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Illness perceptions matter: understanding quality of life and advanced illness behaviors in female patients with late-stage cancer
Background Patients with late-stage cancer are living longer, making it important to understand factors that contribute to maintaining quality of life (QOL) and completing advanced illness behaviors (eg, advance directives).
Objective To examine whether illness perceptions—the cognitive beliefs that patients form about their cancer—may be more important guides to adjustment than clinical characteristics of the cancer.
Methods In a cross-sectional study, 105 female patients diagnosed with stage III (n 66) or IV (n 39) breast (n 44), gynecological (n 38), or lung (n 23) cancer completed self-report measures of illness perceptions, QOL, and advanced illness behaviors. Clinical data was obtained from medical records.
Results Despite modest associations, patients’ beliefs about the cancer were clearly unique from the clinical characteristics of the cancer. Illness perception variables accounted for a large portion of the variance (PS .01) for QOL and advanced illness behaviors, whereas clinical characteristics did not. QOL scores were predicted by patients’ reports of experiencing more cancer related symptoms (ie, illness identity), believing that their cancer is central to their self-identity, and higher income. Higher completion of advanced illness behaviors was predicted by higher income, the cancer being recurrent, and participants perceiving their cancer as more severe but also more understandable.
Limitations This study was limited by a cross-sectional design, small sample size, and focus on female patients.
Conclusion Addressing patients’ beliefs about their cancer diagnosis may provide important targets for intervention to improve QOL and illness behaviors in patients with late-stage cancer.
Click on the PDF icon at the top of this introduction to read the full article.
Background Patients with late-stage cancer are living longer, making it important to understand factors that contribute to maintaining quality of life (QOL) and completing advanced illness behaviors (eg, advance directives).
Objective To examine whether illness perceptions—the cognitive beliefs that patients form about their cancer—may be more important guides to adjustment than clinical characteristics of the cancer.
Methods In a cross-sectional study, 105 female patients diagnosed with stage III (n 66) or IV (n 39) breast (n 44), gynecological (n 38), or lung (n 23) cancer completed self-report measures of illness perceptions, QOL, and advanced illness behaviors. Clinical data was obtained from medical records.
Results Despite modest associations, patients’ beliefs about the cancer were clearly unique from the clinical characteristics of the cancer. Illness perception variables accounted for a large portion of the variance (PS .01) for QOL and advanced illness behaviors, whereas clinical characteristics did not. QOL scores were predicted by patients’ reports of experiencing more cancer related symptoms (ie, illness identity), believing that their cancer is central to their self-identity, and higher income. Higher completion of advanced illness behaviors was predicted by higher income, the cancer being recurrent, and participants perceiving their cancer as more severe but also more understandable.
Limitations This study was limited by a cross-sectional design, small sample size, and focus on female patients.
Conclusion Addressing patients’ beliefs about their cancer diagnosis may provide important targets for intervention to improve QOL and illness behaviors in patients with late-stage cancer.
Click on the PDF icon at the top of this introduction to read the full article.
Background Patients with late-stage cancer are living longer, making it important to understand factors that contribute to maintaining quality of life (QOL) and completing advanced illness behaviors (eg, advance directives).
Objective To examine whether illness perceptions—the cognitive beliefs that patients form about their cancer—may be more important guides to adjustment than clinical characteristics of the cancer.
Methods In a cross-sectional study, 105 female patients diagnosed with stage III (n 66) or IV (n 39) breast (n 44), gynecological (n 38), or lung (n 23) cancer completed self-report measures of illness perceptions, QOL, and advanced illness behaviors. Clinical data was obtained from medical records.
Results Despite modest associations, patients’ beliefs about the cancer were clearly unique from the clinical characteristics of the cancer. Illness perception variables accounted for a large portion of the variance (PS .01) for QOL and advanced illness behaviors, whereas clinical characteristics did not. QOL scores were predicted by patients’ reports of experiencing more cancer related symptoms (ie, illness identity), believing that their cancer is central to their self-identity, and higher income. Higher completion of advanced illness behaviors was predicted by higher income, the cancer being recurrent, and participants perceiving their cancer as more severe but also more understandable.
Limitations This study was limited by a cross-sectional design, small sample size, and focus on female patients.
Conclusion Addressing patients’ beliefs about their cancer diagnosis may provide important targets for intervention to improve QOL and illness behaviors in patients with late-stage cancer.
Click on the PDF icon at the top of this introduction to read the full article.
Walking program eased chemo-related joint pain
SAN DIEGO – A 6-week, low-impact walking program relieved joint pain and stiffness and increased the number of minutes per week walking among elderly breast cancer survivors on aromatase inhibitors.
"A breast cancer diagnosis can be an ‘a-ha’ moment for women," Kirsten A. Nyrop, Ph.D, said during a press briefing at the annual meeting of the American College of Rheumatology. "Some of the women with whom we spoke said: ‘My cardiologist told me to walk and my general practitioner told me to walk, but when my oncologist asked me to walk, I started walking.’ "
Dr. Nyrop, of the Thurston Arthritis Research Center at the University of North Carolina at Chapel Hill, and her associates studied 20 patients who were taking an aromatase inhibitor for stage I-III breast cancer and had self-reported joint pain. The walking program they used was the Arthritis Foundation’s Walk With Ease. The program recommends that participants walk 30 minutes per day at least 5 days per week.
"We wanted to be certain we were reaching these women with a message that would resonate with them and a program that they felt was safe, something that they could comfortably do," Dr. Nyrop said.
The researchers administered visual analog scales (VAS) for joint pain, stiffness, and fatigue, as well as Arthritic Self-Efficacy (ASE) scales for joint and pain symptoms. The mean age of study participants was 71 years, 85% were white, and their mean body mass index was 29 kg/m2.
After 6 weeks in the walking program, researchers noticed improvements from baseline in the VAS pain score (effect size = 0.15) and VAS fatigue score (effect size = 0.22); changes in the VAS stiffness score approached statistical significance (effect size = 0.56). "That’s promising," Dr. Nyrop said. Scores on the ASE scales also improved from baseline for pain and fatigue, but the changes did not reach significance.
Significant increases in walking were observed from baseline in terms of the number of times per week walked (mean increase of 1.9 times; effect size = 0.68), number of minutes per walk (mean increase of 8.3 minutes; effect size = 0.48), and total number of minutes walked per week (mean increase of 62.6 minutes; effect size = 0.53).
One study participant wrote: "I absolutely feel the connection between aromatase inhibitors and exercise. On days I don’t walk, I am stiff, but if I walk, I am not stiff. Keep moving; it really helps."
A larger, follow-up study with a randomized controlled design is underway with funding by the National Cancer Institute.
The study was funded by the University of North Carolina Institute on Aging. Dr. Nyrop said that she had no relevant financial conflicts to disclose.
SAN DIEGO – A 6-week, low-impact walking program relieved joint pain and stiffness and increased the number of minutes per week walking among elderly breast cancer survivors on aromatase inhibitors.
"A breast cancer diagnosis can be an ‘a-ha’ moment for women," Kirsten A. Nyrop, Ph.D, said during a press briefing at the annual meeting of the American College of Rheumatology. "Some of the women with whom we spoke said: ‘My cardiologist told me to walk and my general practitioner told me to walk, but when my oncologist asked me to walk, I started walking.’ "
Dr. Nyrop, of the Thurston Arthritis Research Center at the University of North Carolina at Chapel Hill, and her associates studied 20 patients who were taking an aromatase inhibitor for stage I-III breast cancer and had self-reported joint pain. The walking program they used was the Arthritis Foundation’s Walk With Ease. The program recommends that participants walk 30 minutes per day at least 5 days per week.
"We wanted to be certain we were reaching these women with a message that would resonate with them and a program that they felt was safe, something that they could comfortably do," Dr. Nyrop said.
The researchers administered visual analog scales (VAS) for joint pain, stiffness, and fatigue, as well as Arthritic Self-Efficacy (ASE) scales for joint and pain symptoms. The mean age of study participants was 71 years, 85% were white, and their mean body mass index was 29 kg/m2.
After 6 weeks in the walking program, researchers noticed improvements from baseline in the VAS pain score (effect size = 0.15) and VAS fatigue score (effect size = 0.22); changes in the VAS stiffness score approached statistical significance (effect size = 0.56). "That’s promising," Dr. Nyrop said. Scores on the ASE scales also improved from baseline for pain and fatigue, but the changes did not reach significance.
Significant increases in walking were observed from baseline in terms of the number of times per week walked (mean increase of 1.9 times; effect size = 0.68), number of minutes per walk (mean increase of 8.3 minutes; effect size = 0.48), and total number of minutes walked per week (mean increase of 62.6 minutes; effect size = 0.53).
One study participant wrote: "I absolutely feel the connection between aromatase inhibitors and exercise. On days I don’t walk, I am stiff, but if I walk, I am not stiff. Keep moving; it really helps."
A larger, follow-up study with a randomized controlled design is underway with funding by the National Cancer Institute.
The study was funded by the University of North Carolina Institute on Aging. Dr. Nyrop said that she had no relevant financial conflicts to disclose.
SAN DIEGO – A 6-week, low-impact walking program relieved joint pain and stiffness and increased the number of minutes per week walking among elderly breast cancer survivors on aromatase inhibitors.
"A breast cancer diagnosis can be an ‘a-ha’ moment for women," Kirsten A. Nyrop, Ph.D, said during a press briefing at the annual meeting of the American College of Rheumatology. "Some of the women with whom we spoke said: ‘My cardiologist told me to walk and my general practitioner told me to walk, but when my oncologist asked me to walk, I started walking.’ "
Dr. Nyrop, of the Thurston Arthritis Research Center at the University of North Carolina at Chapel Hill, and her associates studied 20 patients who were taking an aromatase inhibitor for stage I-III breast cancer and had self-reported joint pain. The walking program they used was the Arthritis Foundation’s Walk With Ease. The program recommends that participants walk 30 minutes per day at least 5 days per week.
"We wanted to be certain we were reaching these women with a message that would resonate with them and a program that they felt was safe, something that they could comfortably do," Dr. Nyrop said.
The researchers administered visual analog scales (VAS) for joint pain, stiffness, and fatigue, as well as Arthritic Self-Efficacy (ASE) scales for joint and pain symptoms. The mean age of study participants was 71 years, 85% were white, and their mean body mass index was 29 kg/m2.
After 6 weeks in the walking program, researchers noticed improvements from baseline in the VAS pain score (effect size = 0.15) and VAS fatigue score (effect size = 0.22); changes in the VAS stiffness score approached statistical significance (effect size = 0.56). "That’s promising," Dr. Nyrop said. Scores on the ASE scales also improved from baseline for pain and fatigue, but the changes did not reach significance.
Significant increases in walking were observed from baseline in terms of the number of times per week walked (mean increase of 1.9 times; effect size = 0.68), number of minutes per walk (mean increase of 8.3 minutes; effect size = 0.48), and total number of minutes walked per week (mean increase of 62.6 minutes; effect size = 0.53).
One study participant wrote: "I absolutely feel the connection between aromatase inhibitors and exercise. On days I don’t walk, I am stiff, but if I walk, I am not stiff. Keep moving; it really helps."
A larger, follow-up study with a randomized controlled design is underway with funding by the National Cancer Institute.
The study was funded by the University of North Carolina Institute on Aging. Dr. Nyrop said that she had no relevant financial conflicts to disclose.
AT THE ACR ANNUAL MEETING
Major finding: After 6 weeks in a low-impact walking program, patients experienced improvements from baseline on the visual analog scale (VAS) for pain (effect size = 0.15) and the VAS for fatigue (effect size = 0.22); changes in the VAS stiffness score approached statistical significance (effect size = 0.56).
Data source: A pilot study of 20 patients at the North Carolina Cancer Hospital in Chapel Hill who were taking an aromatase inhibitor for stage I-III breast cancer and had self-reported joint pain.
Disclosures: The study was funded by the University of North Carolina Institute on Aging. Dr. Nyrop said that she had no relevant financial conflicts to disclose.
Simple intensity-modulated radiotherapy improves breast cancer cosmesis
Dose homogeneity with intensity-modulated radiotherapy reduced the risk of skin telangiectasia, resulting in superior overall cosmesis for early breast cancer patients in a 5-year single-center trial.
"This study should act as an evidence-based lever for change for radiotherapy centers that have yet to implement breast IMRT (intensity-modulated radiotherapy)," wrote Dr. Mukesh B. Mukesh of Cambridge (England) University Hospitals National Health Service Foundation Trust, and colleagues.
The Cambridge Breast IMRT Trial randomized 1,145 women with early breast cancer to receive either standard radiotherapy or simple intensity-modulated radiotherapy (IMRT), which uses additional irradiation fields to smooth out the dose to the target area.
In the multivariate analysis, significantly fewer patients in the IMRT arm had suboptimal overall cosmesis (OR, 0.65; 95% CI, 0.44 to 0.98; P = .038) and skin telangiectasia (OR, 0.57; 95% CI, 0.34 to 0.95; P = .031), according to data published online in the Journal of Clinical Oncology (doi:10.1200/JCO.2013.49.7842). However the two groups did not significantly differ based on photographically assessed breast shrinkage, clinically assessed edema, tumor bed induration or pigmentation, according to the researchers.
Also, there was no statistically significant difference in 5-year locoregional recurrence and overall survival rates.
Surgical cosmesis had a significant impact on outcomes, as patients with moderate to poor baseline surgical cosmesis were more likely to have suboptimal final cosmesis (OR, 8.15; 95% CI, 6.09 to 10.92; P < .001), tumor bed induration (OR, 1.80; 95% CI, 1.44 to 2.26; P < .001), and photographically assessed breast shrinkage (OR, 1.54; 95% CI, 1.21 to 1.96; P < .001).
Factors such as large breast volume and tumor bed boost were also associated with an increased risk of suboptimal overall cosmesis. Older patients, and those with postoperative breast infections, large breast volume, and tumor bed boost, were also more likely to develop skin telangiectasia.
The patients enrolled in the study all had operable unilateral, histologically confirmed invasive breast cancer or ductal carcinoma in situ requiring radiotherapy after breast-conservation surgery.
All patients were assigned a standard radiotherapy plan. Those with satisfactory dose homogeneity were not randomly assigned but treated with standard radiotherapy and followed up as if randomly assigned, while those whose plan had significant dose inhomogeneity (defined as > or = 2 cm3 volume receiving greater than 107% of the prescribed dose) were randomized between standard radiotherapy (control arm) and simple IMRT.
There were a significant number of patient withdrawals at the 5-year analysis due to factors such as travel difficulties, social issues, and personal choice, and cancer-related factors.
The researchers declared having no conflicts of interest.
Dose homogeneity with intensity-modulated radiotherapy reduced the risk of skin telangiectasia, resulting in superior overall cosmesis for early breast cancer patients in a 5-year single-center trial.
"This study should act as an evidence-based lever for change for radiotherapy centers that have yet to implement breast IMRT (intensity-modulated radiotherapy)," wrote Dr. Mukesh B. Mukesh of Cambridge (England) University Hospitals National Health Service Foundation Trust, and colleagues.
The Cambridge Breast IMRT Trial randomized 1,145 women with early breast cancer to receive either standard radiotherapy or simple intensity-modulated radiotherapy (IMRT), which uses additional irradiation fields to smooth out the dose to the target area.
In the multivariate analysis, significantly fewer patients in the IMRT arm had suboptimal overall cosmesis (OR, 0.65; 95% CI, 0.44 to 0.98; P = .038) and skin telangiectasia (OR, 0.57; 95% CI, 0.34 to 0.95; P = .031), according to data published online in the Journal of Clinical Oncology (doi:10.1200/JCO.2013.49.7842). However the two groups did not significantly differ based on photographically assessed breast shrinkage, clinically assessed edema, tumor bed induration or pigmentation, according to the researchers.
Also, there was no statistically significant difference in 5-year locoregional recurrence and overall survival rates.
Surgical cosmesis had a significant impact on outcomes, as patients with moderate to poor baseline surgical cosmesis were more likely to have suboptimal final cosmesis (OR, 8.15; 95% CI, 6.09 to 10.92; P < .001), tumor bed induration (OR, 1.80; 95% CI, 1.44 to 2.26; P < .001), and photographically assessed breast shrinkage (OR, 1.54; 95% CI, 1.21 to 1.96; P < .001).
Factors such as large breast volume and tumor bed boost were also associated with an increased risk of suboptimal overall cosmesis. Older patients, and those with postoperative breast infections, large breast volume, and tumor bed boost, were also more likely to develop skin telangiectasia.
The patients enrolled in the study all had operable unilateral, histologically confirmed invasive breast cancer or ductal carcinoma in situ requiring radiotherapy after breast-conservation surgery.
All patients were assigned a standard radiotherapy plan. Those with satisfactory dose homogeneity were not randomly assigned but treated with standard radiotherapy and followed up as if randomly assigned, while those whose plan had significant dose inhomogeneity (defined as > or = 2 cm3 volume receiving greater than 107% of the prescribed dose) were randomized between standard radiotherapy (control arm) and simple IMRT.
There were a significant number of patient withdrawals at the 5-year analysis due to factors such as travel difficulties, social issues, and personal choice, and cancer-related factors.
The researchers declared having no conflicts of interest.
Dose homogeneity with intensity-modulated radiotherapy reduced the risk of skin telangiectasia, resulting in superior overall cosmesis for early breast cancer patients in a 5-year single-center trial.
"This study should act as an evidence-based lever for change for radiotherapy centers that have yet to implement breast IMRT (intensity-modulated radiotherapy)," wrote Dr. Mukesh B. Mukesh of Cambridge (England) University Hospitals National Health Service Foundation Trust, and colleagues.
The Cambridge Breast IMRT Trial randomized 1,145 women with early breast cancer to receive either standard radiotherapy or simple intensity-modulated radiotherapy (IMRT), which uses additional irradiation fields to smooth out the dose to the target area.
In the multivariate analysis, significantly fewer patients in the IMRT arm had suboptimal overall cosmesis (OR, 0.65; 95% CI, 0.44 to 0.98; P = .038) and skin telangiectasia (OR, 0.57; 95% CI, 0.34 to 0.95; P = .031), according to data published online in the Journal of Clinical Oncology (doi:10.1200/JCO.2013.49.7842). However the two groups did not significantly differ based on photographically assessed breast shrinkage, clinically assessed edema, tumor bed induration or pigmentation, according to the researchers.
Also, there was no statistically significant difference in 5-year locoregional recurrence and overall survival rates.
Surgical cosmesis had a significant impact on outcomes, as patients with moderate to poor baseline surgical cosmesis were more likely to have suboptimal final cosmesis (OR, 8.15; 95% CI, 6.09 to 10.92; P < .001), tumor bed induration (OR, 1.80; 95% CI, 1.44 to 2.26; P < .001), and photographically assessed breast shrinkage (OR, 1.54; 95% CI, 1.21 to 1.96; P < .001).
Factors such as large breast volume and tumor bed boost were also associated with an increased risk of suboptimal overall cosmesis. Older patients, and those with postoperative breast infections, large breast volume, and tumor bed boost, were also more likely to develop skin telangiectasia.
The patients enrolled in the study all had operable unilateral, histologically confirmed invasive breast cancer or ductal carcinoma in situ requiring radiotherapy after breast-conservation surgery.
All patients were assigned a standard radiotherapy plan. Those with satisfactory dose homogeneity were not randomly assigned but treated with standard radiotherapy and followed up as if randomly assigned, while those whose plan had significant dose inhomogeneity (defined as > or = 2 cm3 volume receiving greater than 107% of the prescribed dose) were randomized between standard radiotherapy (control arm) and simple IMRT.
There were a significant number of patient withdrawals at the 5-year analysis due to factors such as travel difficulties, social issues, and personal choice, and cancer-related factors.
The researchers declared having no conflicts of interest.
FROM THE JOURNAL OF CLINICAL ONCOLOGY
Major finding: Significantly fewer patients in the IMRT arm had suboptimal overall cosmesis (OR, 0.65; 95%CI, 0.44 to 0.98; P = .038) and skin telangiectasia (OR, 0.57; 95% CI, 0.34 to 0.95; P = .031).
Data source: Single-center randomized controlled trial of 1,145 patients with early breast cancer.
Disclosures: Dr. Mukesh had no conflicts of interest to declare.
Best age to begin screening mammograms: How I manage my patients
Controversy has surrounded the utility of screening mammograms, particularly in women in their 40s. In 2009, the US Preventive Services Task Force recommended that screening mammography begin at age 50 and that women aged 50 to 74 receive a mammogram every 2 years.1 However, the American Cancer Society2 and other professional groups continue to recommend that annual screening begin at age 40, leading to controversy and confusion among women’s health clinicians and our patients.
In a recent study, Webb and colleagues3 used registry data based on a health plan in a single US city to assess the cause of death and mammogram history of 1,705 women who died following a diagnosis of invasive breast cancer from 1990 to 1999. They confirmed that 609 of these deaths were from breast cancer. How many of these patients were screened?
What did they find?
The investigators found that 29% of the 609 women who died from breast cancer had been screened for it—19% of the cancers that caused death were screen-detected and 10% were interval cancers. (Interval cancers were defined as symptomatic or palpable tumors that presented less than 2 years after the prior screening mammogram.) That means that 71% of 609 deaths from breast cancer were among unscreened women, with 6% of the fatal cancers diagnosed more than 2 years after the last mammogram and 65% never found upon screening because screening did not occur.
Among deaths caused (n = 609) and not caused (n = 905) by breast cancer, the median age at diagnosis was 49 and 72 years, respectively. Investigators concluded that regular screening of women younger than age 50 years would lower the death rate from breast cancer.
Related Article: Biennial vs annual mammography: How I manage my patients Andrew M. Kaunitz, MD (June 2013)
Let’s not jump to any conclusions
Although some may find the report by Webb and colleagues persuasive, I am concerned about this study’s limitations, of which there are a few. First, analyses that focus on women diagnosed with breast cancers do not allow comparison of outcomes among screened and unscreened populations.
Moreover, this report provides no information on treatment received by screened and unscreened women. It is likely that women who have never been screened, or who have been screened only infrequently, are considerably less affluent and less educated than women who are regularly screened. Accordingly, upon noting a palpable breast mass, unscreened women may be less likely to seek timely medical attention than regularly screened women, leading to differences in breast cancer outcomes, which are independent of screening history.
How I counsel my patients
For now, I will continue to be laissez-fare in my recommendations about screening mammograms for average-risk women in their 40s by supporting their individual preferences about when to initiate such screening.
- Screening for breast cancer, Topic Page. US Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. Updated July 2010. Accessed October 28, 2013.
- American Cancer Society Guidelines for the Early Detection of Cancer: Breast cancer. American Cancer Society Web site. http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Updated May 3, 2013. Accessed October 28, 2013.
- Webb ML, Cady B, Michaelson JS, et al. A failure analysis of invasive breast cancer: Most deaths from disease occur in women not regularly screened [published online ahead of print September 9, 2013]. Cancer. doi:10.1002/cncr.28199.
Andrew M. Kaunitz, MD
Dr. Kaunitz is Professor and Associate Chairman, Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville. He serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Andrew M. Kaunitz, MD
Dr. Kaunitz is Professor and Associate Chairman, Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville. He serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Andrew M. Kaunitz, MD
Dr. Kaunitz is Professor and Associate Chairman, Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville. He serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Controversy has surrounded the utility of screening mammograms, particularly in women in their 40s. In 2009, the US Preventive Services Task Force recommended that screening mammography begin at age 50 and that women aged 50 to 74 receive a mammogram every 2 years.1 However, the American Cancer Society2 and other professional groups continue to recommend that annual screening begin at age 40, leading to controversy and confusion among women’s health clinicians and our patients.
In a recent study, Webb and colleagues3 used registry data based on a health plan in a single US city to assess the cause of death and mammogram history of 1,705 women who died following a diagnosis of invasive breast cancer from 1990 to 1999. They confirmed that 609 of these deaths were from breast cancer. How many of these patients were screened?
What did they find?
The investigators found that 29% of the 609 women who died from breast cancer had been screened for it—19% of the cancers that caused death were screen-detected and 10% were interval cancers. (Interval cancers were defined as symptomatic or palpable tumors that presented less than 2 years after the prior screening mammogram.) That means that 71% of 609 deaths from breast cancer were among unscreened women, with 6% of the fatal cancers diagnosed more than 2 years after the last mammogram and 65% never found upon screening because screening did not occur.
Among deaths caused (n = 609) and not caused (n = 905) by breast cancer, the median age at diagnosis was 49 and 72 years, respectively. Investigators concluded that regular screening of women younger than age 50 years would lower the death rate from breast cancer.
Related Article: Biennial vs annual mammography: How I manage my patients Andrew M. Kaunitz, MD (June 2013)
Let’s not jump to any conclusions
Although some may find the report by Webb and colleagues persuasive, I am concerned about this study’s limitations, of which there are a few. First, analyses that focus on women diagnosed with breast cancers do not allow comparison of outcomes among screened and unscreened populations.
Moreover, this report provides no information on treatment received by screened and unscreened women. It is likely that women who have never been screened, or who have been screened only infrequently, are considerably less affluent and less educated than women who are regularly screened. Accordingly, upon noting a palpable breast mass, unscreened women may be less likely to seek timely medical attention than regularly screened women, leading to differences in breast cancer outcomes, which are independent of screening history.
How I counsel my patients
For now, I will continue to be laissez-fare in my recommendations about screening mammograms for average-risk women in their 40s by supporting their individual preferences about when to initiate such screening.
Controversy has surrounded the utility of screening mammograms, particularly in women in their 40s. In 2009, the US Preventive Services Task Force recommended that screening mammography begin at age 50 and that women aged 50 to 74 receive a mammogram every 2 years.1 However, the American Cancer Society2 and other professional groups continue to recommend that annual screening begin at age 40, leading to controversy and confusion among women’s health clinicians and our patients.
In a recent study, Webb and colleagues3 used registry data based on a health plan in a single US city to assess the cause of death and mammogram history of 1,705 women who died following a diagnosis of invasive breast cancer from 1990 to 1999. They confirmed that 609 of these deaths were from breast cancer. How many of these patients were screened?
What did they find?
The investigators found that 29% of the 609 women who died from breast cancer had been screened for it—19% of the cancers that caused death were screen-detected and 10% were interval cancers. (Interval cancers were defined as symptomatic or palpable tumors that presented less than 2 years after the prior screening mammogram.) That means that 71% of 609 deaths from breast cancer were among unscreened women, with 6% of the fatal cancers diagnosed more than 2 years after the last mammogram and 65% never found upon screening because screening did not occur.
Among deaths caused (n = 609) and not caused (n = 905) by breast cancer, the median age at diagnosis was 49 and 72 years, respectively. Investigators concluded that regular screening of women younger than age 50 years would lower the death rate from breast cancer.
Related Article: Biennial vs annual mammography: How I manage my patients Andrew M. Kaunitz, MD (June 2013)
Let’s not jump to any conclusions
Although some may find the report by Webb and colleagues persuasive, I am concerned about this study’s limitations, of which there are a few. First, analyses that focus on women diagnosed with breast cancers do not allow comparison of outcomes among screened and unscreened populations.
Moreover, this report provides no information on treatment received by screened and unscreened women. It is likely that women who have never been screened, or who have been screened only infrequently, are considerably less affluent and less educated than women who are regularly screened. Accordingly, upon noting a palpable breast mass, unscreened women may be less likely to seek timely medical attention than regularly screened women, leading to differences in breast cancer outcomes, which are independent of screening history.
How I counsel my patients
For now, I will continue to be laissez-fare in my recommendations about screening mammograms for average-risk women in their 40s by supporting their individual preferences about when to initiate such screening.
- Screening for breast cancer, Topic Page. US Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. Updated July 2010. Accessed October 28, 2013.
- American Cancer Society Guidelines for the Early Detection of Cancer: Breast cancer. American Cancer Society Web site. http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Updated May 3, 2013. Accessed October 28, 2013.
- Webb ML, Cady B, Michaelson JS, et al. A failure analysis of invasive breast cancer: Most deaths from disease occur in women not regularly screened [published online ahead of print September 9, 2013]. Cancer. doi:10.1002/cncr.28199.
- Screening for breast cancer, Topic Page. US Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. Updated July 2010. Accessed October 28, 2013.
- American Cancer Society Guidelines for the Early Detection of Cancer: Breast cancer. American Cancer Society Web site. http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Updated May 3, 2013. Accessed October 28, 2013.
- Webb ML, Cady B, Michaelson JS, et al. A failure analysis of invasive breast cancer: Most deaths from disease occur in women not regularly screened [published online ahead of print September 9, 2013]. Cancer. doi:10.1002/cncr.28199.
Genetic profiling transforms cancer treatment trials
BRUSSELS – The ballooning list of genetic markers linked with various cancers is spawning a radical shift in the design of oncology treatment trials.
These days, the trend is to incorporate detailed genetic analysis into the trials, so that once the results are in, researchers can try to correlate treatment responses or failures with variations in each tumor’s genetic profile.
Leaders in the field say that, ideally, the tumor of every single patient now entering a cancer treatment trial should undergo a baseline genetic analysis, either using a large panel of targeted genetic markers or full-genome sequencing – although they acknowledge that, for the time being, complete sequencing provides much more information than can be used practically.
This changing paradigm of cancer treatment trial design comes with a major, built-in limitation that seems solvable only by dramatically increasing the scope of patients enrolled in trials: Each mutational cancer "driver" seems specific for just a few percent of patients. That means making statistically meaningful correlations among the responses of patients to various drugs and their tumors’ genetic profiles requires sifting through thousands of patients, far more than usually enroll in treatment trials today.
"The big challenge is to identify the mutations or genetic alterations that help inform the results of clinical trials. There are a lot of potential genetic markers, but very few have been validated. Tumors are being sequenced, and we find lots of mutations; but we don’t yet know what to do with most of this information," said Dr. Francisco J. Esteva, professor of medicine and director of the breast medical oncology program at New York University in an interview during a meeting on markers in cancer.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
"Finding ‘actionable’ mutations is very complicated because of next-generation sequencing," Dr. Esteva added. "We have some very good inhibitor drugs" aimed at certain mutations that can be highly effective in selected patients, "but when we give these drugs to larger populations of patients, the drugs may not work."
Even though a tumor may carry a genetic mutation identified as a cancer driver and thus an effective target for drug treatment in some patients, the mutation may not be the most important driver in other patients.
"Trying to find the mutations or other genetic changes that can be effective targets for treatment sounds simple, but it’s really not so simple," noted Dr. Esteva, an organizer of the meeting, sponsored by the American Society of Clinical Oncology, the European Organization for Research and Treatment of Cancer, and the National Cancer Institute.
"We’ve been in an era where we looked at one genetic marker at a time. Now it’s pretty clear that this approach will not move us forward fast enough," said Dr. Lisa A. Carey, professor and medical director of the breast center at the University of North Carolina in Chapel Hill, and another organizer of the meeting.
"Looking at a full genetic profile of the tumor has great appeal but is also more complicated," Dr. Carey explained. "Today, we have a limited portfolio of genetic markers with known clinical significance and a limited portfolio of drugs. We’ve had some huge success stories [with targeted therapy], but it’s not simple, and it is far from solved."
"Finding a target in a patient’s tumor and having an agent that inhibits the target does not imply clinical benefit," said Dr. Shivaani Kummar, head of early clinical trials development in the division of cancer treatment and diagnosis of the National Cancer Institute.
The enormous volume of genetic information now available from next-generation sequencing, which can supply data on hundreds or even potentially thousands of individual genes for a relatively affordable price, "is affecting trial design, leading to ‘umbrella’ designs that use a variety of genetic markers and panels of several drugs," said Dr. Robert L. Becker Jr., a chief medical officer at the Center for Devices and Radiological Health of the Food and Drug Administration.
"Is the current model for development of diagnostic markers and drugs sustainable?’" Dr. Becker asked. "Next-generation sequencing is different, because it can query an almost unlimited number of analytes in a single assay."
At the meeting, a series of researchers from the United States and Europe described and discussed several recently designed drug treatment trials prospectively structured to collect wide-ranging genetic data from the tumors of enrolled patients.
One example is the MATCH (Molecular Analysis for Therapy Choice) trial, expected to start in 2014 with a goal of enrolling about 1,000 patients with solid tumors that have progressed following initial treatment with at least one drug. The investigators will use targeted mutations or amplifications as well as whole exome sequencing to try to better assign patients to their next regimen, said Dr. Kummar.
"It’s a new paradigm of trial design for cancer," said Dr. Esteva. "Going forward, all major drug trials should be designed" to include genetic analyses.
But the MATCH trial, as well as several others outlined at the meeting, will require casting large nets to find adequate numbers of appropriate patients to enroll.
"It’s a small subset of patients with each type of mutation, so getting the sample size required to get information about treatments will require a community effort," said Dr. Esteva. "It’s very important to have a lot of patients to get meaningful results." Progressing from studies with relatively small numbers of patients at academic centers to the larger populations of patients treated by community oncologists "will be one of the biggest challenges," he said.
Incorporating routine genetic analyses into trials and into routine practice also raises other issues, Dr. Carey noted. "Does the tumor evolve during treatment, so that what was found with testing at baseline is no longer the disease being treated?"
Once genetic profiling of tumors becomes routine, another challenge will be efficiently and reliably alerting physicians and patients when a genetic marker that had no known clinical consequence when it was first found in a patient’s tumor is subsequently discovered to be effectively treated with a targeted drug, she said.
And no consensus has emerged on whether it’s best to do genetic assessments of tumors using specimens collected by direct biopsy or by collecting tumor cells or tumor DNA circulating in a patient’s blood, Dr. Carey cautioned.
For now, the key step is making genetic analysis a routine part of every cancer-treatment trial. "We need tumor analyses for every patient," she said. "We should get correlates for 100% of cancers."
Dr. Becker, Dr. Carey, Dr. Esteva, and Dr. Kummar all said that they had no disclosures.
On Twitter @mitchelzoler
BRUSSELS – The ballooning list of genetic markers linked with various cancers is spawning a radical shift in the design of oncology treatment trials.
These days, the trend is to incorporate detailed genetic analysis into the trials, so that once the results are in, researchers can try to correlate treatment responses or failures with variations in each tumor’s genetic profile.
Leaders in the field say that, ideally, the tumor of every single patient now entering a cancer treatment trial should undergo a baseline genetic analysis, either using a large panel of targeted genetic markers or full-genome sequencing – although they acknowledge that, for the time being, complete sequencing provides much more information than can be used practically.
This changing paradigm of cancer treatment trial design comes with a major, built-in limitation that seems solvable only by dramatically increasing the scope of patients enrolled in trials: Each mutational cancer "driver" seems specific for just a few percent of patients. That means making statistically meaningful correlations among the responses of patients to various drugs and their tumors’ genetic profiles requires sifting through thousands of patients, far more than usually enroll in treatment trials today.
"The big challenge is to identify the mutations or genetic alterations that help inform the results of clinical trials. There are a lot of potential genetic markers, but very few have been validated. Tumors are being sequenced, and we find lots of mutations; but we don’t yet know what to do with most of this information," said Dr. Francisco J. Esteva, professor of medicine and director of the breast medical oncology program at New York University in an interview during a meeting on markers in cancer.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
"Finding ‘actionable’ mutations is very complicated because of next-generation sequencing," Dr. Esteva added. "We have some very good inhibitor drugs" aimed at certain mutations that can be highly effective in selected patients, "but when we give these drugs to larger populations of patients, the drugs may not work."
Even though a tumor may carry a genetic mutation identified as a cancer driver and thus an effective target for drug treatment in some patients, the mutation may not be the most important driver in other patients.
"Trying to find the mutations or other genetic changes that can be effective targets for treatment sounds simple, but it’s really not so simple," noted Dr. Esteva, an organizer of the meeting, sponsored by the American Society of Clinical Oncology, the European Organization for Research and Treatment of Cancer, and the National Cancer Institute.
"We’ve been in an era where we looked at one genetic marker at a time. Now it’s pretty clear that this approach will not move us forward fast enough," said Dr. Lisa A. Carey, professor and medical director of the breast center at the University of North Carolina in Chapel Hill, and another organizer of the meeting.
"Looking at a full genetic profile of the tumor has great appeal but is also more complicated," Dr. Carey explained. "Today, we have a limited portfolio of genetic markers with known clinical significance and a limited portfolio of drugs. We’ve had some huge success stories [with targeted therapy], but it’s not simple, and it is far from solved."
"Finding a target in a patient’s tumor and having an agent that inhibits the target does not imply clinical benefit," said Dr. Shivaani Kummar, head of early clinical trials development in the division of cancer treatment and diagnosis of the National Cancer Institute.
The enormous volume of genetic information now available from next-generation sequencing, which can supply data on hundreds or even potentially thousands of individual genes for a relatively affordable price, "is affecting trial design, leading to ‘umbrella’ designs that use a variety of genetic markers and panels of several drugs," said Dr. Robert L. Becker Jr., a chief medical officer at the Center for Devices and Radiological Health of the Food and Drug Administration.
"Is the current model for development of diagnostic markers and drugs sustainable?’" Dr. Becker asked. "Next-generation sequencing is different, because it can query an almost unlimited number of analytes in a single assay."
At the meeting, a series of researchers from the United States and Europe described and discussed several recently designed drug treatment trials prospectively structured to collect wide-ranging genetic data from the tumors of enrolled patients.
One example is the MATCH (Molecular Analysis for Therapy Choice) trial, expected to start in 2014 with a goal of enrolling about 1,000 patients with solid tumors that have progressed following initial treatment with at least one drug. The investigators will use targeted mutations or amplifications as well as whole exome sequencing to try to better assign patients to their next regimen, said Dr. Kummar.
"It’s a new paradigm of trial design for cancer," said Dr. Esteva. "Going forward, all major drug trials should be designed" to include genetic analyses.
But the MATCH trial, as well as several others outlined at the meeting, will require casting large nets to find adequate numbers of appropriate patients to enroll.
"It’s a small subset of patients with each type of mutation, so getting the sample size required to get information about treatments will require a community effort," said Dr. Esteva. "It’s very important to have a lot of patients to get meaningful results." Progressing from studies with relatively small numbers of patients at academic centers to the larger populations of patients treated by community oncologists "will be one of the biggest challenges," he said.
Incorporating routine genetic analyses into trials and into routine practice also raises other issues, Dr. Carey noted. "Does the tumor evolve during treatment, so that what was found with testing at baseline is no longer the disease being treated?"
Once genetic profiling of tumors becomes routine, another challenge will be efficiently and reliably alerting physicians and patients when a genetic marker that had no known clinical consequence when it was first found in a patient’s tumor is subsequently discovered to be effectively treated with a targeted drug, she said.
And no consensus has emerged on whether it’s best to do genetic assessments of tumors using specimens collected by direct biopsy or by collecting tumor cells or tumor DNA circulating in a patient’s blood, Dr. Carey cautioned.
For now, the key step is making genetic analysis a routine part of every cancer-treatment trial. "We need tumor analyses for every patient," she said. "We should get correlates for 100% of cancers."
Dr. Becker, Dr. Carey, Dr. Esteva, and Dr. Kummar all said that they had no disclosures.
On Twitter @mitchelzoler
BRUSSELS – The ballooning list of genetic markers linked with various cancers is spawning a radical shift in the design of oncology treatment trials.
These days, the trend is to incorporate detailed genetic analysis into the trials, so that once the results are in, researchers can try to correlate treatment responses or failures with variations in each tumor’s genetic profile.
Leaders in the field say that, ideally, the tumor of every single patient now entering a cancer treatment trial should undergo a baseline genetic analysis, either using a large panel of targeted genetic markers or full-genome sequencing – although they acknowledge that, for the time being, complete sequencing provides much more information than can be used practically.
This changing paradigm of cancer treatment trial design comes with a major, built-in limitation that seems solvable only by dramatically increasing the scope of patients enrolled in trials: Each mutational cancer "driver" seems specific for just a few percent of patients. That means making statistically meaningful correlations among the responses of patients to various drugs and their tumors’ genetic profiles requires sifting through thousands of patients, far more than usually enroll in treatment trials today.
"The big challenge is to identify the mutations or genetic alterations that help inform the results of clinical trials. There are a lot of potential genetic markers, but very few have been validated. Tumors are being sequenced, and we find lots of mutations; but we don’t yet know what to do with most of this information," said Dr. Francisco J. Esteva, professor of medicine and director of the breast medical oncology program at New York University in an interview during a meeting on markers in cancer.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
"Finding ‘actionable’ mutations is very complicated because of next-generation sequencing," Dr. Esteva added. "We have some very good inhibitor drugs" aimed at certain mutations that can be highly effective in selected patients, "but when we give these drugs to larger populations of patients, the drugs may not work."
Even though a tumor may carry a genetic mutation identified as a cancer driver and thus an effective target for drug treatment in some patients, the mutation may not be the most important driver in other patients.
"Trying to find the mutations or other genetic changes that can be effective targets for treatment sounds simple, but it’s really not so simple," noted Dr. Esteva, an organizer of the meeting, sponsored by the American Society of Clinical Oncology, the European Organization for Research and Treatment of Cancer, and the National Cancer Institute.
"We’ve been in an era where we looked at one genetic marker at a time. Now it’s pretty clear that this approach will not move us forward fast enough," said Dr. Lisa A. Carey, professor and medical director of the breast center at the University of North Carolina in Chapel Hill, and another organizer of the meeting.
"Looking at a full genetic profile of the tumor has great appeal but is also more complicated," Dr. Carey explained. "Today, we have a limited portfolio of genetic markers with known clinical significance and a limited portfolio of drugs. We’ve had some huge success stories [with targeted therapy], but it’s not simple, and it is far from solved."
"Finding a target in a patient’s tumor and having an agent that inhibits the target does not imply clinical benefit," said Dr. Shivaani Kummar, head of early clinical trials development in the division of cancer treatment and diagnosis of the National Cancer Institute.
The enormous volume of genetic information now available from next-generation sequencing, which can supply data on hundreds or even potentially thousands of individual genes for a relatively affordable price, "is affecting trial design, leading to ‘umbrella’ designs that use a variety of genetic markers and panels of several drugs," said Dr. Robert L. Becker Jr., a chief medical officer at the Center for Devices and Radiological Health of the Food and Drug Administration.
"Is the current model for development of diagnostic markers and drugs sustainable?’" Dr. Becker asked. "Next-generation sequencing is different, because it can query an almost unlimited number of analytes in a single assay."
At the meeting, a series of researchers from the United States and Europe described and discussed several recently designed drug treatment trials prospectively structured to collect wide-ranging genetic data from the tumors of enrolled patients.
One example is the MATCH (Molecular Analysis for Therapy Choice) trial, expected to start in 2014 with a goal of enrolling about 1,000 patients with solid tumors that have progressed following initial treatment with at least one drug. The investigators will use targeted mutations or amplifications as well as whole exome sequencing to try to better assign patients to their next regimen, said Dr. Kummar.
"It’s a new paradigm of trial design for cancer," said Dr. Esteva. "Going forward, all major drug trials should be designed" to include genetic analyses.
But the MATCH trial, as well as several others outlined at the meeting, will require casting large nets to find adequate numbers of appropriate patients to enroll.
"It’s a small subset of patients with each type of mutation, so getting the sample size required to get information about treatments will require a community effort," said Dr. Esteva. "It’s very important to have a lot of patients to get meaningful results." Progressing from studies with relatively small numbers of patients at academic centers to the larger populations of patients treated by community oncologists "will be one of the biggest challenges," he said.
Incorporating routine genetic analyses into trials and into routine practice also raises other issues, Dr. Carey noted. "Does the tumor evolve during treatment, so that what was found with testing at baseline is no longer the disease being treated?"
Once genetic profiling of tumors becomes routine, another challenge will be efficiently and reliably alerting physicians and patients when a genetic marker that had no known clinical consequence when it was first found in a patient’s tumor is subsequently discovered to be effectively treated with a targeted drug, she said.
And no consensus has emerged on whether it’s best to do genetic assessments of tumors using specimens collected by direct biopsy or by collecting tumor cells or tumor DNA circulating in a patient’s blood, Dr. Carey cautioned.
For now, the key step is making genetic analysis a routine part of every cancer-treatment trial. "We need tumor analyses for every patient," she said. "We should get correlates for 100% of cancers."
Dr. Becker, Dr. Carey, Dr. Esteva, and Dr. Kummar all said that they had no disclosures.
On Twitter @mitchelzoler
EXPERT ANALYSIS AT THE MARKERS IN CANCER MEETING
Axillary treatment unnecessary after some total mastectomies
SAN FRANCISCO – Regional recurrence and recurrence-free survival rates were statistically similar in subgroups of 730 patients who had sentinel lymph node–positive, invasive breast cancer and underwent total mastectomy.
The outcomes were comparable regardless of whether or not patients had a subsequent completion axillary lymph node dissection and radiation therapy. A marginally higher 10-year regional recurrence rate of 4.9% in patients who did not have completion lymphadenectomy was not significantly different from rates seen in patients who had completion lymphadenectomy but not radiation therapy (1.4% of whom had a regional recurrence) or in patients who had completion lymphadenectomy plus radiation therapy (3.1% had a regional recurrence), in the retrospective institutional study.
Recurrence-free survival rates also did not differ between groups, reported Dr. Elizabeth FitzSullivan and her associates.
Using the M.D. Anderson Cancer Center nomogram to predict whether lymph nodes other than the sentinel node will have cancer, the investigators predicted a significantly lower probability of additional lymph node positivity in the 98 patients who did not undergo completion lymphadenectomy (a median 10% probability), compared with the 632 patients who had a completion lymphadenectomy (23% probability), reported Dr. FitzSullivan of the University of Texas M.D. Anderson Cancer Center, Houston.
"In select patients with early-stage breast cancer treated with mastectomy with a positive sentinel lymph node biopsy, completion lymphadenectomy may be avoided without adversely affecting recurrence or recurrence-free survival," the investigators concluded in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology. The study won a Merit Award at the meeting.
The retrospective analysis of data from patients treated at the M.D. Anderson Cancer Center during 1994-2010 defined completion lymphadenectomy as removal of 10 or more lymph nodes. Median follow-up was 66 months.
In general, patients with early-stage breast cancer who are treated with conserving therapy and who have minimal axillary disease on sentinel lymph node biopsy often don’t undergo completion lymphadenectomy. The increasing rate of total mastectomies heightens the need to identify patients who undergo total mastectomy who may not benefit from completion lymphadenectomy and axillary radiation therapy, the researchers noted.
There were several baseline characteristics that differed significantly between patients who did or did not undergo completion lymphadenectomy in the study. Compared with patients who did have completion lymphadenectomy, those who did not undergo the additional axillary surgery were older (57 years vs. 53 years, respectively); had smaller tumors (a median of 2 cm vs. 2.3 cm); and were less likely to have stage T3 disease (8% vs. 17%), lymphovascular invasion (25% vs. 41%), or extranodal extension of disease (4% vs. 24%). The median size of sentinel node metastasis was smaller in patients who did not have completion lymphadenectomy (1.1 mm) compared with those who did (4 mm).
The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.
Dr. FitzSullivan reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Regional recurrence and recurrence-free survival rates were statistically similar in subgroups of 730 patients who had sentinel lymph node–positive, invasive breast cancer and underwent total mastectomy.
The outcomes were comparable regardless of whether or not patients had a subsequent completion axillary lymph node dissection and radiation therapy. A marginally higher 10-year regional recurrence rate of 4.9% in patients who did not have completion lymphadenectomy was not significantly different from rates seen in patients who had completion lymphadenectomy but not radiation therapy (1.4% of whom had a regional recurrence) or in patients who had completion lymphadenectomy plus radiation therapy (3.1% had a regional recurrence), in the retrospective institutional study.
Recurrence-free survival rates also did not differ between groups, reported Dr. Elizabeth FitzSullivan and her associates.
Using the M.D. Anderson Cancer Center nomogram to predict whether lymph nodes other than the sentinel node will have cancer, the investigators predicted a significantly lower probability of additional lymph node positivity in the 98 patients who did not undergo completion lymphadenectomy (a median 10% probability), compared with the 632 patients who had a completion lymphadenectomy (23% probability), reported Dr. FitzSullivan of the University of Texas M.D. Anderson Cancer Center, Houston.
"In select patients with early-stage breast cancer treated with mastectomy with a positive sentinel lymph node biopsy, completion lymphadenectomy may be avoided without adversely affecting recurrence or recurrence-free survival," the investigators concluded in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology. The study won a Merit Award at the meeting.
The retrospective analysis of data from patients treated at the M.D. Anderson Cancer Center during 1994-2010 defined completion lymphadenectomy as removal of 10 or more lymph nodes. Median follow-up was 66 months.
In general, patients with early-stage breast cancer who are treated with conserving therapy and who have minimal axillary disease on sentinel lymph node biopsy often don’t undergo completion lymphadenectomy. The increasing rate of total mastectomies heightens the need to identify patients who undergo total mastectomy who may not benefit from completion lymphadenectomy and axillary radiation therapy, the researchers noted.
There were several baseline characteristics that differed significantly between patients who did or did not undergo completion lymphadenectomy in the study. Compared with patients who did have completion lymphadenectomy, those who did not undergo the additional axillary surgery were older (57 years vs. 53 years, respectively); had smaller tumors (a median of 2 cm vs. 2.3 cm); and were less likely to have stage T3 disease (8% vs. 17%), lymphovascular invasion (25% vs. 41%), or extranodal extension of disease (4% vs. 24%). The median size of sentinel node metastasis was smaller in patients who did not have completion lymphadenectomy (1.1 mm) compared with those who did (4 mm).
The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.
Dr. FitzSullivan reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Regional recurrence and recurrence-free survival rates were statistically similar in subgroups of 730 patients who had sentinel lymph node–positive, invasive breast cancer and underwent total mastectomy.
The outcomes were comparable regardless of whether or not patients had a subsequent completion axillary lymph node dissection and radiation therapy. A marginally higher 10-year regional recurrence rate of 4.9% in patients who did not have completion lymphadenectomy was not significantly different from rates seen in patients who had completion lymphadenectomy but not radiation therapy (1.4% of whom had a regional recurrence) or in patients who had completion lymphadenectomy plus radiation therapy (3.1% had a regional recurrence), in the retrospective institutional study.
Recurrence-free survival rates also did not differ between groups, reported Dr. Elizabeth FitzSullivan and her associates.
Using the M.D. Anderson Cancer Center nomogram to predict whether lymph nodes other than the sentinel node will have cancer, the investigators predicted a significantly lower probability of additional lymph node positivity in the 98 patients who did not undergo completion lymphadenectomy (a median 10% probability), compared with the 632 patients who had a completion lymphadenectomy (23% probability), reported Dr. FitzSullivan of the University of Texas M.D. Anderson Cancer Center, Houston.
"In select patients with early-stage breast cancer treated with mastectomy with a positive sentinel lymph node biopsy, completion lymphadenectomy may be avoided without adversely affecting recurrence or recurrence-free survival," the investigators concluded in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology. The study won a Merit Award at the meeting.
The retrospective analysis of data from patients treated at the M.D. Anderson Cancer Center during 1994-2010 defined completion lymphadenectomy as removal of 10 or more lymph nodes. Median follow-up was 66 months.
In general, patients with early-stage breast cancer who are treated with conserving therapy and who have minimal axillary disease on sentinel lymph node biopsy often don’t undergo completion lymphadenectomy. The increasing rate of total mastectomies heightens the need to identify patients who undergo total mastectomy who may not benefit from completion lymphadenectomy and axillary radiation therapy, the researchers noted.
There were several baseline characteristics that differed significantly between patients who did or did not undergo completion lymphadenectomy in the study. Compared with patients who did have completion lymphadenectomy, those who did not undergo the additional axillary surgery were older (57 years vs. 53 years, respectively); had smaller tumors (a median of 2 cm vs. 2.3 cm); and were less likely to have stage T3 disease (8% vs. 17%), lymphovascular invasion (25% vs. 41%), or extranodal extension of disease (4% vs. 24%). The median size of sentinel node metastasis was smaller in patients who did not have completion lymphadenectomy (1.1 mm) compared with those who did (4 mm).
The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.
Dr. FitzSullivan reported having no financial disclosures.
On Twitter @sherryboschert
AT THE ASCO BREAST CANCER SYMPOSIUM
Major finding: Median 10-year regional recurrence rates were 4.9% in patients who did not undergo completion lymphadenectomy, 3.1% for patients who had completion lymphadenectomy plus radiation therapy, and 1.4% for patients with completion lymphadenectomy but not radiation therapy.
Data source: A retrospective study of 730 patients with invasive breast cancer and a positive sentinel lymph node biopsy, treated with total mastectomy, between 1994 and 2010 at the University of Texas M.D. Anderson Cancer Center, Houston.
Disclosures: Dr. FitzSullivan reported having no financial disclosures.
Breast MRI both overused and underused
In real-world practice, breast MRI is being overused in women who won’t benefit and might even be harmed by it, but at the same time underused by the women who could gain the most from it, according to two separate studies reported online Nov. 18 in JAMA Internal Medicine.
The two large cohort studies, which involved different patient populations and different methodologies, had remarkably similar findings. In addition to the widespread overuse and underuse of breast MRI, both studies found that overall use of the technology has soared since the year 2000 for a variety of indications, even though the evidence only supports its use for a few particular indications.
Thankfully, that rapid increase appears to have plateaued in the most recent years for which data are available, both research groups noted.
Both studies were performed simply to gather data on national patterns of breast MRI use in community practice, because of the dearth of information on this topic.
National guidelines support breast MRI to screen asymptomatic women only if they are at high risk for breast cancer because they carry BRCA gene mutations, are first-degree relatives of BRCA carriers but haven’t been tested themselves, or are at more than 20% lifetime risk of breast cancer according to risk assessment tools based on family history.
In the first study, investigators assessed breast MRI use using data from five regional registries participating in the Breast Cancer Surveillance Consortium. The study population comprised women aged 18-79 years who had breast MRI (8,931 exams in 6,777 subjects) and/or screening mammography (1,288,924 subjects) during 2005-2009, reported Karen J. Wernli, Ph.D., of Group Health Research Institute, Seattle, and her associates.
During the relatively brief study period, the overall use of breast MRI nearly tripled, from 4.2 to 11.5 exams per 1,000 women. The total number of exams rose steeply during the first 2 years, from 863 in 2005 to 2,264 in 2007; it then remained stable at about 2,150 per year through 2009.
Overall, only 25% of women who had screening breast MRI were considered at high lifetime risk for breast cancer and thus fit the recommended criteria for the procedure. That proportion was only 9% in 2005, and it rose to 29% in 2009.
It appears that most of these women and their clinicians overestimated their breast cancer risk. They may obtain more accurate assessments by using approved risk calculators rather than by relying on family history alone, Dr. Wernli and her colleagues said (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.11963]).
Conversely, fewer than 5% of the approximately 25,200 study participants deemed to be at high lifetime risk for breast cancer underwent screening breast MRI. Previous studies have reported that the most common reasons that high-risk women cite for forgoing breast MRI were claustrophobia, time constraints, financial concerns, a physician who didn’t endorse the procedure, lack of patient interest, and lack of access to the technology.
In the second study, investigators assessed the use of breast MRI from 2000 through 2011 in a large, not-for-profit health plan covering more than 1 million patients throughout New England. The study population involved 10,518 women aged 20-89 years (mean age, 49 years) who had 18,215 breast MRI exams, reported Natasha K. Stout, Ph.D., of the department of population medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, and her associates.
Overall use of the procedure increased 14-fold during the study period, from 198 per 10,000 women in 2000 to 2,744 per 10,000 in 2011. As in the previous study, there was a steep rise in breast MRI use until approximately 2008, followed by a leveling off. This coincides with the release of American Cancer Society guidelines in 2007 recommending breast MRI as a screening tool only for women at high risk of breast cancer, Dr. Stout and her colleagues said.
Only 21% of the women who underwent screening breast MRI were at high risk and thus met the recommended criteria for the procedure. And fewer than half of the women who were at high risk by virtue of their BRCA status or family history underwent breast MRI (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.11958]).
"Understanding who is receiving breast MRI and the downstream consequences of this use should be a high research priority, to ensure that the limited health care funds available are used wisely to maximize population health," Dr. Stout and her colleagues said.
Dr. Wernli’s study was supported in part by the National Cancer Institute and the Agency for Healthcare Research and Quality. Dr. Wernli reported no financial conflicts of interest; her associates reported ties to GE Medical Systems, Phillips Medical Systems, and other companies. Dr. Stout’s study was supported in part by the American Cancer Society and the National Center for Research Resources. Dr. Stout and her associates reported no financial conflicts of interest.
The "striking" overuse of breast MRI in women who didn’t meet guideline criteria and simultaneous underuse in women who could derive the greatest benefit "clearly indicate the need for better patient selection," said Dr. E. Shelley Hwang and Dr. Isabelle Bedrosian.
Both studies also showed that the procedure continues to be used for nonscreening purposes – such as for staging newly diagnosed breast cancers and post-treatment surveillance – for which there is insufficient data supporting that use.
"A thoughtful, data-driven allocation of technology is necessary for clinicians and patients to make the best choices. As a medical community, we bear a collective responsibility to ensure that breast MRI provides sufficient clinical benefit to warrant the additional biopsies, increased patient anxiety, and cost that accrue with its use," they said.
Dr. Hwang is at Duke Cancer Institute, Durham, N.C. Dr. Bedrosian is at M.D. Anderson Cancer Center, Houston. They reported no potential financial conflicts of interest. These remarks were taken from their invited commentary accompanying Dr. Wernli’s and Dr. Stout’s reports (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.10502]).
The "striking" overuse of breast MRI in women who didn’t meet guideline criteria and simultaneous underuse in women who could derive the greatest benefit "clearly indicate the need for better patient selection," said Dr. E. Shelley Hwang and Dr. Isabelle Bedrosian.
Both studies also showed that the procedure continues to be used for nonscreening purposes – such as for staging newly diagnosed breast cancers and post-treatment surveillance – for which there is insufficient data supporting that use.
"A thoughtful, data-driven allocation of technology is necessary for clinicians and patients to make the best choices. As a medical community, we bear a collective responsibility to ensure that breast MRI provides sufficient clinical benefit to warrant the additional biopsies, increased patient anxiety, and cost that accrue with its use," they said.
Dr. Hwang is at Duke Cancer Institute, Durham, N.C. Dr. Bedrosian is at M.D. Anderson Cancer Center, Houston. They reported no potential financial conflicts of interest. These remarks were taken from their invited commentary accompanying Dr. Wernli’s and Dr. Stout’s reports (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.10502]).
The "striking" overuse of breast MRI in women who didn’t meet guideline criteria and simultaneous underuse in women who could derive the greatest benefit "clearly indicate the need for better patient selection," said Dr. E. Shelley Hwang and Dr. Isabelle Bedrosian.
Both studies also showed that the procedure continues to be used for nonscreening purposes – such as for staging newly diagnosed breast cancers and post-treatment surveillance – for which there is insufficient data supporting that use.
"A thoughtful, data-driven allocation of technology is necessary for clinicians and patients to make the best choices. As a medical community, we bear a collective responsibility to ensure that breast MRI provides sufficient clinical benefit to warrant the additional biopsies, increased patient anxiety, and cost that accrue with its use," they said.
Dr. Hwang is at Duke Cancer Institute, Durham, N.C. Dr. Bedrosian is at M.D. Anderson Cancer Center, Houston. They reported no potential financial conflicts of interest. These remarks were taken from their invited commentary accompanying Dr. Wernli’s and Dr. Stout’s reports (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.10502]).
In real-world practice, breast MRI is being overused in women who won’t benefit and might even be harmed by it, but at the same time underused by the women who could gain the most from it, according to two separate studies reported online Nov. 18 in JAMA Internal Medicine.
The two large cohort studies, which involved different patient populations and different methodologies, had remarkably similar findings. In addition to the widespread overuse and underuse of breast MRI, both studies found that overall use of the technology has soared since the year 2000 for a variety of indications, even though the evidence only supports its use for a few particular indications.
Thankfully, that rapid increase appears to have plateaued in the most recent years for which data are available, both research groups noted.
Both studies were performed simply to gather data on national patterns of breast MRI use in community practice, because of the dearth of information on this topic.
National guidelines support breast MRI to screen asymptomatic women only if they are at high risk for breast cancer because they carry BRCA gene mutations, are first-degree relatives of BRCA carriers but haven’t been tested themselves, or are at more than 20% lifetime risk of breast cancer according to risk assessment tools based on family history.
In the first study, investigators assessed breast MRI use using data from five regional registries participating in the Breast Cancer Surveillance Consortium. The study population comprised women aged 18-79 years who had breast MRI (8,931 exams in 6,777 subjects) and/or screening mammography (1,288,924 subjects) during 2005-2009, reported Karen J. Wernli, Ph.D., of Group Health Research Institute, Seattle, and her associates.
During the relatively brief study period, the overall use of breast MRI nearly tripled, from 4.2 to 11.5 exams per 1,000 women. The total number of exams rose steeply during the first 2 years, from 863 in 2005 to 2,264 in 2007; it then remained stable at about 2,150 per year through 2009.
Overall, only 25% of women who had screening breast MRI were considered at high lifetime risk for breast cancer and thus fit the recommended criteria for the procedure. That proportion was only 9% in 2005, and it rose to 29% in 2009.
It appears that most of these women and their clinicians overestimated their breast cancer risk. They may obtain more accurate assessments by using approved risk calculators rather than by relying on family history alone, Dr. Wernli and her colleagues said (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.11963]).
Conversely, fewer than 5% of the approximately 25,200 study participants deemed to be at high lifetime risk for breast cancer underwent screening breast MRI. Previous studies have reported that the most common reasons that high-risk women cite for forgoing breast MRI were claustrophobia, time constraints, financial concerns, a physician who didn’t endorse the procedure, lack of patient interest, and lack of access to the technology.
In the second study, investigators assessed the use of breast MRI from 2000 through 2011 in a large, not-for-profit health plan covering more than 1 million patients throughout New England. The study population involved 10,518 women aged 20-89 years (mean age, 49 years) who had 18,215 breast MRI exams, reported Natasha K. Stout, Ph.D., of the department of population medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, and her associates.
Overall use of the procedure increased 14-fold during the study period, from 198 per 10,000 women in 2000 to 2,744 per 10,000 in 2011. As in the previous study, there was a steep rise in breast MRI use until approximately 2008, followed by a leveling off. This coincides with the release of American Cancer Society guidelines in 2007 recommending breast MRI as a screening tool only for women at high risk of breast cancer, Dr. Stout and her colleagues said.
Only 21% of the women who underwent screening breast MRI were at high risk and thus met the recommended criteria for the procedure. And fewer than half of the women who were at high risk by virtue of their BRCA status or family history underwent breast MRI (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.11958]).
"Understanding who is receiving breast MRI and the downstream consequences of this use should be a high research priority, to ensure that the limited health care funds available are used wisely to maximize population health," Dr. Stout and her colleagues said.
Dr. Wernli’s study was supported in part by the National Cancer Institute and the Agency for Healthcare Research and Quality. Dr. Wernli reported no financial conflicts of interest; her associates reported ties to GE Medical Systems, Phillips Medical Systems, and other companies. Dr. Stout’s study was supported in part by the American Cancer Society and the National Center for Research Resources. Dr. Stout and her associates reported no financial conflicts of interest.
In real-world practice, breast MRI is being overused in women who won’t benefit and might even be harmed by it, but at the same time underused by the women who could gain the most from it, according to two separate studies reported online Nov. 18 in JAMA Internal Medicine.
The two large cohort studies, which involved different patient populations and different methodologies, had remarkably similar findings. In addition to the widespread overuse and underuse of breast MRI, both studies found that overall use of the technology has soared since the year 2000 for a variety of indications, even though the evidence only supports its use for a few particular indications.
Thankfully, that rapid increase appears to have plateaued in the most recent years for which data are available, both research groups noted.
Both studies were performed simply to gather data on national patterns of breast MRI use in community practice, because of the dearth of information on this topic.
National guidelines support breast MRI to screen asymptomatic women only if they are at high risk for breast cancer because they carry BRCA gene mutations, are first-degree relatives of BRCA carriers but haven’t been tested themselves, or are at more than 20% lifetime risk of breast cancer according to risk assessment tools based on family history.
In the first study, investigators assessed breast MRI use using data from five regional registries participating in the Breast Cancer Surveillance Consortium. The study population comprised women aged 18-79 years who had breast MRI (8,931 exams in 6,777 subjects) and/or screening mammography (1,288,924 subjects) during 2005-2009, reported Karen J. Wernli, Ph.D., of Group Health Research Institute, Seattle, and her associates.
During the relatively brief study period, the overall use of breast MRI nearly tripled, from 4.2 to 11.5 exams per 1,000 women. The total number of exams rose steeply during the first 2 years, from 863 in 2005 to 2,264 in 2007; it then remained stable at about 2,150 per year through 2009.
Overall, only 25% of women who had screening breast MRI were considered at high lifetime risk for breast cancer and thus fit the recommended criteria for the procedure. That proportion was only 9% in 2005, and it rose to 29% in 2009.
It appears that most of these women and their clinicians overestimated their breast cancer risk. They may obtain more accurate assessments by using approved risk calculators rather than by relying on family history alone, Dr. Wernli and her colleagues said (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.11963]).
Conversely, fewer than 5% of the approximately 25,200 study participants deemed to be at high lifetime risk for breast cancer underwent screening breast MRI. Previous studies have reported that the most common reasons that high-risk women cite for forgoing breast MRI were claustrophobia, time constraints, financial concerns, a physician who didn’t endorse the procedure, lack of patient interest, and lack of access to the technology.
In the second study, investigators assessed the use of breast MRI from 2000 through 2011 in a large, not-for-profit health plan covering more than 1 million patients throughout New England. The study population involved 10,518 women aged 20-89 years (mean age, 49 years) who had 18,215 breast MRI exams, reported Natasha K. Stout, Ph.D., of the department of population medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, and her associates.
Overall use of the procedure increased 14-fold during the study period, from 198 per 10,000 women in 2000 to 2,744 per 10,000 in 2011. As in the previous study, there was a steep rise in breast MRI use until approximately 2008, followed by a leveling off. This coincides with the release of American Cancer Society guidelines in 2007 recommending breast MRI as a screening tool only for women at high risk of breast cancer, Dr. Stout and her colleagues said.
Only 21% of the women who underwent screening breast MRI were at high risk and thus met the recommended criteria for the procedure. And fewer than half of the women who were at high risk by virtue of their BRCA status or family history underwent breast MRI (JAMA Intern. Med. 2013 Nov. 18 [doi: 10.1001/jamainternmed.2013.11958]).
"Understanding who is receiving breast MRI and the downstream consequences of this use should be a high research priority, to ensure that the limited health care funds available are used wisely to maximize population health," Dr. Stout and her colleagues said.
Dr. Wernli’s study was supported in part by the National Cancer Institute and the Agency for Healthcare Research and Quality. Dr. Wernli reported no financial conflicts of interest; her associates reported ties to GE Medical Systems, Phillips Medical Systems, and other companies. Dr. Stout’s study was supported in part by the American Cancer Society and the National Center for Research Resources. Dr. Stout and her associates reported no financial conflicts of interest.
FROM JAMA INTERNAL MEDICINE
Major finding: Only 25% of the women in one study and 21% in the other who underwent breast MRI met the high-risk criteria recommended for the procedure.
Data source: A cohort study involving women across the country who underwent 8,931 breast MRI exams and more than 1.2 million mammograms during 2005-2009, and a separate cohort study involving 10,518 women in New England who underwent these exams during 2000-2011.
Disclosures: Dr. Wernli’s study was supported in part by the National Cancer Institute and the Agency for Healthcare Research and Quality. Dr. Wernli reported no financial conflicts of interest; her associates reported ties to GE Medical Systems, Phillips Medical Systems, and other companies. Dr. Stout’s study was supported in part by the American Cancer Society and the National Center for Research Resources. Dr. Stout and her associates reported no financial conflicts of interest.
No greater risk of lymph node involvement in triple-negative breast cancer
SAN FRANCISCO – Patients with triple-negative breast cancer had no higher risk for metastases in the lymph nodes as compared with patients whose breast cancer was not triple-negative, a review of 2,957 cases found.
The study included patients with invasive breast cancer treated surgically between January 2000 and May 2012. Immunohistochemical identification of markers showed that 2,201 (74%) had luminal A subtype breast cancer (estrogen receptor– and progesterone receptor–positive and HER2 negative), 344 (12%) had luminal B subtype (all three markers positive), 144 (5%) were HER2 positive but estrogen and progesterone receptors–negative, and 278 (9%) were negative for all three markers (the triple-negative group). The study excluded men, patients treated with neoadjuvant therapy, patients with distant metastases, and those who did not undergo nodal sampling.
At least one positive lymph node was found in 35% of patients, and four or more positive nodes were found in 10% of patients.
Patients in the triple-negative group were significantly younger at diagnosis and significantly more likely to have higher-grade tumors, compared with patients with other subtypes of breast cancer. Grade 3 cancer was seen in 87% of the triple-negative group and in 27% of the luminal A group, 51% of the luminal B group, and 80% of the HER2-positive group, Dr. Alexandra Gangi and her associates reported at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
In multivariant analyses, younger age, higher tumor grade, larger tumor size, and lymphovascular invasion predicted increased likelihood of lymph node metastases. The triple-negative phenotype predicted neither a higher risk for lymph node positivity nor a greater likelihood of having four or more positive lymph nodes, which was found in 9% of the triple-negative group, 9% of the luminal A group, 14% of the luminal B group, and 19% of the HER2-positive group, reported Dr. Gangi of Cedars-Sinai Hospital, Los Angeles.
The likelihood of lymph node metastases was 50% higher in patients younger than 50 years as compared with older patients, 70% higher with grade 2 cancer as compared with grade 1 cancer, and 90% higher with grade 3 cancer as compared with grade 1 cancer. Lymphovascular invasion increased the likelihood of lymph node involvement four-fold. The risk of lymph node metastases was three times higher in patients with stage T2 breast cancer and 11 times higher in patients with stage T3 disease as compared with those with stage T1 breast cancer. All of these differences were statistically significant.
The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.
Dr. Gangi reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Patients with triple-negative breast cancer had no higher risk for metastases in the lymph nodes as compared with patients whose breast cancer was not triple-negative, a review of 2,957 cases found.
The study included patients with invasive breast cancer treated surgically between January 2000 and May 2012. Immunohistochemical identification of markers showed that 2,201 (74%) had luminal A subtype breast cancer (estrogen receptor– and progesterone receptor–positive and HER2 negative), 344 (12%) had luminal B subtype (all three markers positive), 144 (5%) were HER2 positive but estrogen and progesterone receptors–negative, and 278 (9%) were negative for all three markers (the triple-negative group). The study excluded men, patients treated with neoadjuvant therapy, patients with distant metastases, and those who did not undergo nodal sampling.
At least one positive lymph node was found in 35% of patients, and four or more positive nodes were found in 10% of patients.
Patients in the triple-negative group were significantly younger at diagnosis and significantly more likely to have higher-grade tumors, compared with patients with other subtypes of breast cancer. Grade 3 cancer was seen in 87% of the triple-negative group and in 27% of the luminal A group, 51% of the luminal B group, and 80% of the HER2-positive group, Dr. Alexandra Gangi and her associates reported at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
In multivariant analyses, younger age, higher tumor grade, larger tumor size, and lymphovascular invasion predicted increased likelihood of lymph node metastases. The triple-negative phenotype predicted neither a higher risk for lymph node positivity nor a greater likelihood of having four or more positive lymph nodes, which was found in 9% of the triple-negative group, 9% of the luminal A group, 14% of the luminal B group, and 19% of the HER2-positive group, reported Dr. Gangi of Cedars-Sinai Hospital, Los Angeles.
The likelihood of lymph node metastases was 50% higher in patients younger than 50 years as compared with older patients, 70% higher with grade 2 cancer as compared with grade 1 cancer, and 90% higher with grade 3 cancer as compared with grade 1 cancer. Lymphovascular invasion increased the likelihood of lymph node involvement four-fold. The risk of lymph node metastases was three times higher in patients with stage T2 breast cancer and 11 times higher in patients with stage T3 disease as compared with those with stage T1 breast cancer. All of these differences were statistically significant.
The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.
Dr. Gangi reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Patients with triple-negative breast cancer had no higher risk for metastases in the lymph nodes as compared with patients whose breast cancer was not triple-negative, a review of 2,957 cases found.
The study included patients with invasive breast cancer treated surgically between January 2000 and May 2012. Immunohistochemical identification of markers showed that 2,201 (74%) had luminal A subtype breast cancer (estrogen receptor– and progesterone receptor–positive and HER2 negative), 344 (12%) had luminal B subtype (all three markers positive), 144 (5%) were HER2 positive but estrogen and progesterone receptors–negative, and 278 (9%) were negative for all three markers (the triple-negative group). The study excluded men, patients treated with neoadjuvant therapy, patients with distant metastases, and those who did not undergo nodal sampling.
At least one positive lymph node was found in 35% of patients, and four or more positive nodes were found in 10% of patients.
Patients in the triple-negative group were significantly younger at diagnosis and significantly more likely to have higher-grade tumors, compared with patients with other subtypes of breast cancer. Grade 3 cancer was seen in 87% of the triple-negative group and in 27% of the luminal A group, 51% of the luminal B group, and 80% of the HER2-positive group, Dr. Alexandra Gangi and her associates reported at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
In multivariant analyses, younger age, higher tumor grade, larger tumor size, and lymphovascular invasion predicted increased likelihood of lymph node metastases. The triple-negative phenotype predicted neither a higher risk for lymph node positivity nor a greater likelihood of having four or more positive lymph nodes, which was found in 9% of the triple-negative group, 9% of the luminal A group, 14% of the luminal B group, and 19% of the HER2-positive group, reported Dr. Gangi of Cedars-Sinai Hospital, Los Angeles.
The likelihood of lymph node metastases was 50% higher in patients younger than 50 years as compared with older patients, 70% higher with grade 2 cancer as compared with grade 1 cancer, and 90% higher with grade 3 cancer as compared with grade 1 cancer. Lymphovascular invasion increased the likelihood of lymph node involvement four-fold. The risk of lymph node metastases was three times higher in patients with stage T2 breast cancer and 11 times higher in patients with stage T3 disease as compared with those with stage T1 breast cancer. All of these differences were statistically significant.
The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American Society for Radiation Oncology.
Dr. Gangi reported having no financial disclosures.
On Twitter @sherryboschert
AT THE ASCO BREAST CANCER SYMPOSIUM
Major finding: The likelihood of lymph node metastases was 50% higher in patients younger than 50 years as compared with older patients, 70% higher with grade 2 cancer as compared with grade 1 cancer, and 90% higher with grade 3 cancer as compared with grade 1 cancer.
Data source: A prospect review of 2,957 women treated surgically for breast cancer between January 2000 and May 2012.
Disclosures: Dr. Gangi reported having no financial disclosures.
Women choose mastectomy to gain control
SAN FRANCISCO – Fear and a desire for control over breast cancer may drive women to choose mastectomy over less aggressive management, a qualitative study of 30 patients has shown.
She interviewed 15 women who were candidates for breast-conserving surgery but chose unilateral mastectomy and 15 average-risk women who were candidates for surgery in one breast but also chose prophylactic contralateral mastectomy.
Fear led patients to overestimate their risk of local recurrence and contralateral cancer and to misunderstand their odds of dying of breast cancer. The fear combined with wanting to eliminate and control the risk of cancer resulted in the patient choosing mastectomy or bilateral mastectomy, factors that probably are contributing to increasing rates of mastectomy for early-stage breast cancer, Dr. Andrea M. Covelli reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
When deciding on treatment, the women sought out multiple sources of information but gave greatest weight to the experiences of people they’d known with breast cancer and information from breast cancer survivors. It was the patients, not clinicians, who raised the topic of contralateral prophylactic mastectomy, which some patients chose in an attempt to eliminate any risk of contralateral breast cancer.
"More surgery is seen as more control," reported Dr. Covelli of the University of Toronto. A better understanding of patients’ decision process may help physicians be better able to discuss issues important to their patients in making treatment decisions.
Dr. Covelli conducted semistructured one-on-one interviews with patients with early-stage breast cancer chosen from five hospitals in the greater Toronto area to represent a variety of ages and ethnicities. Twelve were treated at academic cancer centers, 6 were treated at academic noncancer centers, and 12 were treated at community medical centers.
She identified several themes in the results. The diagnosis brought shock and fear. Patients discussed both breast-conserving surgery and unilateral mastectomy during their surgical consultation, during which the physician discouraged contralateral prophylactic mastectomy. Patients relied on multiple sources of information in their decision making, but the greatest impact came from the experiences of others with breast cancer, she reported.
Women who chose unilateral mastectomy did so most often out of fear of recurrence and the misguided notion that it would give them a survival advantage. Occasionally, they chose unilateral mastectomy to avoid radiation therapy.
Women who also chose contralateral prophylactic mastectomy initiated discussions about it, which their surgeons then discouraged. These patients chose it anyway because they overestimated the risk of contralateral cancer and mistakenly believed it would improve their chance of survival. Occasionally they added contralateral prophylactic mastectomy for body symmetry.
In essence, patients chose these more aggressive surgeries because they were actively trying to control their cancer outcomes and ensure that they "never have to go through this again," Dr. Covelli said.
The study cohort had a mean age of 55 years, with ages ranging from 36 to 84 years.
Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
On Twitter @sherryboschert
This study asks the question, What motivates a woman with early-stage breast cancer to choose mastectomy, whether that be a unilateral mastectomy when she’s a candidate for breast conservation or the addition of a contralateral prophylactic mastectomy in the absence of an indication?
|
|
The bottom line is that the diagnosis is met with fear and shock. When we present options in a very neutral, evidence-based way, we are talking to our patients about breast-conserving surgery and mastectomy. And we are, and we should be, talking about whether there’s a role for contralateral prophylactic surgery.
Bearing witness is something that needs to be understood here. A lot of the discussion that you have with your patients is going to be interpreted based on what those patients are hearing, seeing, and witnessing in their own lives. So, if Aunt Judy had breast-conserving surgery and died 5 years later, you’ve got to take that into account.
There is a desire for control. There is a need to reduce risks so it never happens to them again, and there is a desire to increase their odds of surviving. That comes down to patients’ decision-making experience, their reasons for choosing a surgery that is far more aggressive than it possibly should be, and their goal to control cancer. We’re seeing an increasing mastectomy rate – more surgery, more control.
There is a process of deliberation where we take many factors into consideration before determining what we want to do. The implication based on this abstract, I think, is whether clinicians need to identify the deliberations that are leading to a decision before acting surgically.
Dr. Covelli’s preliminary work suggests that decisions around surgery are incredibly complex, and ensuring decisions are informed is complicated. Learning how patients deliberate is important – what experiences and what social networks are informing that decision? (And I don’t mean Twitter and Facebook, I mean in patients’ own real, face-to-face lives.) What is the role of the preoperative work-up in influencing those deliberations? How is that preoperative MRI influencing these decisions, based on anything that potentially might be happening?
I think this is very provocative work that can go further. The take-home points for me: Engage cognitively, engage with evidence, engage with data, but you have to engage practically. You need to know: Where is that person hearing information that I’m not telling her? How is she processing that information with information that I have just given? Engage cognitively; engage affectively.
Dr. Don S. Dizon is a medical gynecologic oncologist and director of the oncology sexual health clinic at Massachusetts General Hospital, Boston. These are excerpts of his remarks as the discussant of Dr. Covelli’s study at the meeting. He disclosed that he has been employed by UpToDate.
This study asks the question, What motivates a woman with early-stage breast cancer to choose mastectomy, whether that be a unilateral mastectomy when she’s a candidate for breast conservation or the addition of a contralateral prophylactic mastectomy in the absence of an indication?
|
|
|
The bottom line is that the diagnosis is met with fear and shock. When we present options in a very neutral, evidence-based way, we are talking to our patients about breast-conserving surgery and mastectomy. And we are, and we should be, talking about whether there’s a role for contralateral prophylactic surgery.
Bearing witness is something that needs to be understood here. A lot of the discussion that you have with your patients is going to be interpreted based on what those patients are hearing, seeing, and witnessing in their own lives. So, if Aunt Judy had breast-conserving surgery and died 5 years later, you’ve got to take that into account.
There is a desire for control. There is a need to reduce risks so it never happens to them again, and there is a desire to increase their odds of surviving. That comes down to patients’ decision-making experience, their reasons for choosing a surgery that is far more aggressive than it possibly should be, and their goal to control cancer. We’re seeing an increasing mastectomy rate – more surgery, more control.
There is a process of deliberation where we take many factors into consideration before determining what we want to do. The implication based on this abstract, I think, is whether clinicians need to identify the deliberations that are leading to a decision before acting surgically.
Dr. Covelli’s preliminary work suggests that decisions around surgery are incredibly complex, and ensuring decisions are informed is complicated. Learning how patients deliberate is important – what experiences and what social networks are informing that decision? (And I don’t mean Twitter and Facebook, I mean in patients’ own real, face-to-face lives.) What is the role of the preoperative work-up in influencing those deliberations? How is that preoperative MRI influencing these decisions, based on anything that potentially might be happening?
I think this is very provocative work that can go further. The take-home points for me: Engage cognitively, engage with evidence, engage with data, but you have to engage practically. You need to know: Where is that person hearing information that I’m not telling her? How is she processing that information with information that I have just given? Engage cognitively; engage affectively.
Dr. Don S. Dizon is a medical gynecologic oncologist and director of the oncology sexual health clinic at Massachusetts General Hospital, Boston. These are excerpts of his remarks as the discussant of Dr. Covelli’s study at the meeting. He disclosed that he has been employed by UpToDate.
This study asks the question, What motivates a woman with early-stage breast cancer to choose mastectomy, whether that be a unilateral mastectomy when she’s a candidate for breast conservation or the addition of a contralateral prophylactic mastectomy in the absence of an indication?
|
|
|
The bottom line is that the diagnosis is met with fear and shock. When we present options in a very neutral, evidence-based way, we are talking to our patients about breast-conserving surgery and mastectomy. And we are, and we should be, talking about whether there’s a role for contralateral prophylactic surgery.
Bearing witness is something that needs to be understood here. A lot of the discussion that you have with your patients is going to be interpreted based on what those patients are hearing, seeing, and witnessing in their own lives. So, if Aunt Judy had breast-conserving surgery and died 5 years later, you’ve got to take that into account.
There is a desire for control. There is a need to reduce risks so it never happens to them again, and there is a desire to increase their odds of surviving. That comes down to patients’ decision-making experience, their reasons for choosing a surgery that is far more aggressive than it possibly should be, and their goal to control cancer. We’re seeing an increasing mastectomy rate – more surgery, more control.
There is a process of deliberation where we take many factors into consideration before determining what we want to do. The implication based on this abstract, I think, is whether clinicians need to identify the deliberations that are leading to a decision before acting surgically.
Dr. Covelli’s preliminary work suggests that decisions around surgery are incredibly complex, and ensuring decisions are informed is complicated. Learning how patients deliberate is important – what experiences and what social networks are informing that decision? (And I don’t mean Twitter and Facebook, I mean in patients’ own real, face-to-face lives.) What is the role of the preoperative work-up in influencing those deliberations? How is that preoperative MRI influencing these decisions, based on anything that potentially might be happening?
I think this is very provocative work that can go further. The take-home points for me: Engage cognitively, engage with evidence, engage with data, but you have to engage practically. You need to know: Where is that person hearing information that I’m not telling her? How is she processing that information with information that I have just given? Engage cognitively; engage affectively.
Dr. Don S. Dizon is a medical gynecologic oncologist and director of the oncology sexual health clinic at Massachusetts General Hospital, Boston. These are excerpts of his remarks as the discussant of Dr. Covelli’s study at the meeting. He disclosed that he has been employed by UpToDate.
SAN FRANCISCO – Fear and a desire for control over breast cancer may drive women to choose mastectomy over less aggressive management, a qualitative study of 30 patients has shown.
She interviewed 15 women who were candidates for breast-conserving surgery but chose unilateral mastectomy and 15 average-risk women who were candidates for surgery in one breast but also chose prophylactic contralateral mastectomy.
Fear led patients to overestimate their risk of local recurrence and contralateral cancer and to misunderstand their odds of dying of breast cancer. The fear combined with wanting to eliminate and control the risk of cancer resulted in the patient choosing mastectomy or bilateral mastectomy, factors that probably are contributing to increasing rates of mastectomy for early-stage breast cancer, Dr. Andrea M. Covelli reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
When deciding on treatment, the women sought out multiple sources of information but gave greatest weight to the experiences of people they’d known with breast cancer and information from breast cancer survivors. It was the patients, not clinicians, who raised the topic of contralateral prophylactic mastectomy, which some patients chose in an attempt to eliminate any risk of contralateral breast cancer.
"More surgery is seen as more control," reported Dr. Covelli of the University of Toronto. A better understanding of patients’ decision process may help physicians be better able to discuss issues important to their patients in making treatment decisions.
Dr. Covelli conducted semistructured one-on-one interviews with patients with early-stage breast cancer chosen from five hospitals in the greater Toronto area to represent a variety of ages and ethnicities. Twelve were treated at academic cancer centers, 6 were treated at academic noncancer centers, and 12 were treated at community medical centers.
She identified several themes in the results. The diagnosis brought shock and fear. Patients discussed both breast-conserving surgery and unilateral mastectomy during their surgical consultation, during which the physician discouraged contralateral prophylactic mastectomy. Patients relied on multiple sources of information in their decision making, but the greatest impact came from the experiences of others with breast cancer, she reported.
Women who chose unilateral mastectomy did so most often out of fear of recurrence and the misguided notion that it would give them a survival advantage. Occasionally, they chose unilateral mastectomy to avoid radiation therapy.
Women who also chose contralateral prophylactic mastectomy initiated discussions about it, which their surgeons then discouraged. These patients chose it anyway because they overestimated the risk of contralateral cancer and mistakenly believed it would improve their chance of survival. Occasionally they added contralateral prophylactic mastectomy for body symmetry.
In essence, patients chose these more aggressive surgeries because they were actively trying to control their cancer outcomes and ensure that they "never have to go through this again," Dr. Covelli said.
The study cohort had a mean age of 55 years, with ages ranging from 36 to 84 years.
Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
On Twitter @sherryboschert
SAN FRANCISCO – Fear and a desire for control over breast cancer may drive women to choose mastectomy over less aggressive management, a qualitative study of 30 patients has shown.
She interviewed 15 women who were candidates for breast-conserving surgery but chose unilateral mastectomy and 15 average-risk women who were candidates for surgery in one breast but also chose prophylactic contralateral mastectomy.
Fear led patients to overestimate their risk of local recurrence and contralateral cancer and to misunderstand their odds of dying of breast cancer. The fear combined with wanting to eliminate and control the risk of cancer resulted in the patient choosing mastectomy or bilateral mastectomy, factors that probably are contributing to increasing rates of mastectomy for early-stage breast cancer, Dr. Andrea M. Covelli reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
When deciding on treatment, the women sought out multiple sources of information but gave greatest weight to the experiences of people they’d known with breast cancer and information from breast cancer survivors. It was the patients, not clinicians, who raised the topic of contralateral prophylactic mastectomy, which some patients chose in an attempt to eliminate any risk of contralateral breast cancer.
"More surgery is seen as more control," reported Dr. Covelli of the University of Toronto. A better understanding of patients’ decision process may help physicians be better able to discuss issues important to their patients in making treatment decisions.
Dr. Covelli conducted semistructured one-on-one interviews with patients with early-stage breast cancer chosen from five hospitals in the greater Toronto area to represent a variety of ages and ethnicities. Twelve were treated at academic cancer centers, 6 were treated at academic noncancer centers, and 12 were treated at community medical centers.
She identified several themes in the results. The diagnosis brought shock and fear. Patients discussed both breast-conserving surgery and unilateral mastectomy during their surgical consultation, during which the physician discouraged contralateral prophylactic mastectomy. Patients relied on multiple sources of information in their decision making, but the greatest impact came from the experiences of others with breast cancer, she reported.
Women who chose unilateral mastectomy did so most often out of fear of recurrence and the misguided notion that it would give them a survival advantage. Occasionally, they chose unilateral mastectomy to avoid radiation therapy.
Women who also chose contralateral prophylactic mastectomy initiated discussions about it, which their surgeons then discouraged. These patients chose it anyway because they overestimated the risk of contralateral cancer and mistakenly believed it would improve their chance of survival. Occasionally they added contralateral prophylactic mastectomy for body symmetry.
In essence, patients chose these more aggressive surgeries because they were actively trying to control their cancer outcomes and ensure that they "never have to go through this again," Dr. Covelli said.
The study cohort had a mean age of 55 years, with ages ranging from 36 to 84 years.
Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
On Twitter @sherryboschert
AT THE ASCO BREAST CANCER SYMPOSIUM
Major finding: Fear and a desire for control over cancer drove women to choose mastectomy.
Data source: A qualitative study of 30 women with early-stage breast cancer who were candidates for breast-conserving surgery but chose unilateral mastectomy with or without contralateral prophylactic mastectomy.
Disclosures: Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
Cardiovascular risk factors common with breast cancer
SAN FRANCISCO – Breast cancer survivors shared several body composition characteristics associated with increased cardiac risk and were referred for cardiac consultation most commonly for a high body mass index, an elevated LDL* level, insufficient exercise, and exposure to anthracycline, two separate studies found.
In the first study, kinesiologists measured various characteristics in 3,674 nononcology female patients and compared them with measurements in 740 women in a breast cancer survivorship clinic who were stratified into 8 groups according to the type of treatment they received. All breast cancer patients underwent surgery: 41 women had surgery alone, 13 also underwent chemotherapy, 51 had surgery and radiotherapy, and 48 had surgery and hormone therapy. Most cancer survivors underwent multiple therapies: surgery, chemotherapy, radiation, and hormone therapy in 244; surgery, radiation, and hormone therapy in 207; surgery, chemotherapy, and radiation in 83; and surgery, chemotherapy, and hormone therapy in 30, David H. Jones and his associates found.
Statistically significant differences were seen between the control group and five of the eight treatment groups. Compared with the control group, patients who underwent surgery, chemotherapy, radiation, and hormone therapy had significantly higher mean diastolic blood pressure (77 vs. 74 mm Hg), mean systolic blood pressure (128 vs. 123 mm Hg), mean arterial pressure (94 vs. 90 mm Hg), A faster mean heart rate (77 vs. 73 beats per minute), a higher percentage of body fat (37% vs. 34%), and a greater waist circumference (88 vs. 85 cm), Mr. Jones reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
Patients who underwent surgery, radiation, and hormone therapy also had a higher mean systolic blood pressure compared with controls (130 mm Hg), a higher mean arterial pressure (94 mm Hg), and greater body fat (37%). Patients who underwent surgery, chemotherapy, and radiotherapy had a higher mean systolic blood pressure (129 mm Hg), mean arterial pressure (94 mm Hg), heart rate (79 bpm), and body fat (38%) compared with controls, reported Mr. Jones of Ville-Marie Medical Center, Montreal.
Patients treated with surgery alone had a higher body mass index (29 vs. 26 kg/mm2), body fat percentage (39%), and waist circumference (90 cm) than did controls. Patients who underwent surgery and chemotherapy had significantly less mean muscle mass compared with controls (9.6 vs. 10.1 kg).
Previous studies have associated these body composition characteristics with increased risk for cardiovascular diseases and metabolic problems, Mr. Jones noted.
In the second study of 365 women with nonmetastatic breast cancer seen at a survivorship center in 2006-2012, 13% already were being followed by a cardiologist, 21% were referred to cardio-oncology after their initial visit to the survivorship center, and 66% were not referred, Jennifer R. Klemp, Ph.D., and her associates found.
Patients who were not referred had an average of four risk factors for cardiovascular disease, significantly fewer than the average of six cardiovascular risk factors in patients referred to cardio-oncology and those already seeing a cardiologist, reported Dr. Klemp, director of cancer survivorship at the University of Kansas, Westwood.
The risk factors considered in the study included exposure to cardiotoxic breast cancer treatment as well as traditional risk factors: a BMI greater than 25, diabetes; hypertension, an elevated HDL level, a history of smoking, a family history of an MI before age 60 years, and exercising fewer than 150 min/wk. Breast cancer treatment–related risk factors included an ejection fraction less than 50%; anti-hormone therapy; use of tamoxifen, anthracycline, or Herceptin (trastuzumab); and left chest wall radiation.
Among patients referred to cardio-oncology, 92% showed up. Most often they received additional diagnostic tests, changes in medications, or return visits for follow-up.
"These findings demonstrate the need to determine how to include treatment-related risk factors along with traditional cardiovascular risk factors in assessing and managing cardiovascular risk in breast cancer survivors," Dr. Klemp said.
Mr. Jones and Dr. Klemp reported having no relevant financial disclosures. Most of Dr. Jones’ associates were employees or leaders of Ville-Marie Medical Center.
On Twitter @sherryboschert
*Correction, 11/20/2013: A previous version of this article misstated one of the symptoms for both increased cardiac risk and increased risk for cardio-oncology referrals.
The study by Mr. Jones and his coinvestigators compared anthropometric baseline and vital sign measurements in 3,674 nononcology female patients with measurements in 740 cancer survivors. They evaluated the patients post treatment by eight different treatment regimens. Compared with a nononcology group, the patients undergoing breast cancer surgery alone had significantly higher blood pressure values, greater amounts of body fat, and larger waist circumferences. Adding two additional therapies such as hormone therapy, radiotherapy, or chemotherapy tended to show worsening parameters. The more therapy the patient had, the more likely she was to have one of these worse parameters.
The investigators concluded that several unfavorable body composition characteristics seemed to be associated with women who had completed treatment for breast cancer. And many of these changes in body composition led to an increased risk of developing cardiovascular diseases and different types of metabolic problems.
|
|
These findings corroborate those from previous studies. For example, these patients have been found to have more high-risk features after they complete their breast cancer therapy. One small study that looked at physical activity in the year after breast cancer was treated found that total activity was reduced after breast cancer treatment – including household, sports, and occupational activities. Across the board, patients remained less active 1 year post treatment, with implications for their cardiovascular health (Breast Cancer Res. Treat. 2010;123:417-25).
This becomes very important when you think about the increased number of risk factors following therapy, and the fact that patients got less exercise the year after treatment. When you put that in perspective, the lifetime risk of death from cardiovascular disease among women aged 55 and older increases dramatically with additional risk factors (N. Engl. J. Med. 2012;366:321-9).
The study by Dr. Klemp and his associates looked at cardiovascular risk factors among 365 breast cancer survivors and the outcomes of cardio-oncology referrals at the university’s survivorship center between 2006 and 2012. The investigators evaluated the number of patients with three or more cardiovascular risk factors, both preexisting and treatment related. The cardiac risk factors were pretty similar to those in the general population. The cardiology referrals accounted for 21% of patients. The most common risk factors associated with cardio-oncology referrals were a high body mass index, an elevated LDL* level, less exercise exposure, and anthracycline exposure. The most common outcomes for those seen by cardio-oncology were additional diagnostic tests and medication changes. Interventions by cardiology referrals correlated with a higher number of risk factors. Patients with the highest number of risk factors were the most likely to continue with the cardiologist, receive medication, and undergo diagnostic tests.
These two studies together demonstrate the important message that cardiovascular disease is a significant risk for breast cancer survivors. With time, as the risk of breast cancer death decreases, the risk of cardiovascular death increases.
The best method for improved outcomes from breast cancer may be the addition of an exercise machine in our waiting rooms.
Dr. Julia White is the director of breast radiation oncology at Ohio State University, Columbus. These are excerpts of her remarks as the discussant of these papers at the meeting. She reported having no financial relevant financial disclosures.
The study by Mr. Jones and his coinvestigators compared anthropometric baseline and vital sign measurements in 3,674 nononcology female patients with measurements in 740 cancer survivors. They evaluated the patients post treatment by eight different treatment regimens. Compared with a nononcology group, the patients undergoing breast cancer surgery alone had significantly higher blood pressure values, greater amounts of body fat, and larger waist circumferences. Adding two additional therapies such as hormone therapy, radiotherapy, or chemotherapy tended to show worsening parameters. The more therapy the patient had, the more likely she was to have one of these worse parameters.
The investigators concluded that several unfavorable body composition characteristics seemed to be associated with women who had completed treatment for breast cancer. And many of these changes in body composition led to an increased risk of developing cardiovascular diseases and different types of metabolic problems.
|
|
|
These findings corroborate those from previous studies. For example, these patients have been found to have more high-risk features after they complete their breast cancer therapy. One small study that looked at physical activity in the year after breast cancer was treated found that total activity was reduced after breast cancer treatment – including household, sports, and occupational activities. Across the board, patients remained less active 1 year post treatment, with implications for their cardiovascular health (Breast Cancer Res. Treat. 2010;123:417-25).
This becomes very important when you think about the increased number of risk factors following therapy, and the fact that patients got less exercise the year after treatment. When you put that in perspective, the lifetime risk of death from cardiovascular disease among women aged 55 and older increases dramatically with additional risk factors (N. Engl. J. Med. 2012;366:321-9).
The study by Dr. Klemp and his associates looked at cardiovascular risk factors among 365 breast cancer survivors and the outcomes of cardio-oncology referrals at the university’s survivorship center between 2006 and 2012. The investigators evaluated the number of patients with three or more cardiovascular risk factors, both preexisting and treatment related. The cardiac risk factors were pretty similar to those in the general population. The cardiology referrals accounted for 21% of patients. The most common risk factors associated with cardio-oncology referrals were a high body mass index, an elevated LDL* level, less exercise exposure, and anthracycline exposure. The most common outcomes for those seen by cardio-oncology were additional diagnostic tests and medication changes. Interventions by cardiology referrals correlated with a higher number of risk factors. Patients with the highest number of risk factors were the most likely to continue with the cardiologist, receive medication, and undergo diagnostic tests.
These two studies together demonstrate the important message that cardiovascular disease is a significant risk for breast cancer survivors. With time, as the risk of breast cancer death decreases, the risk of cardiovascular death increases.
The best method for improved outcomes from breast cancer may be the addition of an exercise machine in our waiting rooms.
Dr. Julia White is the director of breast radiation oncology at Ohio State University, Columbus. These are excerpts of her remarks as the discussant of these papers at the meeting. She reported having no financial relevant financial disclosures.
The study by Mr. Jones and his coinvestigators compared anthropometric baseline and vital sign measurements in 3,674 nononcology female patients with measurements in 740 cancer survivors. They evaluated the patients post treatment by eight different treatment regimens. Compared with a nononcology group, the patients undergoing breast cancer surgery alone had significantly higher blood pressure values, greater amounts of body fat, and larger waist circumferences. Adding two additional therapies such as hormone therapy, radiotherapy, or chemotherapy tended to show worsening parameters. The more therapy the patient had, the more likely she was to have one of these worse parameters.
The investigators concluded that several unfavorable body composition characteristics seemed to be associated with women who had completed treatment for breast cancer. And many of these changes in body composition led to an increased risk of developing cardiovascular diseases and different types of metabolic problems.
|
|
|
These findings corroborate those from previous studies. For example, these patients have been found to have more high-risk features after they complete their breast cancer therapy. One small study that looked at physical activity in the year after breast cancer was treated found that total activity was reduced after breast cancer treatment – including household, sports, and occupational activities. Across the board, patients remained less active 1 year post treatment, with implications for their cardiovascular health (Breast Cancer Res. Treat. 2010;123:417-25).
This becomes very important when you think about the increased number of risk factors following therapy, and the fact that patients got less exercise the year after treatment. When you put that in perspective, the lifetime risk of death from cardiovascular disease among women aged 55 and older increases dramatically with additional risk factors (N. Engl. J. Med. 2012;366:321-9).
The study by Dr. Klemp and his associates looked at cardiovascular risk factors among 365 breast cancer survivors and the outcomes of cardio-oncology referrals at the university’s survivorship center between 2006 and 2012. The investigators evaluated the number of patients with three or more cardiovascular risk factors, both preexisting and treatment related. The cardiac risk factors were pretty similar to those in the general population. The cardiology referrals accounted for 21% of patients. The most common risk factors associated with cardio-oncology referrals were a high body mass index, an elevated LDL* level, less exercise exposure, and anthracycline exposure. The most common outcomes for those seen by cardio-oncology were additional diagnostic tests and medication changes. Interventions by cardiology referrals correlated with a higher number of risk factors. Patients with the highest number of risk factors were the most likely to continue with the cardiologist, receive medication, and undergo diagnostic tests.
These two studies together demonstrate the important message that cardiovascular disease is a significant risk for breast cancer survivors. With time, as the risk of breast cancer death decreases, the risk of cardiovascular death increases.
The best method for improved outcomes from breast cancer may be the addition of an exercise machine in our waiting rooms.
Dr. Julia White is the director of breast radiation oncology at Ohio State University, Columbus. These are excerpts of her remarks as the discussant of these papers at the meeting. She reported having no financial relevant financial disclosures.
SAN FRANCISCO – Breast cancer survivors shared several body composition characteristics associated with increased cardiac risk and were referred for cardiac consultation most commonly for a high body mass index, an elevated LDL* level, insufficient exercise, and exposure to anthracycline, two separate studies found.
In the first study, kinesiologists measured various characteristics in 3,674 nononcology female patients and compared them with measurements in 740 women in a breast cancer survivorship clinic who were stratified into 8 groups according to the type of treatment they received. All breast cancer patients underwent surgery: 41 women had surgery alone, 13 also underwent chemotherapy, 51 had surgery and radiotherapy, and 48 had surgery and hormone therapy. Most cancer survivors underwent multiple therapies: surgery, chemotherapy, radiation, and hormone therapy in 244; surgery, radiation, and hormone therapy in 207; surgery, chemotherapy, and radiation in 83; and surgery, chemotherapy, and hormone therapy in 30, David H. Jones and his associates found.
Statistically significant differences were seen between the control group and five of the eight treatment groups. Compared with the control group, patients who underwent surgery, chemotherapy, radiation, and hormone therapy had significantly higher mean diastolic blood pressure (77 vs. 74 mm Hg), mean systolic blood pressure (128 vs. 123 mm Hg), mean arterial pressure (94 vs. 90 mm Hg), A faster mean heart rate (77 vs. 73 beats per minute), a higher percentage of body fat (37% vs. 34%), and a greater waist circumference (88 vs. 85 cm), Mr. Jones reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
Patients who underwent surgery, radiation, and hormone therapy also had a higher mean systolic blood pressure compared with controls (130 mm Hg), a higher mean arterial pressure (94 mm Hg), and greater body fat (37%). Patients who underwent surgery, chemotherapy, and radiotherapy had a higher mean systolic blood pressure (129 mm Hg), mean arterial pressure (94 mm Hg), heart rate (79 bpm), and body fat (38%) compared with controls, reported Mr. Jones of Ville-Marie Medical Center, Montreal.
Patients treated with surgery alone had a higher body mass index (29 vs. 26 kg/mm2), body fat percentage (39%), and waist circumference (90 cm) than did controls. Patients who underwent surgery and chemotherapy had significantly less mean muscle mass compared with controls (9.6 vs. 10.1 kg).
Previous studies have associated these body composition characteristics with increased risk for cardiovascular diseases and metabolic problems, Mr. Jones noted.
In the second study of 365 women with nonmetastatic breast cancer seen at a survivorship center in 2006-2012, 13% already were being followed by a cardiologist, 21% were referred to cardio-oncology after their initial visit to the survivorship center, and 66% were not referred, Jennifer R. Klemp, Ph.D., and her associates found.
Patients who were not referred had an average of four risk factors for cardiovascular disease, significantly fewer than the average of six cardiovascular risk factors in patients referred to cardio-oncology and those already seeing a cardiologist, reported Dr. Klemp, director of cancer survivorship at the University of Kansas, Westwood.
The risk factors considered in the study included exposure to cardiotoxic breast cancer treatment as well as traditional risk factors: a BMI greater than 25, diabetes; hypertension, an elevated HDL level, a history of smoking, a family history of an MI before age 60 years, and exercising fewer than 150 min/wk. Breast cancer treatment–related risk factors included an ejection fraction less than 50%; anti-hormone therapy; use of tamoxifen, anthracycline, or Herceptin (trastuzumab); and left chest wall radiation.
Among patients referred to cardio-oncology, 92% showed up. Most often they received additional diagnostic tests, changes in medications, or return visits for follow-up.
"These findings demonstrate the need to determine how to include treatment-related risk factors along with traditional cardiovascular risk factors in assessing and managing cardiovascular risk in breast cancer survivors," Dr. Klemp said.
Mr. Jones and Dr. Klemp reported having no relevant financial disclosures. Most of Dr. Jones’ associates were employees or leaders of Ville-Marie Medical Center.
On Twitter @sherryboschert
*Correction, 11/20/2013: A previous version of this article misstated one of the symptoms for both increased cardiac risk and increased risk for cardio-oncology referrals.
SAN FRANCISCO – Breast cancer survivors shared several body composition characteristics associated with increased cardiac risk and were referred for cardiac consultation most commonly for a high body mass index, an elevated LDL* level, insufficient exercise, and exposure to anthracycline, two separate studies found.
In the first study, kinesiologists measured various characteristics in 3,674 nononcology female patients and compared them with measurements in 740 women in a breast cancer survivorship clinic who were stratified into 8 groups according to the type of treatment they received. All breast cancer patients underwent surgery: 41 women had surgery alone, 13 also underwent chemotherapy, 51 had surgery and radiotherapy, and 48 had surgery and hormone therapy. Most cancer survivors underwent multiple therapies: surgery, chemotherapy, radiation, and hormone therapy in 244; surgery, radiation, and hormone therapy in 207; surgery, chemotherapy, and radiation in 83; and surgery, chemotherapy, and hormone therapy in 30, David H. Jones and his associates found.
Statistically significant differences were seen between the control group and five of the eight treatment groups. Compared with the control group, patients who underwent surgery, chemotherapy, radiation, and hormone therapy had significantly higher mean diastolic blood pressure (77 vs. 74 mm Hg), mean systolic blood pressure (128 vs. 123 mm Hg), mean arterial pressure (94 vs. 90 mm Hg), A faster mean heart rate (77 vs. 73 beats per minute), a higher percentage of body fat (37% vs. 34%), and a greater waist circumference (88 vs. 85 cm), Mr. Jones reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
Patients who underwent surgery, radiation, and hormone therapy also had a higher mean systolic blood pressure compared with controls (130 mm Hg), a higher mean arterial pressure (94 mm Hg), and greater body fat (37%). Patients who underwent surgery, chemotherapy, and radiotherapy had a higher mean systolic blood pressure (129 mm Hg), mean arterial pressure (94 mm Hg), heart rate (79 bpm), and body fat (38%) compared with controls, reported Mr. Jones of Ville-Marie Medical Center, Montreal.
Patients treated with surgery alone had a higher body mass index (29 vs. 26 kg/mm2), body fat percentage (39%), and waist circumference (90 cm) than did controls. Patients who underwent surgery and chemotherapy had significantly less mean muscle mass compared with controls (9.6 vs. 10.1 kg).
Previous studies have associated these body composition characteristics with increased risk for cardiovascular diseases and metabolic problems, Mr. Jones noted.
In the second study of 365 women with nonmetastatic breast cancer seen at a survivorship center in 2006-2012, 13% already were being followed by a cardiologist, 21% were referred to cardio-oncology after their initial visit to the survivorship center, and 66% were not referred, Jennifer R. Klemp, Ph.D., and her associates found.
Patients who were not referred had an average of four risk factors for cardiovascular disease, significantly fewer than the average of six cardiovascular risk factors in patients referred to cardio-oncology and those already seeing a cardiologist, reported Dr. Klemp, director of cancer survivorship at the University of Kansas, Westwood.
The risk factors considered in the study included exposure to cardiotoxic breast cancer treatment as well as traditional risk factors: a BMI greater than 25, diabetes; hypertension, an elevated HDL level, a history of smoking, a family history of an MI before age 60 years, and exercising fewer than 150 min/wk. Breast cancer treatment–related risk factors included an ejection fraction less than 50%; anti-hormone therapy; use of tamoxifen, anthracycline, or Herceptin (trastuzumab); and left chest wall radiation.
Among patients referred to cardio-oncology, 92% showed up. Most often they received additional diagnostic tests, changes in medications, or return visits for follow-up.
"These findings demonstrate the need to determine how to include treatment-related risk factors along with traditional cardiovascular risk factors in assessing and managing cardiovascular risk in breast cancer survivors," Dr. Klemp said.
Mr. Jones and Dr. Klemp reported having no relevant financial disclosures. Most of Dr. Jones’ associates were employees or leaders of Ville-Marie Medical Center.
On Twitter @sherryboschert
*Correction, 11/20/2013: A previous version of this article misstated one of the symptoms for both increased cardiac risk and increased risk for cardio-oncology referrals.
AT THE ASCO BREAST CANCER SYMPOSIUM
Major finding: Mean blood pressures were 128/77 mm Hg in patients treated with surgery, chemotherapy, radiation, and hormone therapy compared with 123/74 mm Hg in controls, in one study. In a second study, 13% of patients at a survivorship center were seeing a cardiologist and 21% were referred to one.
Data source: A prospective study comparing 740 breast cancer survivors with 3,674 nononcology patients, and a separate retrospective study of 365 women at a survivorship center.
Disclosures: Mr. Jones and Dr. Klemp reported having no relevant financial disclosures. Most of Mr. Jones’ associates were employees or leaders of Ville-Marie Medical Center.
