Immunotherapy use in older adults with cancer with frailty: A young SIOG review paper

Immune checkpoint inhibitors (ICIs) became a treatment option in most tumor types and improved survival in patients with cancer in the last decade. Older patients with cancer are underrepresented in the pivotal clinical trials with ICIs. Older patients with cancer often have significant comorbidities and geriatric syndromes like frailty, which can complicate cancer care and treatment decisions. Frailty is among the most prevalent geriatric syndromes in patients with cancer and could lead to inferior survival and a higher risk of complications in patients treated with chemotherapy. However, the effect of frailty on the efficacy and safety of ICIs is understudied. This review focuses on the available evidence regarding the association between frailty and ICI efficacy and safety. Although the survival benefits of ICIs have generally been shown to be independent of age, the available real-world data has generally suggested higher rates of immune-related adverse events (irAEs) and treatment discontinuation in older patients. While international organizations recommend conducting a comprehensive geriatric assessment CGA to assess and address frailty before the start of anti-cancer therapies, an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or higher is frequently used in clinical practice as synonymous with frailty, albeit with significant limitations. The available data has generally demonstrated diminished ICI efficacy in patients with an ECOG 2 or higher compared to patients with better performance status, while the incidence of high-grade irAEs were similar. Whilst evidence regarding outcomes with ICI in older patients and in those with sub-optimal performance status is growing, there is very limited data specifically evaluating the role of frailty with ICIs. These studies found a shortened overall survival, yet no evidence of a lower response rate to ICIs. These patients experienced more AEs, but they did not necessarily have a higher incidence of irAEs.

Overview and characterization of penile cancer content across social media platforms

Background

Social media platforms (SMP) are an emerging resource that allows physicians, patients, and families to converse on cancer prevention, diagnosis, and treatment. We aimed to characterize penile cancer (PC) content shared on SMP.

Methods

We searched PC posts on Twitter, Facebook, and Instagram from July 1st, 2021, through June 30th, 2022. Two independent, blinded reviewers analyzed the hashtags: #PenileCancer, #PenileCancerAwareness, and #PenileNeoplasm. Descriptive statistics were used for posts characterization, Pearson´s correlation coefficient for associations, and Cohen's weighted kappa coefficient for inter-rater agreement rate.

Results

A total of 791 posts were analyzed, with Twitter accounting for 52%, Facebook for 12.2%, and Instagram for 35.5%, and. Most posts originated from high-income countries, such as the United Kingdom (48.8%). We found no correlation between the number of posts with PC incidence (p = 0.64) or users on SMP (p = 0.27). Most accounts were classified as "support and awareness communities" (43.6%) and "physicians and clinical researchers" (38.2%). Urology was the most common medical specialty to post (60.9%), followed by oncology (11.3%). Most posts were classified as "prevention and awareness for users" (45.1%). Global inter-reviewer agreement rate was almost perfect (k=0.95; p ≤ 0.01). On Twitter, "physicians and clinical researchers" shared more content on "treatment updates and medical papers published in medical journals," while on Facebook and Instagram, "support and awareness communities" focused on "personal and support comments."

Conclusion

Overall, the number of PC posts was low compared to other neoplasms across the SMP evaluated in this study. "Physicians and clinical researchers" shared more content on Twitter, while "support and awareness communities" on Facebook and Instagram. Encouraging the use of a common SMP among the medical community and general users could lead to a more effective communication between physicians, patients, and support groups, and to increased awareness of PC.

Impact of healthcare inequities on survival in Mexican patients with metastatic renal cell carcinoma

Introduction

The survival of patients with metastatic renal cell carcinoma (mRCC) has improved dramatically due to novel systemic treatments. However, mRCC mortality continues to rise in Latin America.

Methods

A retrospective, multicenter study of patients diagnosed with mRCC between 2010-2018 in Mexico City was conducted. The aim of the study was to evaluate the impact of healthcare insurance on access to treatment and survival in patients with mRCC.

Results

Among 924 patients, 55.4%, 42.6%, and 1.9% had no insurance (NI), social security, (SS) and private insurance (PI), respectively. De novo metastatic disease was more common in NI patients (70.9%) compared to SS (47.2%) and PI (55.6%) patients (p<0.001). According to IMDC Prognostic Index, 20.2% were classified as favorable, 49% as intermediate, and 30.8% as poor-risk disease. Access to systemic treatment differed by healthcare insurance: 36.1%, 99.5%, and 100% for the NI, SS, and PI patients, respectively (p<0.001). NI patients received fewer lines of treatment, with 24.8% receiving only one line of treatment (p<0.001). Median overall survival (OS) was 13.9 months for NI, 98.9 months for SS, and 147.6 months for NI patients (p<0.001). In multivariate analysis, NI status, brain metastases, sarcomatoid features, bone metastases, no treatment were significantly associated with worse OS.

Conclusion

OS in mRCC was affected by insurance availability in this resource-limited cohort of Mexican patients. These results underscore the need for effective strategies to achieve equitable healthcare access in an era of effective, yet costly systemic treatments.

Abstract P4-03-38: Rare Breast Cancer Histologic Subtypes: 30-year experience in a Mexican Cancer Center

Introduction Breast cancer (BC) is a heterogeneous disease composed of multiple histologic subtypes. Invasive ductal carcinoma is the most common subtype, accounting for 75% of all BC cases and is followed by lobular carcinoma which represents another 15%. Other rare histologic subtypes make up the remaining 10%. To date, limited evidence exists regarding about the frequency, clinicopathologic characteristics, and prognoses of these uncommon variants in Mexico.

Methods A single center retrospective cohort including women diagnosed with invasive BC between January 1990 and December 2019 was conducted. Only patients with rare histologic subtypes, excluding not otherwise specified ductal and lobular carcinoma, were included. The main objective of this study was to describe the frequency, clinicopathological characteristics, and outcomes of these histologic subtypes. Descriptive statistics including means, medians, and standard deviations, were used to analyze clinicopathological characteristics. Recurrence-free survival (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method and compared by the log-rank test. A p value of &lt; 0.05 was considered statistically significant.

Results Out of 1744 women diagnosed with invasive BC, 106 patients (6.1%) had a rare histologic subtype. Among the most frequent subtypes, 39 (36.8%) were mucinous, 12 (11.3%) metaplastic, 11 (10.4%) tubulolobular, 11 (10.4%) papillary, 10 (9.4%) tubular, and 8 (7.5%) medullary carcinomas. In the less common histologic subtypes (referred as “others”), 7 (6.6%) were apocrine, 4 (3.8%) neuroendocrine, 1 (0.9%) micropapillary, 1 (0.9%) signet cell, 1 (0.9%) acinic cell, and 1 (0.9%) histiocytoid carcinoma.

In the overall population, the median age at diagnosis was 58 years, 76.4% were postmenopausal at diagnosis, 29.2% had a family history of BC, and 7.5% had personal history of BC. Seventy percent of the patients were overweight or obese at time of diagnosis and 82.1% had diabetes mellitus type 2 diagnosis. An important proportion of women were diagnosed by self-detected tumors (61.3%), as opposed to less than a quarter (24.5%) detected by screening mammography. The median time of diagnosis interval was 3 months, 71.7% were diagnosed with early (I – IIA), 22.6% with locally advanced (IIB – IIIC) and 5.7% with metastatic (IV) disease. Most tumors (58.3%) expressed hormone receptors (HR), 7.2% were HER2 enriched, 8.3% expressed both HR and HER2, whereas 26% were triple negative. Clinicopathological characteristics according to the most frequent histologic subtypes are listed in Table 1.

With a median follow-up of 108 months, 12 recurrences were identified (5 mucinous, 3 metaplastic, 2 tubulolobular and 2 apocrine), 41% were local and 59% were distant recurrences. Globally, 15-year RFS and OS were 83% and 61%, respectively. Differences in RFS and OS were not statistically different according to histologic subtypes. The 15-year RFS and OS was 83% and 80% for mucinous, 100% and 78% for tubular, 100% and 58% for medullary, 65% and 52% for metaplastic, 77% and 86% for tubulolobular, and 100% and 49% for papillary carcinoma, respectively.

Conclusions To our knowledge, this is the first study describing the frequency, clinicopathological characteristics, and outcomes of rare histologic BC subtypes in a large Mexican cohort. Our results show that these subtypes represent 6% of all invasive BC cases, that they are commonly diagnosed at an early stage, and present long RFS and OS.

Table 1: Clinicopathological characteristics according to the most frequent histologic subtypes

Citation Format: Paola Valdez-Sandoval, Bertha Alejandra Martinez-Cannon, Sandra Ileana Perez Alvarez, Eucario Leon-Rodriguez. Rare Breast Cancer Histologic Subtypes: 30-year experience in a Mexican Cancer Center [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-03-38.

Abstract P3-05-58: Frequency and prognosis of HER2-low status in Mexican patients with metastatic breast cancer

Background

Breast cancer (BC) is the leading cause of cancer and cancer-related death in Mexican women. Recently, low expression of HER2 (HER2-low), defined as immunohistochemically 1+ or 2+ and lack of HER2 gene amplification, has gained increased attention as a promising new predictive biomarker for treatment with antibody-drug conjugates, such as trastuzumab-deruxtecan, not currently available in Mexico. To date, the frequency and prognostic value of HER2-low status in the Mexican population with metastatic BC remains unknown.

Methods

Single center retrospective cohort of patients diagnosed with metastatic BC between 2017 and 2020. Only patients with known HER2 status and available survival data were included. Patients’ sociodemographic and clinicopathological characteristics, and outcomes were collected from medical records. Descriptive statistics were used to analyze sociodemographic and clinicopathological characteristics. X2 tests were used to evaluate associations between HER2 status and other characteristics. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier method and compared by the log-rank test according to HER2 status. Multivariable adjusted hazard ratios were estimated by Cox regression models. A p value of &lt; 0.05 was considered statistically significant.

Results

Among 55 patients with metastatic BC, median age at diagnosis was 51 years, 56.4% were postmenopausal and 25.5% had family history of BC. The most frequent histologic subtype was ductal (65.5%), followed by lobular (20%). Approximately 2/3 presented with metastatic disease de novo (67.3%), 69.1% presented with visceral metastases and the median number of lines of treatment was 2. According to intrinsic subtypes 54.5% were luminal HER2-negative (HER2-), 16.4% luminal HER2-positive (HER2+), 10.9% HER2 enriched, and 18.2% triple negative. According to HER2 status, 11 (20%) were HER2+, 26 (47.3%) were HER2-low, and 18 (32.7%) were HER2-. HER2-low expression was more frequent in the hormone-receptor positive (HR+) (51.3%) than in HR negative (HR-) (31.3%), however, this difference was not statistically significant (p = 0.11). Patients’ characteristics according to HER2 status are shown in Table 1.

With a median follow-up of 39.9 months, there were no differences in PFS and OS according to HER2 status. Median OS was 45, 30.8, and 46.4 months, for HER2+, HER2-low, and HER2-, respectively (p = 0.48). On univariate analysis, age, menopausal status, RH status, HER2 status, disease presentation and visceral metastases were not associated with improved OS. In patients with HER2-low status, median OS was 36.6 and 15.8 months for patients with HR+ and HR- disease (p = 0.009). In the HER2-low subgroup, multivariate analysis showed that HR status (hazard ratio 10.96 [95% CI 2.11-56.92], p = 0.004) and having received ≥2 lines of treatment (hazard ratio 13.34 [95% CI 1.97-90.37], p = 0.008) were statistically associated with better OS.

Conclusion

Our findings show that almost half of patients with metastatic BC have a low HER2 expression. Although HER2-low status did not impact survival in a small cohort of Mexican patients, HR status and lines of treatment were associated with better prognosis in patients with HER2-low disease. These results demonstrate the high burden of Mexican patients with HER2-low disease who could benefit from targeted therapies after first line therapy, and the importance of ensuring access to effective treatment options.

Table 1. Patient characteristics.

Citation Format: Bertha Alejandra Martinez-Cannon, Haydee Cristina Verduzco-Aguirre. Frequency and prognosis of HER2-low status in Mexican patients with metastatic breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-05-58.

Do circulating neutrophil extracellular traps predict recurrence in early breast cancer?

Background

Neutrophil extracellular traps (NETs), three-dimensional structures formed by neutrophil enzymes such as neutrophil elastase (NE) and nuclear components (DNA), have been associated with progression and metastasis in breast cancer (BC). Thus, the aim of this study was to evaluate the association of circulating NETs with clinicopathological characteristics and outcomes in early BC.

Methods

A prospective cohort included women with newly diagnosed early BC. NETs were defined as the presence of NE-DNA complexes in plasma, measured by optical density. Levels of NETs were dichotomized according to the median, as low and high levels of circulating NETs. Fisher's exact test was used to evaluate associations between NETs and clinicopathological characteristics and outcomes. Survival was assessed using the Kaplan Meier method and log-rank test.

Results

Forty patients were included, 23 (57.5%) patients with low and 17 (42.5%) with high levels of circulating NETs. No associations were found between clinicopathological characteristics and circulating NETs levels. Recurrence (p = 0.99) and site of recurrence (p = 0.99) were not statistically associated with plasma NETs levels. Overall, recurrence-free survival was not statistically different between circulating levels of NETs.

Conclusions

With a short follow-up and low number of events, our results suggest that circulating levels of NETs at diagnosis of early BC are not associated with more aggressive clinicopathological characteristics, recurrence, or site of recurrence.

Physicians' attitudes and perceived barriers to adherence to the national breast cancer clinical practice guidelines in Mexico: a survey study

BACKGROUND

Adherence to clinical practice guidelines improves outcomes for patients with breast cancer. However, their implementation may not be feasible in low- and middle-income countries. This study aimed to evaluate physicians' adherence, attitudes, and barriers towards the Colima Consensus, which is the Mexican national breast cancer clinical practice guideline.

METHODS

A cross-sectional, 31-item survey was e-mailed to Consensus attendees and members of the Mexican Society of Oncology and Mexican Mastology Association. Descriptive statistics, univariate, and multivariate analysis were used to analyze the associations between participants' characteristics, adherence, attitudes, and barriers.

RESULTS

Of 439 respondents, 78% percent adhered to Consensus recommendations and 94% believed it was applicable to their clinical practice. Forty percent reported using the Consensus as their sole breast cancer guideline. This was associated with being a surgical oncologist (OR 3.3, 95% CI 2.0-5.3) and practicing at a public hospital (OR 2.1, 95% CI 1.2-3.7). The most common barriers to adherence were lack of resources and logistical problems. Regarding attitudes towards the Consensus, 90% considered it a good educational tool, 89% considered it a reliable source of information, and 90% thought it improved quality of care.

CONCLUSIONS

We showed high levels of adherence and positive attitudes towards the Colima Consensus, with a significant proportion of physicians using it as their only guideline. Lack of resources and logistical issues were the main barriers to adherence. Our results highlight the relevance of local breast cancer guidelines and suggest a need for the creation of resource-stratified guidelines.

Physicians’ adherence, attitudes, and perceived barriers to the Mexican breast cancer clinical practice guidelines (BCCPG)

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Background: Adherence to BCCPG improves outcomes for patients with breast cancer. However, the implementation of international BCCPG may not be feasible in low- and middle-income countries, and a potential solution may be developing BCCPG adapted to local contexts. The National Consensus on Diagnosis and Treatment of Breast Cancer ( Colima Consensus, http://consensocancermamario.com) is the Mexican BCCPG. This study aimed at evaluating physicians’ uptake of the Colima Consensus and identifying barriers impacting adherence. Methods: A cross-sectional, 30-item survey exploring adherence, barriers, and attitudes towards the Colima Consensus was e-mailed to Consensus attendees and members of the Mexican Society of Oncology and Mexican Mastology Association. Answers were collected between 06/21-09/21. Descriptive statistics, univariate, and multivariate analysis were used to analyze the associations between participants’ characteristics, adherence, attitudes, and barriers. Results: Among 1553 physicians invited to participate, 439 (28%) completed the survey. Fifty-four percent were male, 66% were age 30-49 years, and 39% practiced in Mexico City. Twenty-six percent were surgical, 13% medical, and 10% radiation oncologists. Ninety-two percent reported using the Consensus to guide decision-making, 78% adhered to its recommendations, 89% agreed with its recommendations, and 94% believed it was applicable to their clinical practice. Regarding attitudes towards the Consensus, 90% agreed/strongly agreed with it being a good educational tool, 89% a reliable source of information, and 90% thought it improved quality of care. The most common barriers to adherence were lack of resources (54%) and logistical problems (29%). Physicians working with a multidisciplinary team were less likely to cite lack of resources as reason for non-adherence (p < 0.01). Forty percent reported using the Consensus as their only BCCPG. Surgical oncologists (p < 0.01), those practicing in public hospitals (p < 0.01), in institutions with local BCCPG (p < 0.01), with ≤5 new patients/month (p < 0.01), and not involved in research (p < 0.01) were more likely to use the Consensus as their only BCCPG. In multivariate analysis, being a surgical oncologist (OR 3.26, p < 0.01) and working in a public hospital (OR 2.12, p < 0.01) increased the odds of using the Consensus as the only BCCPG. Conclusions: We show high levels of adherence and positive attitudes towards the Colima Consensus, with a significant proportion using it as their main BCCPG. Lack of resources and logistical issues were the main barriers to adherence. Our results highlight the relevance of local BCCPG and suggest a need for the creation of stratified recommendations adapted to various healthcare settings.

Young Women with Breast Cancer in Resource-Limited Settings: What We Know and What We Need to Do Better

Young women with breast cancer (YWBC) account for a variable proportion of patients diagnosed with breast cancer around the globe, with a higher prevalence in resource-limited settings than in high-income countries. This group represents a unique population that warrants special attention due to specific biological considerations and age-specific supportive care issues. This review aims to explore existing knowledge regarding YWBC's needs, particularly in resource-restricted settings. To date, scarce information regarding the care of YWBC in resource-constrained countries is available, with most reports describing suboptimal care in terms of survivorship needs. Health care providers should implement actions to improve endocrine treatment adherence, referrals for fertility counseling and preservation, contraceptive use compliance, timely body image and sexual function interventions, comprehensive genetic risk assessments, and early quality of life and psychosocial health interventions. While high costs act as a barrier for optimal care in resource-limited settings, improving patient education represents a promising and cost-effective solution to improve patient care. Future research on developing tailored educational resources for YWBC in resource-limited settings should be considered a priority.

Physicians' Attitudes, Knowledge, and Perceived Barriers toward Fertility Preservation in Young Breast Cancer Patients in a Developing Country

BACKGROUND

In Mexico, up to 15% of breast cancer (BC) patients are 40 years or younger. Therefore, fertility preservation and pregnancy after cancer treatment are major concerns in this population. However, no data are available regarding Mexican physicians' knowledge and attitudes toward these issues.

OBJECTIVE

The objective of the study was to describe physicians' attitudes, knowledge, and perceived barriers toward fertility preservation among young women with BC (YWBC) in a developing country.

METHODS

A cross-sectional study was conducted among physicians attending the 2016 Mexican Society of Oncology (SMeO) Annual Meeting or affiliated to SMeO. Chi-squared tests were used to assess factors associated with a higher likelihood of disclosing infertility risks, discussing fertility preservation methods, referring to specialists, and effective counseling.

RESULTS

Of the 314 participants, 83% reported a high sense of responsibility about informing treatment-related infertility risks, 58% always informed patients about those risks, 38% always discussed fertility preservation procedures, 52% always referred interested patients to fertility specialists, and 24% wrongly considered pregnancy and GnRH analogs detrimental in YWBC. Barriers for discussing fertility preservation were costs, lack of specialists, and prognosis.

CONCLUSIONS

It is crucial to promote physicians' knowledge and to endorse policies to overcome barriers obstructing universal access to fertility preservation for YWBC in Mexico.

Adherence to Adjuvant Tamoxifen in Mexican Young Women with Breast Cancer

BACKGROUND

Breast cancer (BC) in young women is characterized by an unfavorable prognosis in hormone receptor-positive/HER2-negative tumors, which may be explained by low rates of tamoxifen adherence. In Mexico, up to 14% of all BC diagnoses occur in young women and no data on tamoxifen adherence has been reported.

OBJECTIVE

To estimate the rate of adherence to adjuvant tamoxifen in Mexican young women with BC (YWBC).

METHODS

A cross-sectional survey was conducted at the National Cancer Institute in Mexico City, among YWBC (≤40 years at diagnosis) receiving adjuvant tamoxifen. Adherence was measured subjectively, through self-reported surveys, and objectively, through medication possession ratio (MPR). Descriptive statistics were used to analyze sociodemographic characteristics. To compare associations between patients' characteristics and adherence, Chi-square test was used for categorical variables and Student's t-test or Mann-Whitney U-test for quantitative variables.

RESULTS

A total of 141 YWBC receiving adjuvant tamoxifen were included. Regarding subjective adherence, 95% expressed taking tamoxifen regularly, 70% reported missing 0 doses in the past 30 days, and 71.6% reported having adverse effects. Regarding objective adherence, 74.8% of patients had an MPR ≥80%. The association between subjective and objective adherence was statistically significant (p = 0.004). Subjective adherence was associated with not skipping tamoxifen doses when feeling worse. Objective adherence was associated with having a stable job, not skipping tamoxifen doses when feeling worse, taking additional medications, and time on tamoxifen treatment. Fifty-six percent considered the information on tamoxifen to be insufficient and 37% not understandable.

CONCLUSION

In our study, high subjective and objective adherence rates to adjuvant tamoxifen were reported, although an important proportion of women reported high rates of adverse effects and not fully understanding the benefits of tamoxifen. Strategies to increase tamoxifen adherence may be even more important now that longer durations of treatment or further ovarian function suppression have become the standard of care in YWBC.

Comparison of characteristics in Mexican women with breast cancer according to healthcare coverage

Objective:

To compare the sociodemographic, diagnostic, clinical, and treatment-related characteristics and outcomes of patients with breast cancer in two hospitals in Mexico according to type of healthcare coverage.

Methods:

A retrospective cohort study of women with breast cancer according to public or private healthcare coverage in two hospitals was done. Patients were treated by the same group of physicians and healthcare infrastructure. Groups were compared using the chi-square test for categorical variables, Mann–Whitney U-test and Student’s t-test for quantitative variables, and Kaplan–Meier estimator and log-rank test for time dependent outcomes (including recurrence-free and overall survival). A value of p < 0.05 was considered statistically significant.

Results:

A total of 282 women were included. Mean age at diagnosis was 52 years. Women with public healthcare coverage were diagnosed more frequently with self-detected tumors (82.8% vs 47.9%, p < 0.001) and advanced clinical stage (III and IV) (31.1% vs 17.8%, p = 0.014). More women with public healthcare insurance underwent initial systemic treatment (41.1% vs 17.8%, p < 0.001) and mastectomy (70.1% vs 54.9%, p = 0.020), and received more chemotherapy (79.4% vs 43.8%, p < 0.001) and adjuvant radiotherapy (68.9% vs 53.4%, p = 0.017). Overall, no differences were found in survival outcomes according to healthcare coverage. Trends suggesting worse recurrence-free and overall survival were observed in patients with public coverage at 3 years follow-up in stage III (85.7% vs 67.3% and 100% vs 84.6%, respectively) and triple negative disease (83.3% vs 74.5% and 100% vs 74.1%, respectively).

Conclusion:

Strategies to promote preventive medicine, diagnostic mammograms, and prompt diagnosis of breast cancer in Mexican women with public health coverage are needed. Access to the main treatment modalities by Seguro Popular and good quality care by an experienced group of physicians likely explains the similar outcomes between patients with private and public healthcare coverage. However, trends suggesting worse survival for patients with public medical coverage with stage III and triple-negative disease should encourage close follow-up.

Suboptimal Use of Effective Contraceptive Methods in Young Mexican Women With Breast Cancer

Purpose

Contraceptive counseling and adherence in young women with breast cancer (BC) is a relevant issue because chemotherapy and hormonal treatment resulting in amenorrhea do not preclude unintended pregnancies. Currently, there is limited evidence from high-income countries; however, there are no studies regarding use of contraceptives in patients with BC in Mexico. This study aimed to determine the rate of contraceptive use in young Mexican women with BC during cancer treatment, characterize their contraceptive preferences, and assess contraceptive counseling by Mexican physicians.

Patients and Methods

A cross-sectional survey was conducted regarding contraceptive use and counseling among women age 40 years or younger at BC diagnosis who had completed chemotherapy in the previous 5 years or who were currently receiving long-term treatment with hormonal therapy and/or trastuzumab at a large tertiary health care facility in Mexico.

Results

Of a total of 104 eligible women with median age at diagnosis of 34 years, 51.1% reported using a contraceptive during chemotherapy and 45.7% reported using a contraceptive during other types of cancer treatment (hormonal therapy and trastuzumab). Of the 51 patients (49%) who were sexually active during chemotherapy, 76.5% used contraception, but only 29.4% used an effective contraceptive method. When asked about contraceptive counseling, only 16.7% recalled being advised by their health care provider. Sexually active women who received contraceptive counseling used contraceptives more often than women who were not counseled (83.3% v 22.2%).

Conclusion

A minority of young women with BC in Mexico use effective contraception methods during cancer treatment and receive contraceptive counseling. Informing all premenopausal patients with BC about effective use of contraception methods during treatment should be an essential aspect of the supportive care of young women.

Impact of chemotherapy sequence on the efficacy of scalp cooling devices for alopecia prevention

e12034

Background: The use of scalp cooling devices (SCD) has been widely adopted for prevention against chemotherapy-induced alopecia (CIA). However, efficacy of SCD varies between different chemotherapy (CT) regimens. The aim of this study was to evaluate the effectiveness of SCD in breast cancer patients with different CT regimens treated in a tertiary cancer center in Monterrey, Mexico. Methods: All consecutive patients who used SCD were included. Data regarding treatment regimens and efficacy outcomes were prospectively collected. A descriptive analysis was performed to compare the effectiveness among the different CT regimens and sequences used. Results: We included a total of 49 patients with SCD usage from July 2016-January 2019. Table summarizes SCD efficacy, toxicities and CT regimens. In our study, 76% of patients had grade ≤1 CIA using SCD. 35% withdrew SCD use, with hair loss being the most common reason. 58% of patients who received upfront anthracycline-cyclophosphamide (AC) experienced grade 2 CIA. In contrast, no patients receiving taxane-only treatment had grade 2 CIA. Notably, only 3 of 16 patients (19%) who received upfront paclitaxel followed by anthracyclines developed grade 2 CIA. Conclusions: SCD proved to be highly effective in preventing grade 2 CIA with different CT regimens, including patients that received anthracycline-based regimens who started treatment with taxanes upfront. Accordingly, our results suggest that CT sequence, rather than type of CT agent may have a significant impact on the efficacy of SCD in CIA prevention. The results of larger studies are required to confirm our findings.[Table: see text]

Abstract P1-11-17: Effects of depression, anxiety, and sexual functioning on quality of life among young breast cancer patients in Mexico

Background: Despite the disproportionately high-rates of breast cancer (BC) in young women in Mexico, cancer-control efforts have been predominantly aimed at improving oncological treatment, bypassing survivorship issues and supportive care for this group. The “Joven & Fuerte” cohort, the first supportive care and research program for young BC patients in Latin America, aims to describe and assess the burden of BC in young Mexican women. In this study, we focused on evaluating the association between quality of life (QoL) and anxiety, depression, and sexual functioning in young women with BC (≤ 40 years).

Methods: This study included non-metastatic and non-recurrent patients belonging to the cohort's pilot phase. QoL was assessed with the EORTC QLQ-C30 global score. Patients were classified in the domains of anxiety and depression with the Hospital Anxiety and Depression Scale (HADS) as either probable case, doubtful case, or not a case. Sexual functioning was assessed with the Female Sexual Function Index (FSFI) and the sexual functioning and enjoyment domains of the EORTC QLQ-BR23. Assessments were performed at baseline, 6 months, 1 year, and 2 years. Pearson chi-square and analysis of variance (ANOVA) were used for analysis. Nominal unadjusted significance is reported with p&lt;0.05.

Results: 73 out of 96 (76%) pilot phase patients met the inclusion criteria and had complete assessments up to 2 years follow-up. Global QoL was significantly worse for cases with anxiety and depression at baseline (means for non-cases, doubtful cases and cases, respectively: for anxiety, 81.09, 69.54, and 61.54, p&lt;.001; and for depression, 75.63, 64.17, and 55.00, p=0.01) and depression at 6 months (76.55, 66.67, and 35.42, respectively, p&lt;.001). Classification of case level anxiety was associated with FSFI morbidity during the first year (baseline, p=0.03; 6 months, p=0.09; 1 year, p=0.04). There was no significant association between case level depression and FSFI morbidity in the first 2 years. Neither anxiety nor depression was generally associated with significantly different BR23 sexual functioning or sexual enjoyment; however, a sporadic association was observed between anxiety and BR23 sexual functioning at 6 months (p=0.04).

Conclusion: This study confirmed an association between anxiety and/or depression and worse QoL at diagnosis of BC and after 6 months. Additionally, worse sexual function was significantly associated with the classification of case level anxiety. These findings support the current recommendation that physicians should regularly assess patients' psychosocial health and sexual functioning and provide prompt referral to corresponding supportive care services. Additional efforts must be conducted in low-resource settings, where sexual health and psychosocial care are not considered routine cancer treatment. Dedicated programs that promote multidisciplinary and supportive care services, such as “Joven & Fuerte”, should be incorporated into institutional health-care protocols to systematically address patients' emerging needs and improve QoL.

Citation Format: Villarreal-Garza C, Platas A, Miaja M, Lopez-Martinez EA, Muñoz-Lozano JF, Fonseca A, Pineda C, Barragan-Carrillo R, Martinez-Cannon BA, Chapman J-AW, Goss PE, Bargallo-Rocha JE, Mohar A, Castro-Sanchez A. Effects of depression, anxiety, and sexual functioning on quality of life among young breast cancer patients in Mexico [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-17.

Psychological Impact of Alterations in Sexuality, Fertility, and Body Image in Young Breast Cancer Patients and Their Partners

Young women with breast cancer have age-specific concerns regarding changes in sexuality, fertility, and body image. However, the psychological impact of BC and its treatments is not exclusive to young patients and it also affects their social context, especially their partners, as they experience higher illness intrusiveness than the partners of older women. In young BC patients, relationships, body image, and sexual problems are related to most quality of life domains. While BC treatment is being planned, all women should be informed about the possible side-effects of treatment on sexuality, fertility, and body image. Inclusion of partners into decision making should be pursued to restore, improve, and maintain effective communication and positive relationships in young couples facing BC. The aim of this review is to describe the psychological impact of alterations in sexuality, fertility, and body image in young BC patients and their partners, and to recommend strategies to address such issues in a timely manner.

Abstract P6-11-09: Physician knowledge and attitudes towards fertility preservation in Mexican young breast cancer patients

Background: In Mexico, approximately 30% of young women with breast cancer (YWBC) are childless and &gt;40% express concern about infertility risk secondary to cytotoxic treatment. However, only 30% of patients recall being disclosed by their physician of such risk. The aim of this study was to characterize and analyze the caregivers' behavior, attitudes and knowledge towards fertility preservation in YWBC in a limited resource setting, such as Mexico.

Materials and Methods: A 20-item survey was designed and validated by an expert panel, which was answered by participants of the annual meeting of the Mexican Society of Oncology 2016, as well as by physicians affiliated to the same association via web. Pearson chi-square tests were used to assess factors associated with the likelihood of disclosure of infertility risk, discussion about methods of fertility preservation and referral to a reproductive health specialist.

Results: The participants' demographic characteristics are displayed in Table 1 and are associated with the main areas of interest in Table 2.

Characteristics%Age ≤40y56&gt;40y44Gender Male69Female31Specialty Medical36Surgical53Other12Clinical Practice Public26Private9Both65Knowledge safety subsequent pregnancy Fair64Not fair36Knowledge safety ovulation inductors Fair38Not fair62Knowledge safety GnRH analogues Fair37Not fair63

 Inform about infertility riskInform about preservation strategiesRefer to a specialist %p%p%pAge      ≤40y56.5 46.2 54.9 &gt;40y44.5.8653.8.00845.1.72Gender      Male67.6 73.1 65.4 Female32.4.7226.9.14934.5.24Specialty      Medical30.2 31.1 28.4 Surgical57.7 57.7 60.5 Other12.1.579.2.4211.1.18Clinical practice      Public19.8 12.6 19.8 Private19.8 21.0 15.4 Both60.4.0266.4.00264.8.51Sense of responsibility      Low-Middle8.8 5.0 8.0 High91.2&lt;.00195.5&lt;.00192.0&lt;.001Inform about infertility risk      Always--94.1 64.8 Not always--5.9&lt;.00135.2.013

The caregivers' most influential factor in all areas was their self-reported sense of responsibility on disclosing patients about infertility risk. Those physicians that inform patients about infertility risk are statistically more likely to discuss fertility preservation strategies and to refer to a reproductive health specialist. As for the main barriers for fertility preservation, costs were the most frequently mentioned (29.6%), followed by lack of specialists (11.2%), and patient's prognosis according to clinical stage (11.2%).

Conclusions: This represents the first Latinamerican study evaluating the YWBC's caregivers' attitudes and practices towards fertility preservation, as well as their general knowledge concerning oncofertility issues. The fact that only one third of the enquired physicians were aware of the safety of ovulation inductors and use of GnRH analogues in YWBC is striking, which may translate into worse survivorship care. Furthermore, physicians reported that access barriers were the most prevalent factors that hindered appropriate referral. Health-care providers play a major role in the timely detection of the patient's interest in future offspring, thus it is crucial to promote knowledge about this relevant topic and endorse policies that can provide universal access to assisted reproductive technologies.

Citation Format: Villarreal-Garza CM, Barragan-Carrillo R, Bargallo-Rocha JE, Peña-Curiel O, Martinez-Cannon BA, Platas A, Torres J, Mohar A, Rivera S, Garcia-Valdovino VJ, Garcia-Leon GA, Castro-Sanchez A. Physician knowledge and attitudes towards fertility preservation in Mexican young breast cancer patients [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 P6-11-09.

Adherence to tamoxifen in Mexican young women with breast cancer

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Background: Young age has been associated with significantly increased risk of breast cancer (BC) death among women with luminal BC. One contributing factor might be the low rate of tamoxifen (TMX) adherence previously reported in this young group. Given that in Mexico a disproportionate rate of BC is diagnosed among YW, information regarding TMX adherence is particularly relevant. Our study's aim was to report TMX adherence in Mexican YW and its associated determinants. Methods: Consecutive patients ≤40y at diagnosis at the National Cancer Institute in Mexico City, under TMX treatment, completed a multiple-choice survey regarding the use and attitudes about hormonal therapy and adherence. Data of TMX disposal was collected from the pharmacy’s records, and the medication possession ratio (MPR) was calculated; an MPR ≥80% was considered adherent. Results: 135 YW with a median age at diagnosis of 35.7y (24-40) were included. 77% were undergraduate, 28% unpaired and 33% childless. Median follow-up was 26 months. 95% of patients reported a regular TMX intake: 70% did not miss any doses, while 25% missed 1-6 doses a month. Only 45% considered that the information received regarding TMX therapy was sufficient and for 37% was incomprehensive. 43% thought TMX significantly reduced their recurrence-risk and 60% strongly believed that they needed to be on TMX treatment. 73% of women reported adverse effects, being menopausal symptoms the most frequent, but only 27% were worried about the treatment long-term effects. From the 99 patients with a pharmacy record, 73% had an MPR > 80%. No significant factor was statistically associated with TMX adherence. Conclusions: Although Mexican YW and pharmacy data surprisingly sustained higher rates of TMX adherence compared to previous data, still a significant proportion of patients were non-adherent. Two-thirds of our patients reported having adverse effects, which might contribute to late TMX discontinuation. Since the newer recommendations of double hormonal blockade could lead to higher withdrawal rates of endocrine therapy in YW, adherence should be emphasized and closely monitored. Accordingly, hormonal treatment adherence should be a key component in the medical assessment of young luminal BC patients.

Fertility concerns among breast cancer patients in Mexico

OBJECTIVE

Young women represent a high proportion of the total number of breast cancer (BC) patients in Mexico; however, no previous studies addressing their attitudes regarding the risk of chemotherapy-induced infertility and its contributing factors are available. The aim of this study was to evaluate the concerns of young women with BC towards the risk of infertility in two referral centers in Mexico with access to public health services.

METHODS

A cross-sectional study including women with newly or previously detected BC aged 40 years or younger at diagnosis was conducted. Variables regarding concerns about fertility were collected from an adapted version of the Fertility Issues Survey.

RESULTS

134 consecutive eligible women responded to the in-person paper survey. 55% were partnered, 35.1% had no children, and 48% reported willingness to have children prior to BC diagnosis. Only 3% of patients considered to be able to afford extra expenses. At diagnosis, 44% of women expressed some level of concern about infertility risk. The only factor significantly associated with fertility concern was the desire of having children prior to diagnosis (OR 11.83, p = 0.006). Only 30.6% patients recalled having received information regarding infertility risk from their physicians.

CONCLUSION

A minority of young women with breast cancer in Mexico is informed about the risk of BC treatment-induced infertility, despite substantial interest. Informing all patients about infertility risk and available options for fertility preservation should be an essential aspect of the supportive care of young women with BC, even in low-middle income countries such as Mexico.

Abstract P4-20-04: Young women with breast cancer in Mexico: A report of the pilot phase of the “Mujer Joven y Fuerte” prospective cohort

Background: Despite high rates of breast cancer in young women from low-and-middle-income countries (LMICs), their needs and concerns are not systematically studied or addressed. Understanding the characteristics of young women with breast cancer (YWBC) and the issues they face is of great relevance to the medical community, in order to tailor clinical interventions and supportive care for this unique and understudied patient population. The Mexican cohort “Mujer Joven y Fuerte” (Young and Strong Woman) has the goal of comprehensively characterizing and assessing the needs of YWBC in Mexico using patient- and physician-based surveys. Methods: A prospective cohort of newly diagnosed YWBC was established in November 2014 at two Mexican cancer centers in Mexico City and Monterrey. Eligible women answer web-based surveys on relevant topics including physical activity, genetics, psychosocial needs, and fertility. Clinicians complete pre-specified surveys using the US NIH BOLD Task Force common data elements registering clinical/pathologic characteristics and outcomes. Patients are evaluated at diagnosis, after 6 months, and annually for 5 years. Sub-studies assessing changes in cognition, sexual function and satisfaction, quality of life and depression/anxiety are being conducted, and biologic samples are stored for future research. Results: 96 YWBC with median age at diagnosis of 34 (21-41 y) were accrued to our pilot phase. 26% were single and 25% childless. 43% had higher education and 28% were employed. 90% presented with a self-detected mass. Clinical stage at diagnosis was distributed as follows: stage 0: 2%; I: 15%; IIA: 13%; IIB: 17%; III: 47%, and stage IV: 6%. The most frequent molecular subtype was HR+/HER2- (47%), followed by HER2+ (26%) and triple negative (21%). First follow-up results will be available shortly. Conclusions: To our knowledge, this represents the first prospective cohort of YWBC in Latin America. We are expanding this project to other centers in the region. Our findings will help develop culturally tailored interventions aimed at improving the psychosocial and medical outcomes of this vulnerable patient population.

Citation Format: Villareal-Garza CM, Platas A, Castro-Sánchez A, Miaja M, Bargalló-Rocha E, Martinez-Cannon BA, Vega Y, Fonseca A, Ramos-Elias P, Márquez-Perez CJ, Bukowski A, Goss P, St. Louis J, Chapman J-A, Partridge A, Meneses A, Mohar A. Young women with breast cancer in Mexico: A report of the pilot phase of the “Mujer Joven y Fuerte” prospective cohort [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-20-04.

Predictors of optimal cytoreduction in patients with newly diagnosed advanced-stage epithelial ovarian cancer: Time to incorporate laparoscopic assessment into the standard of care

The standard management of advanced-stage ovarian cancer has been a subject of debate, and much controversy remains as to whether patients should have primary cytoreductive surgery followed by chemotherapy or neoadjuvant chemotherapy followed by interval cytoreductive surgery. In addition, there is increasing evidence that the patients who ultimately gain the most benefit from surgery are those with no residual disease at the completion of surgery (R0 resection). Therefore, to determine the best therapeutic strategy (primary cytoreductive surgery vs. neoadjuvant chemotherapy) for an individual patient, it is critically important to estimate the likelihood that primary cytoreductive surgery will leave no macroscopic residual disease. A number of studies have evaluated the use of serologic markers, such as CA-125, and imaging modalities, such as computed tomography (CT) or positron emission tomography/CT (PET/CT), to determine which patients are ideal candidates for primary cytoreductive surgery. More recently, laparoscopy has been proposed as a reliable predictor of R0 resection. In this report, we provide a review of the existing literature on the proposed criteria to predict the outcome of cytoreductive surgery and the role of laparoscopy-based scores in the management of advanced ovarian cancer.