accuracy. The 140 patient group is being analysed and the findings are so far are consistent with the initial training cohort and indicate a significant association with outcomes.

Conclusion:

• A 4 gene model with clinical potential has been developed and validated to predict response to neoadjuvant aromatase inhibitors.

• This 4 gene model predicts for response and also predicts relapse free and overall survival.

• Proteins encoded by 2 of these 4 genes measured by IHC in an initial test set of 42 patients predict accurately both EFS and OS

• A validation cohort (n=140) with over 10-years of follow-up will be available at SABCS 2015 to determine if this 2 biomarker test can predict outcome on adjuvant endocrine therapy.

Citation Format: Turnbull AK, Arthur LM, Webber V, Thomas J, Uddin S, Webb H, Dunbier A, Dowsett M, Renshaw L, Sims AH, Dixon JM. A validated test for neoadjuvant clinical response to endocrine therapy in breast cancer that estimates accurately recurrence-free and overall survival. [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 P3-07-20.

Abstract P5-09-01: Comprehensive gene assessment of estrogen receptor positive breast cancer reveals that HER2 plays an important role in resistance to neoadjuvant letrozole

Background

10% of all breast cancers are HER2+/ER+ and these cancers exhibit both intrinsic and acquired resistance to endocrine therapy. They have a worse prognosis than HER2-/ER+ cancers.

Aims

1. To investigate the role of HER2 in response to neoadjuvant Letrozole.

2. To predict which HER2+ cancers do not respond to Letrozole.

Methods

23 postmenopausal women with large, operable, locally advanced HER2+/ER+ breast cancer treated with neoadjuvant Letrozole had response assessed by periodic 3D ultrasound. Core biopsies taken at 0, 14 days and 3 months of treatment. RNA were extracted, amplified, labelled and hybridised to Illumina HT-12 whole genome beadarrays. A group of patients with ER+/HER2- disease were identified to compare clinical and molecular response.

Results

13 (57%) HER2+/ER+ patients responded (R) and 10 (43%) patients did not (NR). HER2 expression was significantly higher at baseline in the NR group (p = 0.005). There were differences in gene expression between HER2+/ER+ R and NR and between the HER2+/ER+ and HER2-/ER+ NR groups. In the HER2+/ER+ NR group, there was virtually no change in gene expression during treatment with Letrozole.

Table 1  Up Regulated GenesDown Regulated Genes n0-14 days14 days-3 months0-3 months0-14 days14 days-3 months0-3 monthsHER2-ve Responders43122833505127213HER2-ve Non Responders1588361432340129HER2+ve Responders13541272703831125HER2+ve Non Responders10851117106

Considerable gene changes with overlap in the genes that changed most was evident in HER2+/ER+ and HER2-/ER+ responders.

Analysis of 55 estrogen sensitive proliferation genes revealed significantly less reduction in the HER2+/ER+ NR group than in the HER2+/ER+ R group (AUC = 10.57 vs 27.93 respectively; p&lt;0.0001). This difference was apparent by 14 days (AUC = 25.55 vs 17.94; p = 0.005).

The HER2+/ER+ NR group had significantly less reduction in these 55 estrogen sensitive proliferation genes when compared to the HER2-/ER+ NR group at 14 days (AUC = 17.94 vs 18.05 respectively; p = 0.0007) and by 3 months (AUC = 10.57 vs 26.26; p&lt;0.0001).

In logistic regression analysis, HER2 status was predictive of disease progression (p = 0.048). A single gene classifier predicted response to endocrine therapy in the ER+/HER2+ group. This was accurate in 94% of patients in the test set (n = 23). This classifier was also predictive of progression free survival (p = 0.006) in HER2+/ER+ patients.

Conclusions

In this large cohort of patients treated with neoadjuvant letrozole:

• HER2+/ER+ cancers have a low rate of response.

• Changes in gene expression are similar in HER2+/ER+ and HER2-/ER+ responders.

• HER2+/ER+ cancers that do not respond to letrozole have few gene changes and little reduction in estrogen signalling pathways.

• In contrast HER2-/ER+ non responders show significant gene changes and reduced expression of estrogen sensitive proliferation genes.

• A single gene classifier at diagnosis in ER+/HER2+ has been identified which predicts response to Letrozole with 94% accuracy.

• Validation continues. This single gene classifier may provide a simple test to predict which HER2+/ER+ cancers are endocrine resistant.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-09-01.

Abstract PD3-2: Accurate and robust prediction of clinical response to aromatase inhibitors by two weeks of neoadjuvant breast cancer treatment

Background: Aromatase inhibitors (AIs) have an established role in the treatment of estrogen receptor alpha positive (ER+) post-menopausal breast cancer. Response rates are 50-70% in the neoadjuvant setting and lower in advanced disease. There is a need to identify biomarkers to predict response that outperform those currently available, to be able to offer more stratified treatments and improved patient care.

Methods: Pre- and on-treatment (at 14 days and 3-months) biopsies were obtained from 89 post-menopausal women with ER+ breast cancer receiving 3 months of neoadjuvant Letrozole. Illumina Beadarray gene expression data (n = 34) were combined with Affymetrix GeneChip data (n = 55) and cross-platform integration approaches developed as part of this study were implemented to combine data. Dynamic clinical response was assessed for each patient using periodic 3D ultrasound measurements performed during treatment. A gene classifier was developed from pre and 14 day gene array expression data to predict response. An independent series from the Royal Marsden was used to validate the classifier.

Results: Response to endocrine therapy in the neoadjuvant setting based on the expression of 4 genes has been developed. The classifier comprises baseline expression of an immune signalling gene and an apoptosis related gene, together with 14 day expression of two proliferation genes. Early on-treatment gene changes in combination with pre-treatment gene expression significantly improve predictive power compared to pre-treatment gene expression alone. The classifier had a 96% accuracy in a training dataset (n = 73) and 91% accuracy in an independent validation dataset (n = 44) dataset.

Table 1 AccuracySensitivitySpecificityPPVNPVAUC (ROC)Training0.960.890.980.890.960.96Validation0.910.80.970.920.9NASensitivity and specificity of model in training and validation datasets

Expression of the pre-treatment immune signalling gene alone predicted for response with 85% and 82% accuracy in training and validation datasets respectively. Higher pre-treatment levels of this gene were associated with a significantly better 1 year progression free survival (PFS) (P = 0.0001). In a larger series of patients treated with neoadjuvant Letrozole (n = 129) higher expression of this gene alone was associated with a significantly improved 10 year RFS (p = 0.0359). In a separate tamoxifen treated cohort (n = 212) higher expression of this gene at diagnosis was associated with a significantly improved 5 year (p = 0.0015) and 10 year (p = 0.04) recurrence free survival (RFS).

Conclusion:

• A 4 gene classifier has been developed and validated to predict response to neoadjuvant Letrozole.

• One of the genes identified is a significant predictor in independent data sets of long term RFS in endocrine treated patients.

• This new classifier has the potential to predict accurately the benefit of endocrine therapy and has huge potential clinical value.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD3-2.

Abstract P6-04-10: Comprehensive gene and protein assessment of the role of Her2 in the response to neoadjuvant Letrozole suggests patients without amplification may also benefit from anti-Her2 treatment

Background: Older postmenopausal patients with large operable or locally advanced oestrogen receptor positive, invasive breast cancers are candidates for treatment with neoadjuvant letrozole. HER2 positivity is a potential marker for early endocrine therapy resistance. In this study we have evaluated the effects of HER2 amplification, gene and protein expression at diagnosis and following 14 and 90 days of treatment with neoadjuvant Letrozole.

Methods: 70 postmenopausal women with large operable and locally advanced oestrogen receptor (ER) positive invasive breast cancers were treated with neoadjuvant letrozole. Response was assessed by 3D ultrasound. Sequential core biopsies were taken at 0, 14 days and 3 months of treatment. 12 patients were HER2 positive (either 3+ or 2+ FISH positive), 20 were HER2 2+ FISH negative and 38 were HER2 negative (0 or +).

Results: 43 patients were responders to letrozole and 17 were non-responders. 7 of the 17 non-responders were HER2 positive. Analysing response in two groups (HER2 2+ and 3+ together versus 0 or +) there was a greater difference in response rate between these two groups than when splitting into conventional HER2 positive and negative groups (P &lt; 0.0001). In non-responding patients HER2 gene expression levels from the microarrays taken at baseline were significantly higher than the HER2 expression in responding patients (p = 0.01). There was also an increase in HER2 gene expression seen during the first 14 days of treatment in non-responding but not responding patients (p = 0.08). Rank product analysis of gene expression identified 34 down-regulated genes and 7 up-regulated genes which were shared between the HER2 2+ FISH negative samples and samples which were HER2 3+ or HER2 2+ FISH positive.

Conclusion: This large cohort of patients treated with neoadjuvant letrozole shows that:

HER2 expression correlates with response to letrozole.

A better cut off for prediction of response to letrozole is the split between 0 and + versus 2+ and 3+ rather than the traditional 3+.

Patients with increased MRNA expression at diagnosis for HER2 have a significantly lower response rate to neoadjuvant letrozole.

Endocrine therapy together with anti-HER2 therapies should be considered for patients having neoadjuvant endocrine therapy for cancers which over express HER2.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-04-10.

Counselling in an inner city general practice: analysis of its use and uptake

BACKGROUND

In recognition of the emotional problems which frequently underlie somatic complaints, practices increasingly offer counselling as part of their services to patients. In an inner city practice, a combination of short term counselling, volunteer befriending, community outreach and social work services is offered as a means of responding to the full range of patients' counselling needs.

AIM

This study set out to establish the use and uptake of these services.

METHOD

A retrospective analysis of patients referred for counselling over one year was carried out.

RESULTS

The analysis identified a broad range of emotional problems among referred patients as well as problems of a practical nature. A quarter of the patients referred failed to keep their initial appointments or to complete their contracts. One fifth of the patients were referred on for longer term counselling and/or psychotherapy. Subsequent feedback revealed that preparation of a patient before referral was an important factor affecting uptake of counselling.

CONCLUSION

Early assessment of the use and uptake of such services is essential if they are to be integrated successfully and a counsellor's individual skills employed effectively.