Abstract P3-12-11: Disparities in adjuvant hormone adherence in breast cancer patients within a universal healthcare model

Background: Patient adherence to adjuvant hormonal therapy for breast cancer (BC) is correlated with improved survival. Recent publications have demonstrated ethnic disparities in adjuvant hormone adherence (AHA) for privatized healthcare models.

Objective: To identify disparities in AHA for BC patients within a universal healthcare system in Alberta, Canada.

Methods: Patients diagnosed from 2007-2014 with stage I-III, ER+/HER2- BC receiving adjuvant FECD or DC chemotherapy and at least one month of adjuvant hormonal therapy in Alberta, Canada were retrospectively assessed. Hormone monotherapy (tamoxifen, AI), switch strategies (tam to AI), and treatment duration were collected. Compliance was assessed with central pharmacy data. Patient ethnicity was identified using patient first/last and parental last name via Onolytics® ethnographic software. Ethnicity was further verified using a centrally collected place of birth. Age, AJCC stage, psychiatric diagnoses (mood, bipolar), and comorbidity were collected. Log rank and Chi squared were used to assess difference between adjuvant hormonal therapy for variables at 1, 2, and 5 years. Log rank p-values at 2 years are reported.

Results: A total of 2,399 ER+ patients were included for analysis. AHA was non-significant for ethnicity (p=0.797), comorbidity (p=0.623), psychiatric disorders (p=0.145), or elderly cohorts (p= 0.814). AHA by stage was significant with stage III > II > I (p=0.004) having the highest compliance rates. AHA was highest for planned hormonal switch strategies (p=0.004) compared to monotherapy.

Hormone Adherence RatesCharacteristicsNo. of Patients% AdherenceEthnicity  Caucasian211891.6Asian15293.4Middle Eastern/African9593.7Hispanic2491.7Age  <65207791.8>6534192.1Comorbidity  096191.21-3134392.2>311493Psychiatric Dx  Yes31189.7No210792.1Stage  I45388.3II151292.1III45394.5Hormone Strategy  Monotherapy173190.9Switch68794.2

Conclusion: AHA is not dependent on ethnicity, age, comorbidity, or psychiatric diagnosis in a universal healthcare model. Conversely, higher rates of AHA are seen with planned switch strategy compared to monotherapy, contradictory to the BIG I-98 trial. Patients with higher stage, and thus higher risk of BC recurrence have increased adherence compared to their low risk counterparts. Reinforcement of AHA for low/moderate risk BC patients, in addition to tamoxifen to AI switch strategies may improve overall adherence.

Citation Format: Veitch ZW, Khan OF, Tilley D, Kostaras X, King K, Lupichuk S, Tang P. Disparities in adjuvant hormone adherence in breast cancer patients within a universal healthcare model [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-12-11.

Abstract P5-20-12: Adjuvant DCH vs TCH for low-risk (node negative); and FECDH vs TCH for high-risk (node positive) HER2+ breast cancer – A retrospective provincial analysis

Background: Chemotherapy plus trastuzumab for early HER2+ breast cancer (BC) is associated with improved survival. Optimal regimens for low-risk (node negative) and high-risk (node positive) HER2+ breast cancers are unknown and choice of regimen varies in real-world clinical practice.

Objective: (1) For low-risk breast cancer, to compare DCH (4 cycles) and TCH (6 cycles) in terms of disease free (DFS) and overall survival (OS). (2) For high-risk breast cancer, to compare FECDH (6 cycles) and TCH (6 cycles) in terms of DFS and OS.

Methods: All women diagnosed from 2007-2014 with stage I-III, hormone receptor (HR) +/-, HER2+ BC receiving adjuvant chemotherapy plus trastuzumab (n=986) in Alberta, Canada were included. Patients with low-risk (node negative) disease were stratified into DCH (n=104) or TCH (n=360) cohorts for DFS/OS comparison (Kaplan-Meier). Patients with high-risk (node positive) disease were stratified into FECDH (n=145) or TCH (n=314) cohorts. Subgroup analysis of the high-risk cohorts by HR+/HER2+ and HR-/HER2+ for FECDH vs TCH were performed. Chi-square was used to evaluate for difference between cohort variables.

Low- Risk Cohort DCH TCH  n (104)%n (360)%Age (mean)55.3 53.0 Hormone Status    ER+ or PR+8682.727676.7ER and PR-1817.38423.3Grade    121.951.423230.88523.637067.327075.0Surgery    lumpectomy525010830.5mastectomy525024669.5

High-Risk Cohort FECDH TCH  n (145)%n (314)%Age (mean)50.2 53.6 Hormone Status    ER+ or PR+11579.323875.8ER and PR-3020.77624.2Grade    10051.6229206119.631168014678.8Surgery    lumpectomy3927.19831.2mastectomy10572.921668.8Node Status    N18357.219461.8N24128.37323.2N32114.54715

Results: Median follow-up was 58.1 months in the low-risk cohort and 63.1 months in the high-risk cohort. In the low-risk group, patients receiving TCH had more mastectomy (69.5%) than lumpectomy (30.5%; p<0.001) compared to those receiving DCH (50%; 50%). No significant difference was seen in DFS (p=0.153) or OS (p=0.409) for patients in the DCH (92.3%; 95.2%) vs TCH (95.2%; 96.9%) cohorts. In the high-risk group, no significant difference was seen in DFS (p=0.226) or OS (p=0.164) for FECDH (92.4; 95.2%) or TCH (88.5%; 91.4%) respectively. In subgroup analysis of high-risk HR+/HER2+ BC, patients receiving FECDH demonstrated superior OS (98.3%; p=0.014) and a trend towards superior DFS (94.8%; p=0.069) relative to TCH patients (OS = 91.6%; DFS= 88.7%). Conversely, analysis of high-risk HR-/HER2+ BC, patients demonstrated higher DFS and OS for TCH (88.2%; 90.8%) relative to FECDH (83.3%; 83.3%); although this was non-significant (p=0.516; p=0.298) and likely underpowered. Nodal status was balanced between all groups (p=0.602).

Conclusion: In low-risk HER2+ BC, 4 cycles of DCH chemotherapy has high survival with similar outcomes to 6 cycles of TCH. In high-risk HER2+ BC, FECDH has comparable outcomes to TCH consistent with BCIRG-006. This study suggests that women with HR+/HER2+ breast cancer have improved OS with anthracycline containing regimens, such as FECDH. Although non-significant, patients with HR-/HER2+ BC may have some improvement in DFS and OS with TCH, a carboplatin containing regimen.

Citation Format: Veitch ZW, Khan OF, Tilley D, Kostaras X, Tang PA, King K, Lupichuk S. Adjuvant DCH vs TCH for low-risk (node negative); and FECDH vs TCH for high-risk (node positive) HER2+ breast cancer – A retrospective provincial analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-20-12.

Assessment and Synthesis of 50 Years of Published Drainage Phosphorus Losses

The prevalence of anthropogenic drainage systems in intensively cropped areas across North America combined with the degradation of important freshwater resources in these regions has created a critical intersection where understanding phosphorus (P) transport in drainage waters is vital. In this study, drainage-associated nutrient load data were retrieved and quantitatively analyzed to develop a more comprehensive understanding of the P loading and crop yield impacts of agronomic management practices within drained landscapes. Using the Drain Load table in the MANAGE (Measured Annual Nutrient loads from AGricultural Environments) database, the effect of factors such as soil characteristics, tillage, and nutrient management on P loading were analyzed. Across site-years, generally less than 2% of applied P was lost in drainage water, which corroborates the order of magnitude difference between agronomic P application rates and P loadings that can cause deleterious water quality impacts. The practice of no-till significantly increased drainage dissolved P loads compared with conventional tillage (0.12 vs. 0.04 kg P ha). The timing and method of P application are both known to be important for P losses, but these conclusions could not be verified due to low site-year counts. Findings indicate there is a substantial need for additional field-scale studies documenting not only P losses in drainage water but also important cropping management, nutrient application, soil property, and drainage design impacts on such losses.

The Neurobehavioral Phenotype in Mucopolysaccharidosis Type IIIB: an Exploratory Study

OBJECTIVES

Our goal was to describe the neurobehavioral phenotype in mucopolysaccharidosis Type IIIB (MPS IIIB). Parents report that behavioral abnormalities are a major problem in MPS III posing serious challenges to parenting and quality-of-life for both patient and parent. Our previous research on MPS IIIA identified autistic symptoms, and a Klüver-Bucy-type syndrome as indicated by reduced startle and loss of fear associated with amygdala atrophy. We hypothesized that MPS IIIB would manifest similar attributes when assessed with the same neurobehavioral protocol.

METHODS

Ten patients with MPS IIIB were compared with 9 MPS IIIA patients, all older than 6. 8 younger children with Hurler syndrome (1H) were chosen as a comparison group for the Risk Room procedure; MPS IH does not directly affect social/emotional function and these younger children were closer to the developmental level of the MPS IIIB group. To examine disease severity, cognitive ability was assessed. Four evaluations were used: the Risk Room procedure (to measure social-emotional characteristics, especially fear and startle responses), the Autism Diagnostic Observation Schedule (ADOS), the Sanfilippo Behavior Rating Scale (SBRS), and amygdala brain volumes calculated from manually-traced MRI images.

RESULTS

The two groups are equivalent in severity and show severe cognitive impairment. On the ADOS, the MPS IIIB patients exhibited the same autistic features as IIIA. The IIIB means differed from MPS IH means on most measures. However, the IIIB group did not approach the Risk Room stranger, like the MPS IH group who kept their distance, but unlike the IIIA group who showed no fear of the stranger. On the SBRS, the MPS IIIB patients were described as more inattentive and more fearful, especially of new people than the MPS IIIA. Onsets of some disease characteristics appeared more closely spaced and slightly earlier in MPS IIIB than IIIA.

CONCLUSIONS

On most behavioral measures, MPS IIIB patients did not differ substantially from MPS IIIA patients over age six, demonstrating autistic features and a Klüver Bucy-like syndrome including lack of fear and poor attention. Delay in onset of behavioral symptoms was associated with later diagnosis in two patients. Lack of fear, poor attention, and autistic-like symptomatology are as characteristic of MPS IIIB as they are of MPS IIIA. A possible difference is that the some behavioral abnormalities develop more quickly in MPS IIIB, If this is so, these patients may become at risk for harm and present a challenge for parenting even earlier than do those with MPS IIIA. .In future clinical trials of new treatments, especially with respect to quality of life and patient management, improvement of these behaviors will be an essential goal. Because very young patients were not studied, prospective natural history documentation of the early development of abnormal behaviors in MPS IIIB is needed.

Sensitivity Analysis of the Agricultural Policy/Environmental eXtender (APEX) for Phosphorus Loads in Tile-Drained Landscapes

Numerical modeling is an economical and feasible approach for quantifying the effects of best management practices on dissolved reactive phosphorus (DRP) loadings from agricultural fields. However, tools that simulate both surface and subsurface DRP pathways are limited and have not been robustly evaluated in tile-drained landscapes. The objectives of this study were to test the ability of the Agricultural Policy/Environmental eXtender (APEX), a widely used field-scale model, to simulate surface and tile P loadings over management, hydrologic, biologic, tile, and soil gradients and to better understand the behavior of P delivery at the edge-of-field in tile-drained midwestern landscapes. To do this, a global, variance-based sensitivity analysis was performed, and model outputs were compared with measured P loads obtained from 14 surface and subsurface edge-of-field sites across central and northwestern Ohio. Results of the sensitivity analysis showed that response variables for DRP were highly sensitive to coupled interactions between presumed important parameters, suggesting nonlinearity of DRP delivery at the edge-of-field. Comparison of model results to edge-of-field data showcased the ability of APEX to simulate surface and subsurface runoff and the associated DRP loading at monthly to annual timescales; however, some high DRP concentrations and fluxes were not reflected in the model, suggesting the presence of preferential flow. Results from this study provide new insights into baseline tile DRP loadings that exceed thresholds for algal proliferation. Further, negative feedbacks between surface and subsurface DRP delivery suggest caution is needed when implementing DRP-based best management practices designed for a specific flow pathway.

An audit of the management of thyroid disease in children with Down syndrome

Children with Down syndrome are at a higher risk of thyroid dysfunction than children in the general population. The aim of this audit was to determine thyroid screening practice at University Hospital Limerick and to compare it to the Irish guidelines for the medical management of children with Down syndrome. The thyroid function tests (TFT) of 148 children with Down syndrome were assessed through retrospective database review. Overall compliance with the guidelines was 79/148 (53%), although this varied by age category. The 0-5 years category had a compliance rate of 47/54 (87%), the 6-11 years category was 22/51 (43%), and the 12-17 years category had a compliance rate of 10/43 (23%). The guidelines are effective for monitoring purposes, although performing an annual TFT throughout childhood may be warranted.