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Xu H, Mohamed M, Flannery M, Peppone L, Ramsdale E, Loh KP, Wells M, Jamieson L, Vogel VG, Hall BA, Mustian K, Mohile S, Culakova E. An Unsupervised Machine Learning Approach to Evaluating the Association of Symptom Clusters With Adverse Outcomes Among Older Adults With Advanced Cancer: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e234198. [PMID: 36947036 PMCID: PMC10034574 DOI: 10.1001/jamanetworkopen.2023.4198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 12/20/2022] [Indexed: 03/23/2023] Open
Abstract
Importance Older adults with advanced cancer who have high pretreatment symptom severity often experience adverse events during cancer treatments. Unsupervised machine learning may help stratify patients into different risk groups. Objective To evaluate whether clusters identified from baseline patient-reported symptom severity were associated with adverse outcomes. Design, Setting, and Participants This secondary analysis of the Geriatric Assessment Intervention for Reducing Toxicity in Older Patients With Advanced Cancer (GAP70+) Trial (2014-2019) included patients who completed the National Cancer Institute Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) before starting a new cancer treatment regimen and received care at community oncology sites across the United States. An unsupervised machine learning algorithm (k-means with Euclidean distance) clustered patients based on similarities of baseline symptom severities. Clustering variables included severity items of 24 PRO-CTCAE symptoms (range, 0-4; corresponding to none, mild, moderate, severe, and very severe). Total severity score was calculated as the sum of 24 items (range, 0-96). Whether the clusters were associated with unplanned hospitalization, death, and toxic effects was then examined. Analyses were conducted in January and February 2022. Exposures Symptom severity. Main Outcomes and Measures Unplanned hospitalization over 3 months (primary), all-cause mortality over 1 year, and any clinician-rated grade 3 to 5 toxic effect over 3 months. Results Of 718 enrolled patients, 706 completed baseline PRO-CTCAE and were included (mean [SD] age, 77.2 [5.5] years, 401 [56.8%] male patients; 51 [7.2%] Black and 619 [87.8%] non-Hispanic White patients; 245 [34.7%] with gastrointestinal cancer; 175 [24.8%] with lung cancer; mean [SD] impaired Geriatric Assessment domains, 4.5 [1.6]). The algorithm classified 310 (43.9%), 295 (41.8%), and 101 (14.3%) into low-, medium-, and high-severity clusters (within-cluster mean [SD] severity scores: low, 6.3 [3.4]; moderate, 16.6 [4.3]; high, 29.8 [7.8]; P < .001). Controlling for sociodemographic variables, clinical factors, study group, and practice site, compared with patients in the low-severity cluster, those in the moderate-severity cluster were more likely to experience hospitalization (risk ratio, 1.36; 95% CI, 1.01-1.84; P = .046). Moderate- and high-severity clusters were associated with a higher risk of death (moderate: hazard ratio, 1.31; 95% CI, 1.01-1.69; P = .04; high: hazard ratio, 2.00; 95% CI, 1.43-2.78; P < .001), but not toxic effects. Conclusions and Relevance In this study, unsupervised machine learning partitioned patients into distinct symptom severity clusters; patients with higher pretreatment severity were more likely to experience hospitalization and death. Trial Registration ClinicalTrials.gov Identifier: NCT02054741.
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Affiliation(s)
- Huiwen Xu
- School of Public and Population Health, University of Texas Medical Branch, Galveston
- Sealy Center on Aging, University of Texas Medical Branch, Galveston
| | - Mostafa Mohamed
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Marie Flannery
- School of Nursing, University of Rochester Medical Center, Rochester, New York
| | - Luke Peppone
- Department of Surgery, Supportive Care in Cancer, University of Rochester Medical Center, Rochester, New York
| | - Erika Ramsdale
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Megan Wells
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Leah Jamieson
- Metro Minnesota Community Oncology Research Program, St Louis Park, Minnesota
| | - Victor G. Vogel
- Geisinger Cancer Institute National Cancer Institute Community Oncology Research Program, Danville, Pennsylvania
| | - Bianca Alexandra Hall
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Karen Mustian
- Department of Surgery, Supportive Care in Cancer, University of Rochester Medical Center, Rochester, New York
| | - Supriya Mohile
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Eva Culakova
- Department of Surgery, Supportive Care in Cancer, University of Rochester Medical Center, Rochester, New York
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2
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Hershman DL, Bansal A, Sullivan SD, Lyman GH, Barlow WE, Arnold KB, Watabayashi K, Bell-Brown A, Le-Lindqwister N, Dul CL, Brown-Glaberman U, Behrens RJ, Vogel VG, Alluri N, Ramsey SD. A pragmatic cluster-randomized trial of a standing physician order entry intervention for colony stimulating factor use among patients at intermediate risk for febrile neutropenia (SWOG S1415CD). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.1518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1518 Background: Primary prophylactic colony stimulating factors (PP-CSF) are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia (FN) but their benefit for regimens with intermediate FN risk is uncertain. Within a pragmatic, randomized trial of a standing order entry (SOE) intervention for prescribing PP-CSF, we designed a substudy to evaluate the effectiveness of PP-CSF for patients receiving therapy with intermediate FN risk. Methods: TrACER was a cluster randomized trial where NCI community Oncology Research Program practices were randomized to usual care (UC) or a guideline-based SOE intervention. In the primary study, sites were randomized 3:1 to a SOE of automated PP-CSF orders for NCCN-designated high FN risk chemotherapy regimens and alerts against PP-CSF orders for low FN risk regimens (intervention) versus usual care. A secondary randomization assigned intervention sites to a SOE intervention either to prescribe or not prescribe PP-CSF for patients receiving intermediate FN risk regimens. Clinicians were allowed to override the SOE. Patients age ≥18 with either breast, colorectal or non-small cell lung cancer were enrolled and followed for 12 mo. PP-CSF was defined as initiation within 24-72 hours after systemic chemotherapy. Sample size calculations were based on an FN risk reduction from 15% to 7.5%, and provided 80% power at a planned enrollment of 90 patients per site. Mixed effect logistic regression models were used to test differences between sites randomized to prescribe or not prescribe PP-CSF. Results: Between January 2016 and April 2020, 24 sites (2,287 patients) were randomized to the intervention. Among intervention sites, 12 were randomized to either SOE to prescribe or an alert to not prescribe PP-CSF for the 542 patients receiving intermediate FN risk regimens. Rates of PP-CSF use were higher among sites randomized to prescribe PP-CSF (37.1% vs 9.9%, OR = 5.90 (95% CI 1.72-20.20; p = 0.0048)). Overall, the rates of FN were low and identical between PP-CSF and no PP-CSF arms (3.7% vs 3.7%). Among patients who did not receive PP-CSF, rates of FN were also low and similar between arms (3.8% vs 4.1%). Conclusions: While implementation of a SOE intervention for PP-CSF significantly increased PP-CSF use among patients receiving intermediate risk regimens, FN rates did not differ between arms. Despite SOE, 63% of patients assigned to receive PP-CSF did not receive it. FN rates overall were lower than expected and did not differ between patients that did or did not receive PP-CSF. Although this guideline-informed SOE influenced prescribing, the results suggest that neither the SOE nor PP-CSF itself provide sufficient benefit to justify their use for persons receiving intermediate FN risk regimens. Clinical trial information: NCT02728596.
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Affiliation(s)
- Dawn L. Hershman
- Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Sean D Sullivan
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA
| | | | | | | | | | | | | | - Carrie L. Dul
- Ascension Saint John Hospital (Michigan Cancer Research Consortium NCORP), Detroit, MI
| | | | - Robert J. Behrens
- Med Onc & Hem Assoc-Des Moines (Iowa-Wide Oncology Research Coalition NCORP), Des Moines, IA
| | | | - Nitya Alluri
- Saint Luke's Cancer Institute (Pacific Cancer Research Consortium NCORP), Boise, ID
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3
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Ramsey SD, Bansal A, Sullivan SD, Lyman GH, Barlow WE, Arnold KB, Watabayashi K, Bell-Brown A, Le-Lindqwister N, Dul CL, Brown-Glaberman U, Behrens RJ, Vogel VG, Alluri N, Hershman DL. A pragmatic cluster-randomized trial of a computerized clinical decision support system to improve colony stimulating factor prescribing for patients with cancer receiving myelosuppressive chemotherapy (SWOG S1415CD). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.1525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1525 Background: Primary prophylactic colony stimulating factors (PP-CSF) are prescribed to patients undergoing chemotherapy to reduce the risk of febrile neutropenia (FN). Prior studies have shown that 55-95% of CSF prescribing is inconsistent with practice guidelines. We conducted a cluster randomized trial to determine if guideline-informed standing orders for PP-CSF improved prescribing and reduced the incidence of FN. Methods: Patients age ≥18 with breast, colorectal or non-small cell lung cancer initiating first cancer-directed therapy with NCCN-recommended regimens were eligible. The intervention consisted of automated PP-CSF orders for high FN risk chemotherapy regimens and an alert not to use PP-CSF for low FN risk regimens. Regimen FN risk was based on NCCN guidelines. Clinicians could override the orders. Primary and secondary outcomes were PP-CSF use among patients receiving high and low risk regimens FN incidence within 6 months of initial therapy. Sample size estimates assumed an FN risk of 25% for high-risk chemotherapy. 32 NCI Community Oncology Research Program (NCORP) practices randomized 3:1 to the order entry system (intervention) versus usual care (UC) provided 90% power to detect a 50% reduction in FN at a planned enrollment of 90 patients per site. Mixed effect logistic regression models were used to test differences among randomized sites. 13 practices with pre-existing PP-CSF order sets enrolled in a parallel cohort study. Patients and other stakeholder groups informed study design, conduct and reporting. Results: Between January 2016 and April 2020, 2,946 patients were randomized (2287 intervention, 659 UC); 718 were enrolled in the cohort. Mean age across arms was 58.1. 77% of patients were female; 61% diagnosed with breast cancer. Among patients receiving high-risk regimens, PP-CSF use did not differ between arms (89.2% intervention; 95.8% UC, adjusted p = 0.21) and was similar to the cohort patients (93.0%). The FN rate for high-risk patients was 5.7% in intervention clinics and 4.2% in UC clinics (adjusted p = 0.26); FN was 14.9% among high-risk patients who did not receive PP-CSF. Among patients receiving low-risk regimens, PP-CSF use did not differ between arms (intervention 6.3%, UC 5.5%, adjusted p = 0.74) and was slightly lower than the cohort (8.3%). FN rates did not differ between low risk groups (intervention 1.5%, UC 0.8%, adjusted p = 0.51). Conclusions: Guideline-informed standing orders did not increase PP-CSF use in high-risk patients, nor did it decrease use in low-risk patients. Adherence to guidelines in both risk groups exceeded historical reports. FN rates among patients not receiving PP-CSF were substantially below those reported in CSF guidelines. Automated standing orders for PP-CSF do not appear to be helpful or necessary. Clinical trial information: NCT02728596.
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Affiliation(s)
| | | | - Sean D. Sullivan
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA
| | | | | | | | | | | | | | - Carrie L. Dul
- Ascension Saint John Hospital (Michigan Cancer Research Consortium NCORP), Detroit, MI
| | | | - Robert J. Behrens
- Med Onc & Hem Assoc-Des Moines (Iowa-Wide Oncology Research Coalition NCORP), Des Moines, IA
| | | | - Nitya Alluri
- Saint Luke's Cancer Institute (Pacific Cancer Research Consortium NCORP), Boise, ID
| | - Dawn L. Hershman
- Columbia University College of Physicians and Surgeons, New York, NY
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4
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Lund JL, Duberstein PR, Loh KP, Gilmore N, Plumb S, Lei L, Keil AP, Islam JY, Hanson LC, Giguere JK, Vogel VG, Burnette BL, Mohile SG. Life expectancy in older adults with advanced cancer: Evaluation of a geriatric assessment-based prognostic model. J Geriatr Oncol 2022; 13:176-181. [PMID: 34483079 PMCID: PMC8882125 DOI: 10.1016/j.jgo.2021.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/06/2021] [Accepted: 08/25/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Oncologists estimate patients' prognosis to guide care. Evidence suggests oncologists tend to overestimate life expectancy, which can lead to care with questionable benefits. Information obtained from geriatric assessment may improve prognostication for older adults. In this study, we created a geriatric assessment-based prognostic model for older adults with advanced cancer and compared its performance to alternative models. MATERIALS AND METHODS We conducted a secondary analysis of a trial (URCC 13070; PI: Mohile) capturing geriatric assessment and vital status up to one year for adults age ≥ 70 years with advanced cancer. Oncologists estimated life expectancy as 0-6 months, 7-12 months, and > 1 year. Three statistical models were developed: (1) a model including age, sex, cancer type, and stage (basic model), (2) basic model + Karnofsky Performance Status (≤50, 60-70, and 80+) (KPS model), and (3) basic model +16 binary indicators of geriatric assessment impairments (GA model). Cox regression was used to model one-year survival; c-indices and time-dependent c-statistics assessed model discrimination and stratified survival curves assessed model calibration. RESULTS We included 484 participants; mean age was 75; 48% had gastrointestinal or lung cancer. Overall, 43% of patients died within one year. Oncologists classified prognosis accurately for 55% of patients, overestimated for 35%, and underestimated for 10%. C-indices were 0.61 (basic model), 0.62 (KPS model), and 0.63 (GA model). The GA model was well-calibrated. CONCLUSIONS The GA model showed moderate discrimination for survival, similar to alternative models, but calibration was improved. Further research is needed to optimize geriatric assessment-based prognostic models for use in older adults with advanced cancer.
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Affiliation(s)
- Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Nikesha Gilmore
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Sandy Plumb
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Alexander P Keil
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jessica Y Islam
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeffrey K Giguere
- NCORP of the Carolinas (Greenville Health System NCORP), Greenville, SC, USA
| | | | - Brian L Burnette
- Cancer Research of Wisconsin and Northern Michigan (CROWN) NCORP, Grand Rapids, MI, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
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5
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Zhang Y, Mohile S, Culakova E, Norton S, Loh KP, Kadambi S, Kehoe L, Grossman VA, Vogel VG, Burnette BL, Bradley TP, Flannery M. The shared uncertainty experience of older adults with advanced cancer and their caregivers. Psychooncology 2022; 31:1041-1049. [PMID: 35112424 DOI: 10.1002/pon.5895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE One primary source of psychological distress in patients with cancer and their caregivers is uncertainty. However, the uncertainty trajectory and its relationship between older adults with advanced cancer and their caregivers have rarely been examined. This study describes the uncertainty trajectory in patient-caregiver dyads, explores the effect of geriatric assessment (GA) intervention on trajectory, and examines the interdependent relationship of uncertainty. METHODS This secondary analysis used longitudinal data from a national cluster-randomized controlled trial examining a GA intervention compared to usual care. Participants completed the modified 9-item Mishel Uncertainty in Illness Scale at enrollment, 4-6 weeks, 3 months, and 6 months. The dyadic growth model and cross-lagged actor-partner interdependence model were used. RESULTS A total of 397 dyads (patient age M=76.81 ± SD5.43; caregiver age M=66.69 ± SD12.52) were included. Both had a trend of decreased uncertainty over time (b=-0.16, p<.01). There was a greater decrease in uncertainty among caregivers in the GA group than those in the usual care group (b=-0.46, p=.02). For both patients and caregivers, their past uncertainty was a significant predictor of their own current uncertainty (i.e. actor effect, p<.01). The individual's past uncertainty was a significant predictor of the other dyad member's current uncertainty (i.e. partner effect, p<.05), indicating an interdependent relationship between patient and caregiver uncertainty over time. CONCLUSIONS Findings suggest patient and caregiver function as a unit with uncertainty levels affecting each other. Future interventions could build on GA to address uncertainty for older patients with advanced cancer and caregivers. BACKGROUND In the United States, there were approximately 1,898,160 new cancer cases reported in 2021; 60% of these cases are associated with individuals 65 years and older.1 Family members and friends often assume caregiving roles to complement the roles of the healthcare team, especially for older patients.2 Diagnosis and treatment of advanced cancer brings substantial stress for both patients and their caregivers.3 Prior studies have shown that older patients experience substantial adverse physical and psychological conditions, such as symptom burden, diminished quality of life, and distress.4-7 Similarly, caregivers also suffer distress, depression, significant caregiving burden, and impaired quality of life.2,8-10 Among the myriad psychosocial experiences, uncertainty, defined as the inability to navigate illness-related events and unfamiliar treatment strategies through decision-making or disease understanding, is a common psychological reaction in patients and caregivers.11,12 Evidence shows that unrelieved uncertainty is associated with decreased quality of life and poor psychological adjustment in older patients with cancer.13,14 Like other stressors, uncertainty affects both members of the patient-caregiver dyad. Previous studies identified uncertainty as a core overarching theme in the cancer experience and reported high uncertainty levels among caregivers.12,15,16 This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yingzi Zhang
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Supriya Mohile
- Division of Hematology/Oncology, Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Culakova
- Division of Hematology/Oncology, Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Sally Norton
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Sindhuja Kadambi
- Division of Hematology/Oncology, Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Lee Kehoe
- Department of Surgery, Cancer Control, University of Rochester Medical Center, Rochester, New York, USA
| | - Valerie Aarne Grossman
- SCOREboard patient and caregiver advocacy group, University of Rochester Medical Center, Rochester, New York, USA
| | - Victor G Vogel
- Geisinger Cancer Institute NCORP, Danville, Pennsylvania, USA
| | - Brian L Burnette
- Cancer Research of Wisconsin and Northern Michigan, Green Bay, Wisconsin, USA
| | | | - Marie Flannery
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
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Leese EN, Weeder JL, Manikowski JJ, DeLaRue AM, Conger AR, Mahadevan A, Vogel VG, Mongelluzzo GJ, Gatson NTN. PA- and NP-led Ommaya clinics to manage leptomeningeal carcinomatosis. JAAPA 2021; 34:35-41. [PMID: 34772854 DOI: 10.1097/01.jaa.0000800264.81721.3d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Physician assistants (PAs) and NPs are essential to quality care delivery. The need to demonstrate value and optimize PA and NP roles in neurology subspecialty clinics is unmet. We outline the development of a PA- and NP-led neuro-oncology procedural clinic and provide metrics to support the institutional and clinician value added. METHODS We designed a PA- and NP-led Geisinger Ommaya Clinic (GOC) to manage leptomeningeal carcinomatosis (LMC) with defined clinician roles and the GOC treatment protocol. A retrospective review of 135 patients (2012-2019) compared survival outcomes for patients treated on the protocol compared with those treated off the protocol. RESULTS Centralized care in the GOCs minimized shared physician encounters and improved PA and NP autonomy and utility. LMC therapy as part of the GOC protocol improved care continuity and survival outcomes. CONCLUSIONS PA- and NP-led procedural clinics optimize use of these clinicians and open physician availability for nonprocedural duties. This research highlights the institutional patient and financial benefit while demonstrating the operational and leadership growth potential for PAs and NPs.
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Affiliation(s)
- Erika N Leese
- At Geisinger Medical Center in Danville, Pa., Erika N. Leese is lead neuro-oncology advanced practice provider in the Neuroscience Institute, Jamie L. Weeder is chief advanced practice provider of hematology/oncology for the central and western regions, Jesse J. Manikowski is a data scientist in the Geisinger Cancer Institute, Angela M. DeLaRue is lead LPN for the neuro-oncology division, Andrew R. Conger is a lead neurosurgeon in neurosurgical oncology, Anand Mahadevan is chair of the department of radiation oncology, Victor G. Vogel is director of breast medical oncology/radiology, Gino J. Mongelluzzo is chair of the department of neuroradiology, and Na Tosha N. Gatson is director of the neuro-oncology division. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Buchanan AH, Manickam K, Meyer MN, Wagner JK, Hallquist MLG, Williams JL, Rahm AK, Williams MS, Chen ZME, Shah CK, Garg TK, Lazzeri AL, Schwartz MLB, Lindbuchler DAM, Fan AL, Leeming R, Servano PO, Smith AL, Vogel VG, Abul-Husn NS, Dewey FE, Lebo MS, Mason-Suares HM, Ritchie MD, Davis FD, Carey DJ, Feinberg DT, Faucett WA, Ledbetter DH, Murray MF. Correction to: Early cancer diagnoses through BRCA1/2 screening of unselected adult biobank participants. Genet Med 2021; 23:2470. [PMID: 34646007 PMCID: PMC9119243 DOI: 10.1038/s41436-021-01304-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Adam H Buchanan
- Geisinger Health System, Danville, PA, USA. .,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA.
| | - Kandamurugu Manickam
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Michelle N Meyer
- Geisinger Health System, Danville, PA, USA.,Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA, USA
| | - Jennifer K Wagner
- Geisinger Health System, Danville, PA, USA.,Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA, USA
| | - Miranda L G Hallquist
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Janet L Williams
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Alanna Kulchak Rahm
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Marc S Williams
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Zong-Ming E Chen
- Geisinger Health System, Danville, PA, USA.,Laboratory Medicine, Geisinger Health System, Danville, PA, USA
| | - Chaitali K Shah
- Geisinger Health System, Danville, PA, USA.,Radiology, Geisinger Health System, Danville, PA, USA
| | - Tullika K Garg
- Geisinger Health System, Danville, PA, USA.,Department of Urology, Geisinger Health System, Danville, PA, USA
| | - Amanda L Lazzeri
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Marci L B Schwartz
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - D' Andra M Lindbuchler
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Audrey L Fan
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Rosemary Leeming
- Geisinger Health System, Danville, PA, USA.,General Surgery, Geisinger Health System, Danville, PA, USA
| | - Pedro O Servano
- Geisinger Health System, Danville, PA, USA.,Family Medicine, Geisinger Health System, Danville, PA, USA
| | - Ashlee L Smith
- Geisinger Health System, Danville, PA, USA.,Women's Health, Geisinger Health System, Danville, PA, USA
| | - Victor G Vogel
- Geisinger Health System, Danville, PA, USA.,Hematology & Oncology, Geisinger Health System, Danville, PA, USA
| | | | | | - Matthew S Lebo
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, MA, USA
| | - Heather M Mason-Suares
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, MA, USA
| | - Marylyn D Ritchie
- Geisinger Health System, Danville, PA, USA.,Biomedical and Translational Informatics, Geisinger Health System, Danville, PA, USA
| | - F Daniel Davis
- Geisinger Health System, Danville, PA, USA.,Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA, USA
| | - David J Carey
- Geisinger Health System, Danville, PA, USA.,Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - David T Feinberg
- Geisinger Health System, Danville, PA, USA.,Office of the Chief Executive Officer, Geisinger Health System, Danville, PA, USA
| | - W Andrew Faucett
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - David H Ledbetter
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
| | - Michael F Murray
- Geisinger Health System, Danville, PA, USA.,Genomic Medicine Institute, Geisinger Health System, Danville, PA, USA
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Vogel VG. Implementation of Risk-reducing Strategies for Breast Cancer is Long Overdue. Cancer Prev Res (Phila) 2020; 14:1-4. [PMID: 33177071 DOI: 10.1158/1940-6207.capr-20-0556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 11/16/2022]
Abstract
Despite strong evidence that it is efficacious, chemoprevention has been underused in eligible women. Reasons offered not to adopt and initiate strategies to reduce the risk of breast cancer include the fear of adverse effects, medication costs, lack of reasonably accurate and feasible methods for assessing an individual's personal risk, and lack of established risk thresholds that maximize benefit and minimize harms. The article by Macdonald and colleagues remind us that the problem of lack of uptake of risk-reducing medications for breast cancer remains a worldwide clinical challenge despite endorsements from national and international organizations that recommend the use of risk-reducing medications for breast cancer with level I evidence. Several strategies are suggested to improve uptake and utilization of safe and effective chemoprevention medications with high therapeutic indices.See related article by Macdonald et al., p. 131.
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Xu H, Mohile SG, Flannery MA, Peppone LJ, Mohamed M, Ramsdale EE, Patil A, Jonnalagadda S, Jamieson L, Vogel VG, Katato K, Hall B, Mustian KM, Culakova E. Using machine learning to identify older adults at high risk for hospitalization and mortality via the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
169 Background: PRO-CTCAE captures symptomatic adverse events (e.g. pain, fatigue) and may indicate poor treatment tolerability in older patients (pts) with advanced cancer. Using unsupervised machine learning which can detect unknown patterns in data, we aimed to evaluate if clusters identified based on PRO-CTCAE severity were associated with hospitalization and survival. Methods: We included pts randomized to the control arm of GAP 70+ (URCC 13059; PI: Mohile), which enrolled pts aged ≥70, with incurable solid tumors or lymphoma, and ≥1 geriatric assessment (GA) domain impairment starting a new treatment regimen. Measures included 24 PRO-CTCAE items (v1.0) with severity attributes (item 0-4; total score 0-96, higher score = greater severity). The unsupervised algorithm (K-means with Euclidean Distance) clustered pts at baseline based on similarities of severities of the 24 items. We examined if the clusters were associated with treatment-related hospitalization within 3 months and lower survival at 6 months using Logistic and Cox regressions. Results: Of the 369 control pts, 366 completed GA and PRO-CTCAE at baseline (mean age 77.2, 94.3% white, 30.9% with GI and 31.4% with lung cancer; mean number of impaired GA 4.4). By PRO-CTCAE, the most prevalent symptoms were fatigue (82.7%), pain (60.9%), and decreased appetite (58.7%). Greater GA impairment was associated with 20 PRO-CTCAE items (fatigue, pain, and decreased appetite having the strongest associations; all Pearson's r > 0.33). Three clusters were identified: Low Severity (51.4%); Moderate Severity (34.4%), and High Severity (14.2%). Mean total severity score was 6.9 (low), 16.9 (moderate), and 28.7 (high), respectively (p < 0.01). No difference in demographics was found among clusters. Percent of pts hospitalized were 21.3% (low), 36.5% (moderate), and 38.5% (high) (p < 0.01); survival rates were 81.9% (low), 71.4% (moderate), and 55.3% (high) (p < 0.01). Controlling for cancer type and GA, compared to pts in Low Severity cluster, pts in Moderate and High Severity were more likely to be hospitalized (odds ratio = 1.77, p = 0.03); pts in High Severity cluster were more likely to die (hazard ratio = 2.23, p = 0.01). Conclusions: Unsupervised machine learning was able to partition pts into different PRO-CTCAE severity clusters; pts with higher baseline severity were more likely to be hospitalized or die. PRO-CTCAE provides additional information to GA. Funding: R01CA177592, U01CA233167, UG1CA189961.
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Affiliation(s)
- Huiwen Xu
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | | | | | - Amita Patil
- University of Rochester Medical Center, Rochester, NY
| | | | - Leah Jamieson
- Metro Minnesota Community Oncology Research Program, St Louis Park, MN
| | | | | | - Bianca Hall
- University of Rochester Medical Center, Rochester, NY
| | | | - Eva Culakova
- University of Rochester Medical Center, Rochester, NY
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Abstract
7051 Background: Long-term use of aromatase inhibitor (AI) therapy has been shown to decrease bone mineral density (BMD) and is associated with at least twice the fracture risk when compared to an age-matched healthy population. AI’s are a common treatment in hormone receptor-positive breast cancer for post-menopausal women. Similarly, tamoxifen has been shown to decrease BMD in premenopausal women. As a result, the National Comprehensive Cancer Network (NCCN) recommends BMD screening for women being treated with anti-estrogen therapy (AET), typically via Dual-energy X-ray absorptiometry (DEXA) scan. Previous studies have shown poor adherence to BMD screening with AI therapy, but no known study has evaluated compliance with tamoxifen therapy. Methods: We evaluated a retrospective cohort (December 2015 – July 2019) of all women with a breast cancer diagnosis initiating AET using data from the electronic health records of patients throughout a rural integrated health system. We assessed non-adherence to baseline and annual BMD screening using descriptive statistics along with preliminary data regarding fractures associated with AET therapy. Results: A total of 3,693 health records of women with a breast cancer diagnosis and documented prescription for AET were evaluated. In the year before AET initiation, 16% of women received BMD screening. Overall, 1,189 women treated with AET had a DEXA scan ordered at any point after drug initiation: 37% for AI’s and 12% for tamoxifen. Of those treated with AI, 84% had no DEXA ordered within 12 months of starting drug after a minimum of 9 months of continuous use; this value was 96% for tamoxifen use. Patients complied with the ordered DEXA scan within the first year 81% of the time. Repeat DEXA scans were ordered 34% of the time, and patient compliance decreased to 55%. There was no significant difference in the number of patient co-morbidities between patients who did and did not have a DEXA scan ordered. After starting an AI, 131 fractures were documented; 44% occurred within the first year following starting drug treatment with an average of 5 months from drug start to diagnosis. Conclusions: A significant proportion of breast cancer patients treated with AET did not receive guideline-recommended BMD screening. These findings should raise awareness of the importance of BMD screening by responsible providers, including oncologists, primary care physicians, care managers and insurance companies in order to decrease avoidable morbidity.
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Abstract
Millions of women in the United States are at increased risk of breast cancer. Multiple prospective, randomized clinical trials have demonstrated both the efficacy and safety of selective estrogen receptor modulators and aromatase inhibitors in reducing substantially the risk of invasive breast cancer in women at increased risk. Published tables are available to aid clinicians in shared decision-making regarding drug interventions with their patients who are at increased risk of breast cancer. Both professional and governmental agencies have advised that these interventions should be offered to women at increased risk of breast cancer. Doing so would reduce breast cancer morbidity substantially.
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Affiliation(s)
- Victor G Vogel
- Breast Medical Oncology/Research, Geisinger Health System, Danville, Pennsylvania
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Loh KP, Duberstein P, Zittel J, Lei L, Culakova E, Xu H, Plumb S, Flannery MA, Magnuson A, Bautista J, Wittink M, Gilmore N, Targia V, Conlin A, Berenberg J, Vogel VG, Mohile SG. Relationships of self-perceived age with geriatric assessment domains in older adults with cancer. J Geriatr Oncol 2019; 11:1006-1010. [PMID: 31899198 DOI: 10.1016/j.jgo.2019.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/22/2019] [Accepted: 12/26/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Older self-perceived age is associated with poor health and higher healthcare utilization in the geriatric population. We evaluated the associations of self-perceived age with geriatric assessment (GA) domain impairments in older adults with cancer. METHODS This was a secondary analysis of baseline data from a GA cluster-randomized trial (URCC 13070; PI: Mohile). We included patients aged ≥70 with incurable stage III/IV solid tumor or lymphoma considering or receiving treatment and had ≥1 GA domain impairment other than polypharmacy. Multivariate analyses were used to evaluate the associations of age difference between chronological and self-perceived age (categorized into "feeling younger than chronological age" vs. "feeling the same or older than their chronological age") with GA domain impairments. RESULTS We included 533 patients; mean age was 76.6 (SD 5.2). On multivariate analyses, compared to those who felt younger than their chronological age, those who felt the same or older were more likely to have impairments in physical performance [Adjusted Odds Ratio (AOR) 5.42, 95% Confidence Interval (CI) 1.69-17.40)], functional status (AOR 2.31, 95% CI 1.73-3.07), comorbidity (AOR 1.62, 95% CI 1.20-2.19), psychological health (AOR 2.62, 95% CI 1.85-3.73), and nutrition (AOR 1.65, 95% CI 1.20-2.28). They were also more likely to screen positively for polypharmacy (AOR 1.86, 95% CI 1.30-2.65). CONCLUSIONS Older adults with cancer who felt the same or older than their chronological age were more likely to have GA domain impairments. Further studies are needed to better understand the relationships between self-perceived age, aging-related conditions, and outcomes in this population.
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Affiliation(s)
- Kah Poh Loh
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Paul Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, NJ, USA.
| | - Jason Zittel
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Lianlian Lei
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Eva Culakova
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Huiwen Xu
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Sandy Plumb
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Marie A Flannery
- School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Allison Magnuson
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Javier Bautista
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Marsha Wittink
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Nikesha Gilmore
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Valerie Targia
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Alison Conlin
- Pacific Cancer Research Consortium National Cancer Institute Community Oncology Research Program (NCORP), Seattle, WA, USA.
| | - Jeffrey Berenberg
- Hawaii National Cancer Institute Community Oncology Research Program (MU-NCORP), Honolulu, HI, USA.
| | | | - Supriya G Mohile
- James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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13
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Chopra A, Wojtowicz M, Manikowski J, Maddineni B, Kirchner L, Panikkar RP, Vogel VG. Pathological complete response rate (pCR) in thirty-three women with triple-negative breast cancer (TNBC) treated with a neoadjuvant carboplatin-based regimen. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e12099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12099 Background: The purpose of this retrospective case series was to assess pCR rate, progression-free survival and prognostic factors in TNBC. Methods: We reviewed medical records for 33 consecutive female patients with TNBC (41% node+) treated between July 2015 and April 2018 with neoadjuvant paclitaxel 80 mg/m2 IV weekly plus concurrent carboplatin (AUC 4) every 3 weeks for a total of 12 weeks followed by dose-dense doxorubicin 60 mg/m2 plus cyclophosphamide 600 mg/m2 every 2 weeks for a total of 4 cycles. Surgical pathology was studied to determine the presence or absence of residual disease at surgery. Age at treatment, tumor stage, subsequent hospitalizations, and genetic testing were recorded. Patients with residual disease were treated with adjuvant capecitabine 1500 mg PO BID, one week on, one week off, for 6 monthly cycles ± radiation; some patients with a complete pathological response also received postoperative radiation. Results: Among 33 patients, 17 patients had pCR (52%, median age 58 yrs), 10 had a partial response and 6 had no response or progression (median age 63.5). After surgery 24 patients received radiation therapy (XRT). There were 6 hospitalizations, 3 that were treatment related, 2 for neutropenic fever and one for renal failure induced by carboplatin; all 3 resulted in chemotherapy dose reductions; all 3 had pCR. 3 progressions/recurrences were recorded: 2 after treatment and 1 progression during treatment. Two deaths occurred, 1 secondary to progressive disease. Median progression free survival time was 8.5 months (range 0.1 to 24.0 mos). Median time since diagnosis is 16.7 months (range 8.1 to 37.6 mos). There was no significant difference in the median age of patients who had a pCR compared with patients with residual disease. Conclusions: We observed pCR in patients with TNBC treated with a pre-operative carboplatin-containing regimen (superior to historical pCR rates in patients receiving taxanes and anthracyclines only). Although there are insufficient data to demonstrate increased overall survival, we show an improvement in prognosis with a carboplatin-containing regimen for TNBC.
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Manickam K, Buchanan AH, Schwartz MLB, Hallquist MLG, Williams JL, Rahm AK, Rocha H, Savatt JM, Evans AE, Butry LM, Lazzeri AL, Lindbuchler DM, Flansburg CN, Leeming R, Vogel VG, Lebo MS, Mason-Suares HM, Hoskinson DC, Abul-Husn NS, Dewey FE, Overton JD, Reid JG, Baras A, Willard HF, McCormick CZ, Krishnamurthy SB, Hartzel DN, Kost KA, Lavage DR, Sturm AC, Frisbie LR, Person TN, Metpally RP, Giovanni MA, Lowry LE, Leader JB, Ritchie MD, Carey DJ, Justice AE, Kirchner HL, Faucett WA, Williams MS, Ledbetter DH, Murray MF. Exome Sequencing-Based Screening for BRCA1/2 Expected Pathogenic Variants Among Adult Biobank Participants. JAMA Netw Open 2018; 1:e182140. [PMID: 30646163 PMCID: PMC6324494 DOI: 10.1001/jamanetworkopen.2018.2140] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Detection of disease-associated variants in the BRCA1 and BRCA2 (BRCA1/2) genes allows for cancer prevention and early diagnosis in high-risk individuals. OBJECTIVES To identify pathogenic and likely pathogenic (P/LP) BRCA1/2 variants in an unselected research cohort, and to characterize the features associated with P/LP variants. DESIGN, SETTING, AND PARTICIPANTS This is a cross-sectional study of adult volunteers (n = 50 726) who underwent exome sequencing at a single health care system (Geisinger Health System, Danville, Pennsylvania) from January 1, 2014, to March 1, 2016. Participants are part of the DiscovEHR cohort and were identified through the Geisinger MyCode Community Health Initiative. They consented to a research protocol that included sequencing and return of actionable test results. Clinical data from electronic health records and clinical visits were correlated with variants. Comparisons were made between those with (cases) and those without (controls) P/LP variants in BRCA1/2. MAIN OUTCOMES Prevalence of P/LP BRCA1/2 variants in cohort, proportion of variant carriers not previously ascertained through clinical testing, and personal and family history of relevant cancers among BRCA1/2 variant carriers and noncarriers. RESULTS Of the 50 726 health system patients who underwent exome sequencing, 50 459 (99.5%) had no expected pathogenic BRCA1/2 variants and 267 (0.5%) were BRCA1/2 carriers. Of the 267 cases (148 [55.4%] were women and 119 [44.6%] were men with a mean [range] age of 58.9 [23-90] years), 183 (68.5%) received clinically confirmed results in their electronic health record. Among the 267 participants with P/LP BRCA1/2 variants, 219 (82.0%) had no prior clinical testing, 95 (35.6%) had BRCA1 variants, and 172 (64.4%) had BRCA2 variants. Syndromic cancer diagnoses were present in 11 (47.8%) of the 23 deceased BRCA1/2 carriers and in 56 (20.9%) of all 267 BRCA1/2 carriers. Among women, 31 (20.9%) of 148 variant carriers had a personal history of breast cancer, compared with 1554 (5.2%) of 29 880 noncarriers (odds ratio [OR], 5.95; 95% CI, 3.88-9.13; P < .001). Ovarian cancer history was present in 15 (10.1%) of 148 variant carriers and in 195 (0.6%) of 29 880 variant noncarriers (OR, 18.30; 95% CI, 10.48-31.4; P < .001). Among 89 BRCA1/2 carriers without prior testing but with comprehensive personal and family history data, 44 (49.4%) did not meet published guidelines for clinical testing. CONCLUSIONS AND RELEVANCE This study found that compared with previous clinical care, exome sequencing-based screening identified 5 times as many individuals with P/LP BRCA1/2 variants. These findings suggest that genomic screening may identify BRCA1/2-associated cancer risk that might otherwise remain undetected within health care systems and may provide opportunities to reduce morbidity and mortality in patients.
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Affiliation(s)
- Kandamurugu Manickam
- Molecular and Human Genetics Department, Nationwide Children’s Hospital, Columbus, Ohio
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | | | | | | | | | - Heather Rocha
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | - Alyson E. Evans
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Loren M. Butry
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | | | | | | | - Victor G. Vogel
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Matthew S. Lebo
- Laboratory for Molecular Medicine, Partners HealthCare, Cambridge, Massachusetts
| | | | - Derick C. Hoskinson
- Laboratory for Molecular Medicine, Partners HealthCare, Cambridge, Massachusetts
| | | | | | | | | | - Aris Baras
- Regeneron Genetics Center, Tarrytown, New York
| | | | | | | | | | - Korey A. Kost
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | - Amy C. Sturm
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | - T. Nate Person
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | | | - Lacy E. Lowry
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | - Marylyn D. Ritchie
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
- Center for Translational Bioinformatics, University of Pennsylvania, Philadelphia
| | - David J. Carey
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Anne E. Justice
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | | | | | | | | | - Michael F. Murray
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut
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15
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Vogel VG. The Burdens and Uncertainties of Doing What One Should Do. Cancer Prev Res (Phila) 2017; 10:431-433. [PMID: 28739585 DOI: 10.1158/1940-6207.capr-17-0173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 06/15/2017] [Accepted: 06/21/2017] [Indexed: 11/16/2022]
Abstract
Despite FDA approval of drugs to reduce the risk of breast cancer in women at increased risk, uptake of these drugs has been poor despite the publication of numerous studies that demonstrate both their effectives and safety. National organizations have made recommendations for their use, but both physicians and their patients do not fully understand either breast cancer risk factors or risk assessment or the indications for using risk-reducing agents. Histologically predisposing conditions, such as ductal or lobular atypia and lobular carcinoma in situ, impart particularly high risks of developing subsequent invasive breast cancer. Resources should be committed to both provider and patient education to reduce the risk of breast cancer in women who are at increased risk. Cancer Prev Res; 10(8); 431-3. ©2017 AACR.
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Affiliation(s)
- Victor G Vogel
- Breast Medical Oncology/Research, Geisinger Health System, Danville, Pennsylvania.
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16
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Vogel VG. Raloxifene: A Selective Estrogen Receptor Modulator for Reducing the Risk of Invasive Breast Cancer in Postmenopausal Women. Womens Health (Lond Engl) 2016; 3:139-53. [DOI: 10.2217/17455057.3.2.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Raloxifene hydrochloride is a selective estrogen receptor modulator that has antiestrogenic effects on breast and endometrial tissue and estrogenic effects on bone, lipid metabolism and blood clotting. Tamoxifen is the prototypical selective estrogen receptor modulator and reduces the risk of both in situ and invasive breast cancers by half when compared with placebo. The limitations on the use of tamoxifen for breast cancer risk reduction relate to its well-known, but rare, side effects. A number of clinical trials have established the benefit of raloxifene on osteoporosis and fracture. Raloxifene significantly improves serum lipids and serum markers of cardiovascular disease risk, but has no significant effect on the risk of primary coronary events. In several osteoporosis trials and the Raloxifene Use for The Heart (RUTH) trial, raloxifene decreased the risk of estrogen receptor-positive breast cancer by 44–90%. In the Study of Tamoxifen And Raloxifene (STAR) trial, the effect of raloxifene on invasive breast cancer was equivalent to that of tamoxifen, with more favorable effects on uterine malignancy and clotting events. Symptomatic side effects are acceptable. In total, the available data indicate that raloxifene represents an acceptable alternative to tamoxifen for the reduction of the risk of postmenopausal breast cancer in high-risk women. The potential market for a compound shown to reduce the risk of breast cancer in postmenopausal women who are at increased risk for breast cancer is more than 10 million women in the USA alone.
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Affiliation(s)
- Victor G Vogel
- UPMC Cancer Center Magee-Women's Hospital, 300 Halket Street, Room 3524, Pittsburgh, PA 15213, USA, Tel.: +1 412 641 6500; Fax: +1 412 641 6461
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17
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Vogel VG. Update on Breast Cancer Risk Reduction Therapy. Curr Breast Cancer Rep 2016. [DOI: 10.1007/s12609-016-0221-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Wang H, Larson S, Snyder CF, Vogel VG, Kirchner L, Zeng YM, Sun H, Yan XS. Breast cancer chemoprevention in primary care: Assessing readiness for change. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.1547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Abstract
Risk for breast cancer can be easily and rapidly assessed using validated, quantitative models. Multiple randomized studies show that the selective estrogen response modifiers (SERMs) tamoxifen and raloxifene can safely reduce the risk of invasive breast cancer in both pre- and postmenopausal women. Treatment resulted in a 38% reduction in breast cancer incidence, and 42 women would need to be treated to prevent one breast cancer event in the first 10 years of follow-up. Reduction was larger in the first 5 years of follow-up than in years 5 to 10, but no studies treated patients for longer than 5 years. Thromboembolic events were significantly increased with all SERMs, whereas vertebral fractures were reduced. Tamoxifen provides net benefit to all premenopausal women who are at increased risk, whereas raloxifene reduces risk nearly as much in postmenopausal women and offers increased safety. Both tamoxifen and raloxifene reduce the incidence of in situ cancers. Lasofoxifene reduced the risk of breast cancer by 79% in postmenopausal women with osteoporosis. The MAP3 trial showed a 65% reduction in the annual incidence of invasive breast cancer in postmenopausal women who were at moderately increased risk for breast cancer who took the aromatase inhibitor exemestane. The IBIS-II trial showed a 53% reduction in the risk of invasive breast cancer in postmenopausal women aged 40 to 70 who took the aromatase inhibitor anastrozole. Of the 50 million white women in the United States aged 35 to 79, 2.4 million would have a positive benefit/risk index for chemoprevention.
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21
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Wickerham DL, Cecchini RS, Vogel VG, Costantino JP, Cronin WM, Bevers TB, Fehrenbacher L, Pajon ER, Wade JL, Robidoux A, Margolese RG, James JM, Runowicz CD, Ganz PA, Reis SE, McCaskill-Stevens WJ, Ford LG, Jordan VC, Wolmark N. Final updated results of the NRG Oncology/NSABP Protocol P-2: Study of Tamoxifen and Raloxifene (STAR) in preventing breast cancer. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.1500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Victor G. Vogel
- Geisinger Medical Center, and the University of Pittsburgh, Danville, PA
| | | | | | | | - Louis Fehrenbacher
- NRG Oncology/NSABP, and Kaiser Permanente Northern California, Novato, CA
| | - Eduardo R. Pajon
- NRG Oncology/NSABP, and the Colorado Cancer Research Program, Denver, CO
| | | | - Andre Robidoux
- NRG Oncology/NSABP, and Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Richard G. Margolese
- NRG Oncology/NSABP, and The Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Joan M. James
- NRG Oncology/NSABP, and the Fox Chase Cancer Center, Philadelphia, PA
| | - Carolyn D. Runowicz
- NRG Oncology/NSABP, and the Florida International University, Herbert Wertheim College of Medicine, Miami, FL
| | - Patricia A. Ganz
- NRG Oncology/NSABP, and the University of California, Los Angeles, Los Angeles, CA
| | - Steven E. Reis
- NRG Oncology, and The University of Pittsburgh, Pittsburgh, PA
| | | | | | - V. Craig Jordan
- NRG Oncology/NSABP, and the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Norman Wolmark
- NRG Oncology/NSABP, and the Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA
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22
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Abstract
Selective estrogen receptor modulators (SERMs) reduce the risk of recurrence of invasive breast cancer and the incidence of first breast cancers in women who are at increased risk. Multiple, randomized clinical trials have shown both the efficacy and safety of SERMs in reducing the risk of breast cancer. Long-term follow-up as long as 20 years in the randomized trials shows persistent efficacy with acceptable safety. Hormone replacement therapy given concurrently with tamoxifen abrogates its preventive effect, but women with atypical hyperplasia derive particular benefit from SERM therapy. Aromatase inhibitors also reduce the risk of developing invasive breast cancer, but the experience with them for risk reduction is limited to few trials. National organizations have made recommendations to use SERMs and aromatase inhibitors to reduce the risk of breast cancer in high-risk women and additional efforts should be made to increase their use in clinical practice, where the number of women needed to treat to prevent one case of breast cancer conforms to accepted standards of preventive medicine.
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Affiliation(s)
- Victor G Vogel
- Director, Breast Medical Oncology/Research, Geisinger Health System, Danville, PA, 17822, USA.
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24
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Abstract
Breast cancer is the second leading cause of cancer deaths in US women today. This year, approximately 216,000 US women will be diagnosed with invasive breast cancer and another 60,000 with in situ disease. Numerous factors can quantify individual risks for breast cancer, guide therapy and predict outcome. This review focuses on the clinical, pathologic, molecular and genetic prognostic tools available for use in patients with breast cancer, and their impact on clinical decisions and treatment selection.
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Affiliation(s)
- Avina Kapoor
- University of Pittsburgh School of Medicine, Department of Medicine, Magee-Womens Hospital, 300 Halket Street, Room 3524, Pittsburgh, PA 15213-3180, USA.
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Hudson AG, Reeves KW, Modugno F, Wilson JW, Evans RW, Vogel VG, Gierach GL, Simpson J, Weissfeld JL. Erythrocyte omega-6 and omega-3 fatty acids and mammographic breast density. Nutr Cancer 2013; 65:410-6. [PMID: 23530640 DOI: 10.1080/01635581.2013.760744] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Diets low in omega-6 (n-6) polyunsaturated fatty acids (PUFAs) and high in omega-3 (n-3) PUFAs may protect against breast cancer development. Associations of PUFA intake with mammographic density, an intermediate marker of breast cancer risk, have been inconsistent; however, prior studies have relied on self-reported dietary PUFA intake. We examined the association between circulating erythrocyte n-6 and n-3 PUFAs with mammographic density in 248 postmenopausal women who were not taking exogenous hormones. PUFAs in erythrocytes were measured by gas-liquid chromatography, and mammographic density was assessed quantitatively by planimetry. Spearman's correlation coefficients and generalized linear models were used to evaluate the relationships between PUFA measures and mammographic density. None of the erythrocyte n-6 or n-3 PUFA measures were associated with percent density or dense breast area.
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Affiliation(s)
- Alana G Hudson
- Division of Cancer Epidemiology, Bureau for Public Health, West Virginia Department of Health and Human Resources, Charleston, West Virginia 25301-3715, USA.
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Visvanathan K, Hurley P, Bantug E, Brown P, Col NF, Cuzick J, Davidson NE, DeCensi A, Fabian C, Ford L, Garber J, Katapodi M, Kramer B, Morrow M, Parker B, Runowicz C, Vogel VG, Wade JL, Lippman SM. Use of Pharmacologic Interventions for Breast Cancer Risk Reduction: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2013; 31:2942-62. [DOI: 10.1200/jco.2013.49.3122] [Citation(s) in RCA: 242] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose To update the 2009 American Society of Clinical Oncology guideline on pharmacologic interventions for breast cancer (BC) risk reduction. Methods A systematic review of randomized controlled trials and meta-analyses published from June 2007 through June 2012 was completed using MEDLINE and Cochrane Collaboration Library. Primary outcome of interest was BC incidence (invasive and noninvasive). Secondary outcomes included BC mortality, adverse events, and net health benefits. Guideline recommendations were revised based on an Update Committee's review of the literature. Results Nineteen articles met the selection criteria. Six chemoprevention agents were identified: tamoxifen, raloxifene, arzoxifene, lasofoxifene, exemestane, and anastrozole. Recommendations In women at increased risk of BC age ≥ 35 years, tamoxifen (20 mg per day for 5 years) should be discussed as an option to reduce the risk of estrogen receptor (ER) –positive BC. In postmenopausal women, raloxifene (60 mg per day for 5 years) and exemestane (25 mg per day for 5 years) should also be discussed as options for BC risk reduction. Those at increased BC risk are defined as individuals with a 5-year projected absolute risk of BC ≥ 1.66% (based on the National Cancer Institute BC Risk Assessment Tool or an equivalent measure) or women diagnosed with lobular carcinoma in situ. Use of other selective ER modulators or other aromatase inhibitors to lower BC risk is not recommended outside of a clinical trial. Health care providers are encouraged to discuss the option of chemoprevention among women at increased BC risk. The discussion should include the specific risks and benefits associated with each chemopreventive agent.
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Affiliation(s)
- Kala Visvanathan
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Patricia Hurley
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Elissa Bantug
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Powel Brown
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Nananda F. Col
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Jack Cuzick
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Nancy E. Davidson
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Andrea DeCensi
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Carol Fabian
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Leslie Ford
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Judy Garber
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Maria Katapodi
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Barnett Kramer
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Monica Morrow
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Barbara Parker
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Carolyn Runowicz
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Victor G. Vogel
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - James L. Wade
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
| | - Scott M. Lippman
- Kala Visvanathan, Johns Hopkins Medical Institutions; Elissa Bantug, Johns Hopkins Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore; Leslie Ford and Barnett Kramer, National Cancer Institute, Bethesda, MD; Patricia Hurley, American Society of Clinical Oncology, Alexandria, VA; Powel Brown, MD Anderson Cancer Center, University of Texas, Houston, TX; Nananda F. Col, University of New England, Biddeford, ME; Jack Cuzick, Queen Mary University of London, London, United Kingdom; Nancy E
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Ingle JN, Liu M, Wickerham DL, Schaid DJ, Wang L, Mushiroda T, Kubo M, Costantino JP, Vogel VG, Paik S, Goetz MP, Ames MM, Jenkins GD, Batzler A, Carlson EE, Flockhart DA, Wolmark N, Nakamura Y, Weinshilboum RM. Selective estrogen receptor modulators and pharmacogenomic variation in ZNF423 regulation of BRCA1 expression: individualized breast cancer prevention. Cancer Discov 2013; 3:812-25. [PMID: 23764426 DOI: 10.1158/2159-8290.cd-13-0038] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The selective estrogen receptor modulators (SERM) tamoxifen and raloxifene can reduce the occurrence of breast cancer in high-risk women by 50%, but this U.S. Food and Drug Administration-approved prevention therapy is not often used. We attempted to identify genetic factors that contribute to variation in SERM breast cancer prevention, using DNA from the NSABP P-1 and P-2 breast cancer prevention trials. An initial discovery genome-wide association study identified common single-nucleotide polymorphisms (SNP) in or near the ZNF423 and CTSO genes that were associated with breast cancer risk during SERM therapy. We then showed that both ZNF423 and CTSO participated in the estrogen-dependent induction of BRCA1 expression, in both cases with SNP-dependent variation in induction. ZNF423 appeared to be an estrogen-inducible BRCA1 transcription factor. The OR for differences in breast cancer risk during SERM therapy for subjects homozygous for both protective or both risk alleles for ZNF423 and CTSO was 5.71.
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Affiliation(s)
- James N Ingle
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA.
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Leader JB, Bengier A, Darer J, Stark A, Vogel VG. Abstract P4-13-12: Identifying women at increased risk for breast cancer using the electronic health record in an integrated health system. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p4-13-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Women at increased risk for breast cancer (BC) are eligible to take selective estrogen receptor modulators (SERMs) to reduce their risk; Food and Drug Administration (FDA) approval of tamoxifen or raloxifene for BC risk reduction and American Society of Clinical Oncology (ASCO) guidelines for the use of SERMs recommend the two drugs for any woman over the age of 35 years with a 5-year risk of 1.67% or greater, but identifying those women can be both challenging and costly. We used an electronic database (Centricity RIS-IC) from the Geisinger Health System (GHS) Department of Radiology with 77,000 women ages 35–90 years to calculate 5-year and lifetime risks of developing invasive BC using National Cancer Institute's (NCI) Breast Cancer Risk Assessment Macro (BrCa RAM). BrCa RAM calculates risk based on patient age, number of biopsies, did a biopsy ever display atypical hyperplasia (Yes/No), age at menarche, age at first live birth, number of first degree relatives with breast cancer, and patient race. Demographic information (age, race, sex) was obtained from the electronic health record (EpicCare), pathology information (number of biopsies, atypical hyperplasia) was obtained from the pathology application (CoPath), and personal history (number of first degree relatives with breast cancer) were obtained from RIS. Age at menarche and age at first live birth could not be obtained, but makes a small relative contribution to the risk of BC. Sensitivity analysis explored implications of missing data; imputing ages for age at first live birth and age at menarche showed that the absence of this data did not overestimate the five-year and lifetime risks. There were 5,897 patients with calculated 5-year breast cancer risk 2; mean age was 65.8 years, mean 5-yr risk of BC = 3.05% (max 18.2%). The number of patients by 5-year risk score category were: risk 2–2.5% (n = 1728); 2.5%–3% (n = 3188); 3%+ (n = 981). There were 4,196 patients with a GHS primary care physician (PCP); 5,086 patients had seen any Geisinger physician within the past year; 4,113 women had seen their PCP in the past year. Only 239 patients ever received a prescription for tamoxifen or raloxifene, and some received raloxifene for prevention or treatment of osteoporosis and not for BC risk reduction. Only 40 were currently taking tamoxifen or raloxifene. These data from an integrated health system with an electronic health record validate the under-utilization of SERMs for primary BC risk reduction. Strategies are being designed to increase their use in GHS by using the risk score to identify the population and attempt to intervene using a risk modification clinical program.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-12.
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Affiliation(s)
- JB Leader
- Geisinger Health System, Danville, PA; Geisinger Health System, Lewisburg, PA
| | - A Bengier
- Geisinger Health System, Danville, PA; Geisinger Health System, Lewisburg, PA
| | - J Darer
- Geisinger Health System, Danville, PA; Geisinger Health System, Lewisburg, PA
| | - A Stark
- Geisinger Health System, Danville, PA; Geisinger Health System, Lewisburg, PA
| | - VG Vogel
- Geisinger Health System, Danville, PA; Geisinger Health System, Lewisburg, PA
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Khatcheressian JL, Hurley P, Bantug E, Esserman LJ, Grunfeld E, Halberg F, Hantel A, Henry NL, Muss HB, Smith TJ, Vogel VG, Wolff AC, Somerfield MR, Davidson NE. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2012; 31:961-5. [PMID: 23129741 DOI: 10.1200/jco.2012.45.9859] [Citation(s) in RCA: 390] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To provide recommendations on the follow-up and management of patients with breast cancer who have completed primary therapy with curative intent. METHODS To update the 2006 guideline of the American Society of Clinical Oncology (ASCO), a systematic review of the literature published from March 2006 through March 2012 was completed using MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed the evidence to determine whether the recommendations were in need of updating. RESULTS There were 14 new publications that met inclusion criteria: nine systematic reviews (three included meta-analyses) and five randomized controlled trials. After its review and analysis of the evidence, the Update Committee concluded that no revisions to the existing ASCO recommendations were warranted. RECOMMENDATIONS Regular history, physical examination, and mammography are recommended for breast cancer follow-up. Physical examinations should be performed every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter. For women who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed. The use of complete blood counts, chemistry panels, bone scans, chest radiographs, liver ultrasounds, pelvic ultrasounds, computed tomography scans, [(18)F]fluorodeoxyglucose-positron emission tomography scans, magnetic resonance imaging, and/or tumor markers (carcinoembryonic antigen, CA 15-3, and CA 27.29) is not recommended for routine follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination.
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Vogel VG. Abstract FO02-01: Lessons learned from 20 years of chemoprevention research. Cancer Prev Res (Phila) 2012. [DOI: 10.1158/1940-6207.prev-12-fo02-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
A preventive strategy is more attractive than treating progressive or advanced cancer, but neither the primary care community nor medical oncologists have embraced chemoprevention as their own responsibility, despite the fact that professional organizations have endorsed primary prevention as a standard of care. In order for a preventive strategy to be both effective and efficient, we need an easily identified target population, criteria for identifying those who would benefit from risk reduction, a safe and effective agent, an informed group of practitioners who can provide care to the high-risk group, and an educated population of patients who understand the advantages and the risks of taking a drug to modify their risk. Despite strong evidence that it is efficacious, chemoprevention has been underused. For breast cancer risk reduction, for example, the number needed to treat to prevent a single case of breast cancer are comparable to similar costs of statins to reduce cardiovascular events or of antihypertensives to lower the risk of stroke. Reasons not to adopt and initiate strategies to reduce risk include the fear of adverse effects, medication costs, lack of reasonably accurate and feasible methods for assessing personal and individual risks, and the lack of established risk thresholds that clearly and objectively maximize benefit and minimize harms. Lack of reimbursement for the cost of risk counseling and for the agents administered to reduce risk are also impediments to widespread adoption of preventive strategies. Methods to improve this situation include both professional and public education, tort reform, inclusion of preventive drugs in health care insurance coverage, and the identification of safer, more effective agents for risk reduction.
Citation Format: Victor G. Vogel. Lessons learned from 20 years of chemoprevention research. [abstract]. In: Proceedings of the Eleventh Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2012 Oct 16-19; Anaheim, CA. Philadelphia (PA): AACR; Cancer Prev Res 2012;5(11 Suppl):Abstract nr FO02-01.
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G. Vogel V. Selective Estrogen Receptor Modulators and Aromatase Inhibitors for Breast Cancer Chemoprevention. Curr Drug Targets 2011; 12:1874-87. [DOI: 10.2174/138945011798184164] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 08/20/2010] [Accepted: 08/22/2010] [Indexed: 11/22/2022]
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Runowicz CD, Costantino JP, Wickerham DL, Cecchini RS, Cronin WM, Ford LG, Vogel VG, Wolmark N. Gynecologic conditions in participants in the NSABP breast cancer prevention study of tamoxifen and raloxifene (STAR). Am J Obstet Gynecol 2011; 205:535.e1-5. [PMID: 21872200 DOI: 10.1016/j.ajog.2011.06.067] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 03/22/2011] [Accepted: 06/13/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study reports the gynecologic conditions in postmenopausal women (intact uterus on enrollment) in the National Surgical Adjuvant Breast and Bowel Project (NSABP) study of tamoxifen and raloxifene (STAR)/P-2 trial. STUDY DESIGN This study, with a median follow-up period of 81 months, evaluated the incidence rates/risks of gynecologic conditions among women who were treated with tamoxifen and raloxifene. RESULTS Compared with women who received tamoxifen therapy, women who received raloxifene therapy had a lower incidence of uterine cancer (relative risk, 0.55)/endometrial hyperplasia (relative risk, 0.19), leiomyomas (relative risk, 0.55), ovarian cysts (relative risk, 0.60), and endometrial polyps (relative risk, 0.30) and had fewer procedures performed. Women receiving tamoxifen therapy had more hot flashes (P < .0001), vaginal discharge (P < .0001), and vaginal bleeding (P < .0001). CONCLUSION Our results suggest that tamoxifen has more of an estrogenic effect on the gynecologic reproductive organs. These effects should be considered in counseling women on options for breast cancer prevention.
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Affiliation(s)
- Carolyn D Runowicz
- National Surgical Adjuvant Breast and Bowel Project, National Cancer Institute, Pittsburgh, PA, USA.
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Vogel VG. Update on raloxifene: role in reducing the risk of invasive breast cancer in postmenopausal women. Breast Cancer (Dove Med Press) 2011; 3:127-37. [PMID: 24367182 DOI: 10.2147/bctt.s11288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Risk factors allow us to define women who are at increased lifetime risk for breast cancer, and the most important factor is age. Benign breast disease increases risk, and the most important histologies are atypical lobular or ductal hyperplasia and lobular carcinoma in situ. Family history of breast cancer among first-degree relatives (mother, sisters, daughters) also increases risk. Quantitative measures of risk give accurate predictions of breast cancer incidence for groups of women but not for individual subjects. Multiple published, randomized controlled trials, which employed selective estrogen receptor (ER) modulators (SERMs), have demonstrated consistent reductions of 35% or greater in the risk of ER-positive invasive and noninvasive breast cancer in postmenopausal women. Professional organizations in the US now recommend the use of SERMs to reduce the risk of breast cancer in high-risk, postmenopausal women. Raloxifene and tamoxifen reduce the risk of ER-positive invasive breast cancer with equal efficacy, but raloxifene is associated with a lower risk of thromboembolic disease, benign uterine conditions, and cataracts than tamoxifen in postmenopausal women. No evidence exists establishing whether a reduction in breast cancer risk from either agent translates into reduced breast cancer mortality. Overall quality of life is similar with raloxifene or tamoxifen, but the incidence of dyspareunia, weight gain, and musculoskeletal complaints is higher with raloxifene use, whereas vasomotor symptoms, bladder incontinence, gynecologic symptoms, and leg cramps were higher with tamoxifen use.
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Affiliation(s)
- Victor G Vogel
- Cancer institute, Geisinger Health System, Danville, PA, USA
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Kim C, Tang G, Pogue-Geile KL, Costantino JP, Baehner FL, Baker J, Cronin MT, Watson D, Shak S, Bohn OL, Fumagalli D, Taniyama Y, Lee A, Reilly ML, Vogel VG, McCaskill-Stevens W, Ford LG, Geyer CE, Wickerham DL, Wolmark N, Paik S. Estrogen receptor (ESR1) mRNA expression and benefit from tamoxifen in the treatment and prevention of estrogen receptor-positive breast cancer. J Clin Oncol 2011; 29:4160-7. [PMID: 21947828 DOI: 10.1200/jco.2010.32.9615] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Several mechanisms have been proposed to explain tamoxifen resistance of estrogen receptor (ER) -positive tumors, but a clinically useful explanation for such resistance has not been described. Because the ER is the treatment target for tamoxifen, a linear association between ER expression levels and the degree of benefit from tamoxifen might be expected. However, such an association has never been demonstrated with conventional clinical ER assays, and the ER is currently used clinically as a dichotomous marker. We used gene expression profiling and ER protein assays to help elucidate molecular mechanism(s) responsible for tamoxifen resistance in breast tumors. PATIENTS AND METHODS We performed gene expression profiling of paraffin-embedded tumors from National Surgical Adjuvant Breast and Bowel Project (NSABP) trials that tested the worth of tamoxifen as an adjuvant systemic therapy (B-14) and as a preventive agent (P-1). This was a retrospective subset analysis based on available materials. RESULTS In B-14, ESR1 was the strongest linear predictor of tamoxifen benefit among 16 genes examined, including PGR and ERBB2. On the basis of these data, we hypothesized that, in the P-1 trial, a lower level of ESR1 mRNA in the tamoxifen arm was the main difference between the two study arms. Only ESR1 was downregulated by more than two-fold in ER-positive cancer events in the tamoxifen arm (P < .001). Tamoxifen did not prevent ER-positive tumors with low levels of ESR1 expression. CONCLUSION These data suggest that low-level expression of ESR1 is a determinant of tamoxifen resistance in ER-positive breast cancer. Strategies should be developed to identify, treat, and prevent such tumors.
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Affiliation(s)
- Chungyeul Kim
- National Surgical Adjuvant Breast and Bowel Project, Division of Pathology, 1307 Federal St, Pittsburgh, PA 15212, USA
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Vogel VG. Update on Estrogen Receptor–Positive Breast Cancer Risk Reduction. Curr Breast Cancer Rep 2011. [DOI: 10.1007/s12609-011-0051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Goetz MP, Schaid DJ, Wickerham DL, Safgren S, Mushiroda T, Kubo M, Batzler A, Costantino JP, Vogel VG, Paik S, Carlson EE, Flockhart DA, Wolmark N, Nakamura Y, Weinshilboum RM, Ingle JN, Ames MM. Evaluation of CYP2D6 and efficacy of tamoxifen and raloxifene in women treated for breast cancer chemoprevention: results from the NSABP P1 and P2 clinical trials. Clin Cancer Res 2011; 17:6944-51. [PMID: 21880792 DOI: 10.1158/1078-0432.ccr-11-0860] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Controversy exists regarding the association between CYP2D6 enzyme activity and tamoxifen effectiveness in the adjuvant treatment of invasive breast cancer; however, this association in the primary prevention of breast cancer is unknown. METHODS We conducted a nested case-control study in the context of the NSABP P1 and P2 prevention trials to determine the impact of CYP2D6 genotype, CYP2D6 inhibitor use, and metabolizer status (CYP2D6 genotype combined with CYP2D6 inhibitor use), on breast cancer events. Women who developed breast cancer (both noninvasive and invasive) while on 5 years of selective estrogen receptor modulators therapy (cases) were matched to controls free of breast cancer. Comprehensive CYP2D6 genotyping was conducted for alleles associated with absent (*3, *4, *5, and *6), reduced (*10, *17, and *41), and increased (*1XN and *2XN) enzyme activity. Information regarding the use of CYP2D6 inhibitors was recorded. RESULTS A total of 591 cases were matched to 1,126 controls and DNA was genotyped in more than 97%. In patients treated with tamoxifen, there was no association of CYP2D6 genotype [OR (extensive/poor metabolizer): 0.90; 95% CI: 0.46-1.74, P = 0.74), use of a potent CYP2D6 inhibitor (OR 0.92; 95% CI: 0.575-1.486), or CYP2D6 metabolizer status (OR 1.03; 95% CI: 0.669-1.607) with breast cancer occurrence. Likewise, there was no association between any CYP2D6 metabolism parameter with breast cancer events in raloxifene-treated patients. CONCLUSION In the NSABP P1 and P2 clinical trials, alterations in CYP2D6 metabolism are not associated with either tamoxifen or raloxifene efficacy.
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Affiliation(s)
- Matthew P Goetz
- Department of Oncology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Freedman AN, Yu B, Gail MH, Costantino JP, Graubard BI, Vogel VG, Anderson GL, McCaskill-Stevens W. Benefit/risk assessment for breast cancer chemoprevention with raloxifene or tamoxifen for women age 50 years or older. J Clin Oncol 2011; 29:2327-33. [PMID: 21537036 DOI: 10.1200/jco.2010.33.0258] [Citation(s) in RCA: 152] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Study of Tamoxifen and Raloxifene (STAR) demonstrated that raloxifene was as effective as tamoxifen in reducing the risk of invasive breast cancer (IBC) in postmenopausal women and had lower risks of thromboembolic events, endometrial cancer, and cataracts but had a nonstatistically significant higher risk of noninvasive breast cancer. There is a need to summarize the risks and benefits of these agents. PATIENTS AND METHODS Baseline incidence rates of IBC and other health outcomes, absent raloxifene and tamoxifen, were estimated from breast cancer chemoprevention trials; the Surveillance, Epidemiology and End Results Program; and the Women's Health Initiative. Effects of raloxifene and tamoxifen were estimated from STAR and the Breast Cancer Prevention Trial. We assigned weights to health outcomes to calculate the net benefit from raloxifene compared with placebo and tamoxifen compared with placebo. RESULTS Risks and benefits of treatment with raloxifene or tamoxifen depend on age, race, breast cancer risk, and history of hysterectomy. Over a 5-year period, postmenopausal women with an intact uterus had a better benefit/risk index for raloxifene than for tamoxifen. For postmenopausal women without a uterus, the benefit/risk ratio was similar. The benefits and risks of raloxifene and tamoxifen are described in tables that can help identify groups of women for whom the benefits outweigh the risks. CONCLUSION We developed a benefit/risk index to quantify benefits from chemoprevention with tamoxifen or raloxifene. This index can complement clinical evaluation in deciding whether to initiate chemoprevention and in comparing the benefits and risks of raloxifene versus tamoxifen.
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Affiliation(s)
- Andrew N Freedman
- Division of Cancer Prevention, National Cancer Institute, 6130 Executive Blvd., Bethesda, MD 20892, USA.
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Liu M, Wang L, Schaid D, Wickerham DL, Costantino JP, Goetz MP, Ames MM, Vogel VG, Paik S, Batzler A, Wolmark N, Nakamura Y, Kubo M, Kamatani N, Ingle JN, Weinshilboum RM. Abstract 4727: Breast cancer prevention and selective estrogen response modulators (SERMs): Pharmacogenomics and differential estrogen and SERM regulation of BRCA1 and BRCA2 expression. Cancer Res 2011. [DOI: 10.1158/1538-7445.am2011-4727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: The NSABP P-1 and P-2 breast cancer prevention trials have demonstrated that the SERMs tamoxifen and raloxifene can reduce the risk of breast cancer in high risk women.
Methods: We performed a nested matched case-control GWAS utilizing DNA from participants enrolled in P-1 and P-2. 592 participants developed invasive breast cancer or ductal carcinoma in situ, and were matched with 1171 controls who did not. Genome-wide genotyping with the Illumina 610-Quad chip and CYP2D6 genotyping for pertinent alleles were performed. Functional genomic studies involved the use of cultured cells, with siRNA knockdown, followed by qRT-PCR and Western blot analyses.
Results: Eleven SNPs with p-values < 3E-05 were identified. Twenty one additional SNPs with p < 4E-05 were identified by imputation around the genotyped SNPs on chromosomes (Chrs) 4, 8, 9, 13, 16 and 22, which were then genotyped with the Invader platform. Initial functional genomic studies focused on 6 SNPs on Chr16 (p-values 1.81-9.55E-06), all of which were in ZNF423, a gene encoding a putative zinc-finger protein. The Chr16 minor variant SNP sequences had less risk than the common variant (OR=0.7). Our functional studies showed that incubation of Hs578T cells stably transfected with estrogen receptor (ER) α with 0.1 nM estradiol (E2) induced expression of ZNF423, BRCA1/2 for WT but not variant SNP sequences. There was also a striking difference between E2-induced ZNF423, BRCA1/2 expression for variant and WT SNPs in lymphoblastoid cell lines (LCLs) stably transfected with ERα, with only WT showing induction. ChIP assay showed that ZNF423 could bind to the 5’-flanking region of BRCA1, and reporter gene assays showed that ZNF423 could regulate BRCA1/2 transcription. In LCLs stably transfected with ERα and genotyped for ZNF423 SNPs, estrogen-dependent expression of all 3 genes occurred only in the presence of the WT, but not variant ZNF423 SNP sequences. Blockade of ERα with 4-OH tamoxifen prevented induction of expression in cells with WT sequences, but resulted in gene dose-dependent increases in BRCA1/2 expression in cells with variant SNP sequences-suggested that the minor variant has a “protective” effect during clinical SERM therapy and verified by ChIP assays.
Conclusions: The SNPs in ZNF423 identified during GWAS were associated with differential E2-dependent induction of ZNF423, BRCA1 and BRCA2-implying that ZNF423 is “upstream” for the estrogen-dependent induction of BRCA1/2 expression. However, LCLs with variant SNP sequences showed greatly enhanced expression of ZNF423, BRCA1/2 during 4-OH tamoxifen exposure, while cells with WT sequences did not. These results may reveal a novel mechanism for SERM-dependent regulation of BRCA1/2 expression and may have implications for patient selection for SERM therapy.
Funded by U10-CA37377, U10-CA69974 and U14-GM61388.
Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4727. doi:10.1158/1538-7445.AM2011-4727
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Reeves KW, Stone RA, Modugno F, Ness RB, Vogel VG, Weissfeld JL, Habel LA, Vuga M, Cauley JA. A Method to Estimate Off-Schedule Observations in a Longitudinal Study. Ann Epidemiol 2011; 21:297-303. [DOI: 10.1016/j.annepidem.2010.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 11/23/2010] [Accepted: 11/26/2010] [Indexed: 11/29/2022]
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Vogel VG, Costantino JP, Wickerham DL, McCaskill-Stevens W, Clarfeld RB, Grant MD, Wolmark N. Carcinoma in situ outcomes in National Surgical Adjuvant Breast and Bowel Project Breast Cancer Chemoprevention Trials. J Natl Cancer Inst Monogr 2011; 2010:181-6. [PMID: 20956826 DOI: 10.1093/jncimonographs/lgq041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In the National Surgical Adjuvant Breast and Bowel Project (NSABP) Breast Cancer Prevention Trial (BCPT), the reduction in risk of noninvasive breast cancer was 50%. There were 93 cases in women receiving placebo and 60 in those receiving tamoxifen (P = .008). Through 7 years of follow-up, the cumulative incidence of noninvasive breast cancer among the placebo group was 15.8 per 1000 women vs 10.2 per 1000 women in the tamoxifen group. In the initial report of the Study of Tamoxifen and Raloxifene (STAR trial), the rate for noninvasive breast cancer was 1.51 per 1000 women assigned to tamoxifen and 2.11 per 1000 women assigned to raloxifene (risk ratio, 1.40; 95% confidence interval = 0.98 to 2.00). METHODS Additional follow-up of the NSABP STAR trial through March 31, 2009 is reported with a focus on noninvasive breast cancer events. RESULTS Through 81 months of median follow-up in the NSABP STAR trial, there are 137 cases of noninvasive breast cancer in the raloxifene group compared with 111 cases in the tamoxifen group (risk ratio = 1.02, 95% confidence interval = 0.61 to 1.70). The occurrence of ductal carcinoma in situ with raloxifene was seen more frequently among women with lower baseline Gail scores and no atypical hyperplasia than in women taking tamoxifen therapy. Raloxifene retained 76% of the effectiveness of tamoxifen in preventing invasive breast cancer. CONCLUSIONS Although these data indicate that raloxifene offers less protection than tamoxifen for postmenopausal women who are at increased risk for both invasive and noninvasive breast cancer, the favorable risk-benefit profile for raloxifene affords acceptable clinical reduction in the risk of in situ cancers among postmenopausal women.
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Affiliation(s)
- Victor G Vogel
- National Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA, USA.
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Ganz PA, Land SR, Geyer CE, Cecchini RS, Costantino JP, Pajon ER, Fehrenbacher L, Atkins JN, Polikoff JA, Vogel VG, Erban JK, Livingston RB, Perez EA, Mamounas EP, Wolmark N, Swain SM. Menstrual history and quality-of-life outcomes in women with node-positive breast cancer treated with adjuvant therapy on the NSABP B-30 trial. J Clin Oncol 2011; 29:1110-6. [PMID: 21300930 DOI: 10.1200/jco.2010.29.7689] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Premenopausal women with breast cancer receiving adjuvant chemotherapy are at risk for amenorrhea. The National Surgical Adjuvant Breast and Bowel Project B-30 trial included menstrual history (MH) and quality-of-life (QOL) studies to compare treatments on these outcomes. PATIENTS AND METHODS Patients were randomly assigned to sequential doxorubicin (A) and cyclophosphamide (C) followed by docetaxel (T; AC→T), concurrent TAC, or AT, which varied in duration (24, 12, 12 weeks, respectively), and use of C. Endocrine therapy was prescribed for women with hormone receptor-positive tumors. MH and QOL were assessed with standardized questionnaires at baseline; cycle 4, day 1; and every 6 months through 24 months. Prespecified analyses examined rates of amenorrhea by treatment arm, the relationship between amenorrhea and QOL, and QOL by treatment arm. RESULTS Amenorrhea 12 months after random assignment was significantly different between treatment groups: 69.8% for AC→T, 57.7% for TAC, and 37.9% for AT (P < .001). The AT group without tamoxifen had the lowest rate of amenorrhea. QOL was poorer for patients receiving AC→T at 6 months but similar to others by 12 months. Post-treatment symptoms were increased above baseline for all treatments. Multivariable repeated measures modeling demonstrated that treatment arm, time point, age, and tamoxifen use were significantly associated with symptom severity (all P values < .002). CONCLUSION Amenorrhea rates differed significantly by treatment arm, with the AT arm having the lowest rate. Patients treated with longer duration therapy (AC→T) had greater symptom severity and poorer QOL at 6 months, but did not differ from shorter duration treatments at 12 months.
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Affiliation(s)
- Patricia A Ganz
- National Surgical Adjuvant Breast and Bowel Project Operations Center (NSABP), Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
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Swain SM, Jeong JH, Geyer CE, Costantino JP, Pajon ER, Fehrenbacher L, Atkins JN, Polikoff J, Vogel VG, Erban JK, Rastogi P, Livingston RB, Perez EA, Mamounas EP, Land SR, Ganz PA, Wolmark N. Longer therapy, iatrogenic amenorrhea, and survival in early breast cancer. N Engl J Med 2010; 362:2053-65. [PMID: 20519679 PMCID: PMC2935316 DOI: 10.1056/nejmoa0909638] [Citation(s) in RCA: 236] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chemotherapy regimens that combine anthracyclines and taxanes result in improved disease-free and overall survival among women with operable lymph-node-positive breast cancer. The effectiveness of concurrent versus sequential regimens is not known. METHODS We randomly assigned 5351 patients with operable, node-positive, early-stage breast cancer to receive four cycles of doxorubicin and cyclophosphamide followed by four cycles of docetaxel (sequential ACT); four cycles of doxorubicin and docetaxel (doxorubicin-docetaxel); or four cycles of doxorubicin, cyclophosphamide, and docetaxel (concurrent ACT). The primary aims were to examine whether concurrent ACT was more effective than sequential ACT and whether the doxorubicin-docetaxel regimen would be as effective as the concurrent-ACT regimen. The secondary aims were to assess toxic effects and to correlate amenorrhea with outcomes in premenopausal women. RESULTS At a median follow-up of 73 months, overall survival was improved in the sequential-ACT group (8-year overall survival, 83%) as compared with the doxorubicin-docetaxel group (overall survival, 79%; hazard ratio for death, 0.83; P=0.03) and the concurrent-ACT group (overall survival, 79%; hazard ratio, 0.86; P=0.09). Disease-free survival was improved in the sequential-ACT group (8-year disease-free survival, 74%) as compared with the doxorubicin-docetaxel group (disease-free survival, 69%; hazard ratio for recurrence, a second malignant condition, or death, 0.80; P=0.001) and the concurrent-ACT group (disease-free survival, 69%; hazard ratio, 0.83; P=0.01). The doxorubicin-docetaxel regimen showed noninferiority to the concurrent-ACT regimen for overall survival (hazard ratio, 0.96; 95% confidence interval, 0.82 to 1.14). Overall survival was improved in patients with amenorrhea for 6 months or more across all treatment groups, independently of estrogen-receptor status. CONCLUSIONS Sequential ACT improved disease-free survival as compared with doxorubicin-docetaxel or concurrent ACT, and it improved overall survival as compared with doxorubicin-docetaxel. Amenorrhea was associated with improved survival regardless of the treatment and estrogen-receptor status. (ClinicalTrials.gov number, NCT00003782.)
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Affiliation(s)
- Sandra M Swain
- National Surgical Adjuvant Breast and Bowel Project, Washington Cancer Institute at Washington Hospital Center, Washington, DC 20010, USA.
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Vogel VG, Costantino JP, Wickerham DL, Cronin WM, Cecchini RS, Atkins JN, Bevers TB, Fehrenbacher L, Pajon ER, Wade JL, Robidoux A, Margolese RG, James J, Runowicz CD, Ganz PA, Reis SE, McCaskill-Stevens W, Ford LG, Jordan VC, Wolmark N. Update of the National Surgical Adjuvant Breast and Bowel Project Study of Tamoxifen and Raloxifene (STAR) P-2 Trial: Preventing breast cancer. Cancer Prev Res (Phila) 2010; 3:696-706. [PMID: 20404000 DOI: 10.1158/1940-6207.capr-10-0076] [Citation(s) in RCA: 424] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The selective estrogen-receptor modulator (SERM) tamoxifen became the first U.S. Food and Drug Administration (FDA)-approved agent for reducing breast cancer risk but did not gain wide acceptance for prevention, largely because it increased endometrial cancer and thromboembolic events. The FDA approved the SERM raloxifene for breast cancer risk reduction following its demonstrated effectiveness in preventing invasive breast cancer in the Study of Tamoxifen and Raloxifene (STAR). Raloxifene caused less toxicity (versus tamoxifen), including reduced thromboembolic events and endometrial cancer. In this report, we present an updated analysis with an 81-month median follow-up. STAR women were randomly assigned to receive either tamoxifen (20 mg/d) or raloxifene (60 mg/d) for 5 years. The risk ratio (RR; raloxifene:tamoxifen) for invasive breast cancer was 1.24 (95% confidence interval [CI], 1.05-1.47) and for noninvasive disease, 1.22 (95% CI, 0.95-1.59). Compared with initial results, the RRs widened for invasive and narrowed for noninvasive breast cancer. Toxicity RRs (raloxifene:tamoxifen) were 0.55 (95% CI, 0.36-0.83; P = 0.003) for endometrial cancer (this difference was not significant in the initial results), 0.19 (95% CI, 0.12-0.29) for uterine hyperplasia, and 0.75 (95% CI, 0.60-0.93) for thromboembolic events. There were no significant mortality differences. Long-term raloxifene retained 76% of the effectiveness of tamoxifen in preventing invasive disease and grew closer over time to tamoxifen in preventing noninvasive disease, with far less toxicity (e.g., highly significantly less endometrial cancer). These results have important public health implications and clarify that both raloxifene and tamoxifen are good preventive choices for postmenopausal women with elevated risk for breast cancer.
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Im A, Vogel VG, Ahrendt G, Lloyd S, Ragin C, Garte S, Taioli E. Urinary estrogen metabolites in women at high risk for breast cancer. Carcinogenesis 2009; 30:1532-5. [PMID: 19502596 DOI: 10.1093/carcin/bgp139] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study explored whether average urinary estrogen metabolites in breast cancer high-risk women can be used to identify a subgroup of women at particularly high risk to develop breast cancer, to which prevention strategies should be addressed. METHODS The population consisted of 77 high-risk women, 30 breast cancer patients and 41 controls. All subjects answered a standardized questionnaire; height and weight and spot urine samples were also obtained. Urine hydroxyestrogen metabolites were measured in triplicate by enzyme immunoassay, and the estrogen metabolite ratios for each individual were calculated. RESULTS The 2:16 OHE ratio (2-hydroxyestrone/16-alpha-hydroxyestrone) in women at high risk for breast cancer was similar to that observed in the breast cancer group (1.76 +/- 2.33 versus 1.29 +/- 0.80) and lower than in controls (2.47 +/- 1.14; P = 0.00). At the multivariate linear regression model, the 2:16 OHE ratio was significantly associated with diagnosis (P = 0.000 for both the high risk and breast cancer group versus the controls) and body mass index (P = 0.005), but not with age (P = 0.604), or smoking history (P = 0.478). CONCLUSIONS This study suggests that lower urinary 2:16 OHE ratios are predictors of breast cancer risk. Profiling estrogen metabolites may identify women who are more probably to develop breast cancer within a population of women with known risk factors and may help to further elucidate the clinical relevance of urinary 2:16 OHE ratios as clinical markers and prognostic indicators in this population.
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Affiliation(s)
- Annie Im
- Magee/UPCI Breast Cancer Prevention Program, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
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Visvanathan K, Chlebowski RT, Hurley P, Col NF, Ropka M, Collyar D, Morrow M, Runowicz C, Pritchard KI, Hagerty K, Arun B, Garber J, Vogel VG, Wade JL, Brown P, Cuzick J, Kramer BS, Lippman SM. American society of clinical oncology clinical practice guideline update on the use of pharmacologic interventions including tamoxifen, raloxifene, and aromatase inhibition for breast cancer risk reduction. J Clin Oncol 2009; 27:3235-58. [PMID: 19470930 DOI: 10.1200/jco.2008.20.5179] [Citation(s) in RCA: 220] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To update the 2002 American Society of Clinical Oncology guideline on pharmacologic interventions for breast cancer (BC) risk reduction. METHODS A literature search identified relevant randomized trials published since 2002. Primary outcome of interest was BC incidence (invasive and noninvasive). Secondary outcomes included BC mortality, adverse events, and net health benefits. An expert panel reviewed the literature and developed updated consensus guidelines. Results Seventeen articles met inclusion criteria. In premenopausal women, tamoxifen for 5 years reduces the risk of BC for at least 10 years, particularly estrogen receptor (ER) -positive invasive tumors. Women < or = 50 years of age experience fewer serious side effects. Vascular and vasomotor events do not persist post-treatment across all ages. In postmenopausal women, raloxifene and tamoxifen reduce the risk of ER-positive invasive BC with equal efficacy. Raloxifene is associated with a lower risk of thromboembolic disease, benign uterine conditions, and cataracts than tamoxifen in postmenopausal women. No evidence exists establishing whether a reduction in BC risk from either agent translates into reduced BC mortality. Recommendations In women at increased risk for BC, tamoxifen (20 mg/d for 5 years) may be offered to reduce the risk of invasive ER-positive BC, with benefits for at least 10 years. In postmenopausal women, raloxifene (60 mg/d for 5 years) may also be considered. Use of aromatase inhibitors, fenretinide, or other selective estrogen receptor modulators to lower BC risk is not recommended outside of a clinical trial. Discussion of risks and benefits of preventive agents by health providers is critical to patient decision making.
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Affiliation(s)
- Kala Visvanathan
- Cancer Policy and Clinical Affairs, 2318 Mill Rd, Suite 800, Alexandria, VA 22314, USA
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Vogel VG, Qu Y, Wong M, Mitchell B, Mershon JL. Incidence of invasive breast cancer in postmenopausal women after discontinuation of long-term raloxifene administration. Clin Breast Cancer 2009; 9:45-50. [PMID: 19299240 DOI: 10.3816/cbc.2009.n.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postmenopausal women with osteoporosis had a 66% relative risk reduction for invasive breast cancer over 8 years of raloxifene therapy in the randomized, placebo-controlled 4-year MORE (Multiple Outcomes of Raloxifene Evaluation) trial and the CORE (Continuing Outcomes Relevant to Evista) trial, a 4-year follow-up to MORE. PATIENTS AND METHODS The first post hoc analysis examined the effects of raloxifene on the cumulative incidence of invasive breast cancer on a yearly basis. Another analysis compared the incidence of invasive breast cancer in 3967 patients who continued raloxifene for 8 years (RLX-C, n = 2280), discontinued raloxifene after 4 years in MORE (RLX-D, n = 401), or took placebo (n = 1286) for a mean 2.9 years' treatment duration (57,338 patient-years). RESULTS The unadjusted breast cancer incidence rate was 5.39 per 1000 patient-years in the placebo group compared with 2.26 in the RLX-C group (hazard ratio [HR], 0.41 [95% CI 0.21-0.81]) and 3.59 in the RLX-D group (HR, 0.69 [95% CI 0.23-2.01]). Because the choice of taking the study drug was not randomized in CORE, propensity scores were used to adjust for potential imbalances in baseline characteristics before CORE. Results after adjustment by the propensity score method were similar to the unadjusted results. CONCLUSION This analysis suggests a persistent effect for breast cancer risk reduction in patients who discontinued raloxifene, although this conclusion is limited by the small sample size.
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Affiliation(s)
- Victor G Vogel
- Department of Research, American Cancer Society, Atlanta, GA, USA.
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Abstract
Raloxifene hydrochloride is a selective estrogen receptor modulator (SERM) that has antiestrogenic effects on breast and endometrial tissue and estrogenic effects on bone, lipid metabolism, and blood clotting. Raloxifene significantly improves serum lipids and serum markers of cardiovascular disease risk, but it has no significant effect on the risk of primary coronary events. A meta-analysis of randomized, double-blind, placebo-controlled trials of raloxifene for osteoporosis showed the odds of fracture risk were 0.60 (95% confidence interval [CI] = 0.49–0.74) for raloxifene 60 mg/day compared with placebo. During 8 years of follow-up in an osteoporosis trial, the raloxifene group had a 76% reduction in the incidence of invasive ER-positive breast cancer compared with the placebo group. In the STAR trial, the incidence of invasive breast cancer was 4.30 per 1000 women-years with raloxifene and 4.41 per 1000 with tamoxifen; RR = 1.02; 95% CI, 0.82–1.28. The effect of raloxifene on invasive breast cancer was, therefore, equivalent to that of tamoxifen with more favorable rates of adverse effects including uterine malignancy and clotting events. Millions of postmenopausal women could derive net benefit from raloxifene through reduced rates of fracture and invasive breast cancer.
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Affiliation(s)
- Victor G Vogel
- The University of Pittsburgh Cancer Institute, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA.
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Abstract
In the Study of Tamoxifen and Raloxifene (STAR) trial, postmenopausal women at increased risk of breast cancer received either oral tamoxifen (20 mg/day) or raloxifene (60 mg/day) over 5 years. There were an equal number of cases of invasive breast cancer in women assigned to tamoxifen and raloxifene. There were fewer cases of noninvasive breast cancer in the tamoxifen group than in the raloxifene group (risk ratio [RR]: 1.40; 95% confidence interval [CI]: 0.98-2.02). There were more cases of uterine cancer with tamoxifen than with raloxifene (RR: 0.62; 95% CI: 0.35-1.08). Thromboembolic events occurred less often in the raloxifene group (RR: 0.70; 95% CI: 0.54-0.91) and there were fewer cataracts and cataract surgeries in the women taking raloxifene (RR: 0.79; 95% CI: 0.68-0.92). The STAR trial has shown that raloxifene is as effective as tamoxifen in reducing the risk of invasive breast cancer and has a lower risk of adverse events but a nonstatistically significant higher risk of noninvasive breast cancer. The risk of other cancers, fractures, ischemic heart disease and stroke is similar for both drugs.
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Affiliation(s)
- Victor G Vogel
- University of Pittsburgh Cancer Institute, Magee-Womens Hospital, Pittsburgh, PA 15213-3180, USA.
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Reeves KW, Stone RA, Modugno F, Ness RB, Vogel VG, Weissfeld JL, Habel LA, Sternfeld B, Cauley JA. Longitudinal association of anthropometry with mammographic breast density in the Study of Women's Health Across the Nation. Int J Cancer 2009; 124:1169-77. [PMID: 19065651 DOI: 10.1002/ijc.23996] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
High percent mammographic breast density is strongly associated with increased breast cancer risk. Though body mass index (BMI) is positively associated with risk of postmenopausal breast cancer, BMI is negatively associated with percent breast density in cross-sectional studies. Few longitudinal studies have evaluated associations between BMI and weight and mammographic breast density. We studied the longitudinal relationships between anthropometry and breast density in a prospective cohort of 834 pre- and perimenopausal women enrolled in an ancillary study to the Study of Women's Health Across the Nation (SWAN). Routine screening mammograms were collected and read for breast density. Random intercept regression models were used to evaluate whether annual BMI change was associated with changes over time in dense breast area and percent density. The study population was 7.4% African-American, 48.8% Caucasian, 21.8% Chinese, and 21.9% Japanese. Mean follow-up was 4.8 years. Mean annual weight change was +0.32 kg/year, mean change in dense area was -0.77 cm(2)/year, and mean change in percent density was -1.14%/year. In fully adjusted models, annual change in BMI was not significantly associated with changes in dense breast area (-0.17 cm(2), 95% CI -0.64, 0.29). Borderline significant negative associations were observed between annual BMI change and annual percent density change, with percent density decreasing 0.36% (95% CI -0.74, 0.02) for a one unit increase in BMI over a year. This longitudinal study provides modest evidence that changes in BMI are not associated with changes in dense area, yet may be negatively associated with percent density.
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Affiliation(s)
- Katherine W Reeves
- Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA.
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50
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Ganz PA, Land SR, Geyer CE, Costantino JP, Pajon ER, Fehrenbacher L, Atkins JN, Polikoff JA, Vogel VG, Erban JK, Livingston RB, Perez EA, Mamounas EP, Wolmark N, Swain SM. NSABP B-30: definitive analysis of quality of life (QOL) and menstrual history (MH) outcomes from a randomized trial evaluating different schedules and combinations of adjuvant therapy containing doxorubicin, docetaxel and cyclophosphamide in women with operable, node-positive breast cancer. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-76] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #76
Background: QOL and MH outcomes were integrated into the NSABP B-30 trial as secondary outcomes to the efficacy analyses which are being presented separately. Explicit secondary aims of the NSABP B-30 study were 1) to compare toxicities among the regimens, 2) to compare QOL, and 3) to examine differences in amenorrhea and its relationship to symptoms, QOL, and efficacy. Here we examine the secondary aims of the study as a companion to the efficacy results that are presented separately.
 Materials and Methods: 5351 pts with cT1-3, N0-1, M0 were enrolled from 3/1/99 to 3/31/2004. 2170 were enrolled on the QOL study, and 2449 were enrolled on the MH study and were randomized to one of three treatment groups: Group 1 [doxorubicin (A) 60 mg/m2 and C 600 mg/m2 q 3 weeks (wks) x 4 followed by docetaxel (T) 100 mg/m2 q 3 wks x 4; Group 2 [A 50 mg/m2 and T 75 mg/m2 q 3 wks x 4]; Group 3 [A 50 mg/m2 T 75 mg/m2 and cyclophosphamide (C) 500 mg/m2 q 3 wks x 4]. All patients with ER-positive tumors received hormonal therapy after completing chemotherapy. Preliminary results from Group 1 have been reported previously (Swain, et al. Breast Cancer Res Treat, 2008).
 Results: The protocol specifies that 800 deaths are required for the definitive analysis of treatment, QOL, and MH outcomes, which are expected to occur by fall 2008. For this final report, results from a comparison of the three arms will be analyzed and presented.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 76.
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Affiliation(s)
- PA Ganz
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 2 UCLA Jonsson Comp. Cancer Cntr, Los Angeles, CA
| | - SR Land
- 3 NSABP Biostatistical Center and Dept of Biostatistics, Grad. School of Public Health, Univ of Pittsburgh, Pittsburgh, PA
| | - CE Geyer
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 4 Allegheny Gen. Hospital, Pittsburgh, PA
| | - JP Costantino
- 3 NSABP Biostatistical Center and Dept of Biostatistics, Grad. School of Public Health, Univ of Pittsburgh, Pittsburgh, PA
| | - ER Pajon
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 5 Colarado Cancer Res Prog, Denver, CO
| | - L Fehrenbacher
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 6 Kaiser Permanente, Northern Calif., Vallejo, CA
| | - JN Atkins
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 7 Southeast Cancer Control Consortium CCOP, Goldsboro, NC
| | - JA Polikoff
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 8 Southern California Kaiser Permanente, San Diego, CA
| | - VG Vogel
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 9 University of Pittsburgh, Pittsburgh, PA
| | - JK Erban
- 10 ECOG, Philadelphia, PA
- 11 Massachusetts Gen. Hospital Cancer Cntr, Boston, MA
| | - RB Livingston
- 12 SWOG, Ann Arbor, MI
- 13 Arizona Cancer Cntr/Univ of AZ/Arizona Health Sciences Cntr, Tucson, AZ
| | - EA Perez
- 14 NCCTG, Rochester, MN
- 15 Mayo Clinic Jacksonville, Jacksonville, FL
| | - EP Mamounas
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 16 Aultman Health Foundation, Canton, OH
| | - N Wolmark
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 4 Allegheny Gen. Hospital, Pittsburgh, PA
| | - SM Swain
- 1 National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA
- 17 Washington Cancer Inst./Washington Hosp. Cntr., Washington, DC
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