Treatment-related amenorrhea and sexual functioning in young breast cancer survivors

BACKGROUND

Sexual dysfunction is a known complication of adjuvant therapy for breast cancer and an important determinant of quality of life. However, few studies have explored how treatment and other factors affect sexual functioning in young breast cancer survivors.

METHODS

Four hundred sixty-one premenopausal women with stage 0 through III breast cancer were surveyed an average of 1 year after diagnosis as part of a prospective cohort study of women who were aged ≤40 years at diagnosis. Sexual interest and dysfunction were assessed using the Cancer Rehabilitation Evaluation System (CARES). Mean CARES scores were compared and multiple regression models were fit to assess treatment and a range of menopausal and somatic symptoms in relation to sexual functioning.

RESULTS

Mean CARES sexual interest and dysfunction scores were both highest (indicating poorer functioning) among women who received chemotherapy and were amenorrheic from treatment. After accounting for menopausal and somatic symptoms, treatment-associated amenorrhea remained associated with decreased interest but was no longer an independent predictor of dysfunction. In the multivariable analysis, independent predictors of dysfunction included vaginal pain symptoms, poorer body image, and fatigue. Sexual interest was associated with vaginal pain symptoms, body image, and weight problems.

CONCLUSIONS

Factors associated with decreased sexual functioning in young breast cancer survivors can often be ameliorated. The current findings have implications for premenopausal women with other types of cancer who might be experiencing amenorrhea because of chemotherapy or surgery. Increased awareness and early intervention is essential to help improve sexual functioning and associated quality of life for all young cancer survivors.

Contemporary multidisciplinary treatment of pregnancy-associated breast cancer

Breast cancer diagnosed during pregnancy poses unique challenges. Application of standard treatment algorithms is limited by lack of level I evidence from randomized trials. This study describes contemporary multidisciplinary treatment of pregnancy-associated breast cancer (PABC) in an academic setting and explores early maternal and fetal outcomes. A search of the Dana-Farber/Harvard Cancer Center clinical databases was performed to identify PABC cases. Sociodemographic, disease, pregnancy, and treatment information, as well as data on short-term maternal and fetal outcomes, were collected through retrospective chart review. 74 patients were identified, the majority with early-stage breast cancer. Most (73.5%) underwent surgical resection during pregnancy, including 40% with sentinel lymph node biopsy and 32% with immediate reconstruction. A total of 36 patients received anthracycline-based chemotherapy during pregnancy; of those, almost 20% were on a dose-dense schedule and 8.3% also received paclitaxel. 68 patients delivered liveborn infants; over half were delivered preterm (< 37 weeks), most scheduled to allow further maternal cancer therapy. For the infants with available data, all had normal Apgar scores and over 90% had birth weight >10^th percentile. The rate of fetal malformations (4.4%) was not different than expected population rate. Within a multidisciplinary academic setting, PABC treatment followed contemporary algorithms without apparent increase in maternal or fetal adverse outcomes. A considerable number of preterm deliveries were observed, the majority planned to facilitate cancer therapy. Continued attention to maternal and fetal outcomes after PABC is required to determine the benefit of this delivery strategy.

Body image in recently diagnosed young women with early breast cancer

OBJECTIVE

To assess body image concerns among young women following a breast cancer diagnosis.

METHODS

A total of 419 women with recently diagnosed stage 0-III breast cancer were surveyed following enrollment as part of a prospective cohort study of women age 40 or younger at diagnosis. Body image was assessed using three items from the psycho-social scale of the Cancer Rehabilitation Evaluation System (CARES). CARES scores range from 0 to 4, with higher scores indicative of greater image concerns. Mean CARES scores were calculated and compared between treatment groups using t-tests and analysis of variance. Multiple linear regression models were fit to evaluate the relationship between physical and psychological factors and body image.

RESULTS

Mean time from diagnosis to completion of the baseline survey was 5.2 months. The mean CARES score for all women was 1.28. Mean CARES scores in the mastectomy-only group (1.87) and in the mastectomy with reconstruction group (1.52) were significantly higher (p < 0.0001) compared with the scores in the lumpectomy group (0.85), indicating that radical surgery was associated with more body image concerns. Radiation (p = 0.01), anxiety (p = 0.0001), depression (p < 0.0001), fatigue (p = 0.04), musculoskeletal pain symptoms (p < 0.0001), weight gain (p = 0.01), and weight loss (p = 0.02), in addition to surgery type (p < 0.0001), were all associated with more body image concerns in the multi-variable analysis.

CONCLUSION

This analysis highlights the impact of treatment, along with physical and psychological factors, on body image early in the survivorship period. Our findings provide targets for potential future intervention and may aid young women in the surgical decision-making process.

Sexual functioning in young women with breast cancer

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Background: Sexual dysfunction is a known complication of adjuvant therapy for breast cancer and an important determinant of quality of life. Little is known about the frequency and magnitude of this problem among very young women with breast cancer during the year following diagnosis. Methods: 298 sexually-active women enrolled in an ongoing multi-center cohort study with Stage 0-III breast cancer at or before age 40 were included in this analysis. Treatment data was self-reported on a survey mailed to participants at enrollment. Sexual functioning was assessed using the sexual interest and dysfunction subscales from the Cancer Rehabilitation Evaluation System (CARES). Scores range from 0-4, with higher scores indicative of poorer function. The survey included a measure of anxiety and depression (Hospital Anxiety and Depression Scale), of body image (CARES) and of physical and menopausal symptoms (Breast Cancer Prevention Trial Symptom Checklist). Mean differences in CARES scores between treatment groups (chemotherapy vs. none; hormone therapy vs. none; lumpectomy vs. mastectomy vs. mastectomy + reconstruction vs. no surgery; radiation vs. none) were compared using T-tests and ANOVA. Multiple regression models were fit to assess symptoms thought to be mediators of the treatment-sexual functioning association. Results: Mean age at diagnosis was 36 (range: 22-40) years and mean time from diagnosis to survey completion was 5 months (range: 1-16). Mean CARES sexual interest and dysfunction scores were higher in women who received chemotherapy compared to those who did not (p<0.0001). In the multivariate analysis, chemotherapy was no longer associated with decreased sexual interest or function. Anxiety, depression, musculoskeletal pain, and poorer body image were predictive of both decreased sexual interest and function. Vaginal pain symptoms were associated with greater dysfunction, while unhappiness with appearance was associated with decreased interest. Conclusions: Young women who receive chemotherapy are at risk for problems related to sexual functioning early in the survivorship period. This effect appears to be mediated through several physiologic and psychologic mechanisms, underscoring the need for interventions that target both.

Patient advocates' role in clinical trials: perspectives from Cancer and Leukemia Group B investigators and advocates

BACKGROUND

Patient advocates are increasingly involved in cooperative group trials, single-institution cancer programs, and peer-review of research applications. The purpose of this study was to evaluate the role and value of patient advocates from the perspective of Cancer and Leukemia Group B (CALGB) advocates and investigators.

METHODS

An online survey was sent to current and past (within 5 years) patient advocates and investigators. RESULTS.: Response rates were 72.7% (16 of 22) for advocates and 56.4% (102 of 181) for investigators. Patient advocates were more likely than investigators to report the following: the clinical trial process benefited from advocate involvement on committees (100% of advocates vs 72.1% of investigators; P < .05), advocates contribute to protocol development (92.8% vs 33.8%, respectively; P < .001), the cultural appropriateness of protocols (21.4% vs 10.4%, respectively; P < .05), advocates assist with patient accrual (78.6% vs 23.4%, respectively; P < .001), and advocates add value to concept development and protocol review (100% vs 63.2%, respectively; P < .001). Over half of advocates and investigators reported gaps in patient advocate knowledge and suggested that additional clinical trials training was needed. To improve clinical trials, advocates suggested their earlier involvement in protocol development and increased support from investigators. CALGB investigators recommended improving patient advocate selection and communication skills training:

CONCLUSIONS

The majority of patient advocates and investigators perceived benefits from advocate involvement in the clinical trials process; patient advocates placed more value on their role than investigators. The current results indicated that strategies to improve advocacy training and advocate-investigator communication may further enhance the role of patient advocates, and future studies that clarify the role of advocates in the prioritization and development of protocol, consent, and education materials, and on patient accrual, are warranted.

P4-19-03: Physical and Psychological Sequelae of Breast Cancer in Men

Introduction: Little is known about the physical and emotional health of men with breast cancer. Information is also lacking regarding whether their informational and supportive care needs are being met regarding fertility and genetic concerns.

Methods: In an online pilot study recruiting participants through three websites focused on male breast cancer, www.outoftheshadowofpink.com, www.malebreastcancer.org, and www.malebreastcancer.ca, we surveyed men with breast cancer about their attitudes, symptoms, experiences, and health perceptions. We measured anxiety and depression using the Hospitalized Anxiety and Depression Scale (HADS), health-related quality of life (QOL) using Functional Assessment of Cancer Therapy-Breast (FACT-B), and hormonal and sexual symptoms using the Expanded Prostate Cancer Index Composite (EPIC) Hormonal and Sexual Scales. We assessed select toxicities from therapy and history of genetic and fertility counseling.

Results: Forty-two men responded to this online survey at least in part.

PD04-05: Body Image Issues in Young Breast Cancer Patients: The Impact of Chemotherapy, Hormone Treatment, and Surgery

Background: While there is evidence that younger women with breast cancer are more likely to experience compromised quality of life compared to older women, few studies have prospectively explored the impact of treatment, including surgery, chemotherapy, and hormone therapy, on body image, in particular, in very young women (≤40 years old). This analysis examined treatment-associated differences in self-reported body image among a large cohort of young women diagnosed with breast cancer.

Methods: 431 women enrolled in an ongoing multi-center prospective cohort study with Stage 0-Stage III breast cancer were included in this analysis. Body image was measured at baseline (1-12 months following diagnosis) using three items from the Cancer Rehabilitation Evaluation System (CARES) survey. CARES scores range from 0–4, with higher scores indicative of greater image concerns. Mean differences in CARES scores between treatment groups (chemotherapy within the last month vs. none; hormone therapy vs. none; lumpectomy vs. mastectomy alone vs. mastectomy + reconstruction) were estimated using T-tests and one-way ANOVA. To control for concurrent treatment, stage, and time since diagnosis, multiple linear regression models were fit and least squares means estimated and compared between treatment groups. Multiple comparisons were adjusted for using the Bonferroni correction.

Results: Median age at diagnosis was 37 (range: 17–40) and median time from diagnosis to study enrollment was 5 months (range: 1–12 months). In the unadjusted analysis, there were no significant differences in scores between women who had received chemotherapy within the last month and those who did not (p=0.80), while women who reported hormone treatment had higher mean CARES scores compared to women who did not (p=0.04). Among women who had undergone surgery (n=370), women who had lumpectomies had a mean CARES score of 0.95, which was significantly lower (p&lt;.0001) compared to both women who had undergone mastectomy alone (CARES: 1.89) and women who reported mastectomy + reconstruction (CARES: 1.53). After adjusting for concurrent treatment (including radiation), time since diagnosis, and stage of disease, only differences between surgical groups remained significant (p&lt;.0001), with mean scores among women who had either undergone mastectomy alone (CARES: 2.02) or together with reconstruction (CARES: 1.58) higher compared to those who had a breast conserving procedure (CARES: 0.92) Conclusion: To the best of our knowledge, this is the largest analysis of treatment-related body image issues in young women with breast cancer. Treatment with chemotherapy and hormonal therapy did not appear to affect short-term body image. However, women who had a breast conserving procedure had the fewest body image concerns as measured by the CARES, while women undergoing more radical surgery appear to be at increased risk for low perceived body image though this may be mitigated to a degree by reconstruction. Further analyses will explore whether differences between surgical groups persist over time as well as examine the trajectory of change over the course of follow-up.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD04-05.

P2-19-02: Multidisciplinary Treatment of Pregnancy-Associated Breast Cancer

Background: Breast cancer complicates pregnancy in a significant minority of younger breast cancer (BC) patients (pts). Application of standard treatment algorithms is limited by the lack of randomized data to support safety and efficacy. A multidisciplinary approach attempts to maximize treatment efficacy for a pt while minimizing fetal toxicity. We sought to describe contemporary multidisciplinary BC treatment in an academic setting and explore early maternal and fetal outcomes.

Methods: A search of the Dana-Farber/Harvard Cancer Center clinical database was performed to find BC pts self-identified as pregnant at presentation with &gt;2 visits at our institution. Information available within the database along with complementary chart review provided sociodemographic, disease, staging, pregnancy and treatment information as well as short-term maternal and fetal outcomes.

Results: 55 pts diagnosed between 1996–2011 were identified. The median age at diagnosis was 34 years. 25.5% were stage I, 49.1% stage II, 20% stage III, and 5.4% stage IV. 63.6% had hormone receptor positive disease, 36.3% HER2 positive, and 18.1% triple negative. 71% underwent testing for germline BRCA1/2 mutations, with 9% of all pts testing positive. 29% were diagnosed in the first trimester (T1), 29% in T2, and 42% in T3. 89% underwent ultrasound imaging for staging, 49% X-ray imaging, 16.3% MRI, and 0% CT. 67% underwent surgery during pregnancy: 43.2% mastectomy, 48.6% lumpectomy, and 8.1% lumpectomy with subsequent mastectomy during pregnancy. 18.9% underwent surgery in T1, 45.9% in T2, and 37.8% in T3. 27.2% underwent sentinel lymph node biopsy. 51% received chemotherapy (C) during pregnancy: of those, 100% received anthracycline/cyclophosphamide (2-4 cycles), 11% paclitaxel, and 0% trastuzumab. 28.5% received C on a dose-dense schedule, with 25% supported by growth factors (14.2% filgrastim, 10.8% pegfilgrastim). 28.5% received neoadjuvant C. C was initiated during T1 for 0%, T2 for 64.3%, and T3 for 35.7%. Two pts terminated pregnancy in T1, one spontaneously miscarried at 12 weeks (wks), and two are currently in the third trimester of pregnancy; therefore, a total of 50 pts had delivered at the time of this analysis. The median time of delivery was 36 wks. 50% delivered prior to 37 wks and were considered preterm; of those, 76% were inductions or Caesarian sections planned to facilitate cancer therapy. Only 12% delivered prior to 34 wks. For the 25 infants for whom Apgar scores were available, 76% had scores of ≥ 8 at delivery, and 100% had scores of ≥ 8 at 5 minutes. For the 25 infants for whom birth weights were available, the median birth weight was 6lbs 1oz. Only 4 were less than 5lbs at the time of delivery. A total of 4 fetal abnormalities were noted: cleft palate (2), club foot (1), and ventricular septal defect (1).

Conclusions: Within a multidisciplinary academic center, treatment of pregnancy-associated BC using contemporary treatment algorithms, including taxane chemotherapy, growth factor support, and sentinel lymph node biopsy, has been pursued without significant adverse effect on fetal outcomes when compared to other published series. A considerable number of preterm deliveries have been observed. Further data collection is ongoing for confirmation of initial observations.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-19-02.

P4-11-12: Molecular Phenotype of Breast Cancers in a Large Cohort of Young Women According to Time Interval Since Pregnancy

Background: The increase in breast cancer risk during pregnancy and post partum is well recognized. The cross-over to protective effect does not occur until many years later and varies with age at first birth. Recently, a genomic signature specific to the pregnant compared with the non-pregnant breast has been identified; this signature remains present in the postmenopausal parous breast. Given this, we investigated whether time interval since pregnancy affects the phenotype of breast cancers arising in young women compared with nulliparous women. Methods: We examined molecular phenotype, according to histologic grade and biomarker status, in relation to time since pregnancy in an ongoing prospective cohort study (n=355) of young women (≤40yrs) with breast cancer. Medical records were reviewed for tumor stage and receptor status. Parity was ascertained from questionnaires completed within 9 months of diagnosis. Tumor grade was determined by central pathology review. Using tumor grade and biomarker expression, cancers were categorized as luminal A (ER+ and/or PR+, HER2−, histologic grade 1 or 2); luminal B ( ER+ and/or PR+, HER2+, or ER and/or PR+, HER2− and grade 3); HER2 type (ER-, PR-, HER2+); and triple negative (ER-, PR-, HER2−).

Results: The median age of the study population is 37 years (range 17–40). Overall, 80% of women had stage 1 or 2 disease; 67% of cancers were ER positive and 32% showed HER2 overexpression. The distribution of breast cancer molecular phenotypes by time interval since last pregnancy is shown in the table.

Distribution of molecular phenotype by interval between last pregnancy and diagnosis

Pathologic features and molecular phenotype by patient age in a large cohort of young women with breast cancer

Prior studies have suggested a higher prevalence of high grade, ER-negative, HER2-positive, and basal-like carcinomas in young women with breast cancer. However, the precise distribution of poor prognostic features in this population remains unclear. We examined the pathologic features and distribution of molecular phenotype in relation to patient age in a large group of young women (≤40 years) with invasive breast cancer. Medical records were reviewed for clinical characteristics, tumor stage, and receptor status. Pathologic features, including those features associated with basal-like carcinomas, were examined by central review. Using tumor grade and biomarker expression, cancers were categorized as luminal A (ER+ and/or PR+ and HER2-, histologic grade 1 or 2); luminal B (ER+ and/or PR+ and HER2+, or ER and/or PR+, HER2- and grade 3); HER2 (ER and PR- and HER2+); and triple negative (ER-, PR-, and HER2-). Among 399 women of ≤40 years, 33% had luminal A tumors, 35% luminal B, 11% HER2 (ER-negative), and 21% triple negative. Compared to published results for all breast cancers, a greater proportion of young women had luminal B tumors, and a lesser proportion had luminal A. There were no significant differences in molecular phenotype, tumor stage or grade among the different age groups of young women. However, this population of young women presented with a different distribution of molecular phenotypes compared to the general population of women with breast cancer. These findings may have implications with regard to the etiology and prognosis of breast cancer in young women.

Presentation of breast cancer in young women

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Background: Current guidelines for early detection of breast cancer do not adequately address diagnosis in young women. Furthermore, a lower suspicion for malignancy in this population may cause diagnostic delays. It is unknown how much the lack of routine screening and potential diagnostic delays contribute to the poorer outcomes of younger women. Methods: We surveyed women age <40 with recently diagnosed breast cancer in a prospective multicenter cohort study started in late 2006. We evaluated initial sign/symptom of cancer, time to first seeking medical attention, time from seeking medical attention to diagnosis, and patient factors associated with delays of >30 days in either timeframe. Chi square and Fisher's Exact tests were used to compare those with and without delays. Results: The first 222 women enrolled in the cohort are included in this analysis. Median age at diagnosis was 36 years (range 17–40). 79% of women initially identified their cancers through breast self exam. Only 6% were initially identified by clinical breast exam, 14% by breast imaging, 1% by systemic symptoms. While the median time between initial sign and seeking medical attention was 10 days (range 0–3,600), 54 women had >30 days between initial sign and medical attention (median 102, range 44–3,600). Similarly, median time from seeking medical attention to diagnosis was 21 days (range 0–2,970), yet 59 women had >30 days from attention to diagnosis (median 70, range 33–2,970). Preliminary comparison of women with and without delays did not reveal significant differences in age, race, education, marital status, or gravidity. Analyses will be updated and psychosocial factors, tumor subtype, and stage at diagnosis will be evaluated. Conclusions: In this large modern cohort of young women with breast cancer, nearly 80% presented with a self-detected breast abnormality, and most were diagnosed soon after they developed a sign/symptom. However, nearly 25% delayed seeking medical attention and 25% experienced a delay in diagnosis after seeking medical attention. Further research is warranted to compare delays between younger and older women, to evaluate delays in more diverse populations, to explore predictors of delays, and to assess for prognostic implications of delays in order to improve outcomes in young women.

No significant financial relationships to disclose.

Using students' journals about death experiences as a pedagological tool

The purpose of this article is to evaluate a pedagological tool for student's study of death and bereavement. Previous research suggests that students may be more willing to discuss issues associated with death through written correspondence rather than through oral communication. However, despite these efforts there are still students who experience great difficulty in expressing themselves fully in class by no fault of the teacher but merely due to the student's own disposition. Based on the data, it appears as if journal writing may offer a way around this difficulty. Data were collected from two sites: a private college in New England and a Midwestern state university. Common themes that students stated effected their experiences with death included reactions of significant others to the death in question, the funeral services provided, and the familial events postfuneral. The limitations and benefits of using journaling as a pedagological tool for a bereavement course are discussed. Using projects such as this one may help students to accurately display their learning to the professor while still bringing in their own perceptions of death.