Abstract P3-09-05: Getting the most out of the 21-gene recurrence score assay: Increasing actionable results with a combined pathologic-genomic model

Introduction: The 21-gene recurrence score (RS) assay categorizes hormone receptor positive, node negative breast cancers (BC) into 3 risk groups for recurrence. We previously showed that the AAMC Model, using only standard pathology data, accurately does the same. This study compares the recurrence rate of the AAMC Model's risk groups to RS-based risk groups. A 2-step approach then is used, in which the AAMC model is applied first, and the RS assay is used only for AAMC intermediate risk cases. AAMC intermediate cases were reclassified by RS into low or high risk groups.

Methods: From a prospective registry of newly diagnosed BC, we selected invasive, hormone receptor positive, HER2 negative, lymph node negative cases from 2005 to 2015 tested with RS assay. Five-year Kaplan-Meier distant recurrence rates were calculated for each risk category.

Results: 1268 cases were included. Five-year recurrence rates were similar between the AAMC Model's low risk group and RS<18 low risk group, as well as between the AAMC Model's high risk group and the RS>30 high risk group. Applying the RS assay to the 715 cases in the AAMC Model's intermediate group resulted in re-classifying 417 (58%) as low risk and 41 (6%) as high risk. Using RS alone, 33% of cases were intermediate risk (n=424), whereas in the 2-step approach 20% were intermediate risk (n=257). For the 2-step approach, the 5-year distant recurrence rate was 3.3% for the low risk group (n=740) and 24.4% for the high risk group (n=271).

Conclusions: Five-year recurrence rates in the AAMC Model's low and high risk groups were similar to those in RS-based risk groups. The 2-step approach, with RS used only for AAMC intermediate cases, resulted in larger low and high risk groups with equivalent prognostic accuracy, compared to use of the RS assay alone. The 2-step approach reliably identifies a large number of patients unlikely to benefit from 21 gene assay and provides substantial cost savings.

Kaplan-Meier Calculated 5-year Distant Recurrences Rates for 4 Models: 1268 Patients Oncotype DXTAILORxAAMC Model2 Step Model with OncotypeDX for AAMC IntermediatesLow RiskRS < 18 (n=703)RS < 11 (n=250)Grade 1 and PR ≥ 1% (n=323)AAMC Low or AAMC intermediate/RS <18 (n=740) 3.4% (95% CI 1.6 – 5.1%, nf=17)4.0% (95% CI 0.8 – 7.2%, nf=8)2.7% (95% CI 0.0 – 5.4%, nf=5)3.3% (95% CI 1.4 – 5.2%, nf=16)Intermediate RiskRS 18 - 30 (n=424)RS 11 - 25 (n=787)Not meeting AAMC definition for low or high risk (n=715)AAMC Intermediate and RS 18-30 (n=257) 15.2% (95% CI 10.3 – 20.1%, nf=38)7.3% (95% CI 4.7 – 9.9%, nf=35)8.4% (95% CI 5.4 – 11.3%, nf=36)12.0% (95% CI 5.8 – 18.1%, nf=15)High RiskRS > 30 (n=141)RS > 25 (n=231)Grade 3 or ER < 20% (n=230)AAMC High or AAMC intermediate/RS > 30 (n=271) 23.0% (95% CI 14.7 – 31.3%, nf=27)22.9% (95% CI 15.9 – 29.9%, nf=39)22.8% (95% CI 16.1 – 29.5%, nf=41)24.4% (95% CI 18.0 – 30.7%, nf=51)RS= Recurrence Score, nf=number of recurrences, CI = confidence interval.

Citation Format: Mylander C, Rosman M, Gage M, Fujii T, Le Du F, Raghavendra A, Sinha A, Espinosa Fernandez JR, James A, Ueno N, Tafra L, Jackson R. Getting the most out of the 21-gene recurrence score assay: Increasing actionable results with a combined pathologic-genomic model [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-09-05.

Translational advances regarding hereditary breast cancer syndromes

Approximately 5-10% of breast cancers may be inheritable, up to 90% of which are due to mutations in BRCA1 and BRCA2. A substantial minority are caused by non-BRCA mutations, such as TP53, PTEN, STK11, CHEK2, ATM, BRIP1, and PALB2 mutations. This review highlights translational research advances with regard to the development of probabilistic models for hereditary breast cancer syndromes, the identification of specific genetic mutations responsible for these syndromes, as well as their testing and interpretations.

Whole body vibration and dynamic restraint

The purpose of this study was to identify changes due to whole body vibration in peroneus longus (PL) activation following ankle inversion perturbation. Participants were 22 (age 22.1 +/- 1.8 yrs, ht 168.8 +/- 8.2 cm, mass 65.5 +/- 11.2 kg) physically active male and female students with no recent history of lower extremity injury. Measurements of PL electromechanical delay (EMD), reaction time, and muscle activation were collected from two groups (WBV and control) over 3 time intervals (pretreatment, posttreatment, and 30 min posttreatment). Two-way ANOVAs were used to compare groups over time for all dependent variables. No group x time interactions were detected (p < 0.05) for any of the dependent variables. Whole body vibration did not alter PL EMD, reaction time, peak EMG, or average EMG. The use of WBV for enhancing ankle dynamic stability was not supported by this study. However, more data are needed to determine if WBV is an effective intervention in other areas of injury prevention or rehabilitation. These data were not consistent with the hypothesis that WBV enhances muscle spindle sensitivity.

Expanding the boundaries of occupational therapy practice through student fieldwork experiences: description of a provincially-funded community development project

The numbers of occupational therapists in community practice are not yet large enough to provide fieldwork placements to accommodate all students. This article describes a project designed to educate community agencies that do not employ occupational therapists, about our service while at the same time securing new fieldwork placements. We used on-site different discipline and offsite same discipline supervision to provide students to selected agencies without cost. Funding for one year from the Ontario Ministry of Health to the Ontario University Programs in Rehabilitation Science enabled us to initiate and evaluate the project. Students in the project developed their ability to work independently and to see their potential role in health promotion and prevention. Despite the lack of ongoing government funding, four years later, community sites are not only being maintained, but the number of sites has increased from 28 to 39, providing a total of 75 student placements. By educating a growing number of community agencies about the work of occupational therapists, the project has also expanded the boundaries of practice.

Interdisciplinary pilot project in a rehabilitation setting

This project qualitatively evaluated the planning, implementation, and outcome of an interdisciplinary model of clinical education. Expectations of physiotherapy (PT), occupational therapy (OT), and speech-language pathology (SLP) students and clinicians were assessed to determine whether the model allowed for the acquisition of the interdisciplinary knowledge and skills needed for current practice. Students from OT (n = 5), PT (n = 3), and SLP (n = 1) undertook normally scheduled five-to-eight-week clinical placements, beginning on the same start date. All students were at intermediate or senior levels in their programs. Discipline-specific activities were supervised by clinical instructors from the disciplines. Interdisciplinary sessions during the first five weeks covered cross-disciplinary activities related to clinical reasoning, interviewing techniques, professionalism, and communication skills for team reporting. Themes related to the clinical experience were derived from student and supervisor responses to pre-and post-placement questionnaires, post-placement focus group interviews, and student journals. The response to the model was positive. The students felt they had gained insights into developing interdisciplinary skills, although they did feel that some discipline-specific needs were not met. The instructors were less enthusiastic but, given better planning and communication before the placement, welcomed the opportunity to try it again.

From independence to interdependence. Creating synergistic healthcare teams

As the structure of healthcare institutions changes, nurse administrators frequently are being called on to lead interdisciplinary programs. To be successful in this new health paradigm, teams must strive to create total stakeholder satisfaction by adopting a mindset that work is interdependent, not independent, and then striving to work synergistically. The author presents 12 themes that emerged from a study investigating the essential elements of synergistic team relationships.

Understanding the transition to community living after discharge from an acute care hospital: an exploratory study

OBJECTIVES

This study was conducted to obtain patients' experiences in making the transition from an acute care hospital to their homes in the community.

METHOD

Data were gathered through group and telephone interviews with a volunteer sample of 27 discharged patients. Analysis involved two stages: categorization of shared themes and interpretation of individual occupational experiences.

RESULTS

Informants described their experiences of transition in terms that were analytically categorized as Perceived Self-Efficacy, Resources, Dimensions of Occupation, and Environmental Constraints and Opportunities. Analysis of individual patient transcripts suggests the presence of an hierarchical ordering of desired occupations.

CONCLUSION

Understanding patients' perceptions of enabling and disabling experiences has implications for predischarge and postdischarge practice in occupational therapy.

Breaking the cycle of aggression

The continuous quality improvement literature has taught us that it is important to test out theories about the cause of a problem before generating solutions to the problem. The project described in this article illustrates the value of this systematic analysis as it applies to decreasing injuries related to aggressive actions of patients.

Strategic planning: positioning occupational therapy to be proactive in the new health care paradigm

Strategic planning can be a powerful tool for occupational therapists seeking to position themselves to be leaders in the rapidly changing health care environment. The philosophical base and values of occupational therapy are consistent with those embraced by the emerging health care paradigm. However, occupational therapy staff at Victoria Hospital, an acute care university-affiliated health care institution, identified obstacles to seizing the opportunities offered by this shift in health care. In reviewing the literature, it was discovered that these obstacles were not unique to one particular facility, but were in fact common issues faced by the profession. The strategic planning process described in this paper provided a framework for addressing the identified barriers and positioning occupational therapists to play a proactive role in the evolving health care paradigm.

Re-engineering of health care: opportunity or threat for occupational therapists?

The health care system is responding to a paradigm shift from the industrial era to the knowledge society. The rapidly changing administrative structures of some hospitals and increasing numbers of proposals for new models of care are disconcerting for therapists who are used to working in traditional organizational structures and models of care. However, with a broader understanding of the shift that is occurring, it becomes apparent that this paradigm shift is pushing the system toward care practices that are more consistent with occupational therapy practices than those of the traditional medical model. This paper describes the factors influencing the direction of the paradigm shift, the major emerging models of care and organizational structures associated with the paradigm shift, and then discusses the issue of whether the paradigm shift presents a threat or a challenge to occupational therapists.

Advertised foods on children's television

OBJECTIVE

To assess the quantity and nutritional value of foods advertised on children's television following new regulations and an expanded number of networks.

RESEARCH DESIGN

Children's television hours were surveyed (with use of a method modeled on previously published studies, for purposes of comparison).

SETTING

Seven local network affiliates; all but one are broadcast nationally.

RESULTS

Children viewed an average of 21.3 commercials per hour, each lasting an average of 28.6 seconds. Food advertisements accounted for 47.8% of these commercials. Ninety-one percent of advertised foods are high in fat, sugar, and/or salt. Compared with data collected before new regulations and networks, children now watch more numerous but shorter commercials. Cereals and sweet snacks are advertised proportionately less. Processed foods, canned and prepared foods, and dairy products are more frequently advertised. The proportion of foods high in fat, salt, and sugar has not changed.

CONCLUSIONS

Commercials advertising unhealthy foods account for a large portion of children's televised viewing time. Current regulations and the incursion of cable networks into the children's television market have not meaningfully impacted the nature or number of food advertisements.

Measuring perceived self-efficacy in occupational therapy

OBJECTIVES

Occupational therapists sometimes observe an alarming discrepancy between the occupational performance skills developed in the clinical setting and the degree to which the client willingly puts these skills to use outside the clinical environment. The literature strongly suggests that perceived self-efficacy partially explains this discrepancy; however, an understanding of perceived self-efficacy has not yet been integrated into the practice of occupational therapy. Both a lack of awareness of the construct and a lack of ability to assess perceived self-efficacy within the occupational performance domain are responsible for this lack of integration into practice. This article presents the development, reliability, and validity testing of a measure of perceived self-efficacy developed particularly for use by occupational therapists, the Self-Efficacy Gauge.

METHOD

Reliability and validity testing was performed through use of a mailed survey (n = 126). Test-retest reliability, internal consistency, and alternate form reliability were examined. In addition, the subjects' scores on the Gauge were compared to actual performance and a hopelessness scale.

RESULTS

The Self-Efficacy Gauge has a reasonable degree of reliability when used on a clinical sample whose perceived self-efficacy for occupational performance activities is unlikely to change. The results also provide preliminary support for the validity of the instrument.

CONCLUSION

It is recognized that without a gold standard for comparison, validity testing will be an ongoing need.

Enhancing occupational performance through an understanding of perceived self-efficacy

The construct of perceived self-efficacy, proposed to explain the discrepancy between skill and actual performance, has received widespread attention in the psychological and medical literature. This paper describes the construct in detail, including the difference between self-esteem and perceived self-efficacy, and proposes a goodness of fit with occupational therapy practice. It is postulated that attention to the assessment and monitoring of perceived self-efficacy, along with the use of activities that closely approximate the actual activities to be performed in the community, will result in improved occupational performance and thus, better occupational therapy outcomes. Occupational therapists are challenged to identify and incorporate this construct into their day-to-day clinical programs to enhance treatment outcomes.

The Patient-Driven Interdisciplinary Care Plan

Given the paradigm shift to patient-focused care, the Patient-Driven Interdisciplinary Care Plan is the next, natural evolutionary step for the healthcare industry. The plan, based on four underlying principles, is presented, along with preliminary impressions of staff members and patients on one pilot unit.

The appraisal model of coping: an assessment and intervention model for occupational therapy

This paper presents a new synthesis of the coping literature, the Appraisal Model of Coping. It is based largely on the theoretical concepts of the cognitive relational theory of coping and emotion (Lazarus & Folkman, 1984, 1987) and social cognitive theory (Bandura, 1977). The model provides a conceptual template to guide occupational therapy intervention with respect to assisting patients to cope better with the effects of their disease. It explains the influence of many factors that affect the person's ability to cope with the disease process as well as the effect of feedback concerning the efficacy of the coping plan on future coping efforts.

Retention strategy: a clinical ladder for occupational therapists

This article explores the issue of retention of occupational therapists and its impact on the facility, client, department and the profession. It also describes the use of a clinical ladder as a retention tool and presents the experience of one clinical facility in developing a clinical ladder. The literature, in association with the experience of the aforementioned clinical facility in the development of a clinical ladder in an occupational therapy department, does not provide conclusive evidence of the efficacy of a clinical ladder as a retention tool. However, it does lend enough support for the concept to encourage its further use in occupational therapy departments. There is a need to be creative in the design of retention methodologies which will decrease turn over and attrition from the profession in order to provide a stable pool of personnel to agencies that employ occupational therapists.