The impact of US abortion policy on rheumatology clinical practice: a cross-sectional survey of rheumatologists

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LMIC Research Centers' Experiences Hosting U.S. and LMIC Trainees: Evaluation of the Fogarty Global Health Fellows and Scholars Program, 2012 to 2020

In this mixed-methods study, we explore themes that emerged from a survey assessing the programmatic experiences of mentors and administrators at institutions in low- and middle-income countries (LMICs) hosting trainees supported by the Fogarty International Center's Global Health Program for Fellows and Scholars. A total of 89 of 170 potential respondents representing 31 countries completed the survey (response rate, 52.4%). There was agreement among respondents that their institutions received sufficient funds to support trainees and had the capacity to manage operational and financial aspects of the program. A majority also agreed that both LMIC and U.S. trainees were beneficial to the host institutions, and that trainee projects were relevant to the needs of the host country. Respondents felt that program benefits to LMIC trainees could be improved by increasing the research consumables budget, increasing the flexibility of program timelines, and increasing engagement between LMIC and U.S. trainees and institutions. Respondents indicated that both U.S. and LMIC trainees behaved professionally (including demonstrating respectful and ethical behavior) and took appropriate initiative to conduct their research projects. Findings from this study will help inform innovations to similar training initiatives that will enhance sustainability and improve program performance, and will be responsive to local needs.

High Rates of Viral Suppression and Care Retention Among Youth Born Outside of the United States with Perinatally Acquired HIV

BACKGROUND

Youth born outside of the US with perinatally acquired HIV infection (YBoUS-PHIV) account for most children living with HIV in the US, but there are few data characterizing their care outcomes.

METHODS

We conducted a retrospective study of YBoUS-PHIV receiving care across 3 HIV clinics in the Southeastern US between October 2018 and 2019. Primary outcomes were retention in care and viral suppression defined as (1) proportion of suppressed viral loads (VLs) and (2) having all VLs suppressed (definition 1 presented in the abstract). Primary predictors were age, adoption and disclosure status (full, partial and none/unknown). Multivariable logistic regression and χ 2 tests were used to test for associations with care outcomes. Analysis of disclosure status was restricted to youth greater than or equal to 12 years.

RESULTS

The cohort included 111 YBoUS-PHIV. Median age was 14 years (interquartile range, 12-18), 59% were female, and 79% were international adoptees. Overall, 84% of patients were retained in care, and 88% were virally suppressed at each VL measurement. Adopted youth were more likely to be virally suppressed than nonadopted youth [odds ratio (OR), 7.08; P < 0.01] although the association was not statistically significant in adjusted analysis (adjusted OR, 4.26; P = 0.07). Neither age nor adoption status was significantly associated with retention. Among 89 patients greater than or equal to 12 years, 74% were fully disclosed of their HIV status, 12% were partially disclosed, and 13% had not started the disclosure process. There was no significant difference in retention or viral suppression by disclosure status.

CONCLUSIONS

YBoUS-PHIV achieved high rates of retention and viral suppression. Adopted youth may be more likely to achieve viral suppression which may reflect the need for tailored interventions for nonadopted youth.

Strategies for Successful Clinical Trial Recruitment of People Living with HIV in Low- and Middle-Income Countries: Lessons Learned and Implementation Implications from the Nigeria Renal Risk Reduction (R3) Trial

PURPOSE OF REVIEW

Clinical trials represent a bedrock for measuring efficacy of interventions in biomedical research, but recruitment into clinical trials remains a challenge. Few data have focused on recruitment strategies from the perspective of clinical trial teams, especially in low- and middle-income countries (LMIC), where HIV is most prevalent.

RECENT FINDINGS

We summarized data from the literature and our experience with recruitment for the Renal Risk Reduction trial, aimed at reducing risk of kidney complications among people living with HIV in Nigeria. Using an implementation science framework, we identified strategies that contributed to successful clinical trial recruitment. For strategies that could not be categorized by this framework, we summarized key features according to selected action, actor, target, context, and time. We identified how these identified strategies could map to subsequent implementation outcomes at the patient and provider/health system level, as well as capacity-building efforts to meet needs identified by LMIC partners, which is a priority for success. Our experience highlights the importance of considering implementation outcomes, and the strategies necessary to achieve those outcomes early, in the planning and execution of clinical trials. Clinical trial recruitment can be optimized via methodologies grounded in implementation science.

Comparative analysis of competency coverage within accredited master's in health informatics programs in the East African region

OBJECTIVE

As master of science in health informatics (MSc HI) programs emerge in developing countries, quality assurance of these programs is essential. This article describes a comprehensive comparative analysis of competencies covered by accredited MSc HI programs in the East African common labor and educational zone.

MATERIALS AND METHODS

Two reviewers independently reviewed curricula from 7 of 8 accredited MSc HI university programs. The reviewers extracted covered competencies, coding these based on a template that contained 73 competencies derived from competencies recommended by the International Medical Informatics Association, plus additional unique competencies contained within the MSc HI programs. Descriptive statistics were used to summarize the structure and completion requirements of each MSc HI program. Jaccard similarity coefficient was used to compare similarities in competency coverage between universities.

RESULTS

The total number of courses within the MSc HI degree programs ranged from 8 to 22, with 35 to 180 credit hours. Cohen's kappa for coding competencies was 0.738. The difference in competency coverage was statistically significant across the 7 institutions (P = .012), with covered competencies across institutions ranging from 32 (43.8%) to 49 (67.1%) of 73. Only 4 (19%) of 21 university pairs met a cutoff of over 70% similarity in shared competencies.

DISCUSSION

Significant variations observed in competency coverage within MSc HI degree programs could limit mobility of student, faculty, and labor.

CONCLUSIONS

Comparative analysis of MSc HI degree programs across 7 universities in East Africa revealed significant differences in the competencies that were covered.

Effect of Baseline Symptom Manifestations on Retention in Care and Treatment among HIV-Infected Patients in Nigeria

BACKGROUND

Symptom management is an important component of HIV care. But symptom patterns and how they affect engagement with HIV care and treatment services have not been adequately explored in the era of increased HIV treatment scale-up. We investigated the relationship between symptom patterns among people living with HIV (PLHIV) and 12 months retention in care, within the context of other clinical and demographic characteristics.

METHODS

Retrospective cohort analysis of 5114 PLHIV receiving care within a large HIV treatment program in Nigeria. We assessed the prevalence and burden of baseline symptoms reported during routine clinic visits from January 2015 to December 2017. Multivariable regression was used to identify relationships between 12-month retention and symptom dimensions (prevalence and burden) while controlling for demographic and other clinical variables.

RESULTS

Increasing symptom burden was associated with higher likelihood of retention at 12 months (adjusted odds ratio [aOR] = 1.19 [95% confidence interval, CI: 1.09-1.29]; P < .001) as was the reporting of skin rashes/itching symptom (aOR = 2.59 [95% CI: 1.65-4.09]; P < .001). Likelihood of retention reduced with increasing World Health Organization (WHO) Clinical staging, with CD4 ≥500 cells/mL and self-reported heterosexual mode of HIV transmission. Conclusions: Symptom dimensions and standardized clinical/immunological measures both predicted retention in care, but effects differed in magnitude and direction. Standardized clinical/immunological measures in HIV care (eg, WHO clinical staging and CD4 count categories) can mask important differences in how PLHIVs experience symptoms and, therefore, their engagement with HIV care and treatment. Symptom management strategies are required alongside antiretroviral treatment to improve outcomes among PLHIV, including retention in care.

Coverage of IMIA-recommended Competencies by Masters in Health Informatics Degree Programs in East Africa

OBJECTIVE

The International Medical Informatics Association (IMIA) has provided recommendations on Education in Biomedical and Health Informatics (BMHI) as guidance on competencies relevant to education of BMHI specialists. However, it remains unclear how well these competencies have been adopted to guide emerging degree programs in low- and middle-income countries (LMICs). We evaluated comprehensiveness of IMIA-recommended competency coverage by Masters in Health Informatics (MSc HI) programs in East Africa.

MATERIALS AND METHODS

Two investigators independently reviewed curricula for seven accredited MSc HI university programs in the East Africa region to extract covered competencies using an instrument based on the IMIA education recommendations. Descriptive statistics were used to determine competency coverage by institution and across institutions and by IMIA-defined competency domains. Duplication of competency coverage in courses within each curriculum was also evaluated. Multivariable logistic regression was used to test whether coverage of IMIA-recommended competencies differed between institutions.

RESULTS

Cohen's Kappa for coding competencies within courses was 0.738 (95% CI, 0.713-0.764). Coverage of the 40 recommended required IMIA competencies by institutional curricula ranged from 25 (62.5%) to 39 (97.5%) (p < 0.0001), with only 18 (45%) of these competencies covered by all seven institutions. No significant variations in competency coverage were observed between the domains of information sciences (83.7%), health sciences (71.4%), and core BMHI competencies (83.5%) (p = 0.13). On average, each competency was covered by 3.06 courses in each curriculum (range 0 - 14). Curricula also contained 25 additional competencies not part of the IMIA recommendations, 15 of which were found only within the curriculum of a single institution.

DISCUSSION

There is significant variability in coverage of IMIA-recommended competencies across MSc HI curricula evaluated, with observed duplication of competency coverage within each curriculum. The additional competencies uncovered that were not part of the IMIA-recommendations were not universally shared across institutions.

CONCLUSION

The IMIA education recommendations provide a relevant, comprehensive reference guide for developing and improving health informatics degree programs within LMIC settings. Variability in competency coverage needs to be addressed for institutions within similar educational and labor regions.

Abstract P5-15-02: Evaluating the cost of endocrine therapy vs. radiation therapy alone for low risk hormone positive early stage breast cancer in elderly patients

Objective: Elderly patients with low-risk hormone-positive breast cancer are at risk of over treatment. Avoidance of radiation therapy (RT) in favor of endocrine therapy alone was first heralded as the optimal conservative strategy due to logistical simplicity, low acute sequelae and a reduction of contralateral cancers not seen with RT. However, long-term use of aromatase inhibitors (AI) is not without costs and morbidity, often leading to low compliance and notable late effects. We therefore performed a cost-effectiveness analysis to compare the outcomes and costs between AI for five years without RT versus hypofractionated RT alone without endocrine therapy.

Materials and Methods: Using data from available phase III trials and meta-analyses, we constructed a patient-level microsimulation Markov decision model to replicate the comparative outcomes between the strategies above from the societal perspective among 200,000 simulated patients. Five years of anastrozole was compared to a 15-fraction hypofractionated whole breast RT course without boost in a cohort of patients with low-risk disease as defined by CALGB 9343 entry criteria. Noncompliance with AI was modeled from recent population-based data. Relative effectiveness on ipsilateral breast tumor recurrence and contralateral breast cancers were based off the NSABP B-21 trial, adjusted to match the modern outcomes demonstrated in CALGB 9343 and PRIME II with further adjustment for AI over tamoxifen (ATAC, EBCTCG meta-analysis). Indirect costs of travel were accounted for, as were the costs of common and serious side-effects from RT (dermatitis, fibrosis, second malignancy, heart disease) and AI (arthralgia, hot flashes, osteopenia, fracture, thrombosis). A 1-year cycle time and lifetime horizon were used, with all costs adjusted to 2018 US dollars and extracted primarily from Medicare reimbursement data. The primary measure of efficacy was the quality-adjusted life-year (QALY) with age-adjusted utilities extracted from the literature. Half-cycle correction and a 3% discount rate were applied. Probabilistic sensitivity analysis was used to vary all parameters simultaneously.

Results: On average, RT was approximately $3,981 more expensive than endocrine therapy over the lifetime horizon. Under a number of assumptions, RT appeared similar in long-term effectiveness to AI therapy, with a difference of less than 0.03 quality-adjusted life years. Given the low value of the denominator in the incremental cost-effectiveness ratio (ICER), RT did not meet the formally defined $100,000/QALY threshold. On one-way sensitivity analysis, the ICER was particularly sensitive to the incidence and impact of salvage strategies for recurrence, treatment of contralateral breast cancers, cardiac events and fracture rates.

Conclusions: Modeling with the available evidence suggests it is likely that quality-of-life after RT-alone is nearly identical to an AI-alone strategy but associated with a small increase in cost. These results suggest select patients at risk of noncompliance can safely be treated with RT-alone rather than AI alone. Given the relative pros and cons of each strategy, RT-alone should be considered for select elderly low-risk breast patients.

Citation Format: Ward MC, Vicini F, Chadha M, Pierce L, Recht A, Hayman J, Thaker N, Khan A, Keisch M, Shah C. Evaluating the cost of endocrine therapy vs. radiation therapy alone for low risk hormone positive early stage breast cancer in elderly patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-02.

Familial Risk for Exceptional Longevity

One of the most glaring deficiencies in the current assessment of mortality risk is the lack of information concerning the impact of familial longevity. In this work, we update estimates of sibling relative risk of living to extreme ages using data from more than 1,700 sibships, and we begin to examine the trend for heritability for different birth-year cohorts. We also build a network model that can be used to compute the increased chance for exceptional longevity of a subject, conditional on his family history of longevity. The network includes familial longevity from three generations and can be used to understand the effects of paternal and maternal longevity on an individual's chance to live to an extreme age.

Abstract P6-06-05: RadiotypeDx: Identification and validation of a radiation sensitivity signature in human breast cancer

Purpose: An unmet clinical need in breast cancer (BC) management is the identification of which patients will respond to radiation therapy (RT). We hypothesized that the integration of post-RT clonogenic survival data with gene expression data across a large spectrum of BC cell lines would generate a BC-specific RT sensitivity signature predictive for RT response in BC patients and allow identification of patients with tumors refractive to conventional therapy.

Methods: Using clonogenic survival assays, we identified the range of surviving fraction (SF) after 2 Gy of RT across 21 BC cell lines. Using SF as a continuous variable, the RT sensitivity score (RSS) was correlated to gene expression using a Spearman correlation method on an individual gene basis. Genes were selected for the signature based on positive or negative correlation with a p-value &lt;0.05 and FDR of &lt;0.01. Unsupervised hierarchical clustering identified differences in gene expression across resistant and sensitive cell lines to generate a radiation sensitivity (RS) signature. This signature was trained and validated in a separate human breast tumor dataset (185 pts) containing early stage, node-negative patients treated with surgery and RT alone without adjuvant chemotherapy to assess the predictive effect of RS signature on recurrence risk after RT. Gene function and potentially actionable targets from the signature were validated using clongenic survival and DNA damage assays.

Results: Clonogenic survival identifies a range of radiation sensitivity in human BCC lines (SF 77%-17%) with no significant correlation (r value &lt;0.3) to the intrinsic BC subtype. Using Spearmans correlation method, a total of 126 genes were identified as being associated with radiation sensitivity (72 positively correlated, 54 negatively correlated). Unsupervised hierarchical expression discriminates gene expression patterns in the RT resistant and RT sensitive cell lines and is enriched for genes involved in cell cycle arrest and DNA damage response (enrichment p-value 5.0 E-22). Knockdown of genes associated with the radioresistance signature identifies previously unreported radiation resistance genes, including TACC1 and RND3 with enhancement ratios of 1.25 and 1.37 in BCC lines. Application of this RS signature to an independent breast cancer dataset with clinical outcomes validates the signature and accurately identifies patients with decreased rates of recurrence compared to patients with high expression of the radioresistant signature (p-value &lt;0.0001, misclassification error rate .31, 12/13 patients with locoregional recurrence accurately identified).

Conclusion: In this study, we derive a human BC-specific RT sensitivity signature (RadiotypeDx) with biologic relevance from preclinical studies and validate this signature for prediction of recurrence in an independent clinical dataset. The signature is not correlated to the intrinsic subtypes of human breast cancer and thus provides useful information beyond traditional breast cancer subtyping. By identifying patients with tumors refractory to standard RT, this signature has the potential to allow for personalization of radiotherapy, particularly in patients for whom treatment intensification is needed.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-05.

Abstract P6-04-04: Maternal embryonic leucine zipper kinase (MELK) is a novel radiosensitizing and therapeutic target and is independently prognostic in triple-negative breast cancer

Background: While effective targeted therapies exist for estrogen receptor (ER)-positive and HER2/neu-positive breast cancer, no such effective therapies exist for ER-negative, PR-negative, and HER2-negative (“triple negative”) cancers. Given the lack of targeted agents for triple negative (TN) disease and their relative radiation insensitivity, it is clear that additional targets for treatment are critically needed.

Our previous work identified one such novel molecular target as maternal embryonic leucine zipper kinase (MELK), and we sought to investigate the impact of MELK expression on radiation response and patient outcomes.

Methods: Using gene expression arrays, we interrogated the expression of MELK in 2,061 breast tumor samples as well as a panel of 51 breast cancer cell lines. We measured protein expression in TN cancers with western blotting and used clonogenic survival assays to quantitate radiosensitivity of BCC lines at baseline and after MELK inhibition. Multiple datasets were used to evaluate the prognostic import of MELK. Kaplan-Meier analysis using local control and survival data was performed. Chi squared scores were calculated to determine significance and hazard ratios (HR) and 95% confidence intervals (CI) were calculated. A Cox proportional hazards model was constructed to identify potential factors of survival.

Results: We demonstrate that MELK expression is significantly elevated in human TN breast cancers, including chemoradiation resistant tumors (305 tumors compared to 1756 non-TN breast tumors; p-value 7.5 e-21). MELK protein and RNA expression is induced by ionizing radiation (5.6-7.5 fold at 72 hours, p-value &lt;0.01). We characterized the radiation sensitivity of BCC lines and demonstrated that MELK expression is significantly correlated with radioresistance (as measured by clonogenic survival) in 21 breast cancer cell lines (R: 0.62, p-value 0.003). Inhibition of MELK using both siRNA and small molecule inhibitors induces radiation sensitivity in vitro with and enhancement ratio (ER) of 1.5-1.6. We demonstrate that high MELK expression is strongly correlated with p53 mutation positive status (p-value &lt;0.001). Finally, local control and survival analyses of patients with BC showed that those patients whose tumors have high expression of MELK have significantly higher rates of LR after radiation and an overall poorer prognosis than patients with low expression of MELK (HR for LR 1.89-2.23, p-value 0.001; HR for overall survival 1.46-3.3; p-value &lt;0.001 in 3 independent datasets). In multivariate analysis of all patients, only MELK expression and grade were significantly associated with worse local recurrence free (LRF) survival with a HR of 1.35 (95% CI 1.05-1.72, p-value &lt; 0.01).

Conclusion: Here, we identify MELK as a potential biomarker of radioresistance and target for radiosensitization in triple negative breast cancers. MELK overexpression was associated with local failure across multiple data sets. MVA identified MELK as the strongest factor associated with poor local control. Our results support the rationale for developing clinical strategies to inhibit MELK as a novel target in triple-negative breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-04-04.

Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials

BACKGROUND

After breast-conserving surgery, radiotherapy reduces recurrence and breast cancer death, but it may do so more for some groups of women than for others. We describe the absolute magnitude of these reductions according to various prognostic and other patient characteristics, and relate the absolute reduction in 15-year risk of breast cancer death to the absolute reduction in 10-year recurrence risk.

METHODS

We undertook a meta-analysis of individual patient data for 10,801 women in 17 randomised trials of radiotherapy versus no radiotherapy after breast-conserving surgery, 8337 of whom had pathologically confirmed node-negative (pN0) or node-positive (pN+) disease.

FINDINGS

Overall, radiotherapy reduced the 10-year risk of any (ie, locoregional or distant) first recurrence from 35·0% to 19·3% (absolute reduction 15·7%, 95% CI 13·7-17·7, 2p<0·00001) and reduced the 15-year risk of breast cancer death from 25·2% to 21·4% (absolute reduction 3·8%, 1·6-6·0, 2p=0·00005). In women with pN0 disease (n=7287), radiotherapy reduced these risks from 31·0% to 15·6% (absolute recurrence reduction 15·4%, 13·2-17·6, 2p<0·00001) and from 20·5% to 17·2% (absolute mortality reduction 3·3%, 0·8-5·8, 2p=0·005), respectively. In these women with pN0 disease, the absolute recurrence reduction varied according to age, grade, oestrogen-receptor status, tamoxifen use, and extent of surgery, and these characteristics were used to predict large (≥20%), intermediate (10-19%), or lower (<10%) absolute reductions in the 10-year recurrence risk. Absolute reductions in 15-year risk of breast cancer death in these three prediction categories were 7·8% (95% CI 3·1-12·5), 1·1% (-2·0 to 4·2), and 0·1% (-7·5 to 7·7) respectively (trend in absolute mortality reduction 2p=0·03). In the few women with pN+ disease (n=1050), radiotherapy reduced the 10-year recurrence risk from 63·7% to 42·5% (absolute reduction 21·2%, 95% CI 14·5-27·9, 2p<0·00001) and the 15-year risk of breast cancer death from 51·3% to 42·8% (absolute reduction 8·5%, 1·8-15·2, 2p=0·01). Overall, about one breast cancer death was avoided by year 15 for every four recurrences avoided by year 10, and the mortality reduction did not differ significantly from this overall relationship in any of the three prediction categories for pN0 disease or for pN+ disease.

INTERPRETATION

After breast-conserving surgery, radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. These proportional benefits vary little between different groups of women. By contrast, the absolute benefits from radiotherapy vary substantially according to the characteristics of the patient and they can be predicted at the time when treatment decisions need to be made.

FUNDING

Cancer Research UK, British Heart Foundation, and UK Medical Research Council.

Electron imaging of pyrrhotite superstructures

Natural pyrrhotites, when studied by high resolution electron microscopy, yield crystallographic information on a unit cell scale. Structural heterogeneity is prominent. The many reported superstructures are interpretable through an antiphase model. The 5C pyrrhotite superstructure results from an ordered sequence of antiphase domains while the higher temperature NC type results from a disordered sequence.

Local Therapy in BRCA1/2 Carriers with Operable Breast Cancer: Comparison of Breast Conservation and Mastectomy

Background: Women with inherited germline BRCA1/2 mutations have a 55-85% cumulative risk of breast cancer (BC) by age 70. Thus, knowledge of expected outcomes following various treatments is needed to advise these patients should they be diagnosed with BC. It is unclear whether breast conservation (BCT) offers similar rates of tumor control as mastectomy (M) in BRCA1/2 carriers and it is doubtful whether a randomized trial comparing these options could be performed. Thus, this analysis compares the outcomes between similarly staged women with BRCA1/2 mutations treated with BCT vs. M.Methods: Women with deleterious BRCA1/2 mutations diagnosed with operable BC and who consented to longitudinal studies were identified at 10 institutions in the US, Australia, Spain and Israel. Patient, clinical and treatment characteristics were compared between those receiving BCT and those receiving M +/- RT. Time-to-event endpoints included first failure of treatment, diagnosis of contralateral breast cancer (CBC), and overall and BC-specific survival. Cox regression models were constructed to detect significant associations between patient and clinical characteristics and time-to-event endpoints.Results: Clinical characteristics and outcomes for 302 BCT and 353 M patients were compared. With a median F/U of 8.2 years for BCT patients and 8.9 years following M, 15-year local failure as first failure was significantly higher with BCT vs. M (23.5% vs. 5.5%, p&lt;0.0001). Multivariate analysis indicted choice of local therapy as the only factor significantly predicting local recurrence, with a 4.5-fold risk of local failure with BCT compared to M (p&lt;0.0001). Local failure analyses by cohort revealed the presence of a BRCA2 mutation (HR 2.8; p=0.024) and no use of adjuvant chemotherapy (HR 5.4; p=0.0001) as significant predictors within the BCT group; presence of invasive lobular cancer (HR 9.9; p=0.004) was the only significant predictor within the M cohort. No significant differences were seen in distant failure, BC-specific or overall survival by local therapy. 15-year estimates of CBC were 52.1% with BCT; 41.4% with M; and 37.9% with M+RT (p=0.44). Analyses of BCT vs. M +/- RT and surgery +/- RT did not reveal significant differences in CBC by cohort.Conclusions: The higher risk of local failure in BRCA1/2-associated BC treated with BCT compared to M did not translate into an increased risk of distant failure or mortality. RT did not result in a detectable increase in CBC at 15 years above baseline elevated rates. These results at both the involved and contralateral breasts should be discussed when patients with BRCA1/2-associated BC are considering local treatment options.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 959.

Workshop on Partial Breast Irradiation: State of the Art and the Science, Bethesda, MD, December 8-10, 2002

Breast conserving surgery followed by radiation therapy has been accepted as an alternative to mastectomy in the management of patients with early-stage breast cancer. Over the past decade there has been increasing interest in a variety of radiation techniques designed to treat only the portion of the breast deemed to be at high risk for local recurrence (partial-breast irradiation [PBI]) and to shorten the duration of treatment (accelerated partial-breast irradiation [APBI]). To consider issues regarding the equivalency of the various radiation therapy approaches and to address future needs for research, quality assurance, and training, the National Cancer Institute, Division of Cancer Treatment and Diagnosis, Radiation Research Program, hosted a Workshop on PBI in December 2002. Although 5- to 7-year outcome data on patients treated with PBI and APBI are now becoming available, many issues remain unresolved, including clinical and pathologic selection criteria, radiation dose and fractionation and how they relate to the standard fractionation for whole breast irradiation, appropriate target volume, local control within the untreated ipsilateral breast tissue, and overall survival. This Workshop report defines the issues in relation to PBI and APBI, recommends parameters for consideration in clinical trials and for reporting of results, serves to enhance dialogue among the advocates of the various radiation techniques, and emphasizes the importance of education and training in regard to results of PBI and APBI as they become emerging clinical treatments.

Protection of mice against challenge with homologous and heterologous serovars of Actinobacillus pleuropneumoniae after live vaccination

Protective immune responses and the virulence of Actinobacillus pleuropneumoniae (APP) have been attributed, in part, to toxins (Apx) produced by the bacterium. A mutant of the serovar 7 strain HS93 (HS93Tox-), lacking the genes encoding the structural toxin ApxA and the post-translational activating protein ApxC, but retaining the genes required for secretion ApxB and ApxD, was isolated and shown to be attenuated in a mouse model. A plasmid vector system was developed and used to express the ApxA gene from within the HS93Tox- strain. The resulting strain, HS93Tox-/pIG-T1K, expresses the Apx structural protein in a non-activated form. HS93Tox-/pIG-T1K was shown to be attenuated in a mouse model and to be capable of inducing Apx-specific antibodies, which were boosted on re-inoculation. Live vaccination of mice with HS93Tox-/pIG-T1K offered protection against homologous wild-type serovar 7 challenge, and also heterologous challenge with a serovar 1 strain. This is in contrast to vaccination with the HS93Tox- strain, which failed to protect mice against a heterologous challenge.

Associations of CYP1A1, GSTM1, and CYP2E1 polymorphisms with lung cancer suggest cell type specificities to tobacco carcinogens

The dramatic shift in the pathological presentation of lung cancer [the proportional decrease in squamous cell carcinoma (SCC) and increase in adenocarcinoma (AC)] observed in the United States after the 1950s may have taken place as the result of the reduction in polycyclic aromatic hydrocarbons (PAHs) and the increase in N-nitrosamines in inhaled smoke from filtered low-yield cigarettes. The predominant mutation patterns of these tumors also suggest differences in their etiology. We tested the hypothesis that genetic susceptibility to PAHs, as determined by polymorphisms in CYP1A1 and GSTM1, predominantly causes lung SCCs, and susceptibility to nitrosamines, as determined by polymorphisms in CYP2E1, predominantly causes lung ACs. CYP1A1 and GSTM1 play a major role in the metabolic activation and detoxification of PAHs, respectively, and CYP2E1 plays a major role in the metabolic activation of nitrosamines. We conducted a population-based case-control study among 341 incident lung cancer cases and 456 controls of Caucasian, Japanese, or Hawaiian origin. In-person interviews collected detailed information on lifestyle risk factors, and DNA extracted from peripheral leukocytes was used in PCR-based genotyping assays. Logistic regression analyses were used to compute odds ratios and 95% confidence intervals (CIs) for each cell type, adjusting for smoking and dietary variables. The presence of at least one copy of the CYP1A1 MspI variant allele was found to be associated with a 2.4-fold (95% CI, 1.2-4.7) increase in the risk of SCC when this gene was considered singly and a 3.1-fold (95% CI, 1.2-7.9) increase in the risk of SCC when combined with a GSTM1 deletion. No significant association was found between MspI and all lung cancers or other cell types or with the CYP1A1 exon 7 polymorphism. In contrast, the CYP2E1 RsaI and DraI polymorphisms were not clearly related to SCC risk, but these homozygous variant genotypes were associated with a 10-fold (95% CI, 0.0-0.5) decrease in the risk of overall lung cancer (RsaI variant) and AC (DraI variant) compared to the homozygous wild-type genotypes. Inverse associations with these two closely linked CYP2E1 polymorphisms were also suggested for small cell carcinoma. In agreement with past experimental and epidemiological data, the associations found in this study between CYP1A1 and lung SCC and between CYP2E1 and lung AC suggest a certain specificity of tobacco smoke PAHs for lung SCC and tobacco-specific nitrosamines for lung ACs.

The lived experience of aloneness for older women currently being treated for depression

A phenomenological study was conducted to answer the following question: What is the lived experience of aloneness for older women currently being treated for depression? Eight women from Northern Ohio composed the purposively selected sample. Transcriptions of each 1-hr interview were reviewed by use of Colaizzi's (1978) method of data analysis. The analysis identified two major experiences of self for all participants: aloneness in depression and aloneness in recovery. Five paired, and somewhat dichotomous, themes defined the essence of aloneness: (a) vulnerability versus self-reliance, (b) fear versus hope, (c) helplessness versus resourcefulness, (d) loss of self-control versus self-determination, and (e) identity confusion versus self-reflection. All the participants expressed profound feelings of moving between the five paired themes as they gained clarity of insight into their experiences of depression and recovery. Results of this study make a valuable contribution by providing important insights into the lived experience of aloneness among older women currently being treated for depression, offer direction in the assessment and treatment of these women, and serve as an impetus for further research.

The use of mammography in breast preservation in locally advanced breast cancer

PURPOSE

As the feasibility of breast preservation in locally advanced breast cancer is currently under evaluation, little information is available correlating mammographic changes to chemotherapy with local outcome. To evaluate the role of mammography in selecting candidates with locally advanced breast cancer for conservative local therapy, we analyzed mammographic changes in the breast to induction chemotherapy and correlated the radiologic appearance with pathologic outcome.

METHODS AND MATERIALS

From 1985 through 1993, 91 patients with Stage III breast cancer were enrolled on a multimodality clinical trial using chemohormonal therapy followed by local treatment and maintenance therapy. Induction therapy consisted of cyclophosphamide, doxorubicin, methotrexate,and 5-fluorouracil with hormonal synchronization using tamoxifen and conjugated estrogens. After nine cycles, surgical biopsies of the breast were performed. Through 1988, clinical examination alone directed the site for postinduction biopsy; for patients treated after 1988, mammography, in addition to physical examination, determined the biopsy location. Local treatment was determined by biopsy result. Patients with a pathologic complete response received radiation only to the breast adn regional nodes, while those with pathologically proven residual disease underwent mastectomy and postoperative radiotherapy. Nine additional cycles of maintenance chemotherapy were administered.

RESULTS

Fifty-five of 91 patients (58%) obtained a clinical complete response (CR) to induction chemotherapy. Twenty-eight of the 53 women with a clinical CR had both pre- and postinduction mammograms. Of these 28 women, 9 obtained a pathologic CR and 19 obtained a pathologic partial response (PR). Fifty-five percent of the pathologic complete responders had resolution of mammographic abnormalities on the postinduction mammograms. Sixty-eight percent (13) of the pathologic partial responders had abnormal mammographic findings. The positive predictive value for residual cancer using physical examination was 92%, while the negative predictive value was only 36%. Among patients with a clinical complete response, the positive and negative predictive values for residual cancer using postinduction mammography were 79% and 56%, respectively. Limitations of mammography included uncertain significance of residual microcalcifications and residual masses on postinduction chemotherapy mammograms.

CONCLUSIONS

Although mammography improved the accuracy of noninvasive evaluations in patients with a clinical complete response, pathologic assessment was still required to determine appropriate local therapy. More sensitive imaging modalities or modifications of film-screen mammography may improve noninvasive detection of residual disease following induction chemotherapy.

Frequently selected nursing diagnoses for the rehabilitation client with stroke

From 2 million to 3 million people in the United States live with the aftereffects of stroke. Nursing diagnoses provide a taxonomy that enables nurses to identify similarities and differences for given groups of clients. The purposes of this study were to identify the most frequently chosen nursing diagnoses for rehabilitation stroke clients and to determine the corresponding objective clinical characteristics (related factors) of these diagnoses. A retrospective descriptive design was used to study charts from randomly selected stroke clients (N = 100) at a large rehabilitation center. At admission and at discharge, impaired physical mobility (99%) and self-care deficit (91%) were the most frequently occurring diagnoses. Impaired physical mobility was usually related to neuromuscular impairment, and self-care deficit was usually related to neuromuscular dysfunction. These objective clinical characteristics help to determine how diagnoses are unique to rehabilitation nursing practice.

Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer

BACKGROUND

Breast-conservation therapy for early-stage breast cancer is now an accepted treatment, but there is still controversy about its comparability with mastectomy. Between 1979 and 1987, the National Cancer Institute conducted a randomized, single-institution trial comparing lumpectomy, axillary dissection, and radiation with mastectomy and axillary dissection for stage I and II breast cancer. We update the results of that trial after a median potential follow-up of 10.1 years.

METHODS

Two hundred forty-seven patients with clinical stage I and II breast cancer were randomly assigned to undergo either modified radical mastectomy or lumpectomy, axillary dissection, and radiation therapy. The 237 patients who actually underwent randomization have been followed for a median of 10.1 years. The primary end points were overall survival and disease-free survival.

RESULTS

At 10 years overall survival was 75 percent for the patients assigned to mastectomy and 77 percent for those assigned to lumpectomy plus radiation (P = 0.89). Disease-free survival at 10 years was 69 percent for the patients assigned to mastectomy and 72 percent for those assigned to lumpectomy plus radiation (P = 0.93). The rate of local regional recurrence at 10 years was 10 percent after mastectomy and 5 percent after lumpectomy plus radiation (P = 0.17) after recurrences successfully treated by mastectomy were censored from the analysis.

CONCLUSIONS

In the management of stage I and II breast cancer, breast conservation with lumpectomy and radiation offers results at 10 years that are equivalent to those with mastectomy.

A pilot study of pi-class glutathione S-transferase expression in breast cancer: correlation with estrogen receptor expression and prognosis in node-negative breast cancer

PURPOSE AND METHODS

Previous studies have indicated that RNA levels for pi-class glutathione S-transferase (GST pi), a phase II, drug-metabolizing enzyme, were inversely related to estrogen receptor (ER) and progesterone receptor (PR) levels in human breast tumors. Because GST pi also is expressed in normal breast epithelium, an immunohistochemical assay that uses affinity-purified polyclonal antibodies to GST pi was developed to examine the possible relationship between GST pi expression in breast cancer cells and hormone receptor expression, as well as prognosis, in patients with primary breast cancer.

RESULTS

A strong inverse correlation between GST pi expression and ER (two-sided P [P2] = .002) and PR status (P2 = .023) was found in our study of 189 patients with primary breast cancer. GST pi expression was not related to tumor size, nodal metastasis, nuclear grade, histology, or age of the patient. In node-negative breast cancer (n = 72), increased GST pi expression was associated with decreased disease-free survival (DFS) and overall survival (OS). When GST pi expression was divided into categories of negative (no GST pi-positive tumor cells), intermediate (1% to 70% GST pi-positive tumor cells), and high (> 70% GST pi-positive tumor cells), the relative risk of tumor recurrence in patients with node-negative breast cancer was increased 3.39-fold for each successive category of expression (P2 = .0045; 95% confidence interval, 1.46 to 7.87) and the relative risk of death was increased 4.49-fold for each successive category (P2 = .0003; 95% confidence interval, 2.02 to 10.42). The actuarial 5-year OS was 100%, 79%, and 51%, and the DFS was 94%, 77%, and 44%, for the negative, intermediate, and high tumor groups, respectively. Among the factors studied in multivariate analysis (ER status, PR status, nuclear grade, and tumor size), GST pi expression was the factor that most accurately predicted shorter DFS and OS in node-negative patients.

CONCLUSION

GST pi expression is inversely related to hormone receptor status in breast cancer. This pilot study also suggests that increased GST pi expression may be an important predictor of early recurrence and death in node-negative breast cancer patients that merits additional investigation.

Perceived stress and coping strategies among families of cardiac transplant candidates during the organ waiting period

OBJECTIVE

To explore and describe perceived stress and coping strategies among families of candidates for cardiac transplant during the organ waiting period.

DESIGN

This descriptive, multiinstitutional study was guided by the T-Double ABCX Model of Family Adjustment and Adaptation (McCubbin & Thompson, 1987).

SETTING

Five tertiary care centers with transplant programs in three Southeastern cities.

SUBJECTS

Thirty-eight family members of patients on the active list for cardiac transplantation, including 35 women and three men with a mean age of 44 years (SD = 13.17). Subjects had a family member on the waiting list for a mean of 6.5 months.

INSTRUMENTS

Family members completed the following three instruments: (1) Family Inventory of Life Events and Changes (FILE), (2) Family Crisis Oriented Personal Scale (FCOPES), and (3) Family Perception of the Transplant Experience Scale (FPTES).

RESULTS

Stress: 53% and 47% of respondents indicated that they were experiencing moderate and low degrees of stress, respectively. Coping: Family members used more coping mechanisms than normative subjects in the literature. Coping strategies used in order of decreasing frequency: (1) knowing our family has the strength to solve our problems, (2) facing problems head-on, and (3) seeking support from friends. Appraisal: Mean score of 32.13 reflects subjects' positive perception of the pretransplant experience. The three statements with which the subjects most strongly agreed: (1) heart illness has changed roles of family members, (2) family member will survive the transplant operation; and (3) this is an experience that could bring out the family's strengths.

CONCLUSIONS

An increase in the number of coping strategies used with low to moderate stress levels suggests the effectiveness of coping strategies in mediating stress. The preference for active rather than passive coping strategies may be reflective of the selection criteria for transplant candidates or nursing interventions during this period to minimize stress and promote family coping.