Selection of Germline Genetic Testing Panels in Patients With Cancer: ASCO Guideline

PURPOSE

To guide use of multigene panels for germline genetic testing for patients with cancer.

METHODS

An ASCO Expert Panel convened to develop recommendations on the basis of a systematic review of guidelines, consensus statements, and studies of germline and somatic genetic testing.

RESULTS

Fifty-two guidelines and consensus statements met eligibility criteria for the primary search; 14 studies were identified for Clinical Question 4.

RECOMMENDATIONS

Patients should have a family history taken and recorded that includes details of cancers in first- and second-degree relatives and the patient's ethnicity. When more than one gene is relevant based on personal and/or family history, multigene panel testing should be offered. When considering what genes to include in the panel, the minimal panel should include the more strongly recommended genes from Table 1 and may include those less strongly recommended. A broader panel may be ordered when the potential benefits are clearly identified, and the potential harms from uncertain results should be mitigated. Patients who meet criteria for germline genetic testing should be offered germline testing regardless of results from tumor testing. Patients who would not normally be offered germline genetic testing based on personal and/or family history criteria but who have a pathogenic or likely pathogenic variant identified by tumor testing in a gene listed in Table 2 under the outlined circumstances should be offered germline testing.Additional information is available at www.asco.org/molecular-testing-and-biomarkers-guidelines.

Multicenter Study on the Frequency of Low Bone Mineral Density in Young Women With Breast Cancer and Associated Factors

INTRODUCTION

Young women with breast cancer (BC) may experience bone mineral density (BMD) loss secondary to cancer treatment effects on estrogen levels. Studies assessing BMD in BC patients have had a limited representation of young women. This multicenter retrospective study analyzed the frequency of low BMD and associated factors in this age group.

METHODS

Women diagnosed with stage 0-III BC at ≤40 years, treated with chemotherapy and/or endocrine therapy between 2010 and 2020 at 5 Mexican BC referral centers were eligible. Demographic, clinical and treatment data were collected, as well as bone dual-energy X-ray absorptiometry (DEXA) results. Low BMD was defined as lumbar or femoral neck T-score < -1.0 or Z-score ≤ -2.0.

RESULTS

A total of 1259 patients were included; median age at diagnosis was 36 years (21-40). Overall, 93% received chemotherapy and 65% endocrine therapy (tamoxifen was received at some point by 61%, aromatase inhibitors by 17%, and GnRH agonists/bilateral oophorectomy by 21%). DEXA scans were documented in 254 (20%), of which 163 (64%; 95% confidence interval [CI] 58%-70%) had a low BMD report. Low BMD was associated with receiving aromatase inhibitors (Odds ratio [OR] 1.92; 95% CI 1.13-3.24), and GnRH agonists/bilateral oophorectomy (OR 2.25; 95% CI 1.21-4.21).

CONCLUSION

The suboptimal frequency of BMD monitoring observed displays an alarming disregard for bone health in young patients. Thus, a high proportion of women with low BMD are potentially being missed and precluded from the opportunity to receive timely interventions. Particular focus should be put on BMD monitoring among patients treated with aromatase inhibitors, GnRH agonists or bilateral oophorectomy.

Uptake of Risk-Reducing Measures, Cascade Testing, and Related Challenges Among Carriers of Breast Cancer-Associated Germline Pathogenic Variants in Mexico

PURPOSE

Genetic cancer risk assessment (GCRA) provides pathogenic variant (PV) carriers with the invaluable opportunity to undertake timely cancer risk-reducing (RR) measures and initiate cascade testing (CT). This study describes the uptake of these strategies and the related barriers among breast cancer-associated germline PV carriers in Mexico.

METHODS

Carriers who were at least 6 months after disclosure of genetic test results at two GCRA referral centers were invited to answer a survey assessing sociodemographic characteristics, awareness of their carrier status and its implications, uptake of RR measures according to international guidelines by PV, CT initiation, and associated challenges.

RESULTS

Of the eligible carriers, 246/384 (64%) answered the survey (median age: 44 years). Most were female (88%), married/in domestic partnership (66%), and had personal breast/ovarian cancer history (61%). PVs included BRCA1/2 (75%), CHEK2 (10%), PALB2 (5%), ATM (5%), NF1 (2%), RAD51C (2%), PTEN (1%), and TP53 (1%). Most (87%) participants were aware of their carrier status. When recommended, 37% underwent RR bilateral mastectomy, 48% RR oophorectomy, 70% annual mammogram, and 20% breast magnetic resonance imaging. Challenges hindering the uptake of RR measures included financial limitations (67%), lack of recommendation by their physician (35%), and fear (24%). Nearly all (98%) claimed sharing their results with their relatives. CT was initiated in 63% of families and was associated with carriers being married/in domestic partnership (P = .04) and believing GCRA was useful (P < .001).

CONCLUSION

Despite the resource-constrained setting, relevant rates of RR measures and CT were observed. Targeted interventions to reduce out-of-pocket expenses and improve patient-physician communication and patients' understanding on carrier status are warranted to enhance the overall benefit of GCRA and ultimately improve the provision of patient-centered care to both carriers and their at-risk relatives.

Locoregional therapy containing surgery in metastatic breast cancer: Systematic review and meta-analysis

INTRODUCTION

The role of locoregional therapy (LRT) containing surgery and systematic therapy in metastatic breast cancer patients remains controversial. This study investigated the effect of LRT in patients who were initially diagnosed with metastatic breast cancer (MBC) on overall survival (OS), locoregional progression-free survival (PFS), and distant systemic PFS.

METHODS

The related keywords were searched in MEDLINE/PubMed, SCOPUS, and Web of Science databases up to August 15th, 2022. Hazard ratios (HR) with 95% confidence intervals (CIs) were pooled by the random-effects model.

RESULTS

Seven articles with 1626 participants compared LRT with only systemic therapy (ST) for patients with de novo MBC. LRT did not improve (p = 0.28) OS compared to ST (HR: 0.83, 95% CI: 0.60, 1.16). LRT significantly improved locoregional PFS outcomes compared to ST (HR: 0.31, 95% CI: 0.15, 0.60, p = 0.001). LRT significantly (p = 0.001) improved OS in patients with solitary bone metastases (HR: 0.48; 95% CI: 0.35-0.67).

CONCLUSION

LRT improves locoregional PFS. Furthermore, LRT improves OS in patients with solitary bone metastases.

Real-world data in patients with BRCA mutated breast cancer treated with poly (ADP-ribose) polymerase inhibitors

Breast cancer is the most common type of cancer globally. Hereditary breast cancer accounts for 10% of new cases and 4%-5% of cases are associated to pathogenic variants in BRCA1 or BRCA2 genes. In recent years, poly-adenosine-diphosphate-ribose polymerase inhibitors (PARPi) olaparib and talazoparib have been approved for patients with BRCA-associated, HER2 -negative breast cancer. These drugs have shown positive results in the early and advanced setting with a favourable toxicity profile based on the OlympiAD, OlympiA and EMBRACA phase 3 trials. However, patients included in these randomised trials are highly selected, making toxicity and efficacy in patients encountered in routine clinical care a concern. Since the approval of olaparib and talazoparib for advanced human epidermal growth factor receptor 2-negative (HER2-negative) breast cancer, several phase IIIb-IV trials, expanded access cohorts, and retrospective cohorts have provided information on the efficacy and tolerability of these treatments in patient subgroups underrepresented in the registration trials, such as older adults, patients with poor performance status, and heavily pretreated patients. The aim of this review is to present a critical review of the information regarding the use of PARPi in real-world breast cancer patients.

Tamoxifen use and risk of endometrial cancer in breast cancer patients: A systematic review and dose-response meta-analysis

BACKGROUND

Worse prognosis of endometrial cancers (EC) in tamoxifen-treated women compared to non-tamoxifen-treated women been proposed. The relationship between tamoxifen treatment of breast cancer (BC) and the risk of EC is controversial and there is no agreement between publication results on this issue (the answer to all comments provided in the page 2 of manuscript). The aim of this study is investigation the association between tamoxifen treatment and the risk of EC in patients with BC.

METHODS AND RESULTS

We conducted a comprehensive search with related keywords in MEDLINE/PubMed, SCOPUS, and Web of Science databases until April 16, 2022. Random-effects model (DerSimonian and Laird) was used to pool risk ratios (RRs) with 95% confidence intervals (CIs) of EC. Dose, cumulative dose, and duration-response analysis were performed in linear and non-linear states. Twenty-six studies reported a relation between tamoxifen treatment and risk of EC in patients with BC. Results showed a direct relationship between tamoxifen use and EC (RR: 2.03, 95% CI: 1.68-2.45; I2:76%). By increase the age of participants, the risk of EC was decrease (coef = -.0206), although this was not statistically significant (p = .37). Linear dose-response model indicated a direct significant association between dose and duration use of tamoxifen and EC (dose: exe(b) = 1.019, p = .001; duration: exe(b) = 1.014, p = .001). Non-linear dose-response analysis confirmed linear analysis.

CONCLUSION

This study highlights that tamoxifen use is a significant risk factor related to the incidence of EC in patients with BC.

Abstract P5-08-13: Frequency of low bone mineral density in young women with breast cancer and associated factors

Background: Young women with breast cancer (YWBC) may experience bone mineral density (BMD) loss due to the effects of cancer treatment on estrogen levels. Studies assessing BMD in breast cancer (BC) patients have had a limited representation of young women. This study aimed to analyze the frequency of low BMD and its associated factors in this specific age group.

Methods: This retrospective, multicenter study included women ≤40 years diagnosed with stage 0-III BC, treated with chemotherapy (CT) and/or endocrine therapy (ET) between 2010-2020, and with no documented bone metastases during follow-up. The protocol was conducted in 5 BC referral centers in Mexico. Demographic, clinical and treatment data were collected, as well as bone dual-energy X-ray absorptiometry (DEXA) results. Low BMD was defined as T-score &lt;-1.0 or Z-score ≤-2.0 at the lumbar spine (L1-L4) or femoral neck.

The frequency of low BMD was analyzed with descriptive statistics. Binary logistic regression using complete case analysis was conducted to calculate odds ratios (OR) and 95% confidence intervals (95%CI) of experiencing low BMD according to demographic, clinical and therapeutic factors.

Results: In total, 716 YWBC met inclusion criteria. Median age at BC diagnosis was 36 years (21-40); 708 (99%) women were premenopausal at diagnosis. Most were married (355; 50%), had higher education (381; 53%), were unemployed (433; 61%), and were non-smokers (552; 77%). Body mass index (BMI) was &lt; 18.5 kg/m2 (underweight) and ≥25.0 kg/m2 (overweight/obese) in 14 (2%) and 392 (58%) cases, respectively. The most common BC subtype was hormone receptor (HR) positive/HER2 negative (371; 52%), followed by triple negative (168; 24%), HR positive/HER2 positive (122; 17%) and HR negative/HER2 positive (55; 8%). Patients were mostly diagnosed with stage II (346; 48%) or III (276; 39%) disease. As for treatment, CT in 667 (93%), ET in 468 (65%), anti-HER2 therapy in 168 (24%), and radiotherapy was administered in 562 (79%) cases.

DEXA scans were documented in 213/716 (30%) patients. In total, 286 DEXA results were available. The time elapsed from the start of the first systemic treatment to the DEXA result was 0-12 months in 42 cases (15%); 13-36 months in 103 (36%); 37-60 months in 72 (25%); and &gt;60 months in 69 (24%). Overall, 133/213 patients (62%; 95%CI 56-69%) had at least one low BMD report after the start of CT or ET. T-scores and Z-scores in each period are detailed in the Table. No fractures were recorded in any case after BC diagnosis. The only variable associated with at least one low BMD result was BMI ≥25.0 kg/m2 (OR, 1.88; 95%CI, 1.04-3.40). The described demographic, clinical and treatment factors were not significantly associated with low BMD.

Conclusion: This study showed a suboptimal frequency of bone DEXA monitoring in YWBC. A considerable proportion of YWBC experienced low BMD after initiation of CT and/or ET; and a significant association was found between obesity/overweight at BC diagnosis and subsequent low BMD. These data reflect the importance of requesting DEXA scans in young patients on a regular basis and promoting the maintenance of an adequate body weight, in line with international recommendations. Further studies evaluating the degree of BMD loss and its determinants would contribute to establish the optimal periodicity to monitor BMD in relation to BC therapy, allow timely offering of interventions to reduce bone morbidity, as well as improve the quality and life and survivorship of this young group of patients.

Table. DEXA T-scores and Z-scores.

Citation Format: Fernanda Mesa-Chavez, Yanin Chavarri-Guerra, Sandy Ruiz-Cruz, Paula Cabrera-Galeana, Christopher Jesus del Rio-Martinez, Carmen Guadalupe Bermudez-Barrientos, Brizio Moreno-Jaime, Abigail Samayoa-Mateos, David Vega-Morales, Cynthia Villarreal-Garza. Frequency of low bone mineral density in young women with breast cancer and associated factors [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-08-13.

Abstract P6-02-05: Prevalence of non-BRCA germline pathogenic variants in Mexican women with breast cancer referred for genetic cancer risk assessment

Background:  The prevalence of germline pathogenic variants in Mexican women with breast cancer who met the reference criteria for genetic cancer risk assessment (GCRA) has been previously reported as close to 20%. However, information regarding the spectrum of gPVs in genes other than BRCA in this population is limited. Methods: This prospective study included Mexican women who were diagnosed with BC and met international criteria for GCRA. Participants were enrolled in the Clinical Cancer Genomics Community Research Network (CCGCRN) registry and at two referral breast cancer centers in Mexico, the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City and at the Hospital Zambrano Hellion TecSalud, Monterrey. Participants underwent multigene panel testing (MGPT) for 37 cancer susceptibility genes. For this analysis, only the results of pathogenic and likely pathogenic variants in the index cases were reported. The demographic and molecular characteristics of the variants are described here. Results: From August 2017 to September 2021, 1020 Mexican women with BC underwent MGPT, with a median age at diagnosis of 41 y (range 20-86), of whom 206 (20.2%) were carriers. 208 gPVs were identified with BRCA1/2 representing 70% (145/208) of the gPVs (BRCA1 n=89, BRCA2 n=56). 63 (30%) of gPVs were identified in genes other than BRCA (CHEK2 n=21, PALB2 n=13, TP53 n=7, RAD51C n=5, ATM n=4, NF1 n=3, PTEN n=2, MUTYH homozygous n=2, RAD50 n=1, BRIP1 n=1, CDH1 n=1, NBN n=1, MSH2 n=1 and MSH6 n=1). The recurrent variants previously proposed as founders in the Hispanic population were frequent among those identified in their respective genes: CHEK2 c.707T&gt;C 81% (17/21), PALB2 c.2167_2168delAT 46% (6/13) and BRCA1 del(exons 9-12) 18% (16/89). As a group, the 4 most frequent genes where gPVs were identified (BRCA1, BRCA2, CHEK2 and PALB2) represented 86% (179/208) of the positive results. Conclusion: Among the variants identified in this population of Mexican women with BC, the proportion of gPVs in genes other than BRCA was significant (about 1 out of 3 pts), which justifies the use of MGPT in the assessment of our population. However, a tailored panel (sequencing of BRCA1/BRCA2/CHEK2/PALB2 and MLPA for BRCA1) could be proposed in areas of Mexico with limited medical resources, including the analysis of other genes in selected patients according to clinical suspicion and family history of cancer.

Citation Format: Yanin Chavarri-Guerra, Cynthia Villareal Garza, Jose Luis Rodriguez-Olivares, Dione Aguilar-y Mendez, Gregorio Quintero-Beulo, Francisco Gutierrez-Delgado, Josef Herzog, Stephen Gruber. Prevalence of non-BRCA germline pathogenic variants in Mexican women with breast cancer referred for genetic cancer risk assessment [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-02-05.

End-of-Life Care and Advanced Directives in Hispanic/Latinx Patients: Challenges and Solutions for the Practicing Oncologist

Advanced end-of-life care (EOL) comprises a group of strategies to provide comfort to patients at the end of life. These are associated with better quality of life, better satisfaction, and a lower rate of hospitalizations and aggressive medical treatment. Advanced EOL care, including advanced directives completion and hospice enrollment, is suboptimal among Hispanic/Latinx patients with cancer due to personal, socio-cultural, financial, and health system-related barriers, as well as due to a lack of studies specifically designed for this population. In addition, the extrapolation of programs that increase participation in EOL for non-white Hispanics may not work appropriately for Hispanic/Latinx patients and lead to overall lower satisfaction and enrollment in EOL care. This review will provide the practicing oncologist with the tools to address EOL in the Hispanic/Latinx population. Some promising strategies to address the EOL care disparities in Latinx/Hispanic patients have been culturally tailored patient navigation programs, geriatric assessment-guided multidisciplinary interventions, counseling sessions, and educational interventions. Through these strategies, we encourage oncologists to take advantage of every clinical setting to discuss EOL care. Treating physicians can engage family members in caring for their loved ones while practicing cultural humility and respecting cultural preferences, incorporating policies to foster treatment for the underserved migrant population, and providing patients with validated Spanish language tools.

Abstract 2214: Disparity in the uptake of risk-reducing surgery after GCRA in Hispanic patients in Latin America and in the United States

Background: Patients at increased risk of breast (BC) and/or ovarian (OC) cancer can opt for risk-reducing surgeries (RRS). However, there are disparities in access to genomic cancer risk assessment (GCRA) and cancer prevention interventions related to geography, socioeconomic status, and limited public health support. We studied factors that affect the uptake of risk-reducing mastectomy (RRM) and salpingo-oophorectomy (RRSO) in Hispanic patients of Latin America (LatAm) and the United States (US).

Methods: Hispanic women enrolled in the Clinical Cancer Genomics Community Research Network registry between 1997-2019 who underwent genetic testing, had a personal or family history (FHX) of BC or OC, and had ≥6 months of follow-up data were considered eligible. Demographic and clinical factors associated with risk-appropriate uptake of RRS were considered. Data were analyzed using Fisher’s exact tests and logistic regression models.

Results: 1818 patients with a median follow-up of 43 months were studied. Most were from the US (65%), followed by Mexico (21%), Peru (10%), Colombia (2%), and Puerto Rico (2%). Median age at enrollment was 44 years; 81% had a personal history of BC and 5% of OC. Cancer-associated pathogenic variants (PVs) were identified in 459 patients (25%); 409 were in BRCA, 36 had other BC-susceptibility PVs (ATM, CHEK2, PALB2, PTEN, or TP53), and 14 had other OC-susceptibility PVs (BRIP1, MSH2, MSH6, MLH1, or RAD51C). Overall, 449/1715 (26.2%) patients underwent RRM, with a higher rate among patients in the US than those in LatAm (31% vs. 17%, p&lt;0.01); 377/1517 (25%) patients underwent RRSO, with no regional differences observed (24% vs. 27%, p=0.22). The factors associated with undergoing RRM were US residence (OR 2.2; 95% CI 1.7-2.8), age ≤50 (OR 2.2; 95% CI 1.7-2.8), carrying a BC-predisposing PV (OR 3.5; 95% CI 2.8-4.4), positive FHX for BC (OR 1.5; 95% CI 1.2-1.9), and personal history of cancer (OR 3.6; 95% CI 2.4-5.6). In a multivariate model, US residence, age, and previous BC diagnosis remained independent predictors for RRM in BC-susceptibility gene PV carriers, while age was not a significant factor in non-carriers. The factors associated with undergoing RRSO included being a carrier of an OC-predisposing PV (OR 6.3; 95% CI 4.8-8.1), positive FHX for OC (OR 2.1; 95% CI 1.5-2.8), and previous cancer diagnosis (OR 1.7; 95% CI 1.2-2.5). In carriers of OC-susceptibility gene PVs, residing in US and previous cancer diagnosis were independently associated with RRSO, while positive FHX for OC and previous cancer diagnosis were identified as independent factors in non-carriers.

Conclusion: There are disparities in the uptake of RRS outside the US. Beyond limitations in resources, understanding the factors associated with undergoing RRS could be key to developing targeted interventions to improve the uptake of risk-appropriate measures in hereditary cancer syndrome patients.

Citation Format: Jeffrey N. Weitzel, Yanin Chavarri-Guerra, Ana Ferrigno, Pamela Mora-Alférez, Annette Campbell-Fontaine, Cynthia Villarreal-Garza, Alejandro Mohar-Betancourt, Gubidxa Gutierrez-Seymour, Gary W. Unzeitig, Sandra Brown, Bita Nehoray, Azucena del Toro-Valero, Pamela Ganschow, Ian Komenaka, Yenni Rodriguez, Francisco Gutierrez-Delgado, Kathleen R. Blazer. Disparity in the uptake of risk-reducing surgery after GCRA in Hispanic patients in Latin America and in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2214.

Financial Toxicity Among Older Mexican Adults With Cancer and Their Families: A Mixed-Methods Study

The financial toxicity (FT) of cancer is common among older adults in high-income countries, but little is known about the financial hardships faced by older patients with cancer living in developing countries. The aim of this study was to explore the financial burden of cancer among older Mexican adults and their relatives, as well as factors that might mitigate such burden.

Financial toxicity among older Mexican adults with cancer and their families

Germline pathogenic variants in Mexican patients with hereditary triple-negative breast cancer

Objective. Describe the prevalence of breast cancer (BC)- associated germline pathogenic variants (PVs) among Mexican patients with triple-negative BC (TNBC). Materials and methods. The spectrum of PVs identified among patients with TNBC who were enrolled in a prospective registry and underwent genetic testing was analyzed. Results. Of 387 patients with invasive TNBC and a median age at diagnosis of 39 years (range 21-72), 113 (29%) were carriers of PVs in BC-susceptibility genes: BRCA1 (79%), BRCA2 (15%), and other (6%: ATM, BRIP1, PALB2, PTEN, RAD51C, and TP53). PV carriers were younger at BC diagnosis (37 vs. 40 years, p=0.004) than non-carriers. Conclusion. A large proportion of TNBC in Mexican patients is associated with germline PVs, the vast majority in BRCA. The incremental yield of PVs in other BC-susceptibility genes was modest, and a stepwise approach starting with BRCA testing may be justified if it is more cost-effective than multigene panel testing.

Abstract P2-09-11: Uptake of risk-reducing strategies and related challenges among carriers of breast cancer-associated germline pathogenic variants in Mexico

Background: Genetic cancer risk assessment is a multidisciplinary approach that enables the invaluable opportunity to recommend measures aimed at decreasing the risk of recurrence and new cancer diagnoses in individuals with inherited cancer predisposition. However, different challenges may limit the uptake of risk-reducing (RR) strategies among patients in underserved settings. This study describes the implementation of RR surgeries or surveillance studies and related barriers among carriers of breast cancer-associated germline pathogenic variants (PV). Methods: PV carriers were identified at two referral cancer centers in Mexico ≥6 months after receiving test results and genetic counseling. From October 2020 to June 2021, participants were invited to answer a multiple-choice survey assessing their uptake rate of RR measures according to NCCN guidelines by type of PV, as well as the challenges that had hindered this uptake. Descriptive statistics and Chi-squared or Fisher’s exact tests were used for data analysis. Results: In total, 162 carriers (median age: 42.5 years [range 21-73]) answered the survey. Most were women (89%), lived in an urban setting (91%), were married/in domestic partnership (72%), had at least high school education (69%), and were employed (51%). Monthly household income was lower than the minimum wage in 25% of cases and most patients had public (53%) or no (32%) healthcare coverage. Overall, 105 (65%) had a personal history of cancer, most commonly unilateral (77%) or bilateral (13%) breast cancer. PV were found in BRCA1/BRCA2 (75%), CHEK2 (11%), PALB2 (6%), ATM (4%), RAD51C (3%), and less frequently (3%) in TP53, NF1 or PTEN. Carriers underwent at least one of the recommended RR surgeries and surveillance studies in 61% and 69% of cases, respectively. Specifically, 52/124 (42%) of female BRCA1/BRCA2, PALB2, PTEN or TP53 PV carriers had undergone RR mastectomy, while 45/77 (58%) of eligible BRCA1/BRCA2 or RAD51C PV carriers had RR salpingo-oophorectomy. As for surveillance studies, carriers performed all, some and none of the recommended examinations according to their PV in 34%, 35% and 31% of cases, respectively. When an annual mammogram was recommended, 69/109 (63%) underwent the study in the previous year; in the case of breast MRI, only 23/103 (22%) had performed it in the last year. Notably, 132 (81%) carriers reported ≥1 challenge that hindered the uptake of RR strategies (median: 2 [range 0-10]). The main barriers were lack of insurance coverage of the recommended interventions (60%), financial limitations (50%), belief that their physician had not requested the studies or procedures (36%), and fear (25%). Uptake of RR strategies was not associated with carriers’ age, education level, employment status, income, place of residence, or type of mutation (high-risk vs moderate- or low-risk PV). Significant associations are reported in the Table. Conclusion: An important proportion of PV carriers in this resource-constrained setting underwent all or some of the recommended RR strategies, with the most cited uptake challenges being financial barriers and lack of endorsement by their physician. Targeted interventions to reduce out-of-pocket expenses and improve patient-physician communication and patients’ understanding of the implications of carrying a genetic mutation are warranted to enhance the uptake of RR surgeries and surveillance strategies among PV carriers.

Variables associated with the uptake of RR strategiesVariableUnderwent ≥1 RR surgeryDid not undergo any RR surgeryp-valueVariableUnderwent all or some surveillance studiesDid not undergo any surveillance studiesp-valueMarital status.012Gender&lt;.001Married/Domestic partnership6532Female10133Single/Divorced/Widowed1419Male313Personal cancer history&lt;.001Personal cancer history.002Yes6923Yes7521No1028No2925Attendance to follow-up appointments&lt;.001Attendance to follow-up appointments&lt;.001Yes6225Yes7916No1726No2530Knowledge that a genetic mutation conveys a greater risk of new cancer diagnoses.001Knowledge that a genetic mutation conveys a greater risk of cancer recurrence.012Yes7336Yes7423No615No3023Knowledge of carrier status.044Yes9436No1010Recent cancer diagnosis in a relative.017Yes2922No7524

Citation Format: Cynthia Villarreal-Garza, Fernanda Mesa-Chavez, Yanin Chavarri-Guerra, Dione Aguilar y Mendez, Andrea Becerril-Gaitan, Bryan F Vaca-Cartagena, Salvador G Santiesteban, Alejandro Aranda-Gutierrez, Daniela Obregon-Leal, Melina Miaja-Avila, Maria F Ochoa Chavez, Andres Rodriguez-Faure, Hermes J Franco Jimenez, Jeffrey N Weitzel. Uptake of risk-reducing strategies and related challenges among carriers of breast cancer-associated germline pathogenic variants in Mexico [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-09-11.

MASCC/ISOO expert opinion on the management of oral problems in patients with advanced cancer

PURPOSE

The Palliative Care Study Group in conjunction with the Oral Care Study Group of the Multinational Association for Supportive Care in Cancer (MASCC) formed a sub-group to develop evidence-based guidance on the management of common oral problems in patients with advanced cancer.

METHODS

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews and trials, respectively. Guidance was categorised by the level of evidence, and "category of guideline" (i.e., "recommendation", "suggestion" or "no guideline possible").

RESULTS

Twelve generic suggestions (level of evidence - 5), three problem-specific recommendations and 14 problem-specific suggestions were generated. The generic suggestions relate to oral hygiene measures, assessment of problems, principles of management, re-assessment of problems and the role of dental/oral medicine professionals.

CONCLUSIONS

This guidance provides a framework for the management of common oral problems in patients with advanced cancer, although every patient requires individualised management.

Influence of germline BRCA genotype on the survival of patients with triple-negative breast cancer

The presence of BRCA pathogenic variants (PVs) in triple-negative breast cancer (TNBC) is associated with a distinctive genomic profile that makes the tumor particularly susceptible to DNA-damaging treatments. However, patients with BRCA PVs can develop treatment resistance through the appearance of reversion mutations and restored BRCA expression. As copy-number variants (CNV) could be less susceptible to reversion mutations than point mutations, we hypothesize that carriers of BRCA CNVs may have improved survival after treatment compared to carriers of other BRCA PVs or BRCA wild-type. Women diagnosed with stage I-III TNBC at ≤50 years at a cancer center in Mexico City were screened for BRCA PVs using a recurrent PV assay (HISPANEL; 77% sensitivity). The recurrence-free (RFS) and overall survival (OS) were compared according to mutational status. Among 180 women, 17 (9%) were carriers of BRCA1 ex9-12del CNV and 26 (14%) of other BRCA PVs. RFS at ten years for the whole cohort was 79.2% (95% CI 72.3-84.6%), with no significant differences according to mutational status. 10-year OS for the entire cohort was 85.3% (95%CI: 78.7-90.0%), with BRCA CNV carriers demonstrating numerically superior OS rates other PV carriers and non-carriers (100% vs. 78.6% and 84.7%; log-rank p=0.037 and p=0.051, respectively). This study suggests that BRCA1 ex9-12del CNV carriers with TNBC may have a better OS, and supports the hypothesis that the genotype of BRCA PVs may influence survival by limiting treatment resistance mediated by reversion mutations among CNV carriers.

Cancer control in Latin America and the Caribbean: recent advances and opportunities to move forward

The increasing burden of cancer represents a substantial problem for Latin America and the Caribbean. Two Lancet Oncology Commissions in 2013 and 2015 highlighted potential interventions that could advance cancer care in the region by overcoming existing challenges. Areas requiring improvement included insufficient investment in cancer control, non-universal health coverage, fragmented health systems, inequitable concentration of cancer services, inadequate registries, delays in diagnosis or treatment initiation, and insufficient palliative services. Progress has been made in key areas but remains uneven across the region. An unforeseen challenge, the COVID-19 pandemic, strained all resources, and its negative effect on cancer control is expected to continue for years. In this Series paper, we summarise progress in several aspects of cancer control since 2015, and identify persistent barriers requiring commitment of additional resources to reduce the cancer burden in Latin America and the Caribbean.

Genetic epidemiology of BRCA1- and BRCA2-associated cancer across Latin America

The prevalence and contribution of BRCA1/2 (BRCA) pathogenic variants (PVs) to the cancer burden in Latin America are not well understood. This study aims to address this disparity. BRCA analyses were performed on prospectively enrolled Latin American Clinical Cancer Genomics Community Research Network participants via a combination of methods: a Hispanic Mutation Panel (HISPANEL) on MassARRAY; semiconductor sequencing; and copy number variant (CNV) detection. BRCA PV probability was calculated using BRCAPRO. Among 1,627 participants (95.2% with cancer), we detected 236 (14.5%) BRCA PVs; 160 BRCA1 (31% CNVs); 76 BRCA2 PV frequency varied by country: 26% Brazil, 9% Colombia, 13% Peru, and 17% Mexico. Recurrent PVs (seen ≥3 times), some region-specific, represented 42.8% (101/236) of PVs. There was no ClinVar entry for 14% (17/125) of unique PVs, and 57% (111/196) of unique VUS. The area under the ROC curve for BRCAPRO was 0.76. In summary, we implemented a low-cost BRCA testing strategy and documented a significant burden of non-ClinVar reported BRCA PVs among Latin Americans. There are recurrent, population-specific PVs and CNVs, and we note that the BRCAPRO mutation probability model performs adequately. This study helps address the gap in our understanding of BRCA-associated cancer in Latin America.

Development and Pilot Implementation of the Genomic Risk Assessment for Cancer Implementation and Sustainment (GRACIAS) Intervention in Mexico

PURPOSE

Genomic cancer risk assessment (GCRA) is standard-of-care practice that uses genomic tools to identify individuals with increased cancer risk, enabling screening for early detection and cancer prevention interventions. GCRA is not available in most of Mexico, where breast cancer (BC) is the leading cause of cancer death and ovarian cancer has a high mortality rate.

METHODS

Guided by an implementation science framework, we piloted the Genomic Risk Assessment for Cancer Implementation and Sustainment (GRACIAS) intervention, combining GCRA training, practice support, and low-cost BRCA1/2 (BRCA) gene testing at four centers in Mexico. The RE-AIM model was adapted to evaluate GRACIAS intervention outcomes, including reach, the proportion of new patients meeting adapted National Comprehensive Cancer Network criteria who participated in GCRA. Barriers to GCRA were identified through roundtable sessions and semistructured interviews.

RESULTS

Eleven clinicians were trained across four sites. Mean pre-post knowledge score increased from 60% to 67.2% (range 53%-86%). GCRA self-efficacy scores increased by 31% (95% CI, 6.47 to 55.54; P = .02). Participant feedback recommended Spanish content to improve learning. GRACIAS promoted reach at all sites: 77% in Universidad de Guadalajara, 86% in Instituto Nacional de Cancerología, 90% in Tecnológico de Monterrey, and 77% in Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Overall, a pathogenic BRCA variant was identified in 15.6% (195 of 1,253) of patients. All trainees continue to provide GCRA and address barriers to care.

CONCLUSION

We describe the first project to use implementation science methods to develop and deliver an innovative multicomponent implementation intervention, combining low-cost BRCA testing, comprehensive GCRA training, and practice support in Mexico. Scale-up of the GRACIAS intervention will promote risk-appropriate care, cancer prevention, and reduction in related mortality.

Abstract PS8-15: The spectrum of germline susceptibility gene variants in Mexican patients with breast cancer (BC): A Prospective Multicenter study

Background: BRCA mutations are responsible for a significant proportion of hereditary breast and ovarian cancers. However, other cancer susceptibility genes are also associated with an increased risk of developing breast cancer (BC). In Mexico, approximately 15% of patients with BC have been identified with BRCA mutations. Despite our growing understanding of BRCA mutations, the contribution and characterization of non-BRCA mutations in Mexican patients with a BC diagnosis remains unknown. We aimed to investigate the spectrum of BC-associated mutations among Mexican patients with BC referred for genetic cancer risk assessment (GCRA) in the multinational Clinical Cancer Genomics Community Research Network (CCGCRN). Methods: Mexican patients with a primary BC who were enrolled in the IRB-approved CCGCRN registry protocol and underwent genetic counseling and multigene panel testing (MGPT) were included. Pathogenic and likely pathogenic variants (PV) in genes associated with increased BC risk were used for analyses. Clinical and demographic characteristics of BRCA and non-BRCA carriers were compared. Results: From December 2012 to February 2020, 725 Mexican patients with BC who had MGPT results with a median age (years) of 41 (range 25-76) were included. 142 (19.6%) patients carried a BC-associated PV. Of these, 98 (69.0%) carried BRCA PVs: 58 in BRCA1 (41.5%) and 40 in BRCA2 (26.7%). PVs in other BC-associated genes (n = 42) accounted for 29.5% of all observed PVs and were distributed as follows: PALB2 (n = 13), CHEK2 (n = 11), RAD51C (n = 6), ATM (n = 3), PTEN (n = 3), TP53 (n = 3), BRIP1 (n = 2), and CDH1(n = 1). Other actionable genes represented 3.5% of all PVs (PMS2 [n = 3]; MSH6 [n = 1]; MSH2 [n = 1]). Suspected founder mutations in Latinas, PALB2 c.2167_2168delAT (n = 5) and CHEK2 c.707T&gt;C (n = 9), represented 33.3% (n = 14/42) of the detected non-BRCA PVs. Mean age at first cancer diagnosis (years) for BRCA and non-BRCA carriers was: 37 (range 26-58) and 42 (range 25-76) (p&lt;0.05), respectively. Among carriers, those with BRCA PVs had a significantly greater proportion of triple-negative (TN) tumors compared to non-BRCA PVs (45.2% vs 9.5%; p&lt;0.05). Conclusion: A significant proportion of Mexican women carried a BC-associated mutation and a third were non-BRCA PVs. Among non-BRCA PVs, recurrent PALB2 and CHEK2, which had previously been characterized in BRCA-negative US Latinas with BC, were the most common and confirms their presence and clinical impact in Mexico. BRCA carriers were younger and more commonly had the TN molecular subtype.

Citation Format: Yanin Chavarri-Guerra, Cynthia Villarreal-Garza, Gubidxa Gutierrez Seymour, Dione Aguilar y Mendez, Jazmin Arteaga-Vazquez, Servando Cardona-Huerta, Adrian Daneri-Navarro, Azucena del Toro Valero, Alejandro Mohar-Betancourt, Andrés Rodríguez-Faure, Jose Luis Rodriguez-Olivares, Gregorio Quintero Beulo, Danielle Castillo, Kai Yang, Joseph Herzog, Rosa Mejia, Sharon Sand, Jeffrey N Weitzel. The spectrum of germline susceptibility gene variants in Mexican patients with breast cancer (BC): A Prospective Multicenter study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS8-15.

Genetic cancer predisposition syndromes among older adults

Earlier age at onset is one characteristic of hereditary cancer syndromes, so most studies of genetic testing have focused on young patients with cancer. However, recent studies of multigene panel tests in unselected cancer populations have detected a considerable proportion of older patients with germline pathogenic variants (PVs) in cancer susceptibility genes. As the number of older patients with cancer continues to rise, clinicians should be aware of genetic/genomic cancer risk assessment (GCRA) criteria in both young and older adults. Identifying individuals with a germline PV in a cancer susceptibility gene may be important for precision therapy of current cancers and screening and prevention of new primary cancers, as well as cascade testing to identify high cancer risks for family members. Typically, hereditary predisposition germline genetic testing has been recommended for patients with early onset cancers and/or a family history of cancer. However, more recently international guidelines recommend testing for potential therapeutic intervention regardless of age for some tumors frequently seen in older patients, such as epithelial ovarian, pancreatic, and metastatic prostate and breast cancers. GCRA in older patients may present challenges including: clonal hematopoiesis (CH) confounding test interpretation, ethical aspects (autonomy, nonmaleficence, beneficence), patient health status, comorbidities, as well as lack of insurance coverage. These factors should be considered during genetic counseling and when considering cancer screening and risk reduction procedures. This manuscript reviews available data on common hereditary cancer syndromes in older patients and provides tools to help providers perform GCRA in this population.

Cancer pain management in Mexico

BACKGROUND

Pain control is an essential component of high-quality palliative care. Unfortunately, many low-income and middle-income countries lack an appropriate infrastructure to provide palliative care and suffer from a severe lack of access to opioid analgesics to alleviate pain from various conditions such as cancer.

OBJECTIVES

We aimed to review the history and current status of cancer pain management in Mexico, a middle-income Latin American country. Our objective was to identify existing barriers to proper, effective opioid use, as well as provide practical recommendations for improvement.

METHODS

Using a search of EBSCOhost database, PubMed and Google, we found official documents and peer-reviewed articles related to health legislation, opioid consumption, palliative care infrastructure and palliative care training in Mexico.

RESULTS

Despite advances in palliative care and access to opioids in Mexico, there are still several barriers that undermine effective pain management, showing a major gap between policy and practice. Although Mexican legislation and guidelines include adequate palliative care and pain control as a right for all patients with cancer, the lack of adequate infrastructure and trained personnel severely hampers the implementation of these policies. Additionally, there are important barriers to prescribing opioids, many of which are related to attempts at reducing the consumption of recreational drugs.

CONCLUSIONS

Although Mexico has made significant improvements in pain control and palliative care, much needs to be done. Expansion of drug availability, improvement of palliative care training, and constant oversight of regulations and guidelines will help to strengthen Mexico's palliative care services.

Older breast cancer survivors may harbor hereditary cancer predisposition pathogenic variants and are at risk for clonal hematopoiesis

OBJECTIVE

Our goal was to identify pathogenic variants (PV) associated with germline cancer predisposition in an unselected cohort of older breast cancer survivors. Older patients with cancer may also be at higher risk for clonal hematopoiesis (CH) due to their age and chemotherapy exposure. Therefore, we also explored the prevalence of PVs suggestive of CH.

METHODS

We evaluated 44 older adults (65 years or older) diagnosed with breast cancer who survived at least two years after diagnosis from a prospective study, compared to healthy controls over the age of 65 (n = 36). DNA extracted from blood samples and a multi-gene panel test was used to evaluate for common hereditary cancer predisposition and CH PVs. Fisher's exact test was used to compare PV rates between groups.

RESULTS

Eight PVs in ATM, BRCA2 (x2), PALB2, RAD51D, BRIP1, and MUTYH (x2) were identified in 7 of 44 individuals with breast cancer (15.9%, 95% CI: 7-30%), whereas none were identified in healthy controls (p = .01). Results remained statistically significant after removal of MUTYH carriers (p = .045). PVs indicative of CH (ATM, NBN, and PPM1D [x2]) were identified in three of 27 individuals with breast cancer who received chemotherapy and in one healthy control.

CONCLUSION

Moderate-risk and later disease onset high-risk hereditary cancer predisposition PVs were statistically significantly enriched in our survivorship cohort compared to controls. Because age- and chemotherapy-related CH are more frequent in this population, care must be taken to differentiate potential CH PVs from germline cancer predisposition PVs.

Cost-Effectiveness of Cabozantinib in the Second-Line Treatment of Advanced Hepatocellular Carcinoma

Background: Treatment options are limited for patients with advanced hepatocellular carcinoma (HCC) that progresses after treatment with sorafenib. Cabozantinib, an oral small molecule inhibitor of multiple tyrosine kinase receptors, recently showed improved overall survival (OS) compared with placebo in sorafenib-pretreated patients with advanced HCC in the CELESTIAL trial. This study assessed the cost-effectiveness of cabozantinib for second-line treatment of patients with advanced HCC from a US healthcare system perspective. Patients and Methods: Cost and utility data were extracted from the CELESTIAL trial and used to determine the cost-effectiveness of cabozantinib compared with placebo plus best supportive care. The main outcome of this study was the incremental cost-effectiveness ratio (ICER), expressed as cost per quality-adjusted life year (QALY) gained by using cabozantinib compared with placebo plus best supportive care in sorafenib-pretreated HCC. Results: In the base-case analysis using data from the CELESTIAL trial, the incremental QALY and ICER were 0.067 and $1,040,675 for cabozantinib compared with placebo and best supportive care. OS reported in the CELESTIAL trial (hazard ratio, 0.76; 95% CI, 0.63–0.92) had the strongest association with the ICER. In one-way sensitivity analyses, there were no scenarios in which cabozantinib was cost-effective. In a cost-threshold analysis, cabozantinib would have to be priced at least $50 per pill to be cost-effective considering a willingness to pay of $100,000 per QALY. Although the CELESTIAL trial demonstrated that cabozantinib improves OS compared with placebo in patients with HCC that progresses after treatment with sorafenib, our analysis shows that cabozantinib is not a cost-effective therapy in this scenario. Conclusions: At current costs, cabozantinib is not cost-effective for second-line therapy of HCC in the United States.

The Burden of Breast Cancer Predisposition Variants Across The Age Spectrum Among 10 000 Patients

BACKGROUND/OBJECTIVES

Women diagnosed with breast cancer (BC) at an older age are less likely to undergo genetic cancer risk assessment and genetic testing since the guidelines and referrals are biased toward earlier age at diagnosis. Thus, we determined the prevalence and type of pathogenic cancer predisposition variants among women with a history of BC diagnosed at the age of 65 years or older vs younger than 65 years.

DESIGN

Prospective registration cohort.

SETTING

The Clinical Cancer Genomics Community Research Network, including 40 community-based clinics in the United States and 5 in Latin America.

PARTICIPANTS

Women with BC and genetic testing results.

MEASUREMENTS

Sociodemographic characteristics, clinical variables, and genetic profiles were compared between women aged 65 years and older and those younger than 65 years at BC diagnosis.

RESULTS

Among 588 women diagnosed with BC and aged 65 years and older and 9412 diagnosed at younger than 65 years, BC-associated pathogenic variants (PVs) were detected in 5.6% of those aged 65 years and older (n = 33) and 14.2% of those younger than 65 years (n = 1340) (P < .01). PVs in high-risk genes (eg, BRCA1 and BRCA2) represented 81.1% of carriers among women aged 65 years and older (n = 27) and 93.1% of those younger than 65 years (n = 1248) (P = .01). BRCA2 PVs represented 42.4% of high-risk gene findings for those aged 65 years and older, whereas BRCA1 PVs were most common among carriers younger than 65 years (49.7%). PVs (n = 7) in moderate-risk genes represented 21.2% for carriers aged 65 years and older and 7.3% of those younger than 65 years (n = 98; P < .01). CHEK2 PVs were the most common moderate-risk gene finding in both groups.

CONCLUSION

Clinically actionable BC susceptibility PVs, particularly in BRCA2 and CHEK2, were relatively prevalent among older women undergoing genetic testing. The significant burden of PVs for older women with BC provides a critical reminder to recognize the full spectrum of eligibility and provide genetic testing for older women, rather than exclusion based on chronological age alone. J Am Geriatr Soc 67:884-888, 2019.

Glucocorticoid-dependent expression of IAP participates in the protection against TNF-mediated cytotoxicity in MCF7 cells

Background

Glucocorticoid receptor (GR) activation has been associated with breast cancer cell survival in vitro. Glucocorticoid (GC)-dependent protection against tumor necrosis factor (TNF)-induced cell death has been well characterized in MCF7 luminal A breast cancer cells. The GR activates a variety of protective mechanisms, such as inhibitors of apoptosis proteins (IAPs). However, the relative contribution of the GR-dependent expression of IAPs in the protection of cell death has not, to our knowledge, been evaluated.

Methods

MCF7 cells were used for all experiments. GR was activated with cortisol (CORT) or dexamethasone (DEX) and inhibited with mifepristone (RU486). Cell viability was determined in real-time with the xCELLigence™ RTCA System and at specific endpoints using crystal violet stain. The mRNA levels of the eight members of the IAP family were measured by qRT-PCR. The protein levels of GR, PR, ERα, HER2, PARP1, c-IAP1 and XIAP were evaluated by Western blot analysis. The knockdown of c-IAP1 and XIAP was accomplished via transient transfection with specific siRNAs. GR activation was verified by a gene reporter assay. Via the cBioportal interphase we queried the mRNA levels of GR and IAPs in breast cancer tumors.

Results

RU486 significantly inhibited the anti-cytotoxic effect of both GCs. PARP1 processing was diminished in the presence of both GCs. The combined treatments of GCs + TNF increased the relative mRNA levels of Survivin>c-IAP1 > NAIP>Apollon>XIAP>Ts-IAP > ML-IAP > c-IAP2. Additionally, GR mRNA content increased with the combined treatments of GCs + TNF. Sustained levels of the proteins c-IAP1 and XIAP were observed after 48 h of the combined treatments with GCs + TNF. With c-IAP1 and XIAP gene silencing, the GC-mediated protection was diminished. In the breast tumor samples, the GR mRNA was coexpressed with Apollon and XIAP with a Pearson coefficient greater than 0.3.

Conclusions

The effect of GCs against TNF-mediated cytotoxicity involves increased mRNA expression and sustained protein levels of c-IAP1 and XIAP. The antagonist effects of RU486 and the qRT-PCR results also suggest the role of the GR in this process. This finding may have clinical implications because the GR and IAPs are expressed in breast tumor samples.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5563-y) contains supplementary material, which is available to authorized users.

Perceptions of aging and ageism among Mexican physicians-in-training

INTRODUCTION

Attributing negative stereotypes to older adults (ageism) may lead to undertreatment, but little is known about the prevalence of ageism among physicians treating patients with cancer in Ibero-America. We studied stereotypes of aging among Mexican physicians-in-training.

MATERIALS AND METHODS

Physicians-in-training attending an oncology meeting answered the "Negative Attributes and Positive Potential in Old Age" survey. Ten questions assessed positive characteristics of aging (PPOA; score 1-4, higher scores represent a positive perception), and four assessed negative characteristics (NAOA; score 1-4, higher score representing a negative perception). Descriptive statistics were used to analyze the questionnaires. Participants completed the "Image-of-Aging" question by writing five words describing older adults and young individuals. Each word was rated from - 5 (negative) to + 5 (positive), and presented as word clouds.

RESULTS

One hundred physicians-in-training (median age 28.5) were included. For the PPOA scale, the mean score was 2.9 (SD 0.4), while for the NAOA scale it was 2.1 (SD 0.4). Perceptions of aging were better among women and trainees enrolled in geriatrics and/or oncology-related programs. In the "Image-of-Aging" questions, median rating of words describing older adults was - 2, compared to + 3 for young individuals (p < 0.001). Among words used to describe older adults, the most frequent was "frail/frailty" (n = 45), while "health" (n = 46) was the most frequent for younger individuals.

CONCLUSIONS

Mexican physicians-in-training showed mostly negative perceptions of aging, exemplified by the use of negative terms to describe older adults. Creating educational initiatives aimed at decreasing ageism among oncology trainees is necessary across Ibero-America.

The Effect of a Geriatric Oncology Clinic on Treatment Decisions in Mexican Older Adults With Cancer

OBJECTIVES

Geriatric assessment and interventions improve the care of older adults with cancer, but their effect on treatment decision making in resource-limited settings is unknown. We studied the effect of recommendations made by a consultative geriatric oncology clinic on treatment decision making by oncologists in Mexico.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective chart review of 173 consecutive patients with solid tumors referred before treatment initiation to the geriatric oncology clinic at a third-level public hospital in Mexico City between March 2015 and October 2017. Patients were evaluated by a multidisciplinary geriatric oncology clinic, and treatment recommendations were issued to treating oncologists.

MEASUREMENTS

We determined the overall proportion of agreement between geriatric oncology recommendations and oncologists' treatment decisions. We assessed whether agreement increased when geriatric oncology recommendations were acknowledged in the treating oncologist's clinic note. The homogeneity of agreement was tested using the Stuart-Maxwell test.

RESULTS

Median age was 79 years (range = 64-97 years). "Standard treatment" was recommended in 48% of cases, followed by "less intensive treatment" in 32%, and "best supportive care" in 20%. The overall proportion of agreement for the entire population was 80% (κ = 0.69), although agreement was heterogeneous (X² = 8.16, P = .02). Geriatric oncology recommendations were acknowledged in the treating oncologists' notes in 62% of cases. Overall agreement was higher when the evaluation was acknowledged (83%, κ = 0.74) than when it was not acknowledged (74%, κ = 0.60). Agreement was homogeneous only when recommendations were acknowledged in the oncologist's note (X² = 3.0, P = .22).

CONCLUSIONS

The overall proportion of agreement between geriatric oncology recommendations and final treatment decisions was high, particularly when recommendations were acknowledged in the treating oncologists' note. Including geriatric oncology evaluations in everyday clinical practice and fostering interdisciplinary communication between geriatric oncology and treating oncologists may provide valuable guidance for physicians caring for older patients with cancer in resource-limited settings. J Am Geriatr Soc 67:992-997, 2019.

Patient Navigation to Enhance Access to Care for Underserved Patients with a Suspicion or Diagnosis of Cancer

BACKGROUND

Interventions aimed at improving access to timely cancer care for patients in low- and middle-income countries (LMIC) are urgently needed. We aimed to evaluate a patient navigation (PN) program to reduce referral time to cancer centers for underserved patients with a suspicion or diagnosis of cancer at a public general hospital in Mexico City.

MATERIALS AND METHODS

From January 2016 to March 2017, consecutive patients aged >18 years with a suspicion or diagnosis of cancer seen at Ajusco Medio General Hospital in Mexico City who required referral to a specialized center for diagnosis or treatment were enrolled. A patient navigator assisted patients with scheduling, completing paperwork, obtaining results in a timely manner, transportation, and addressing other barriers to care. The primary outcome was the proportion of patients who obtained a specialized consultation at a cancer center within the first 3 months after enrollment.

RESULTS

Seventy patients (median age 54, range 19-85) participated in this study. Ninety-six percent (n = 67) identified >1 barrier to cancer care access. The most commonly reported barriers to health care access were financial burden (n = 50) and fear (n = 37). Median time to referral was 7 days (range 0-49), and time to specialist appointment was 27 days (range 1-97). Ninety-one percent of patients successfully obtained appointments at cancer centers in <3 months.

CONCLUSION

Implementing PN in LMIC is feasible, and may lead to shortened referral times for specialized cancer care by helping overcome barriers to health care access among underserved patients.

IMPLICATIONS FOR PRACTICE

A patient navigation program for patients with suspicion or diagnosis of cancer in a second-level hospital was feasible and acceptable. It reduced patient-reported barriers, and referral time to specialized appointments and treatment initiation were within international recommended limits. Patient navigation may improve access to care for underserved patients in developing countries.

Targeted agents for HER2-positive breast cancer in older adults: current and future perspectives

INTRODUCTION

One-third of breast cancer (BC) cases worldwide occur in women aged 65 years and older, with 10 to 15% overexpressing the human epidermal growth factor receptor 2 (HER2). Although several HER2-targeted therapies have been developed, the lack of data regarding their use in older patients hampers evidence-based decision-making for this population.

AREAS COVERED

We review current evidence on the efficacy and safety of HER2-targeted therapies in older adults with BC, focusing on approved therapies such as trastuzumab, lapatinib, pertuzumab, ado-trastuzumab-emtansine, and neratinib. Additionally, we discuss drugs under development to target the HER2-receptor, and to overcome resistance to existing therapies. Finally, we highlight the cardiotoxicity of HER2-targeted drugs among older adults.

EXPERT OPINION

Older adults are underrepresented in trials of HER2-targeted therapies in BC. We propose strategies to increase recruitment of older adults in clinical trials in order to increase the evidence base to treat this growing population.

Health-Related Information-Seeking Behaviors and Preferences Among Mexican Patients with Cancer

Understanding the preferred sources of health-related information among patients with cancer is essential for designing successful cancer education and prevention strategies. However, little is known about health-related information-seeking practices among patients living in low- and middle-income countries. We studied the preferred sources of health-related information among Mexican patients with cancer and explored which factors influence these choices. The health-related information-seeking practices among patients with cancer treated at a public hospital in Mexico City were evaluated using questions from the Spanish Version of the Health Information National Trends Survey. The characteristics of patients who sought health-related information, and of those who chose the internet as their preferred source of information, were analyzed. Fisher's exact test and logistic regression were used for statistical analyses. One hundred forty-eight patients answered the survey (median age 60 years, 70% female), of which 88 (59%) had sought for health-related information. On multivariate analysis, the only characteristic associated with lower odds of seeking health-related information was increasing age (OR 0.93, 95% CI 0.90-0.97). Sixty-one respondents (69%) listed the internet as their preferred source of health-related information. On multivariate analysis, only being of the female gender (OR 4.9, 95% CI 1.3-18.3) was related with higher odds of preferring other sources of information over the internet. Among Mexican patients with cancer, the Internet is the most widely used information source. Older age was the characteristic most strongly associated with not seeking health-related information, while being female was strongly associated with preferring other sources of information over the Internet.

Correction to: Health-Related Information-Seeking Behaviors and Preferences Among Mexican Patients with Cancer

The original version of this article unfortunately contained a mistake. The name of "Viridiana Perez-Montessoro" is now corrected in the author group of this article. The original article has been corrected.

Expressed Gene Fusions as Frequent Drivers of Poor Outcomes in Hormone Receptor-Positive Breast Cancer

We sought to uncover genetic drivers of hormone receptor-positive (HR⁺) breast cancer, using a targeted next-generation sequencing approach for detecting expressed gene rearrangements without prior knowledge of the fusion partners. We identified intergenic fusions involving driver genes, including PIK3CA, AKT3, RAF1, and ESR1, in 14% (24/173) of unselected patients with advanced HR⁺ breast cancer. FISH confirmed the corresponding chromosomal rearrangements in both primary and metastatic tumors. Expression of novel kinase fusions in nontransformed cells deregulates phosphoprotein signaling, cell proliferation, and survival in three-dimensional culture, whereas expression in HR⁺ breast cancer models modulates estrogen-dependent growth and confers hormonal therapy resistance in vitro and in vivo Strikingly, shorter overall survival was observed in patients with rearrangement-positive versus rearrangement-negative tumors. Correspondingly, fusions were uncommon (<5%) among 300 patients presenting with primary HR⁺ breast cancer. Collectively, our findings identify expressed gene fusions as frequent and potentially actionable drivers in HR⁺ breast cancer.Significance: By using a powerful clinical molecular diagnostic assay, we identified expressed intergenic fusions as frequent contributors to treatment resistance and poor survival in advanced HR⁺ breast cancer. The prevalence and biological and prognostic significance of these alterations suggests that their detection may alter clinical management and bring to light new therapeutic opportunities. Cancer Discov; 8(3); 336-53. ©2017 AACR.See related commentary by Natrajan et al., p. 272See related article by Liu et al., p. 354This article is highlighted in the In This Issue feature, p. 253.

Tumor-Associated Neutrophils in Breast Cancer Subtypes

Background: Tumor associated neutrophils (TAN) are related to aggressiveness and a poor prognosis with human cancers. However, the relevance of TAN in breast cancer has not been previously investigated and here we sought to determine their presence among different subtypes. Methods: We analyzed patients with stage I-III breast cancers between 2006 and 2012. Tumors were divided into three subtypes: hormone-receptor [ HR]-positive, HER2-negative (HR+,HER2-ve); HER2-positive and triple negative (TN). Hematoxylin and eosin stained sections were examined and the number of TAN per 10 high power fields (HPF, 40x) was recorded. Tumors with >1 TAN per 10 HPF were considered TAN-positive. Fisher’s exact test was used to test for independence between qualitative variables, and logistic regression models were applied for multivariate analysis. Results: A total of 133 patients were assessed for inclusion and 105 were analyzed (28 excluded on various criteria). Some 72 tumors (69%) were classified as HR+, HER2-ve, 15 (14%) as HER2+ and 18 (17%) as TN. Totals of 16 TN (88%), 8 HER2+ (53%) and 4 HR+, HER2-ve tumors (5%) were TAN+ (p<0.001), including 79% of HR-ve tumors (19 of 24), in contrast to 11% of their HR+ve counterparts (9 of 81) (p<0.001). HER2 expression (p=0.023) and tumor grade (p<0.001) were also associated with TAN positivity. On multivariate analysis, only HR negativity (OR 16.85; 95% CI 4.4-64.6, p=<0.0001) was associated with a higher likelihood of TAN positivity. Conclusions: TAN are present in most TN tumors. We found an absence of HR expression to be the only predictor of TAN positivity. These results raise the question as to whether TAN, as part of the tumor microenvironment, have a role in the aggressiveness and progression of TN tumors and thus warrant further investigation in this breast cancer subtype, particularly in relation to response to treatment and prognosis.

Implementation of a School-Based Educational Program to Increase Breast Cancer Awareness and Promote Intergenerational Transmission of Knowledge in a Rural Mexican Community

BACKGROUND

Rural women have limited access to breast cancer education, which partially contributes to late diagnosis and treatment. In this pilot study, we tested the feasibility of implementing a school-based breast cancer educational program for adolescents in a rural Mexican community. We hypothesized that the adolescents' knowledge on breast cancer would increase as a result of the program, and that there would be intergenerational transmission of that knowledge to their older female relatives.

MATERIALS AND METHODS

Female adolescents from a rural middle school received the educational program. The program would be considered feasible and acceptable if more than 75% reported being satisfied with its contents. Changes in knowledge in the students and their relatives were evaluated using baseline and 4 months follow-up questionnaires.

RESULTS

One hundred twenty-six students were enrolled. The program was considered acceptable by 96% of the participants. The students' knowledge regarding breast cancer increased significantly from baseline to 4 months follow-up (63% to 82%). One hundred ninety-four female relatives completed the initial knowledge questionnaires. The relatives' knowledge regarding breast cancer showed a significant increase from baseline to 4 months follow-up (55% to 61%).

CONCLUSION

Implementing breast cancer educational programs for adolescents in rural communities is feasible and acceptable. The program increased the adolescents' knowledge on breast cancer, and promoted the intergenerational transmission of that knowledge to their female relatives. Intergenerational transmission of knowledge represents a potential method for providing population-based health awareness education globally.

IMPLICATIONS FOR PRACTICE

In limited-resource settings, education is a valuable tool for achieving early detection and downstaging of breast cancer. Unfortunately, rural women lack access to educational opportunities and information about breast cancer, which is a factor contributing to late diagnosis and treatment. In this study, we demonstrated that implementing a school-based breast cancer educational program for female adolescents in a rural Mexican community was feasible, acceptable, and increased their knowledge about breast cancer. Furthermore, the program encouraged the transmission of information to the students' older relatives. Intergenerational transmission of knowledge represents a novel and potentially effective tool in cancer education and promotion.

End-of-Life Care in Latin America

Cancer has become a global pandemic with disproportionately higher mortality rates in low- and middle- income countries, where a large fraction of patients present in advanced stages and in need of end-of-life care. Globally, the number of adults needing end-of-life care is greater than 19 million, and up to 78% of these patients are living in low- and middle- income countries. In the Americas alone, more than one million people are in need of end-of-life care, placing an enormous burden on local health systems, which are often unprepared to meet the challenge presented by this complex patient population. In Latin America, cancer care is characterized by the presence of vast inequalities between and within countries, and the provision of end-of-life care is no exception. Disparities in access to advanced care planning, with a lack of provision of adequate palliative care and pain medication, are common in the region. These shortcomings are related in large part to inadequate or inappropriate legislation, lack of comprehensive national palliative care plans, insufficient infrastructure, lack of opportunities for clinical training, unreliable reporting of data, and cultural barriers. This report reviews the current status of end-of-life care in Latin America, focusing on identifying existing deficiencies and providing a framework for improvement.

Genetic Cancer Risk Assessment for Breast Cancer in Latin America

In Latin America, breast cancer is the most common malignancy in women, and limited available data suggest that up to 15% of all breast cancer cases in the region are hereditary. Genetic cancer risk assessment and counseling is a critical component of the appropriate clinical care of patients with hereditary breast cancer and their families. Unfortunately, genetic services are underdeveloped across Latin America, and access to genetic testing and counseling is very scarce in the region. Barriers contributing to the access to genetic care are high cost and lack of insurance coverage for genetic tests, insufficient oncogenetics training or expertise, nonexistence of genetic counseling as a clinical discipline, and lack of supportive healthcare policies. In this review, we highlight relevant initiatives undertaken in several Latin American countries aimed at creating genetic cancer risk assessment programs. Additionally, we present a review of the scientific literature on the current status of breast cancer genomics in Latin America, with specific emphasis on demographic indicators, access to cancer genetic care, training and strategies to improve outcomes, and international collaborations.

Abstract P4-17-05: A school-based breast health (BH) educational program to increase breast cancer awareness in a rural Mexican community: A qualitative comparative analysis of students', relatives' and teachers' perceptions

Background: In order to increase breast cancer awareness, we implemented a school-based educational program for female adolescents in a rural Mexican community, aimed at increasing knowledge and promoting intergenerational transmission of information to their female relatives. Here we report the perspective of the students, their female relatives and the school teachers on the program's impact on the adolescents and their community, as well as the major emergent themes related its implementation.

Methods: Adolescents enrolled in a public rural Mexican middle school were invited to participate in the program. They received age-appropriate, culturally sensitive sessions from expert educators focused on transmitting BH knowledge in their household. The students' opinions of the program were evaluated using open ended questions immediately after its completion. The opinion of the students' female family members and of the school teachers were recorded four months after the intervention using open ended surveys and semi-structured interviews. The interviews were conducted at the school by two oncologists who designed and implemented the program and were recorded in video and audio formats. Data was coded using a narrative research approach, and a constructivist paradigm was used to explore emerging themes. NVivo software was used for qualitative data analysis.

Results: The surveys were answered by 126 students, 185 family members and 18 teachers. Seven teachers then participated in semi-structured interviews. The following major themes were identified as related with the BH educational program by students: (1) the importance of breast self-examination; (2) the power obtained through knowledge and learning; and (3) the importance of disseminating the obtained information. The following major themes were identified by female relatives: (1) the importance of disease prevention; (2) knowledge to perform self-examination and seek medical attention and (3) empowerment through information. An analysis of the teachers' opinions identified the following major themes: (1) the program aided in discussing intimate topics; (2) the relevance of disseminating information in the community; (3) training other teachers and survivors for implementation; and (4) the importance of the acquisition of new knowledge. The relevance of obtaining and disseminating new knowledge was a common emerging theme among the three groups. Interestingly, both the students and their relatives highlighted the power of knowledge in empowering women and allowing them to prevent diseases and take care of their own health.

Conclusions: Obtaining feedback from the relevant stakeholders and promoting active participation of the community is essential for the implementation of successful school-based education programs in cancer. We identified relevant themes related to BH education which could be useful for designing and implementing future programs. Providing adolescents from underserved populations with new knowledge and tools to take care of their health can empower them and aid them not only in preventing disease but in disseminating that knowledge in their communities.

Citation Format: Soto-Perez-de-Celis E, Rojo-Castillo MP, Chavarri-Guerra Y. A school-based breast health (BH) educational program to increase breast cancer awareness in a rural Mexican community: A qualitative comparative analysis of students', relatives' and teachers' perceptions [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-17-05.

Abstract P4-17-03: Global Cancer Institute online tumor boards to improve global patterns of clinical practice for breast cancer

Background: The Global Cancer Institute (GCI) breast cancer multi-disciplinary tumor boards (MTBs) are live, online telemedicine discussions of breast cancer patient case scenarios between breast cancer specialists in low- and middle-income countries (LMICs) and expert breast cancer specialists in the United States (US). In the US MTBs are routinely held in most cancer centers and have been shown to improve patient outcomes and patient and family quality of life. GCI launched breast cancer MTBs in 2012 with the goals to improve breast cancer patient care in underserved populations globally, to establish an online platform to allow live communication and collaboration among oncologists, and to serve as an educational tool for oncologists.

Methods: During our MTBs case scenarios are presented by global oncologists for discussion and input by a panel of both community/tertiary care expert breast oncologists from our global network. During each MTB, three cancer centers present challenging breast cancer patient scenarios. Patient scenarios are presented in English, according to a standard PowerPoint template. After presentation guideline - or clinical trial-based discussions are held for each case. As the patient cases originate from oncologists in LMICs, optimal and best locally available clinical care in rural and remote settings are discussed. For educational purposes the MTBs and the associated YouTube panel discussions are archived online and can subsequently be viewed by practicing oncologists and trainees globally. Links to relevant international guidelines, published and ongoing clinical trials, and other educational resources are also provided to all MTB attendees.

Results: Since its initiation in 2012, the GCI MTBs have engaged a network of 370 oncologists in LMICs and 20 expert panelists from nine cancer centers in the United States. Together the oncologists in LMICs represent 28 tertiary cancer centers and 116 community oncologists in 19 countries across Latin America, Eastern Europe, Asia, and Africa.

Conclusions: GCI breast cancer MTBs are a powerful educational and networking tool for oncologists in LMICs to improve their patterns of clinical practice, conduct multi-disciplinary discussions and access research collaborations. GCI invites oncologists throughout Latin America, Europe, Asia, and Africa to join our tumor boards and further expansion of its MTB network. GCI currently surveys oncologists in our network before and after attendance of MTBs to measure modifications in oncologists' practice and adherence to international clinical practice guidelines.

Citation Format: St. Louis J, Bukowski A, Paulino E, Ferreyra ME, Nunes J, Mejia G, Duarte C, Ruiz R, Touya D, Polo S, Chavarri-Guerra Y, Moreno J, Georgieva N, Tsolko T, Obayedullah Baki M, Luna HC, Goss PE. Global Cancer Institute online tumor boards to improve global patterns of clinical practice for breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-17-03.

New onset vasomotor symptoms but not musculoskeletal symptoms associate with clinical outcomes on extended adjuvant letrozole - Analyses from NCIC CTG MA.17

PURPOSE

New onset symptoms on adjuvant aromatase inhibitors for hormone receptor positive early breast cancer may associate with clinical outcomes. We performed this exploratory analysis of the association of new onset musculoskeletal (MSK) and vasomotor (VM) symptoms with clinical outcomes in the NCIC CTG MA.17 trial 5 years of extended adjuvant endocrine therapy with letrozole after tamoxifen.

METHODS

Symptoms were collected at baseline, 1, 6, and every 12 months on study. Multivariate Cox Models adjusting for age, nodal status, duration of tamoxifen and prior chemotherapy were used to compare disease-free survival (DFS), distant disease-free survival (DDFS), and overall survival (OS) based on data collected before, and after, the unblinding between women with VM or MSK symptoms and those without.

RESULTS

Data post-unblinding showed new VM symptoms on extended letrozole significantly improved DFS and DDFS when occurring 1 month (DFS HR 0.52, 95% CI, 0.28-0.96; p = 0.04; DDFS HR 0.49, 95% CI, 0.24-0.99; p = 0.046) and 6 months (DFS HR 0.43, 95% CI, 0.24-0.78; p = 0.006; DDFS HR 0.44, 95% CI, 0.22-0.85; p = 0.02) after treatment initiation. Those with new VM symptoms at 12 months also had a significantly better DFS (HR 0.47, 95% CI 0.26, 0.84; P = 0.01) and a trend in improved DDFS. Only a trend to improved OS was found for those with VM symptoms 6 month after treatment. No significant improvement was found for those with new MSK symptoms at any time point or for any endpoint.

CONCLUSIONS

New onset VM symptoms with extended letrozole may be useful in predicting treatment benefit.