Risks of second primary cancers among 584,965 female and male breast cancer survivors in England: a 25-year retrospective cohort study

Background

Second primary cancers (SPCs) after breast cancer (BC) present an increasing public health burden, with little existing research on socio-demographic, tumour, and treatment effects. We addressed this in the largest BC survivor cohort to date, using a novel linkage of National Disease Registration Service datasets.

Methods

The cohort included 581,403 female and 3562 male BC survivors diagnosed between 1995 and 2019. We estimated standardized incidence ratios (SIRs) for combined and site-specific SPCs using incidences for England, overall and by age at BC and socioeconomic status. We estimated incidences and Kaplan-Meier cumulative risks stratified by age at BC, and assessed risk variation by socio-demographic, tumour, and treatment characteristics using Cox regression.

Findings

Both genders were at elevated contralateral breast (SIR: 2.02 (95% CI: 1.99-2.06) females; 55.4 (35.5-82.4) males) and non-breast (1.10 (1.09-1.11) females, 1.10 (1.00-1.20) males) SPC risks. Non-breast SPC risks were higher for females younger at BC diagnosis (SIR: 1.34 (1.31-1.38) <50 y, 1.07 (1.06-1.09) ≥50 y) and more socioeconomically deprived (SIR: 1.00 (0.98-1.02) least deprived quintile, 1.34 (1.30-1.37) most).

Interpretation

Enhanced SPC surveillance may benefit BC survivors, although specific recommendations require more detailed multifactorial risk and cost-benefit analyses. The associations between deprivation and SPC risks could provide clinical management insights.

Funding

CRUK Catalyst Award CanGene-CanVar (C61296/A27223). Cancer Research UK grant: PPRPGM-Nov 20∖100,002. This work was supported by core funding from the NIHR Cambridge Biomedical Research Centre (NIHR203312)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Long-term outcomes of hysterectomy with bilateral salpingo-oophorectomy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to provide an up-to-date systematic review of "the long-term outcomes of bilateral salpingo-oophorectomy at the time of hysterectomy" and perform a meta-analysis for the reported associations.

DATA SOURCES

Our study updated a previous systematic review by searching the literature using PubMed, Web of Science, and Embase for publications between January 2015 and August 2022.

STUDY ELIGIBILITY CRITERIA

Our study included studies of women who had a hysterectomy with bilateral salpingo-oophorectomy vs women who had a hysterectomy with ovarian conservation or no surgery.

METHODS

The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations. Adjusted hazard ratios were extracted and combined to obtain fixed effect estimates.

RESULTS

Compared with hysterectomy or no surgery, hysterectomy with bilateral salpingo-oophorectomy in young women was associated with decreased risk of breast cancer (hazard ratio, 0.78; 95% confidence interval, 0.73-0.84) but with an increased risk of colorectal cancer (hazard ratio, 1.27; 95% confidence interval, 1.10-1.47). In addition, it was associated with an increased risk of total cardiovascular diseases, coronary heart disease, and stroke with hazard ratios of 1.18 (95% confidence interval, 1.11-1.25), 1.17 (95% confidence interval, 1.10-1.25), and 1.20 (95% confidence interval, 1.10-1.31), respectively. Compared with no surgery, hysterectomy with bilateral salpingo-oophorectomy before the age of 50 years was associated with an increased risk of hyperlipidemia (hazard ratio, 1.44; 95% confidence interval, 1.25-1.65), diabetes mellitus (hazard ratio, 1.16; 95% confidence interval, 1.09-1.24), hypertension (hazard ratio, 1.13; 95% confidence interval, 1.06-1.20), dementia (hazard ratio, 1.70; 95% confidence interval, 1.07-2.69), and depression (hazard ratio, 1.39; 95% confidence interval, 1.22-1.60). The evidence on the association with all-cause mortality in young women showed substantial heterogeneity between the studies (I2=85%; P<.01).

CONCLUSION

Hysterectomy with bilateral salpingo-oophorectomy was associated with multiple long-term outcomes. The benefits of the addition of bilateral salpingo-oophorectomy to hysterectomy should be balanced against the risks.

Abstract 988: Long-term health outcomes of bilateral salpingo-oophorectomy in women with personal history of breast cancer

Introduction: Breast cancer is the most common cancer in women. Women with personal history of breast cancer are at increased risk of second primary cancers including ovarian cancer. Bilateral salpingo-oophorectomy (BSO) is a well-established option for ovarian cancer risk reduction. However, the benefit of ovarian cancer risk reduction should be balanced against the health sequelae caused by the premature estrogen loss. We examined the associations between BSO after breast cancer diagnosis and long-term health outcomes, using large-scale linked electronic health records.

Methods: We selected women diagnosed with invasive breast cancer before the age of 75 between 1995 and 2019 using data from the National Cancer Registration Dataset (NCRD), which describes all cancers registered in England. These women were linked to the Hospital Episode Statistics (HES) Admitted Patient Care (APC) dataset to identify the delivery of BSO, while the use of hormonal replacement therapy (HRT) was identified from the community dispensed prescriptions dataset. Long-term outcomes (e.g., ischemic heart disease) were selected from HES, and the NCRD provided data on second cancer diagnosis and all-cause mortality. Multiple imputation was used to impute missing data on stage, grade, hormonal receptor status and ethnicity. Women were followed from the date of breast cancer diagnosis to development of an outcome of interest or censoring or end of data collection. Multivariable Cox regression was used to examine the associations, with BSO modeled as a time-dependent covariate. The analysis was stratified by patient age at BSO (&lt;55 and ≥55 years).

Results: The study included 566,731 women, with median follow up time 8.40 (IQR: 4.4-14.5) years. Of those, 23,881 women had BSO after their breast cancer diagnosis. BSO before the age of 55 was not associated with all-cause mortality (hazard ratio (HR):1.03, 95%CI:0.98-1.08), while BSO after the age of 55 was associated with a small reduction in the risk of all-cause mortality (HR:0.93, 95%CI:0.89-0.99). BSO before and after the age of 55 was associated with increased risk of ischemic heart disease with HRs of 1.23(95%CI:1.07-1.41) and 1.13(95%CI:1.02-1.25), respectively. There was no association between BSO and cerebrovascular events (HR:0.97, 95%CI:0.82-1.15, for BSO under age 55, HR:0.96, 95%CI:0.87-1.07, for BSO after age 55). Ongoing analyses are investigating the associations stratified by the severity of cardiovascular outcome (fatal/non-fatal) and the use of HRT, and the associations with second cancers and neuropsychiatric outcomes.

Conclusion: BSO after 55 does not appear to be associated with detrimental health effects in women diagnosed with breast cancer. Further examination of the associations between BSO and other long-term health outcomes and the influence of HRT in younger women is needed.

Citation Format: Hend Hassan, Tameera Rahman, Andrew Bacon, Craig Knott, Isaac Allen, Catherine Huntley, Lucy Loong, Yvonne Walburga, Katrina Lavelle, Eva Morris, Steven Hardy, Bethany Torr, Diana M Eccles, Clare Turnbull, Marc Tischkowitz, Paul Pharoah, Antonis C. Antoniou. Long-term health outcomes of bilateral salpingo-oophorectomy in women with personal history of breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 988.

Abstract 3057: Second primary cancer risks for female and male breast cancer survivors

Background: Second primary cancer (SPC) incidence is rising among breast cancer (BC) survivors, but these risks remain unclear. We estimated SPC risks for male and female BC survivors using large-scale electronic health record data from a linkage of National Cancer Registration and Analysis Service data and Hospital Episode Statistics surgical records in England.

Material and Methods: We used a retrospective cohort study design comprising 763,578 female and 4,795 male BC survivors first diagnosed with BC between 1995-2018. We calculated overall and site-specific SPC standardized incidence ratios (SIRs) by comparing observed and expected SPC counts for 19 cancer sites. Study participants were followed from one year after the first BC diagnosis until either a SPC diagnosis (excluding ipsilateral breast and non-melanoma skin cancers), death, migration, relevant surgical procedures, or the end of 2019. Expected SPC counts were calculated using year-, age- and sex-specific cancer incidence rates in the general English population. We stratified the SIRs by age group, sex, and cancer site. We estimated Kaplan-Meier absolute risks of site-specific SPCs and assessed the influence of age at first BC diagnosis using Cox proportional hazards models.

Results: There were 68,550 and 720 incident SPCs among female and male BC survivors, respectively. There was a significant increased risk of all SPCs combined for female BC survivors (SIR: 1.19, 95%CI: 1.18-1.20). There were significant increased risks for SPC at all sites combined, all non-breast sites combined, and at 12 further specific sites for females and at 2 specific sites for males. Among females, the increase was greatest for contralateral breast (SIR: 1.82, 95%CI: 1.79-1.85) and uterine cancers (SIR: 1.80, 95%CI: 1.76-1.85). The risk at all sites combined was higher for women first diagnosed with BC before age 50 (SIR: 1.89, 95%CI: 1.85-1.92) compared to women diagnosed with BC at age 50 or over (SIR: 1.11, 95%CI: 1.10-1.12). The largest associations were observed for contralateral breast (SIR: 3.19, 95%CI: 3.11-3.29) and uterine (SIR: 1.77, 95%CI: 1.73-1.82) SPCs in the younger and older age groups, respectively. Increasing age at first female BC diagnosis was associated with decreasing CBC absolute risks, but significantly increased absolute risks of all other SPCs. Male BC survivors were at increased risk of contralateral breast (SIR: 42.39, 95%CI: 28.39-60.89) and prostate (SIR: 1.29, 95%CI: 1.13-1.46) SPCs.

Conclusions: This is the largest study to date to assess SPC risks following BC in either men or women. SPC risks were significantly increased, both in combination and at specific sites. These findings could help guide clinical management, such as screening recommendations, for BC survivors. Further analysis is underway to investigate the effects of chemotherapy, radiotherapy, hormonal therapy, comorbidities, or germline BC susceptibility.

Citation Format: Isaac Allen, Tameera Rahman, Andrew Bacon, Craig Knott, Sophie Jose, Sally Vernon, Hend Hassan, Catherine Huntley, Lucy Loong, Yvonne Walburga, Katrina Lavelle, Eva Morris, Steven Hardy, Beth Torr, Diana Eccles, Clare Turnbull, Marc Tischkowitz, Paul Pharoah, Antonis C. Antoniou. Second primary cancer risks for female and male breast cancer survivors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3057.

Risks of second non-breast primaries following breast cancer in women: a systematic review and meta-analysis

BACKGROUND

Second primary cancer incidence is rising among breast cancer survivors. We examined the risks of non-breast second primaries, in combination and at specific cancer sites, through a systematic review and meta-analysis.

METHODS

We conducted a systematic search of PubMed, Embase, and Web of Science, seeking studies published by March 2022. We included studies that reported standardized incidence ratios (SIRs), with associated standard errors, assessing the combined risk of second non-breast primaries following breast cancer. We performed meta-analyses of combined second primary risks, stratifying by age, follow-up duration, and geographic region. We also assessed second primary risks at several specific sites, stratifying by age. The inverse variance method with DerSimonian-Laird estimators was used in all meta-analyses, assuming a random-effects model. Associated biases and study quality were evaluated using the Newcastle-Ottawa scale.

RESULTS

One prospective and twenty-seven retrospective cohort studies were identified. SIRs for second non-breast primaries combined ranged from 0.84 to 1.84. The summary SIR estimate was 1.24 (95% CI 1.14-1.36, I2: 99%). This varied by age: the estimate was 1.59 (95% CI 1.36-1.85) when breast cancer was diagnosed before age 50, which was significantly higher than in women first diagnosed at 50 or over (SIR: 1.13, 95% CI 1.01-1.36, p for difference: < 0.001). SPC risks were also significantly higher when based on Asian, rather than European, registries (Asia-SIR: 1.47, 95% CI 1.29-1.67. Europe-SIR: 1.16, 95% CI 1.04-1.28). There were significantly increased risks of second thyroid (SIR: 1.89, 95% CI 1.49-2.38), corpus uteri (SIR: 1.84, 95% CI 1.53-2.23), ovary (SIR: 1.53, 95% CI 1.35-1.73), kidney (SIR: 1.43, 95% CI 1.17-1.73), oesophagus (SIR: 1.39, 95% CI 1.26-1.55), skin (melanoma) (SIR: 1.34, 95% CI 1.18-1.52), blood (leukaemia) (SIR: 1.30, 95% CI 1.17-1.45), lung (SIR: 1.25, 95% CI 1.03-1.51), stomach (SIR: 1.23, 95% CI 1.12-1.36) and bladder (SIR: 1.15, 95% CI 1.05-1.26) primaries.

CONCLUSIONS

Breast cancer survivors are at significantly increased risk of second primaries at many sites. Risks are higher for those diagnosed with breast cancer before age 50 and in Asian breast cancer survivors compared to European breast cancer survivors. This study is limited by a lack of data on potentially confounding variables. The conclusions may inform clinical management decisions following breast cancer, although specific clinical recommendations lie outside the scope of this review.

Risk of developing a second primary cancer in male breast cancer survivors: a systematic review and meta-analysis

BACKGROUND

With increasing survival after cancer diagnoses, second primary cancers (SPCs) are becoming more prevalent. We investigated the incidence and site of non-breast SPC risks following male breast cancer (BC).

METHODS

PubMed, Embase and Web of Science were systematically searched for studies reporting standardised incidence ratios (SIRs) for SPCs published by March 2022. Meta-analyses used the generic inverse-variance method, assuming a random-effects model. We evaluated SIRs for overall SPCs, site-specific risks, by age at BC onset, time since BC onset and geographic region. We assessed study quality using routine techniques.

RESULTS

Eight population-based retrospective cohort studies were identified. SIRs ranged from 1.05 to 2.17. The summary SIR estimate was 1.27 (95% CI: 1.03-1.56, I²: 86%), and there were increased colorectal (SIR: 1.29, 95% CI: 1.03-1.61), pancreatic (SIR: 1.64, 95% CI: 1.05-2.55) and thyroid (SIR: 5.58, 95% CI: 1.04-30.05) SPC risks. When an outlying study was excluded, the summary SIR for men diagnosed with BC before age 50 was 1.50 (95% CI: 1.21-1.85), significantly higher than men diagnosed at older ages (SIR: 1.14, 95% CI: 0.98-1.33).

CONCLUSIONS

Male BC survivors are at elevated risks of developing second primary colorectal, pancreatic and thyroid cancers. The estimates may assist their clinical management and guide decisions on genetic testing.

Stress in hospital medicine: a problem for key hospital staff

Many factors which contribute to stress in the workplace apply to both consultants and ward sisters. Both groups find that their roles have become more complex while they have increasingly lost control of their own clinical and professional territory in a managerial culture. The erosion of the key relationship between consultants and ward sisters is of concern and the need for teamworking is insufficiently recognized.

Silver syndrome is not linked to any of the previously established autosomal dominant hereditary spastic paraplegia loci

The hereditary spastic paraplegias are a clinically variable and genetically heterogeneous group of disorders characterized by progressive and lower limb spasticity and weakness. Silver syndrome (SS) is a particularly disabling autosomal dominant form of the disease in which there is associated wasting of the hand muscles. In view of the fact that genes for hereditary spastic paraplegia can produce highly variable phenotypes, the eight known autosomal dominant loci were investigated for linkage to Silver syndrome. Genotyping of these loci in two large multigenerational families was incompatible with linkage to any of these regions, suggesting that an additional locus is responsible for this syndrome.

General Medical Council. A clear case of

A review of how the GMC handles complaints against doctors found shortcomings in consistency and transparency of decision-making. The lack of a common definition of what constitutes serious professional misconduct is a major problem. The review found no evidence of discrimination or racial bias in complaints handling. Protocols should be developed for dealing with complaints alleging poor treatment, which account for some 70 per cent of complaints received by the GMC. The whole process of complaints handling should be subject to continual audit, and written records should be kept of all decisions taken.

Factors affecting career choices in medicine

The choice of medicine as a career is often limited by lack of knowledge concerning the wide range of options facing the applicant. Once enrolled, many students regret the choice. Over half the entrants to medical schools are women and career choice is viewed as limited. Careers advice is often patchy and career choices are usually made late and well into the pre-registration year. The choice of obstetrics and gynaecology as a career is low and the choice of an academic career does not register at all. Given that many students have high academic aspirations, it is difficult to understand why this should be the case.

Pathogenesis of multiple sclerosis--the immune diathesis and the role of viruses

Although the evidence of involvement of viruses in the pathogenesis of MS is largely circumstantial, the pattern of association is constant, with little evidence for direct viral infection of the CNS but with a consistent immune response to several common viruses. In parallel with these studies, epidemiological studies, while indicating genetic predisposition, favor an environmental pathogenetic factor and experimental models indicate that viruses can induce demyelination either by oligodendrolysis or by a variety of immune mechanisms with or without persistence in the CNS. In elucidating the pathogenesis of MS, the challenge is to understand the basis of the immune abnormalities, with intrathecal synthesis of viral antibodies and abnormal immune responses to some viruses, and to relate these to the MRI abnormalities which indicate periodic BBB breakdown. There is strong evidence that the breakdown is associated with inflammation. and that cytokines, particularly TNF, may play a role in demyelination. In conclusion, therefore, several factors are probably key in our understanding of MS. These include: (i) the genetic control of the immune system and its interaction with viral antigen; (ii) related effects on cerebral endothelium including cytokine and adhesion molecule regulation; and (iii) associated glial and axonal responses. Such an approach to the pathogenesis of MS may not identify a specific cause. It may, however, indicate that a pathological cascade can be "triggered" by several common viral infections and that therapy can be used to intervene at several points in the pathological response.

Clinical, biochemical and immunoelectron microscopical evidence of dual hormone production in a mammosomatotroph cell adenoma

This paper reports the occurrence of a rare, yet distinct pituitary adenoma which was surgically removed from a 42-year-old male with both clinical and biochemical evidence of acromegaly and mild hyperprolactinaemia. The monomorphic adenoma consisted of mature cells which were ultrastructurally indistinguishable from those of a prolactinoma. Electron immunocytochemistry, including a series of double-labelling techniques using selected colloidal gold particles as markers, indicated the presence of a pituitary adenoma in which the cells were capable of simultaneously producing growth hormone and prolactin and packaging them within the same secretory granule. This is thought to represent a mammosomatotroph cell adenoma.

Rating of the lesions in senile dementia of the Alzheimer type: concordance between laboratories. A European multicenter study under the auspices of EURAGE

The study reported was intended to compare the impressions and analyses of investigators from 11 different laboratories on 2 slides, each from 6 cases with varying quantities of neuropathological change of the type found in Alzheimer's disease and normal ageing. The material came from 6 selected female patients over 75 years of age all of whom had been examined in detail and assessed by the Blessed Test Score. Two were severely demented, 2 mildly demented and 2 were considered to be normal. Unstained paraffin-embedded slides were sent to the investigators, the choice of the staining techniques being left to each laboratory. A quantitative evaluation of the changes was requested in 2 specified areas of the hippocampus and in the first temporal gyrus. Subjective scores of severity and a final guess about the pre mortem intellectual status (demented or not) were asked. The 11 replies were analyzed. A total of 14 different staining techniques were used. Absolute values of density differed much from one investigator to another, for senile plaques as well as for neurofibrillary tangles. Statistical analysis showed that concordance might be improved by the use of corrective factors which would standardize the scales of measurement. The ranking of the slides in increasing order of severity was in good agreement for 9 out of 11 observers concerning the neurofibrillary tangles and 3 out of 9 observers concerning the senile plaques. The correlation between the intellectual status and the density of lesions was higher for neurofibrillary tangles than for senile plaques. The subjective scores were in better agreement for the severely affected cases than for the mildly affected ones. The lowest correlation with intellectual deficit was obtained with the quantitative scores which took into account only the senile plaques or only the hippocampal lesions. The highest correlation coefficients were obtained with the subjective scores. The observers guessed correctly the intellectual status of the 2 most affected cases and often disagreed for the intermediate and normal cases. Neuropathology is mandatory for the diagnosis of definite Alzheimer's disease. Quantitative assessment is useful in cases with few lesions and light dementia but the neuropathological diagnostic procedure has to be more strictly standardized before quantitative histopathological criteria can be reliably transferred from one laboratory to another, especially when mildly affected cases are involved. Concordance seems presently easier to obtain by ranking the lesions and the cases in increasing order of severity than by using quantitative values of density.(ABSTRACT TRUNCATED AT 400 WORDS)

Transfer of extraintestinal stages of Eimeria vermiformis in the mouse

The oral administration of whole blood and liver or lung homogenates from mice donors inoculated 1-3 days previously with Eimeria vermiformis oocysts produced infection in coccidia-free recipient mice.

The establishment and characterization of a cell line and mouse xenografts from a human malignant melanoma

A permanent cell line has been established from a human intracranial secondary melanoma. During 3 years of continuous growth in vitro the cells have maintained their characteristic phenotypic properties including melanin production. The cultured cells are highly tumorigenic in the athymic mouse and the tumours produced are histologically identical to the human tumour of origin.

The nodular form of polymyositis--a possible manifestation of vasculitis

A case of the nodular form of polymyositis is reported in which muscle necrosis and inflammation, and fibrosis of subcutaneous fat were observed. Although the patient had a short history, the presence of extensive fibrosis with acute lesions indicated that the disease had been present for some time. In addition to the nodular lesions, the patient had clinical, electrophysiological and pathological evidence of a more generalised myopathy. The subsequent development of a rash resembling that of vasculitis and a peripheral nerve lesion, suggested that the localised nodular myositis was associated with systemic vasculitis. Although immunoglobulin and complement deposits were not detected in blood vessel walls in muscle or skin, a positive reaction to intradermal injection of autologous serum suggested the presence of circulating immune complexes.

Ganglioneuroma of the Mediastinum

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