Survival of the Hmong population diagnosed with colon and rectal cancers in the United States

BACKGROUND

The Hmong population constitutes an independent ethnic group historically dispersed throughout Southeast Asia; fallout from the Vietnam War led to their forced migration to the United States as refugees. This study seeks to investigate characteristics of the Hmong population diagnosed with in colorectal cancer (CRC) as well as survival within this population.

METHODS

Cases of colon and rectal adenocarcinoma diagnosed between 2004 and 2017 were identified from the National Cancer Database (NCDB). Summary statistics of demographic, clinical, socioeconomic, and treatment variables were generated with emphasis on age and stage at the time of diagnosis. Cox-proportional hazard models were constructed for survival analysis.

RESULTS

Of 881,243 total CRC cases within the NCDB, 120 were classified as Hmong. The average age of Hmong individuals at diagnosis was 58.9 years compared 68.7 years for Non-Hispanic White (NHW) individuals (p < 0.01). The distribution of analytic stage differed between the Hmong population and the reference NHW population, with 61.8% of Hmong individuals compared to 45.8% of NHW individuals with known stage being diagnosed at stage III or IV CRC compared to 0, I, or II (p = 0.001). However, there was no difference in OS when adjusting for potential confounders (HR 1.00 [0.77-1.33]; p = 0.998).

CONCLUSIONS

Hmong individuals are nearly a decade younger at the time of diagnosis of CRC compared to the NHW individuals. However, these data do not suggest an association between Hmong ethnicity and overall survival, when compared to the NHW population.

Analysis of Breast Cancer Mortality in the US-1975 to 2019

Importance

Breast cancer mortality in the US declined between 1975 and 2019. The association of changes in metastatic breast cancer treatment with improved breast cancer mortality is unclear.

Objective

To simulate the relative associations of breast cancer screening, treatment of stage I to III breast cancer, and treatment of metastatic breast cancer with improved breast cancer mortality.

Design, Setting, and Participants

Using aggregated observational and clinical trial data on the dissemination and effects of screening and treatment, 4 Cancer Intervention and Surveillance Modeling Network (CISNET) models simulated US breast cancer mortality rates. Death due to breast cancer, overall and by estrogen receptor and ERBB2 (formerly HER2) status, among women aged 30 to 79 years in the US from 1975 to 2019 was simulated.

Exposures

Screening mammography, treatment of stage I to III breast cancer, and treatment of metastatic breast cancer.

Main Outcomes and Measures

Model-estimated age-adjusted breast cancer mortality rate associated with screening, stage I to III treatment, and metastatic treatment relative to the absence of these exposures was assessed, as was model-estimated median survival after breast cancer metastatic recurrence.

Results

The breast cancer mortality rate in the US (age adjusted) was 48/100 000 women in 1975 and 27/100 000 women in 2019. In 2019, the combination of screening, stage I to III treatment, and metastatic treatment was associated with a 58% reduction (model range, 55%-61%) in breast cancer mortality. Of this reduction, 29% (model range, 19%-33%) was associated with treatment of metastatic breast cancer, 47% (model range, 35%-60%) with treatment of stage I to III breast cancer, and 25% (model range, 21%-33%) with mammography screening. Based on simulations, the greatest change in survival after metastatic recurrence occurred between 2000 and 2019, from 1.9 years (model range, 1.0-2.7 years) to 3.2 years (model range, 2.0-4.9 years). Median survival for estrogen receptor (ER)-positive/ERBB2-positive breast cancer improved by 2.5 years (model range, 2.0-3.4 years), whereas median survival for ER-/ERBB2- breast cancer improved by 0.5 years (model range, 0.3-0.8 years).

Conclusions and Relevance

According to 4 simulation models, breast cancer screening and treatment in 2019 were associated with a 58% reduction in US breast cancer mortality compared with interventions in 1975. Simulations suggested that treatment for stage I to III breast cancer was associated with approximately 47% of the mortality reduction, whereas treatment for metastatic breast cancer was associated with 29% of the reduction and screening with 25% of the reduction.

Change in alcohol consumption during the Covid-19 pandemic and associations with mental health and financial hardship: results from a survey of Wisconsin patients with cancer

PURPOSE

Alcohol consumption increases health risks for patients with cancer. The Covid-19 pandemic may have affected drinking habits for these individuals. We surveyed patients with cancer to examine whether changes in drinking habits were related to mental health or financial effects of the pandemic.

METHODS

From October 2020 to April 2021, adult patients (age 18-80 years at diagnosis) treated for cancer in southcentral Wisconsin were invited to complete a survey. Age-adjusted percentages for history of anxiety or depression, emotional distress, and financial impacts of Covid-19 overall and by change in alcohol consumption (non-drinker, stable, decreased, or increased) were obtained via logistic regression.

RESULTS

In total, 1,875 patients were included in the analysis (median age 64, range 19-87 years), including 9% who increased and 23% who decreased drinking. Compared to stable drinkers (32% of sample), a higher proportion of participants who increased drinking alcohol also reported anxiety or depression (45% vs. 26%), moderate to severe emotional distress (61% vs. 37%) and viewing Covid-19 as a threat to their community (67% vs. 55%). Decreased (vs. stable) drinking was associated with higher prevalence of depression or anxiety diagnosis, emotional distress, and negative financial impacts of the pandemic. Compared to non-drinkers (36% of sample), participants who increased drinking were more likely to report emotional distress (61% vs. 48%).

CONCLUSIONS

Patients with cancer from Wisconsin who changed their alcohol consumption during the Covid-19 pandemic were more likely to report poor mental health including anxiety, depression, and emotional distress than persons whose alcohol consumption was stable.

IMPLICATIONS FOR CANCER SURVIVORS

Clinicians working with cancer survivors should be aware of the link between poor mental health and increased alcohol consumption and be prepared to offer guidance or referrals to counseling, as needed.

Population simulation modeling of disparities in US breast cancer mortality

BACKGROUND

Populations of African American or Black women have persistently higher breast cancer mortality than the overall US population, despite having slightly lower age-adjusted incidence.

METHODS

Three Cancer Intervention and Surveillance Modeling Network simulation teams modeled cancer mortality disparities between Black female populations and the overall US population. Model inputs used racial group-specific data from clinical trials, national registries, nationally representative surveys, and observational studies. Analyses began with cancer mortality in the overall population and sequentially replaced parameters for Black populations to quantify the percentage of modeled breast cancer morality disparities attributable to differences in demographics, incidence, access to screening and treatment, and variation in tumor biology and response to therapy.

RESULTS

Results were similar across the 3 models. In 2019, racial differences in incidence and competing mortality accounted for a net ‒1% of mortality disparities, while tumor subtype and stage distributions accounted for a mean of 20% (range across models = 13%-24%), and screening accounted for a mean of 3% (range = 3%-4%) of the modeled mortality disparities. Treatment parameters accounted for the majority of modeled mortality disparities: mean = 17% (range = 16%-19%) for treatment initiation and mean = 61% (range = 57%-63%) for real-world effectiveness.

CONCLUSION

Our model results suggest that changes in policies that target improvements in treatment access could increase breast cancer equity. The findings also highlight that efforts must extend beyond policies targeting equity in treatment initiation to include high-quality treatment completion. This research will facilitate future modeling to test the effects of different specific policy changes on mortality disparities.

Time-specific impact of mono-benzyl phthalate (MBzP) and perfluorooctanoic acid (PFOA) on breast density of a Chilean adolescent Cohort

INTRODUCTION

High mammographic density is among the strongest and most established predictors for breast cancer risk. Puberty, the period during which breasts undergo exponential mammary growth, is considered one of the critical stages of breast development for environmental exposures. Benzylbutyl phthalate (BBP) and perfluorooctanoic acid (PFOA) are pervasive endocrine disrupting chemicals that may increase hormone-sensitive cancers. Evaluating the potential impact of BBP and PFOA exposure on pubertal breast density is important to our understanding of early-life environmental influences on breast cancer etiology.

OBJECTIVE

To prospectively assess the effect of biomarker concentrations of monobenzyl phthalate (MBzP) and PFOA at specific pubertal window of susceptibility (WOS) on adolescent breast density.

METHOD

This study included 376 Chilean girls from the Growth and Obesity Cohort Study with data collection at four timepoints: Tanner breast stages 1 (B1) and 4 (B4), 1- year post- menarche (1YPM) and 2-years post-menarche (2YPM). Dual-energy X-ray absorptiometry was used to assess the absolute fibroglandular volume (FGV) and percent breast density (%FGV) at 2YPM. We used concentrations of PFOA in serum and MBzP in urine as an index of exposure to PFOA and BBP, respectively. Parametric G-formula was used to estimate the time-specific effects of MBzP and PFOA on breast density. The models included body fat percentage as a time-varying confounder and age, birthweight, age at menarche, and maternal education as fixed covariates.

RESULTS

A doubling of serum PFOA concentration at B4 resulted in a non-significant increase in absolute FGV (β:11.25, 95% confidence interval (CI): -0.28, 23.49)), while a doubling of PFOA concentration at 1YPM resulted in a decrease in % FGV (β:-4.61, 95% CI: -7.45, -1.78). We observed no associations between urine MBzP and breast density measures.

CONCLUSION

In this cohort of Latina girls, PFOA serum concentrations corresponded to a decrease in % FGV. No effect was observed between MBzP and breast density measures across pubertal WOS.

Survival of the Hmong population diagnosed with colorectal cancer in the United States

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Background: The Hmong people constitute an Asian-American subgroup, accounting for 0.1% of the United States (US) population. Originating from Laos and Vietnam, Hmong individuals fought as secret soldiers for the US during the Vietnam War and later immigrated to the US, with the largest settlements in Minnesota, Wisconsin, and California. The Hmong population has faced various health disparities in the domains of mental health, chronic disease, and cancer. This study seeks to investigate trends in colorectal cancer (CRC) survival in the US Hmong population. Methods: Cases of colon and rectal adenocarcinoma diagnosed between 2004-2017 were identified within the National Cancer Database. Summary statistics of demographic, clinical, socioeconomic, and treatment variables were calculated. Multiple Cox proportional hazard models were constructed using sets of demographic, clinical, socioeconomic, and treatment variables to identify factors associated with overall survival (OS) within the Hmong population diagnosed with CRC. Results: One hundred and twenty (0.01%) Hmong individuals were identified within a total of 881,243 CRC cases. Their average age at diagnosis was 58.9 years, compared 68.7 years for Non-Hispanic White (NHW) individuals (p < 0.01). Over half of Hmong individuals (52.5%) were diagnosed with Stage III or VI disease (NHW, 42.5%, p < 0.03), and they more frequently resided in the lowest median income quartile (p < 0.01), the lowest high school degree achievement quartile (p < 0.01), and had higher rates of Medicaid coverage (p < 0.01) compared to NHWs. When adjusting only for age, sex, stage, and Charlson-Deyo comorbidity score, Hmong individuals had a greater hazard of death compared to their NHW counterparts (HR 1.43, p < 0.01). However, in a multivariable model accounting for all variables suspected to be associated with CRC outcomes, OS was similar between these groups (HR 1.01, p < 0.93). Conclusions: Hmong individuals diagnosed with CRC appear to have similar overall survival to Non-Hispanic Whites despite belonging to lower socioeconomic groups, being diagnosed at a younger age and with a higher proportion of Stage III/VI disease. This may point to a robust response to treatment and resilience within the Hmong community. Future efforts will focus on disseminating this information and developing community-based approaches for health screening and prevention.

Contributions of screening, early-stage treatment, and metastatic treatment to breast cancer mortality reduction by molecular subtype in U.S. women, 2000-2017

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Background: Treatment for metastatic breast cancer has advanced since 2000, but we do not know if those advances have reduced mortality in the general population. Methods: Four Cancer Intervention and Surveillance Network (CISNET) models simulated US breast cancer mortality from 2000 to 2017 using national data on mammography use and performance, efficacy and dissemination of estrogen receptor (ER) and HER2-specific treatments of early-stage (stages I-III) and metastatic (stage IV or distant recurrence) disease, and competing mortality. Models compared overall and ER/HER2-specific breast cancer mortality rates from 2000 to 2017 relative to estimated rates with no screening or treatment, and attributed mortality reductions to screening, early-stage or metastatic treatment. Results of an exemplar model are shown. Results: The mortality reduction attributable to early-stage treatment increased from 35.8% in 2000 to 48.2% in 2017, while the proportion attributable to metastatic treatment decreased slightly from 23.9% to 20.6%. The increasing contribution of early-stage treatment reflects the transition of effective metastatic treatments to early-stage disease: accordingly, ten-year distant recurrence-free survival improved (82.5% in 2000, 87.3% in 2017; for ER+HER2+, 78.2% to 90.9%). Survival time after metastatic diagnosis also increased, doubling from 1.48 years in 2000 to 2.80 years in 2017, with the best survival for women with ER+HER2+ cancers (4.08 years) and worst for ER-HER2- (1.22 years). Conclusions: Advances in metastatic breast cancer treatment are reflected in lower population mortality, both through transition to early-stage treatment and gains for women with metastatic disease. These results may inform patient/physician discussions about breast cancer prognosis and expected benefits of treatment. [Table: see text]

Mortality risk and physical activity across the lifespan in endometrial cancer survivors

PURPOSE

Physical activity (pre- and post-diagnosis) has been studied in prevention and survivorship contexts for endometrial cancer. However, the association of physical activity (PA) across the lifespan on mortality risk among endometrial cancer survivors is understudied. The study's objective was to identify the association of lifetime PA on mortality risk in endometrial cancer survivors.

METHODS

Seven hundred forty-five endometrial cancer survivors drawn from a population-based cancer registry (diagnosed between 1991 and 1994) reported the frequency (sessions/week) of moderate- and vigorous intensity physical activity (MVPA) at age 12, age 20, and 5 years pre-interview (post-diagnosis). Cox proportional hazards were used to estimate hazard ratios (HR) and 95% confidence intervals for the association between PA, all-cause, and cardiovascular disease mortality as assessed in 2016. MVPA was modeled using natural cubic splines.

RESULTS

Diagnosis age, body mass index, and smoking (pack-years) were each positively associated with increased all-cause mortality risk. Those who did one session of MVPA 5 years pre-interview had a lower mortality risk (HR 0.61; 95% CI 0.41-0.92) compared to those with no MVPA. Those reporting one session of MVPA was similarly observed at age 12 (HR 0.95; 95% CI 0.86-1.06) and at age 20 (HR 0.87; 95% CI 0.65-1.16).

CONCLUSION

Those who participated in PA, compared to those who did not, in the 5 years before diagnosis had a lower mortality risk. While PA was not independently protective against mortality risk at ages 12 or 20, PA is still important for endometrial cancer survivors for other non-mortality outcomes.

Breast Cancer Screening Among Childhood Cancer Survivors Treated Without Chest Radiation: Clinical Benefits and Cost-Effectiveness

BACKGROUND

Early initiation of breast cancer screening is recommended for high-risk women, including survivors of childhood cancer treated with chest radiation. Recent studies suggest that female survivors of childhood leukemia or sarcoma treated without chest radiation are also at elevated early onset breast cancer risk. However, the potential clinical benefits and cost-effectiveness of early breast cancer screening among these women are uncertain.

METHODS

Using data from the Childhood Cancer Survivor Study, we adapted two Cancer Intervention and Surveillance Modeling Network (CISNET) breast cancer simulation models to reflect the elevated risks of breast cancer and competing mortality among leukemia and sarcoma survivors. Costs and utility weights were based on published studies and databases. Outcomes included breast cancer deaths averted, false-positive-screening results, benign biopsies, and incremental cost-effectiveness ratios (ICERs).

RESULTS

In the absence of screening, the lifetime risk of dying from breast cancer among survivors was 6.8% to 7.0% across models. Early initiation of annual mammography with MRI screening between ages 25 and 40 would avert 52.6% to 64.3% of breast cancer deaths. When costs and quality of life impacts were considered, screening starting at age 40 was the only strategy with an ICER below the $100,000 per quality-adjusted life-year (QALY) gained cost-effectiveness threshold ($27,680 to $44,380 per QALY gained across models).

CONCLUSIONS

Among survivors of childhood leukemia or sarcoma, early initiation of breast cancer screening at age 40 may reduce breast cancer deaths by half and is cost-effective. These findings could help inform screening guidelines for survivors treated without chest radiation.

Does margin width impact breast cancer recurrence rates in women with breast conserving surgery for ductal carcinoma in situ?

PURPOSE

Controversy remains regarding the optimal margin width for patients with ductal carcinoma in situ (DCIS) who undergo breast conserving surgery (BCS).

METHODS

Women with a primary DCIS diagnosis were enrolled in a statewide population-based cohort from 1997 to 2006. Patients were surveyed every two years with follow-up data available through 2016. Surgical pathology reports were collected for 559 participants following breast conserving surgery. Multivariable Cox proportional hazard models evaluated relationships between locoregional recurrence (LRR) and margin width in the presence or absence of adjuvant radiation therapy while controlling for age, menopausal status and duration of endocrine therapy use.

RESULTS

The majority of women in this study were over 50yo (74%), 34% had high grade disease, and 77% underwent radiation. The overall LRR rate was 12%. A LRR occurred in 46 women who had radiation (11%) and 23 women who did not undergo radiation (19%). Univariate analysis identified smaller margin width, younger age, premenopausal status, no radiotherapy, and shorter endocrine therapy use associated with LRR. Multivariable models demonstrated that close margins (< 2 mm) were associated with an increased risk of recurrence when compared to margins ≥ 2 mm in width whether women received radiation (HR 1.98 CI 0.87-4.54) or not (HR 1.32 CI 0.27-6.49), but confidence intervals were wide.

CONCLUSIONS

In this study, patients with DCIS and close margins were less likely to experience recurrence after routine re-excision to margins greater than 2 mm.

Treatment and survival outcomes for Medicaid patients with pancreatic, colon-rectosigmoid, and liver cancers at a national comprehensive cancer center

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Background: Treatment and survival disparities faced by Medicaid patients are documented for pancreatic, colon-rectosigmoid, and liver cancers at a national level. Studies show these disparities persist at academic medical centers. We assessed Medicaid treatment and survival outcomes among University of Wisconsin-Health (UWH) pancreatic, colon-rectosigmoid, and liver cancer patients to determine whether national trends persisted at this academic medical center. Methods: We included UWH registry data for 1567 pancreatic, 2313 colon-rectosigmoid, and 1027 liver cancer patients ages 18+ from 2004-2016. We performed multivariable logistic regression to estimate odds ratios (ORs) to assess insurance disparities in intended resection and Cox Proportional regression to estimate hazard ratios (HRs) to assess all-cause mortality disparities for each cancer, adjusting for age, sex, race/ethnicity, BMI, comorbidity, stage, rurality, and insurance. Results: Median overall survival was 6.5 months (range 0.1-147.5) for pancreatic, 12.8 months (0.1-167.5) for colon-rectosigmoid, and 12.5 months (0.1-168.7) for liver cancer patients. 3% of pancreatic, 5% of colon-rectosigmoid, and 9% of liver cancer patients had Medicaid Insurance. Medicaid patients were less likely to be older and non-Hispanic White than private insurance (private) patients for each cancer. Medicaid patients were diagnosed with more distant disease for colon-rectosigmoid and liver cancers and less distant disease for pancreatic cancer. Medicaid patients were less likely to receive surgery vs private patients for pancreatic (OR 0.41, 95% CI 0.16-1.08) and liver (OR 0.62, 0.26-1.49) cancers, though confidence intervals were wide. Insurance was not associated with surgery in colon-rectosigmoid cancer patients (OR 0.97, 0.48-1.97). Medicaid patients had a higher risk of death vs private patients for colon rectosigmoid cancer (HR 1.50, 1.12-2.01). Risk of death was modestly elevated for Medicaid vs private patients for pancreatic (HR 1.35, 0.97-1.87) but not liver (HR 1.07, 0.77-1.48) cancer. Conclusions: Medicaid pancreatic and liver cancer patients may be less likely to receive surgery than private patients in our one center study. Results suggested that Medicaid pancreatic and colon-rectosigmoid cancer patients may have a slightly elevated risk of death vs private patients, though this needs confirmation in larger samples. Future studies should explore at which local, state, and regional levels Medicaid pancreatic, colon-rectosigmoid, and liver cancer patients experience treatment and survival disparities vs private insurance patients. These studies, combined with Medicaid expansion studies, can guide healthcare leaders and policy makers to design context-appropriate interventions to reduce insurance-related disparities in cancer treatment and outcomes.

Breast cancer screening for carriers of ATM, CHEK2, and PALB2 pathogenic variants: A comparative modeling analysis

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Background: Inherited pathogenic variants in ATM, CHEK2, and PALB2 confer moderate to high risks of breast cancer. The optimal approach to screening in these women has not been established. Methods: We used two simulation models from the Cancer Intervention and Surveillance Modeling Network (CISNET) and data from the Cancer Risk Estimates Related to Susceptibility consortium (CARRIERS) to project lifetime breast cancer incidence and mortality in ATM, CHEK2, and PALB2 carriers. We simulated screening with annual mammography from ages 40-74 alone and with annual magnetic resonance imaging (MRI) starting at ages 40, 35, 30, and 25. Joint and separate mammography and MRI screening performance was based on published literature. Lifetime outcomes per 1,000 women were reported as means and ranges across both models. Results: Estimated risk of breast cancer by age 80 was 22% (21-23%) for ATM, 28% (26-30%) for CHEK2, and 40% (38-42%) for PALB2. Screening with MRI and mammography reduced breast cancer mortality by 52-60% across variants (Table). Compared to no screening, starting MRI at age 30 increased life years (LY)/1000 women by 501 (478-523) in ATM, 620 (587-652) in CHEK2, and 1,025 (998-1,051) in PALB2. Starting MRI at age 25 versus 30 gained 9-12 LY/1000 women with 517-518 additional false positive screens and 197-198 benign biopsies. Conclusions: For women with ATM, CHEK2, and PALB2 pathogenic variants, breast cancer screening with MRI and mammography halves breast cancer mortality. These mortality benefits are similar to those for MRI screening for BRCA1/2 mutation carriers and should inform practice guidelines.[Table: see text]

Trade-Offs Between Harms and Benefits of Different Breast Cancer Screening Intervals Among Low-Risk Women

Background

A paucity of research addresses breast cancer screening strategies for women at lower-than-average breast cancer risk. The aim of this study was to examine screening harms and benefits among women aged 50-74 years at lower-than-average breast cancer risk by breast density.

Methods

Three well-established, validated Cancer Intervention and Surveillance Network models were used to estimate the lifetime benefits and harms of different screening scenarios, varying by screening interval (biennial, triennial). Breast cancer deaths averted, life-years and quality-adjusted life-years gained, false-positives, benign biopsies, and overdiagnosis were assessed by relative risk (RR) level (0.6, 0.7, 0.85, 1 [average risk]) and breast density category, for US women born in 1970.

Results

Screening benefits decreased proportionally with decreasing risk and with lower breast density. False-positives, unnecessary biopsies, and the percentage overdiagnosis also varied substantially by breast density category; false-positives and unnecessary biopsies were highest in the heterogeneously dense category. For women with fatty or scattered fibroglandular breast density and a relative risk of no more than 0.85, the additional deaths averted and life-years gained were small with biennial vs triennial screening. For these groups, undergoing 4 additional screens (screening biennially [13 screens] vs triennially [9 screens]) averted no more than 1 additional breast cancer death and gained no more than 16 life-years and no more than 10 quality-adjusted life-years per 1000 women but resulted in up to 232 more false-positives per 1000 women.

Conclusion

Triennial screening from age 50 to 74 years may be a reasonable screening strategy for women with lower-than-average breast cancer risk and fatty or scattered fibroglandular breast density.

Long-Term Outcomes and Cost-Effectiveness of Breast Cancer Screening With Digital Breast Tomosynthesis in the United States

BACKGROUND

Digital breast tomosynthesis (DBT) is increasingly being used for routine breast cancer screening. We projected the long-term impact and cost-effectiveness of DBT compared to conventional digital mammography (DM) for breast cancer screening in the United States.

METHODS

Three Cancer Intervention and Surveillance Modeling Network breast cancer models simulated US women ages 40 years and older undergoing breast cancer screening with either DBT or DM starting in 2011 and continuing for the lifetime of the cohort. Screening performance estimates were based on observational data; in an alternative scenario, we assumed 4% higher sensitivity for DBT. Analyses used federal payer perspective; costs and utilities were discounted at 3% annually. Outcomes included breast cancer deaths, quality-adjusted life-years (QALYs), false-positive examinations, costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared to DM, DBT screening resulted in a slight reduction in breast cancer deaths (range across models 0-0.21 per 1000 women), small increase in QALYs (1.97-3.27 per 1000 women), and a 24-28% reduction in false-positive exams (237-268 per 1000 women) relative to DM. ICERs ranged from $195 026 to $270 135 per QALY for DBT relative to DM. When assuming 4% higher DBT sensitivity, ICERs decreased to $130 533-$156 624 per QALY. ICERs were sensitive to DBT costs, decreasing to $78 731 to $168 883 and $52 918 to $118 048 when the additional cost of DBT was reduced to $36 and $26 (from baseline of $56), respectively.

CONCLUSION

DBT reduces false-positive exams while achieving similar or slightly improved health benefits. At current reimbursement rates, the additional costs of DBT screening are likely high relative to the benefits gained; however, DBT could be cost-effective at lower screening costs.

A population-based study of causes of death after endometrial cancer according to major risk factors

OBJECTIVE

To identify the most common causes of death and potentially modifiable risk factors in endometrial cancer patients.

METHODS

745 women diagnosed with incident endometrial cancer were enrolled in a population-based study from 1991 to 1994. Participants completed structured interviews about 1 year after diagnosis. Study files were linked with the National Death Index to identify dates and causes of death through 2016. Proportional hazards regression was used to estimate hazard rate ratios for cause of death adjusting for age and stage of disease. Hazard ratios were also examined according to comorbidities.

RESULTS

Of the 745 women, 450 were deceased after a median of 19.9 years. The two most common causes of death were cardiovascular disease (N = 145, 32%) and any cancer (N = 135, 30%), with only 10% of women dying from endometrial cancer (N = 46). Obesity, diabetes and smoking increased risk of all-cause mortality (HRR 1.77, 95%CI 1.36-2.31; HRR 1.74, 95%CI 1.34-2.27; HRR 1.59, 95%CI 1.16-2.17). Diabetes also increased risk of cardiovascular disease-specific mortality (HRR 1.98, 95%CI 1.38-3.08), but not endometrial cancer mortality (HRR 0.55, 95%CI 0.21-1.48). Neither obesity nor smoking was associated with increased risk of cardiovascular disease-specific mortality (HRR 1.46, 95%CI 0.92-2.32; HRR 1.21, 95%CI 0.67-2.18) nor endometrial-cancer specific mortality (HRR 1.81, 95%CI 0.83-3.93; HRR 0.61, 95%CI 0.17-2.15).

CONCLUSIONS

Endometrial cancer patients were 3 times more likely to die of cardiovascular disease than endometrial cancer. Obesity, smoking and diabetes increase the risk of death in these patients and are potentially modifiable. Clinical trials should be developed that incorporate counseling regarding these risk factors into survivorship care to determine impact on mortality.

Equitable application of pancreatic cancer treatment guidelines to mitigate racial and insurance disparities at a comprehensive cancer center

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Background: Race and ethnicity-based treatment and survival disparities are documented for pancreatic cancer. Studies cite patient genetic, biological, and social factors and differences across treatment centers and geographical areas that may contribute to disparities. We investigated treatment and survival disparities for a cohort of 1,569 pancreatic cancer (PC) patients at the local level within a National Cancer Institute-designated comprehensive cancer center. Methods: Data from 1,569 PC patients aged over 18 diagnosed with adenocarcinoma, NOS or infiltrating duct carcinoma, NOS from 2004 to 2016 who received some or all of their care at the University of Wisconsin Carbone Cancer Center were included in the study. Sequential models of adjusted Cox proportional hazard regression were performed to describe the association between race/ethnicity and overall survival. Model I included age, sex and race/ethnicity; model II added BMI, Charlson Comorbidity Index and stage; model III added rurality, treatment course and payer. Treatment course, defined as the receipt of chemoradiation, surgery with/without chemoradiation, or no treatment, rurality, and insurance status were factors of interest. Results: 38.6% of patients were diagnosed with metastatic disease. Overall survival was 11.6 months. Non-Hispanic black (NHB) patients experienced an 88% increased risk of death (95% CI: 23%-188%) and patients categorized as other race/ethnicity experienced a 32% (10%-60%) increased risk of death compared to NH white (NHW) patients in model II. After adding treatment course and insurance status, the hazard ratio for NHB patients decreased to 1.41 (0.92-2.17) and other race/ethnicity patients decreased to 1.27 (1.05-1.53) compared to NHW Patients. Medicaid patients had an adjusted hazard ratio of 1.41 (1.01-1.95) and unknown/uninsured patients had an adjusted hazard ratio of 1.62 (1.71-4.02) compared to managed care patients. Incarcerated patients had an adjusted hazard ratio of 1.28 (0.98-1.67) compared to managed care patients. Conclusions: To reduce disparities across race/ethnicity and insurance status, organizations should invest in financial support programs for patients in need and monitor treatment courses for people of color, underinsured or uninsured patients to verify access to treatment, equitable treatment, and adherence to treatment guidelines. Future studies should investigate the contribution of clinician and healthcare system bias to race and ethnicity-based cancer disparities.

Clinical Benefits, Harms, and Cost-Effectiveness of Breast Cancer Screening for Survivors of Childhood Cancer Treated With Chest Radiation : A Comparative Modeling Study

BACKGROUND

Surveillance with annual mammography and breast magnetic resonance imaging (MRI) is recommended for female survivors of childhood cancer treated with chest radiation, yet benefits, harms, and costs are uncertain.

OBJECTIVE

To compare the benefits, harms, and cost-effectiveness of breast cancer screening strategies in childhood cancer survivors.

DESIGN

Collaborative simulation modeling using 2 Cancer Intervention and Surveillance Modeling Network breast cancer models.

DATA SOURCES

Childhood Cancer Survivor Study and published data.

TARGET POPULATION

Women aged 20 years with a history of chest radiotherapy.

TIME HORIZON

Lifetime.

PERSPECTIVE

Payer.

INTERVENTION

Annual MRI with or without mammography, starting at age 25, 30, or 35 years.

OUTCOME MEASURES

Breast cancer deaths averted, false-positive screening results, benign biopsy results, and incremental cost-effectiveness ratios (ICERs).

RESULTS OF BASE-CASE ANALYSIS

Lifetime breast cancer mortality risk without screening was 10% to 11% across models. Compared with no screening, starting at age 25 years, annual mammography with MRI averted the most deaths (56% to 71%) and annual MRI (without mammography) averted 56% to 62%. Both strategies had the most screening tests, false-positive screening results, and benign biopsy results. For an ICER threshold of less than $100 000 per quality-adjusted life-year gained, screening beginning at age 30 years was preferred.

RESULTS OF SENSITIVITY ANALYSIS

Assuming lower screening performance, the benefit of adding mammography to MRI increased in both models, although the conclusions about preferred starting age remained unchanged.

LIMITATION

Elevated breast cancer risk was based on survivors diagnosed with childhood cancer between 1970 and 1986.

CONCLUSION

Early initiation (at ages 25 to 30 years) of annual breast cancer screening with MRI, with or without mammography, might reduce breast cancer mortality by half or more in survivors of childhood cancer.

PRIMARY FUNDING SOURCE

American Cancer Society and National Institutes of Health.

Abstract D002: Associations between multilevel health factors and cancer mortality according to rural residence

Surveillance reports consistently observe that cancer mortality rates are higher in rural than urban areas, yet data on the multi-level factors that impact rural disparities have not been fully leveraged to identify the areas of greatest need for research and policy changes. To address gaps in cancer data for rural communities, we adapted the County Health Rankings model of the multiple determinants of health to cancer. Using publicly available data, we compared health factors and cancer mortality for rural versus urban counties in Wisconsin. Counties were defined as rural (N=19) or non-rural (“urban”, N=53) based on Rural Urban Continuum Codes 7-9 and 1-6, respectively. Age-adjusted county-specific cancer mortality rates for all cancer sites combined were obtained from the state cancer registry. Health factor data were obtained from multiple sources in 4 categories: health behaviors (smoking, drinking alcohol, obesity, physical activity); clinical care (HPV vaccination; breast, cervical, and colorectal cancer screening; density of primary care physicians); socioeconomic factors (Area Deprivation Index based on 17 census items); and physical environment (access to grocery stores and alcohol outlets, air quality, pesticide use). Items were ranked for the 72 counties with lower-risk values having better ranks, e.g., higher values for screening and lower values for obesity ranked closer to 1. A composite health factor ranking was defined using County Health Rankings weights, equal to 0.3*(behavioral factors) + 0.2*(clinical factors) + 0.4*(socioeconomic factors) + 0.1*(physical environment). Cancer death rates were higher in rural than in urban counties (181 vs 164 per 100,000). The composite health ranking was positively associated with cancer mortality rates (Pearson correlation coefficient 0.38, 95% CI 0.17-0.57), with worse rankings for rural (average 44, interquartile range, IQR 39-51) than for urban counties (average 34, IQR 25-42). The difference in health factor category rankings between rural and urban counties was greatest for socioeconomic factors (rural average rank 50 vs urban average rank 32) followed by clinical care (rural average rank 43 vs urban average rank 34) and behavioral factors (rural average rank 40 vs urban average rank 35). Physical environment factor rankings were slightly better for rural (average 33) than urban (average 37) counties. In conclusion, we confirmed that cancer mortality in Wisconsin is higher in rural as compared with urban areas. Future analyses will (a) refine the set of health factors used to construct the composite health factor ranking (e.g., account more fully for distance to care) and (b) optimize the weights applied to the categories to calculate the composite ranking. These initial findings suggest that, to increase the impact of future research and policy efforts, clinical and behavioral interventions targeting cancer health disparities in rural counties should include strategies to address socioeconomic factors.

Citation Format: Amy Trentham-Dietz, Noelle K LoConte, Betsy Rolland, Lisa Cadmus-Bertram, Tracy M Downs, John M Eason, Cody M Fredrick, John M Hampton, Xiao Zhang, Ronald E Gangnon. Associations between multilevel health factors and cancer mortality according to rural residence [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D002.

Evaluation of Long-Term Satisfaction with Breast Surgery in Patients Treated for Ductal Carcinoma In Situ: A Population-Based Longitudinal Cohort Study

BACKGROUND

Breast-conserving surgery (BCS) and mastectomy have equivalent survival for ductal carcinoma in situ (DCIS), allowing patients to participate in selecting a personalized surgical option; however, this decision-making role can increase patient anxiety. Data evaluating patient satisfaction with their decision to undergo BCS versus mastectomy for the treatment of DCIS are limited.

METHODS

Women with DCIS were enrolled in a population-based, state-wide cohort from 1997 to 2006. Participants were surveyed about their satisfaction with their surgical and reconstruction decisions. Quality-of-life (QoL) evaluations were performed with biennial follow-up surveys though 2016. Multivariable logistic regression modeling examined the relationship between type of surgery and reconstruction with patient satisfaction.

RESULTS

Overall, 1537 women were surveyed, on average, 2.9 years following DCIS diagnosis. Over 90% reported satisfaction with their treatment decision regardless of surgery type. Women who underwent mastectomy with reconstruction were more likely to report lower levels of satisfaction than women who underwent BCS (odds ratio [OR] 2.98, 95% confidence interval [CI] 1.18-7.51, p < 0.01). However, over 80% of women who underwent mastectomies reported satisfaction with their reconstruction decision. Women without reconstruction had the highest levels of satisfaction, while women with implants were more likely to be dissatisfied (implant + autologous: OR 2.77, 95% CI 1.24-6.24; implant alone: OR 4.02, 95% CI 1.947-8.34, p ≤ 0.01). QoL scores were not associated with differences in surgical or reconstruction satisfaction at 5, 10, and 15 years following DCIS diagnosis.

CONCLUSIONS

Women undergoing surgery for DCIS express satisfaction with their treatment decisions. Following mastectomy, most women are satisfied with their reconstruction decision, including women who did not undergo reconstruction.

Contribution of Breast Cancer to Overall Mortality for US Women

OBJECTIVE

Breast cancer simulation models must take changing mortality rates into account to evaluate the potential impact of cancer control interventions. We estimated mortality rates due to breast cancer and all other causes combined to determine their impact on overall mortality by year, age, and birth cohort.

METHODS

Based on mortality rates from publicly available datasets, an age-period-cohort model was used to estimate the proportion of deaths due to breast cancer for US women aged 0 to 119 years, with birth years 1900 to 2000. Breast cancer mortality was calculated as all-cause mortality multiplied by the proportion of deaths due to breast cancer; other-cause mortality was the difference between all-cause and breast cancer mortality.

RESULTS

Breast cancer and other-cause mortality rates were higher for older ages and birth cohorts. The percent of deaths due to breast cancer increased across birth cohorts from 1900 to 1940 then decreased. Among 50-year-old women, in the 1920 birth cohort, 52 (9.9%) of 100,000 deaths (95% CI, 9.8% to 10.1%) were attributed to breast cancer whereas 476 of 100,000 were due to other causes; in the 1960 birth cohort, 22 (8.5%) of 100,000 deaths (95% CI, 8.3% to 8.7%) were attributed to breast cancer with 242 of 100,000 deaths due to other causes. The percentage of all deaths due to breast cancer was highest (4.1% to 12.9%) for women in their 40s and 50s for all birth cohorts.

CONCLUSIONS

This study offers evidence that advances in breast cancer screening and treatment have reduced breast cancer mortality for women across the age spectrum, and provides estimates of age-, year- and birth cohort-specific competing mortality rates for simulation models. Other-cause mortality estimates are important in these models because most women die from causes other than breast cancer.

Age-based versus Risk-based Mammography Screening in Women 40-49 Years Old: A Cross-sectional Study

Background Risk-based screening in women 40-49 years old has not been evaluated in routine screening mammography practice. Purpose To use a cross-sectional study design to compare the trade-offs of risk-based and age-based screening for women 45 years of age or older to determine short-term outcomes. Materials and Methods A retrospective cross-sectional study was performed by using a database of 20 539 prospectively interpreted consecutive digital screening mammograms in 10 280 average-risk women aged 40-49 years who were screened at an academic medical center between January 1, 2006, and December 31, 2013. Two hypothetical screening scenarios were compared: an age-based (≥45 years) scenario versus a risk-based (a 5-year risk of breast cancer greater than that of an average 50-year-old) scenario. Risk factors for risk-based screening included family history, race, age, prior breast biopsy, and breast density. Outcomes included breast cancers detected at mammography, false-positive mammograms, and benign biopsy findings. Short-term outcomes were compared by using the χ² test. Results The screening population included 71 148 screening mammograms in 24 928 women with a mean age of 55.5 years ± 8.9 (standard deviation) (age range, 40-74 years). In women 40-49 years old, usual care included 50 screening-detected cancers, 1787 false-positive mammograms, and 384 benign biopsy results. The age-based (≥45 years) screening strategy revealed more cancers than did the risk-based strategy (34 [68%] vs 13 [26%] of 50; P < .001), while prompting more false-positive mammograms (899 [50.3%] vs 216 [12.1%] of 1787; P < .001) and benign biopsy results (175 [45.6%] vs 49 [12.8%] of 384; P < .001). The risk-based strategy demonstrated low levels of eligibility (few screenings) in the 40-44-year age group. Differences in outcomes in the 45-49-year age group explained the overall hypothetical screening strategy differences. Conclusion Risk-based screening for women 40-49 years old includes few women in the 40-44-year age range. Significant trade-offs in the 45-49-year age group explain the overall difference between hypothetical screening scenarios, both of which reduce the benefits as well as the harms of mammography for women 40-49 years old. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Joe and Hayward in this issue.

Clinical outcomes and cost-effectiveness of breast cancer screening for childhood cancer survivors treated with chest radiation: A comparative modeling study

6525

Background: Survivors of childhood cancer previously treated with chest radiation face elevated breast cancer risk similar to BRCA1 carriers. Children’s Oncology Group (COG) guidelines recommend annual mammography with breast MRI, yet the benefits and costs of various screening strategies are uncertain. Methods: We used two breast cancer simulation models (Model 1 and 2) from the Cancer Intervention and Surveillance Modeling Network (CISNET) and data from the Childhood Cancer Survivor Study to reflect high breast cancer and competing mortality risks among survivors. We simulated 3 screening strategies: annual mammography with MRI starting at age 25 (COG25), annual MRI starting at 25 (MRI25), and biennial mammography starting at 50 (Mammo50). Performance of mammography+/-MRI was based on published studies in BRCA1/2 carriers who have similar cancer risk. Costs and quality of life weights were based on US averages and published studies. Results: Among a simulated cohort of 25-year-old survivors treated with chest radiation, the lifetime breast cancer mortality risk in the absence of screening was 10-11% across models. Compared to no screening, Mammo50, MRI25, and COG25 screening avert approximately 23-25%, 56-62% and 56-71% of deaths, respectively; averted deaths for COG25 compared to MRI25 were higher in Model 1 than Model 2 (9% vs. <1%). In Model 1, both MRI25 and COG25 were cost-effective; in Model 2, MRI25 was preferable (more effective, less costly than COG25). Conclusions: Compared to no screening, initiating annual screening at younger ages for at-risk survivors averts >50% of breast cancer deaths and is cost-effective. Additional data on test performance are needed to inform recommendations on screening modality. [Table: see text]

Variation in coordination of care reported by breast cancer patients according to health literacy

BACKGROUND

Health literacy is the ability to perform basic reading and numerical tasks to function in the healthcare environment. The purpose of this study is to describe how health literacy is related to perceived coordination of care reported by breast cancer patients.

METHODS

Data were retrieved from the Patient-Centered Outcomes Research Institute-sponsored "Share Thoughts on Breast Cancer" Study including demographic factors, perceived care coordination and responsiveness of care, and self-reported health literacy obtained from a mailed survey completed by 62% of eligible breast cancer survivors (N = 1221). Multivariable analysis of variance was used to characterize the association between presence of a single healthcare professional that coordinated care ("care coordinator") and perceived care coordination, stratified by health literacy level.

RESULTS

Health literacy was classified as low in 24% of patients, medium in 34%, and high in 42%. Women with high health literacy scores were more likely to report non-Hispanic white race/ethnicity, private insurance, higher education and income, and fewer comorbidities (all p < 0.001). The presence of a care coordinator was associated with 17.1% higher perceived care coordination scores among women with low health literacy when compared to those without a care coordinator, whereas a coordinator modestly improved perceived care coordination among breast cancer survivors with medium (6.9%) and high (6.2%) health literacy.

CONCLUSION

The use of a single designated care coordinator may have a strong influence on care coordination in patients with lower levels of health literacy.

Disciplinary boundaries and integrating care: using Q-methodology to understand trainee views on being a good doctor

BACKGROUND

Rising numbers of patients with multiple-conditions and complex care needs mean that it is increasingly important for doctors from different specialty areas to work together, alongside other members of the multi-disciplinary team, to provide patient centred care. However, intra-professional boundaries and silos within the medical profession may challenge holistic approaches to patient care.

METHODS

We used Q methodology to examine how postgraduate trainees (n = 38) on a range of different specialty programmes in England and Wales could be grouped based on their rankings of 40 statements about 'being a good doctor'. Themes covered in the Q-set include: generalism (breadth) and specialism (depth), interdisciplinarity and multidisciplinary team working, patient-centredness, and managing complex care needs.

RESULTS

A by-person factor analysis enabled us to map distinct perspectives within our participant group (P-set). Despite high levels of overall commonality, three groups of trainees emerged, each with a clear perspective on being a good doctor. We describe the first group as 'generalists': team-players with a collegial and patient-centred approach to their role. The second group of 'general specialists' aspired to be specialists but with a generalist and patient-centred approach to care within their specialty area. Both these two groups can be contrasted to those in the third 'specialist' group, who had a more singular focus on how their specialty can help the patient.

CONCLUSIONS

Whilst distinct, the priorities and values of trainees in this study share some important aspects. The results of our Q-sort analysis suggest that it may be helpful to understand the relationship between generalism and specialism as less of a dichotomy and more of a continuum that transcends primary and secondary care settings. A nuanced understanding of trainee views on being a good doctor, across different specialties, may help us to bridge gaps and foster interdisciplinary working.

Abstract 3257: Polygenic risk score, stage, and mode of detection in relation to breast cancer risk

Identification of increasing numbers of breast cancer risk variants holds promise to improve risk prediction and identify population subgroups that could benefit from targeted prevention and early detection. We aimed to examine whether women with increased polygenic risk are more likely to be diagnosed with symptomatic breast cancer. A case-control study including data collected from interviews, DNA from saliva, and cancer registry data collected between 2001-2007 (4,315 cases, 3,919 controls) was used to construct a polygenic risk score (PRS). Single nucleotide polymorphisms (SNPs, N=98) were selected from recently published genome-wide association studies of breast cancer and breast density, and comparative rat genome studies. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) associated with the SNPs. SNPs with p-values ≤0.10 (N=24) were used to construct quintiles of the PRS by multiplying the log-odds of the SNPs by the number of risk alleles; multivariable logistic regression models evaluated all women and strata of women defined by method of detection and stage at diagnosis. Odds ratios were adjusted for age, family history of breast cancer, age at menopause/menopausal status, body mass index, parity, and age at first birth. Overall, PRS quintile categories were associated with breast cancer risk in a dose response manner (Q1: OR=1, reference; Q2 OR=1.36, 95% CI 1.16-1.58; Q3 OR=1.66, 95% CI 1.43-1.93; Q4 OR=1.83, 95% CI 1.58-2.12; Q5 OR=2.58, 95% CI 2.23-2.98). Evaluated on a continuous scale, the PRS was associated with an OR=1.38 for a 1-unit change in the standard deviation (SD), 95% CI 1.32-1.45. Odds ratios were essentially unchanged when stratified by method of detection (p-value=0.40). The odds ratio of breast cancer associated with the continuous PRS was elevated among women diagnosed with advanced breast cancer: DCIS, OR=1.36, 95% CI 1.26-1.47 per 1 SD; localized OR=1.37, 95% CI 1.30-1.45 per 1 SD; regional OR=1.38, 95% CI 1.28-1.48 per 1 SD; and distant OR=1.82, 95% CI 1.39-2.40. These results suggest that polygenic risk scores are strongly related to breast cancer risk, that the association does not vary by method of breast cancer detection, but that the association is strongest for metastatic breast cancer.

Citation Format: Amy Trentham-Dietz, John M. Hampton, Irene M. Ong, C David Page, Michael N. Gould, Jill D. Haag, Polly A. Newcomb, James D. Shull, Elizabeth S. Burnside. Polygenic risk score, stage, and mode of detection in relation to breast cancer risk [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3257.

The University of Wisconsin Breast Cancer Epidemiology Simulation Model: An Update

The University of Wisconsin Breast Cancer Epidemiology Simulation Model (UWBCS), also referred to as Model W, is a discrete-event microsimulation model that uses a systems engineering approach to replicate breast cancer epidemiology in the US over time. This population-based model simulates the lifetimes of individual women through 4 main model components: breast cancer natural history, detection, treatment, and mortality. A key feature of the UWBCS is that, in addition to specifying a population distribution in tumor growth rates, the model allows for heterogeneity in tumor behavior, with some tumors having limited malignant potential (i.e., would never become fatal in a woman's lifetime if left untreated) and some tumors being very aggressive based on metastatic spread early in their onset. The model is calibrated to Surveillance, Epidemiology, and End Results (SEER) breast cancer incidence and mortality data from 1975 to 2010, and cross-validated against data from the Wisconsin cancer reporting system. The UWBCS model generates detailed outputs including underlying disease states and observed clinical outcomes by age and calendar year, as well as costs, resource usage, and quality of life associated with screening and treatment. The UWBCS has been recently updated to account for differences in breast cancer detection, treatment, and survival by molecular subtypes (defined by ER/HER2 status), to reflect the recent advances in screening and treatment, and to consider a range of breast cancer risk factors, including breast density, race, body-mass-index, and the use of postmenopausal hormone therapy. Therefore, the model can evaluate novel screening strategies, such as risk-based screening, and can assess breast cancer outcomes by breast cancer molecular subtype. In this article, we describe the most up-to-date version of the UWBCS.

Urinary Magnesium and Other Elements in Relation to Mammographic Breast Density, a Measure of Breast Cancer Risk

PURPOSE

Heavy metals and other elements may act as breast carcinogens due to estrogenic activity. We investigated associations between urine concentrations of a panel of elements and breast density.

METHODS

Mammographic density categories were abstracted from radiology reports of 725 women aged 40-65 yr in the Avon Army of Women. A panel of 27 elements was quantified in urine using high resolution magnetic sector inductively coupled plasma mass spectrometry. We applied LASSO (least absolute shrinkage and selection operator) logistic regression to the 27 elements and calculated odds ratios (OR) and 95% confidence intervals (CI) for dense vs. nondense breasts, adjusting for potential confounders.

RESULTS

Of the 27 elements, only magnesium (Mg) was selected into the optimal regression model. The odds ratio for dense breasts associated with doubling the Mg concentration was 1.24 (95% CI 1.03-1.49). Doubling the calcium-to-magnesium ratio was inversely associated with dense breasts (OR 0.83, 95% CI 0.70-0.98).

CONCLUSIONS

Our cross-sectional study found that higher levels of urinary magnesium were associated with greater breast density. Prospective studies are needed to confirm whether magnesium as evaluated in urine is prospectively associated with breast density and, more importantly, breast cancer.

Collagen Alignment as a Predictor of Recurrence after Ductal Carcinoma In Situ

Background: Collagen fibers surrounding breast ducts may influence breast cancer progression. Syndecan-1 interacts with constituents in the extracellular matrix, including collagen fibers, and may contribute to cancer cell migration. Thus, the orientation of collagen fibers surrounding ductal carcinoma in situ (DCIS) lesions and stromal syndecan-1 expression may predict recurrence.Methods: We evaluated collagen fiber alignment and syndecan-1 expression in 227 women diagnosed with DCIS in 1995 to 2006 followed through 2014 (median, 14.5 years; range, 0.7-17.6). Stromal collagen alignment was evaluated from diagnostic tissue slides using second harmonic generation microscopy and fiber analysis software. Univariate analysis was conducted using χ2 tests and ANOVA. The association between collagen alignment z-scores, syndecan-1 staining intensity, and time to recurrence was evaluated using HRs and 95% confidence intervals (CIs).Results: Greater fiber angles surrounding DCIS lesions, but not syndecan-1 staining intensity, were related to positive HER2 (P = 0.002) status, comedo necrosis (P = 0.03), and negative estrogen receptor (P = 0.002) and progesterone receptor (P = 0.02) status. Fiber angle distributions surrounding lesions included more angles closer to 90 degrees than normal ducts (P = 0.06). Collagen alignment z-scores for DCIS lesions were positively related to recurrence (HR = 1.25; 95% CI, 0.84-1.87 for an interquartile range increase in average fiber angles).Conclusions: Although collagen alignment and stromal syndecan-1 expression did not predict recurrence, collagen fibers perpendicular to the duct perimeter were more frequent in DCIS lesions with features typical of poor prognosis.Impact: Follow-up studies are warranted to examine whether additional features of the collagen matrix may more strongly predict patient outcomes. Cancer Epidemiol Biomarkers Prev; 27(2); 138-45. ©2017 AACR.

Geographic access to mammography facilities and frequency of mammography screening

PURPOSE

To assess the association between geographic access to mammography facilities and women's mammography utilization frequency.

METHODS

Using data from the population-based 1995-2007 Wisconsin Women's Health study, we used proportional odds and logistic regression to test whether driving times to mammography facilities and the number of mammography facilities within 10 km of women's homes were associated with mammography frequency among women aged 50-74 years and whether associations differed between Rural-Urban Commuting Areas and income and education groups.

RESULTS

We found evidence for nonlinear relationships between geographic access and mammography utilization (nonlinear effects of driving times and facility density, P-values .01 and .005, respectively). Having at least one nearby mammography facility was associated with greater mammography frequency among urban women (1 vs. 0 facilities, odds ratio 1.26, 95% confidence interval, 1.09-1.47), with similar effects among rural women. Adding more facilities had decreasing marginal effects. Long driving times tended to be associated with lower mammography frequency. We found no effect modification by income, education, or urbanicity. In rural settings, mammography nonuse was higher, facility density smaller, and driving times to facilities were longer.

CONCLUSIONS

Having at least one mammography facility near one's home may increase mammography utilization, with decreasing effects per each additional facility.

Emerging Trends in Family History of Breast Cancer and Associated Risk

Background: Increase in breast cancer incidence associated with mammography screening diffusion may have attenuated risk associations between family history and breast cancer.Methods: The proportions of women ages 40 to 74 years reporting a first-degree family history of breast cancer were estimated in the Breast Cancer Surveillance Consortium cohort (BCSC: N = 1,170,900; 1996-2012) and the Collaborative Breast Cancer Study (CBCS: cases N = 23,400; controls N = 26,460; 1987-2007). Breast cancer (ductal carcinoma in situ and invasive) relative risk estimates and 95% confidence intervals (CI) associated with family history were calculated using multivariable Cox proportional hazard and logistic regression models.Results: The proportion of women reporting a first-degree family history increased from 11% in the 1980s to 16% in 2010 to 2013. Family history was associated with a >60% increased risk of breast cancer in the BCSC (HR, 1.61; 95% CI, 1.55-1.66) and CBCS (OR, 1.64; 95% CI, 1.57-1.72). Relative risks decreased slightly with age. Consistent trends in relative risks were not observed over time or across stage of disease at diagnosis in both studies, except among older women (ages 60-74) where estimates were attenuated from about 1.7 to 1.3 over the last 20 years (P trend = 0.08 for both studies).Conclusions: Although the proportion of women with a first-degree family history of breast cancer increased over time and by age, breast cancer risk associations with family history were nonetheless fairly constant over time for women under age 60.Impact: First-degree family history of breast cancer remains an important breast cancer risk factor, especially for younger women, despite its increasing prevalence in the mammography screening era. Cancer Epidemiol Biomarkers Prev; 26(12); 1753-60. ©2017 AACR.

Health-related behaviors and mortality outcomes in women diagnosed with ductal carcinoma in situ

PURPOSE

Women diagnosed with ductal carcinoma in situ (DCIS) of the breast are at greater risk of dying from cardiovascular disease and other causes than from breast cancer, yet associations between health-related behaviors and mortality outcomes after DCIS have not been well studied.

METHODS

We examined the association of body mass index, physical activity, alcohol consumption, and smoking with mortality among 1925 women with DCIS in the Wisconsin In Situ Cohort study. Behaviors were self-reported through baseline interviews and up to three follow-up questionnaires. Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for mortality after DCIS, with adjustment for patient sociodemographic, comorbidity, and treatment factors.

RESULTS

Over a mean of 6.7 years of follow-up, 196 deaths occurred. All-cause mortality was elevated among women who were current smokers 1 year prior to diagnosis (HR = 2.17 [95% CI 1.48, 3.18] vs. never smokers) and reduced among women with greater physical activity levels prior to diagnosis (HR = 0.55 [95% CI: 0.35, 0.87] for ≥5 h per week vs. no activity). Moderate levels of post-diagnosis physical activity were associated with reduced all-cause mortality (HR = 0.31 [95% CI 0.14, 0.68] for 2-5 h per week vs. no activity). Cancer-specific mortality was elevated among smokers and cardiovascular disease mortality decreased with increasing physical activity levels.

CONCLUSIONS

There are numerous associations between health-related behaviors and mortality outcomes after a DCIS diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

Women diagnosed with DCIS should be aware that their health-related behaviors are associated with mortality outcomes.

Tailoring Breast Cancer Screening Intervals by Breast Density and Risk for Women Aged 50 Years or Older: Collaborative Modeling of Screening Outcomes

BACKGROUND

Biennial screening is generally recommended for average-risk women aged 50 to 74 years, but tailored screening may provide greater benefits.

OBJECTIVE

To estimate outcomes for various screening intervals after age 50 years based on breast density and risk for breast cancer.

DESIGN

Collaborative simulation modeling using national incidence, breast density, and screening performance data.

SETTING

United States.

PATIENTS

Women aged 50 years or older with various combinations of breast density and relative risk (RR) of 1.0, 1.3, 2.0, or 4.0.

INTERVENTION

Annual, biennial, or triennial digital mammography screening from ages 50 to 74 years (vs. no screening) and ages 65 to 74 years (vs. biennial digital mammography from ages 50 to 64 years).

MEASUREMENTS

Lifetime breast cancer deaths, life expectancy and quality-adjusted life-years (QALYs), false-positive mammograms, benign biopsy results, overdiagnosis, cost-effectiveness, and ratio of false-positive results to breast cancer deaths averted.

RESULTS

Screening benefits and overdiagnosis increase with breast density and RR. False-positive mammograms and benign results on biopsy decrease with increasing risk. Among women with fatty breasts or scattered fibroglandular density and an RR of 1.0 or 1.3, breast cancer deaths averted were similar for triennial versus biennial screening for both age groups (50 to 74 years, median of 3.4 to 5.1 vs. 4.1 to 6.5 deaths averted; 65 to 74 years, median of 1.5 to 2.1 vs. 1.8 to 2.6 deaths averted). Breast cancer deaths averted increased with annual versus biennial screening for women aged 50 to 74 years at all levels of breast density and an RR of 4.0, and those aged 65 to 74 years with heterogeneously or extremely dense breasts and an RR of 4.0. However, harms were almost 2-fold higher. Triennial screening for the average-risk subgroup and annual screening for the highest-risk subgroup cost less than $100 000 per QALY gained.

LIMITATION

Models did not consider women younger than 50 years, those with an RR less than 1, or other imaging methods.

CONCLUSION

Average-risk women with low breast density undergoing triennial screening and higher-risk women with high breast density receiving annual screening will maintain a similar or better balance of benefits and harms than average-risk women receiving biennial screening.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Emerging trends in surgical and adjuvant radiation therapies among women diagnosed with ductal carcinoma in situ

BACKGROUND

The use of surgery and radiation therapy in treating ductal carcinoma in situ (DCIS) is directed by treatment guidelines and evidence from research. This study investigated recent patterns in DCIS treatment by demographic factors.

METHODS

Data for women diagnosed with DCIS between 1998 and 2011 (n = 416,232) in the National Cancer Data Base were assessed for trends in treatment patterns by age group, calendar year, ancestral/ethnic group, and geographic region. The likelihood of receiving specific treatment modalities was analyzed with multivariable logistic regression.

RESULTS

DCIS cases were most frequently treated with breast-conserving surgery (BCS) and adjuvant radiation (45.6%). After an initial rise, the use of adjuvant radiation after BCS plateaued at approximately 70% after 2007, with increasing utilization of mastectomy beyond 2005. In addition, there was an increasing trend in postmastectomy reconstruction over time, and women of African ancestry (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.66-0.72) and Hispanic women (OR, 0.83; 95% CI, 0.78-0.89) were less likely to undergo reconstruction in comparison with women of European ancestry. A similar trend was observed in contralateral risk-reducing mastectomy utilization, with women of European ancestry having a more rapid rise in the utilization of contralateral risk-reducing mastectomy in comparison with all other ancestral/ethnic groups.

CONCLUSIONS

Recent trends demonstrate a plateau in radiation therapy administration after BCS along with increasing utilization of mastectomy, reconstruction, and contralateral risk-reducing mastectomy. There are substantial differences in treatment utilization according to ancestry/ethnicity and geographical region. Further studies examining patient-physician decision making surrounding DCIS treatment are warranted. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2810-2818. © 2016 American Cancer Society.

Trends in Health-Related Quality of Life After a Diagnosis of Ductal Carcinoma In Situ

PURPOSE

Studies of quality of life (QoL) are scarce among survivors of ductal carcinoma in situ (DCIS). The objective of this study was to assess long-term QoL in DCIS survivors in relation to age at diagnosis, time since diagnosis, and treatments received.

METHODS

We assessed physical and mental measures of health-related QoL in 1,604 patients with DCIS diagnosed in 1997 to 2006 with up to four follow-up interviews. We further compared baseline QoL to 1,055 control patients without DCIS. QoL was measured using the validated Medical Outcomes Study Short Form 36 Health Status Survey questionnaire. Among patients with DCIS, we examined trends in QoL over time since diagnosis using generalized linear regression models, adjusting for confounders. We tested for effect modification by surgical treatment choice, post-treatment endocrine therapy use, and age at diagnosis.

RESULTS

Both physical and mental measures of QoL among DCIS survivors at fewer than 2 years after diagnosis were comparable to controls. Mental measures of QoL among patients with DCIS declined at ≥ 10 years after diagnosis and were significantly lower than at less than 2 years after diagnosis (47.4 v 52.0; P < .01). In the first 5 years after a DCIS diagnosis, mental QoL was significantly higher among women diagnosed at ages 50 to 74 years compared with those diagnosed at ages 28 to 49 years, although this difference was not sustained in later time periods.

CONCLUSION

QoL after a DCIS diagnosis was generally comparable to that of women of similar age without a personal history of DCIS. Our findings suggest that DCIS survivors, and particularly those diagnosed at a younger age, may benefit from support for mental QoL.

The Association Between Post-Diagnosis Health Behaviors and Quality of Life in Survivors of Ductal Carcinoma In Situ

Background: Survivors of ductal carcinoma in situ (DCIS), an early stage breast cancer, tend to decrease physical activity, gain weight, and maintain alcohol use following treatment. However, the impact of these health behaviors on long-term quality of life (QoL) in DCIS survivors has not been investigated. Methods: We examined the association of post-diagnosis body mass index (BMI), physical activity and smoking with QoL among 1,448 DCIS survivors aged 20–74, who were diagnosed during 1995–2006 and enrolled in the population-based Wisconsin In Situ Cohort. Health behaviors and QoL were self-reported during biennial post- diagnosis interviews. Physical and mental QoL were measured using the validated SF-36 questionnaire (higher scores reflect more positive QoL). Generalized linear regression was used to establish QoL mean scores in cross-sectional analyses, with multivariable adjustment for age, comorbidity status, education, and income. Results: Women reported 3,444 QoL observations over an average 7.9 years of follow-up. Physical health summary scale measures of QoL were significantly higher among women with healthy BMI (46.5 for healthy weight versus 40.5 for obese, P = 0.02) and those who were physically active (45.9 for active women versus 42.6 for inactive, P = 0.03). Mental health summary scale scores were significantly higher among non-smokers (51.2 for non-smokers versus 47.1 for current smokers, P &lt; 0.01). These associations were consistent over increasing time since treatment up to 15 years. Conclusion: Our preliminary analysis suggests that maintaining healthy behaviors following DCIS treatment is associated with improved long-term QoL. Longitudinal analysis using cross-lagged regression is underway to evaluate the temporal association between health behavior and QoL. Understanding factors that impact QoL in DCIS survivors may inform interventions aimed at preventing negative health behaviors and optimizing long term quality of life following a DCIS diagnosis.

Cigarette Smoking Before and After Breast Cancer Diagnosis: Mortality From Breast Cancer and Smoking-Related Diseases

PURPOSE

Cigarette smoking increases overall mortality, but it is not established whether smoking is associated with breast cancer prognosis.

METHODS

We evaluated the association between smoking status before and after breast cancer diagnosis and mortality in the Collaborative Breast Cancer and Women's Longevity Study, a population-based prospective observational study conducted in Wisconsin, New Hampshire, and Massachusetts. Participants included 20,691 women, ages 20 to 79 years, diagnosed with incident localized or regional invasive breast cancer between 1988 and 2008; a subset of 4,562 of these women were recontacted a median of 6 years after diagnosis. Hazard ratios (HRs) with 95% CIs were calculated according to smoking status for death as a result of breast cancer; cancers of the lung, pharynx, or intrathoracic organs; other cancer; respiratory disease; and cardiovascular disease.

RESULTS

During a median of 12 years, 6,778 women died, including 2,894 who died as a result of breast cancer. Active smokers 1 year before breast cancer diagnosis were more likely than never smokers to die of breast cancer (HR, 1.25; 95% CI, 1.13 to 1.37), respiratory cancer (HR, 14.48; 95% CI, 9.89 to 21.21), other respiratory disease (HR, 6.02; 95% CI, 4.55 to 7.97), and cardiovascular disease (HR, 2.08; 95% CI, 1.80 to 2.41). The 10% of women who continued to smoke after diagnosis were more likely than never smokers to die of breast cancer (HR, 1.72; 95% CI, 1.13 to 2.60). When compared with women who continued to smoke after diagnosis, those who quit smoking after diagnosis had lower mortality from breast cancer (HR, 0.67; 95% CI, 0.38 to 1.19) and respiratory cancer (HR, 0.39; 95% CI, 0.16 to 0.95).

CONCLUSION

Smoking before or after diagnosis was associated with a higher mortality from breast cancer and several other causes.

Partnership Status and Socioeconomic Factors in Relation to Health Behavior Changes after a Diagnosis of Ductal Carcinoma In Situ

BACKGROUND

Change in health behaviors can occur among women newly diagnosed with ductal carcinoma in situ (DCIS). We sought to understand whether partnership status and socioeconomic status (SES) affected behavioral changes in body weight, physical activity, alcohol consumption, and smoking.

METHODS

The Wisconsin In Situ Cohort (WISC) study comprises 1,382 women diagnosed with DCIS with information on demographics, SES factors, and pre- and post-DCIS diagnosis health-related behaviors. Logistic regression models were used to determine the association between partnership status, education, and income with change in behavior variables.

RESULTS

Higher educational attainment was associated with lower likelihood of stopping physical activity [OR, 0.45; 95% confidence interval (CI), 0.32-0.63; college vs. high school degree], or starting to drink alcohol (OR, 0.34; 95% CI, 0.15-0.80). Results suggested that higher family income was associated with lower likelihood of gaining >5% body mass index (P = 0.07) or stopping physical activity (P = 0.09). Living with a partner was not strongly associated with behavior changes.

CONCLUSION

Higher educational attainment and higher income, but not living with a partner, were associated with positive health behaviors after a DCIS diagnosis.

IMPACT

The associations between higher educational attainment and, to a lesser extent, higher income with positive health behaviors underscore the importance of considering SES when identifying those at risk for negative behavioral change after DCIS diagnosis.

Abstract 3727: Influence of patient, physician, and hospital characteristics on the receipt of guideline-concordant care for inflammatory breast cancer

Introduction: Inflammatory breast cancer (IBC) is an aggressive and lethal form of locally advanced breast cancer that makes up 1-6% of all breast cancers and has a median overall survival of less than 4 years. Physically, IBC is characterized by erythema, edema, and fine dimpling, so treatment can be delayed due to misdiagnosis as mastitis or dermatitis. Therapy for IBC tends to vary since no treatments are highly effective. Because IBC is such a rare subtype, studies have been challenged to demonstrate patterns of IBC treatment and analyze factors affecting differences in treatment. In this study we examined factors affecting the receipt of guideline-concordant care and survival for IBC patients.

Methods: Patients diagnosed with non-metastatic IBC in 2004 were identified from the Breast and Prostate Cancer Data Quality and Patterns of Care Study, containing information from cancer registry reports in seven states supplemented through medical record re-abstraction and physician verification. Variation in guideline-concordant care for IBC, based on 2003 National Comprehensive Cancer Network (NCCN) guidelines, was assessed according to patient, physician, and hospital characteristics. Additionally, survival based on receipt of guideline-concordant care was analyzed using Kaplan-Meier curves and log-rank tests.

Results: Of the 107 IBC patients in the study, only 25.8% of them received treatment that was fully concordant with guidelines. The majority of patients received guideline-concordant surgery (90.4%), with percentages lower for chemotherapy (51.9%), radiation (40.7%), and hormone therapy (78.0%). Guideline-concordant care was less common among patients with extreme categories of patient age (under 40 or over 80 years; P = 0.19), non-white race (P = 0.03), lower body mass index (BMI&lt;25 kg/m2, P = 0.003), a surgeon graduating from medical school more than 15 years prior (P = 0.02), and smaller hospital size (&lt;200 beds, P = 0.02).

Results suggested that IBC patients experienced longer breast cancer-specific survival if they received guideline-concordant treatment based on 2003 (P = 0.06) and 2013 (P = 0.06) NCCN guidelines.

Conclusion: Targeting factors associated with receipt of care that is not guideline-concordant may reduce survival disparities in IBC patients. Further research is needed to identify approaches to ensure that physicians are adhering to NCCN guidelines for IBC cases and to identify reasons for non-adherence to guidelines.

Citation Format: Ryan A. Denu, John M. Hampton, Adam Currey, Roger T. Anderson, Rosemary D. Cress, Steven T. Fleming, Joseph Lipscomb, Susan A. Sabatino, Xiao-Cheng Wu, J F. Wilson, Amy Trentham-Dietz. Influence of patient, physician, and hospital characteristics on the receipt of guideline-concordant care for inflammatory breast cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3727. doi:10.1158/1538-7445.AM2015-3727

Variation in Breast Cancer-Risk Factor Associations by Method of Detection: Results From a Series of Case-Control Studies

Concerns about breast cancer overdiagnosis have increased the need to understand how cancers detected through screening mammography differ from those first detected by a woman or her clinician. We investigated risk factor associations for invasive breast cancer by method of detection within a series of case-control studies (1992-2007) carried out in Wisconsin, Massachusetts, and New Hampshire (n=15,648 invasive breast cancer patients and 17,602 controls aged 40-79 years). Approximately half of case women reported that their cancer had been detected by mammographic screening and half that they or their clinician had detected it. In polytomous logistic regression models, parity and age at first birth were more strongly associated with risk of mammography-detected breast cancer than with risk of woman/clinician-detected breast cancer (P≤0.01; adjusted for mammography utilization). Among postmenopausal women, estrogen-progestin hormone use was predominantly associated with risk of woman/clinician-detected breast cancer (odds ratio (OR)=1.49, 95% confidence interval (CI): 1.29, 1.72), whereas obesity was predominantly associated with risk of mammography-detected breast cancer (OR=1.72, 95% CI: 1.54, 1.92). Among regularly screened premenopausal women, obesity was not associated with increased risk of mammography-detected breast cancer (OR=0.99, 95% CI: 0.83, 1.18), but it was associated with reduced risk of woman/clinician-detected breast cancer (OR=0.53, 95% CI: 0.43, 0.64). These findings indicate important differences in breast cancer risk factors according to method of detection.

Prevalence of mammographically dense breasts in the United States

BACKGROUND

National legislation is under consideration that would require women with mammographically dense breasts to be informed of their breast density and encouraged to discuss supplemental breast cancer screening with their health care providers. The number of US women potentially affected by this legislation is unknown.

METHODS

We determined the mammographic breast density distribution by age and body mass index (BMI) using data from 1518 599 mammograms conducted from 2007 through 2010 at mammography facilities in the Breast Cancer Surveillance Consortium (BCSC). We applied these breast density distributions to age- and BMI-specific counts of the US female population derived from the 2010 US Census and the National Health and Nutrition Examination Survey (NHANES) to estimate the number of US women with dense breasts.

RESULTS

Overall, 43.3% (95% confidence interval [CI] = 43.1% to 43.4%) of women 40 to 74 years of age had heterogeneously or extremely dense breasts, and this proportion was inversely associated with age and BMI. Based on the age and BMI distribution of US women, we estimated that 27.6 million women (95% CI = 27.5 to 27.7 million) aged 40 to 74 years in the United States have heterogeneously or extremely dense breasts. Women aged 40 to 49 years (N = 12.3 million) accounted for 44.3% of this group.

CONCLUSION

The prevalence of dense breasts among US women of common breast cancer screening ages exceeds 25 million. Policymakers and healthcare providers should consider this large prevalence when debating breast density notification legislation and designing strategies to ensure that women who are notified have opportunities to evaluate breast cancer risk and discuss and pursue supplemental screening options if deemed appropriate.

Obesity and guideline-concordant systemic therapy for locoregional breast cancer

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Background: Obese breast cancer patients tend to have higher mortality than non-obese patients. Hypothesizing that differences in receipt of adequate treatment may contribute to this mortality differential, we examined whether breast cancer patients with higher body mass index (BMI) received systemic adjuvant treatment consistent with National Comprehensive Cancer Network guidelines. Methods: Female adult stage I-III breast cancer cases diagnosed in 2004 were identified from population-based cancer registries in 7 states and supplemented with abstracted medical records. Differences in receipt of concordant treatment according to BMI were investigated using logistic regression models adjusted for age and other covariates. Results: Among all women, 57% (2,174 of 3,828) received overall guideline-concordant (GC) adjuvant systemic treatment, meaning treatment adherent in each of 3 defined domains: chemotherapy, chemotherapy regimen, and hormonal therapy. Within the domains, 82% of women received GC chemotherapy, and 93% of those received a GC regimen, and 80% received GC hormonal therapy. Women with higher BMI had greater odds of receiving GC systemic therapy (odds ratio for each 5 kg/m2 increase in BMI 1.07, 95% CI 1.01 to 1.14; p value for trend = 0.04). No significant differences in guideline treatment according to BMI were found in the individual therapy domains (adjuvant chemotherapy, p = 0.18; chemotherapy regimen, p = 0.26), although a borderline significant, nonlinear pattern was seen for hormonal therapy, in which the highest odds of GC treatment were found in the lowest and highest BMI ranges (p = 0.07 from χ2 test). Conclusions: Contrary to our hypothesis, odds of guideline concordant systemic therapy increased with higher BMI, and no significant differences were found within any specific treatment domain. Further research describing how multiple factors including treatment patterns influence outcomes for obese breast cancer patients may identify areas where changes in practice can reduce disease burden and mortality. Our research also suggests further investigation into patterns of care for underweight patients.

Modification of breast cancer risk according to age and menopausal status: a combined analysis of five population-based case-control studies

While several risk factors for breast cancer have been identified, studies have not consistently shown whether these factors operate more strongly at certain ages or for just pre- or postmenopausal women. We evaluated whether risk factors for breast cancer differ according to age or menopausal status. Data from five population-based case-control studies conducted during 1988-2008 were combined and analyzed. Cases (N = 23,959) and population controls (N = 28,304) completed telephone interviews. Logistic regression was used to estimate adjusted odds ratios and 95 % confidence intervals and tests for interaction by age and menopausal status. Odds ratios for first-degree family history of breast cancer were strongest for younger women-reaching twofold elevations-but were still statistically significantly elevated by 58-69 % among older women. Obesity was inversely associated with breast cancer among younger women and positively associated with risk for older women (interaction P < 0.0001). Recent alcohol intake was more strongly related to breast cancer risk among older women, although consumption of 3 or more drinks/day among younger women also was associated with elevated odd ratios (P < 0.0001). Associations with benign breast disease and most reproductive/menstrual factors did not vary by age. Repeating analysis stratifying by menopausal status produced similar results. With few exceptions, menstrual and lifestyle factors are associated with breast cancer risk regardless of age or menopausal status. Variation in the association of family history, obesity, and alcohol use with breast cancer risk by age and menopausal status may need to be considered when determining individual risk for breast cancer.

Reproductive windows, genetic loci, and breast cancer risk

PURPOSE

The reproductive windows between age at menarche and age at first birth (standardized age at first birth) and from menarche to menopause (reproductive lifespan) may interact with genetic variants in association with breast cancer risk.

METHODS

We assessed this hypothesis in 6131 breast cancer cases and 7274 controls who participated in the population-based Collaborative Breast Cancer Study. Risk factor information was collected through telephone interviews, and DNA samples were collected on a subsample (N= 1484 cases, 1307 controls) to genotype for 13 genome-wide association study-identified loci. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and P values for the interaction between reproductive windows and genotypes were obtained by adding cross-product terms to statistical models.

RESULTS

For standardized age at first birth, the OR was 1.52 (CI, 1.36-1.71) comparing the highest quintile with the lowest quintile. Carrier status for rs10941679 (5p12) and rs10483813 (RAD51B) appeared to modify this relationship (P = .04 and P = .02, respectively). For reproductive lifespan, the OR comparing the highest quintile with the lowest quintiles was 1.62 (CI, 1.35-1.95). No interactions were detected between genotype and reproductive lifespan (all P > .05). All results were similar regardless of ductal versus lobular breast cancer subtype.

CONCLUSIONS

Our results suggest that the reproductive windows are associated with breast cancer risk and that associations may vary by genetic variants.

Smoking History in Relation to Survival after a Breast Cancer Diagnosis

Smoking history is associated with increased risk of most cancers, including breast cancer. Given the persistent effects of tobacco carcinogens, smoking history may also influence breast cancer survival. The few previous studies assessing this association were hindered by limited numbers of outcomes. METHODS: We assessed pre-diagnosis tobacco smoking in relation to survival in 22,870 female residents of Wisconsin, Massachusetts, or New Hampshire who were diagnosed with incident, invasive breast cancer between 1988–2008 at ages 20–79. All women reported pre-diagnosis tobacco use, as well as other known and suspected breast cancer risk factors. Information on breast cancer staging was obtained from state cancer registries. Proportional hazards regression with baseline hazard stratified on state of residence and study phase was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cause-specific death according to current smoking (at the time of the breast cancer diagnosis) and long-term (&gt;30 years) smoking (prior to the diagnosis) adjusting for age at diagnosis, stage of disease at diagnosis, family history of breast cancer, age at first birth, menopausal status, hormone therapy use, body mass index, alcohol consumption, education, and mammography. RESULTS: During a median follow-up of 11.3 years from diagnosis, 7,807 deaths occurred, including 3,483 attributed to breast cancer, 328 to lung cancer, 415 to respiratory disease, and 1,553 to cardiovascular disease. Compared to nonsmokers, the HR were 1.2 (1.1–1.3. P = trend = 0.0003) for current smokers and 1.2 (1.1–1.3, P trend = 0.01) for &gt;30 years of smoking. Current smoking was also associated with increased mortality from lung cancer, HR = 14.5 (10.1–20.8), cardiovascular disease, HR = 2.2 (1.9–2.5), and respiratory disease HR = 6.3 (4.8–8.2). CONCLUSIONS: In this large population-based sample of breast cancer cases, current and long-term smokers at the time of diagnosis were 20% more likely to die from breast cancer than never smokers adjusting for breast cancer stage. The elevated mortality risk observed here for known smoking-related diseases adds confidence to the breast cancer findings.Smoking history is associated with increased risk of most cancers, including breast cancer. Given the persistent effects of tobacco carcinogens, smoking history may also influence breast cancer survival. The few previous studies assessing this association were hindered by limited numbers of outcomes. METHODS: We assessed pre-diagnosis tobacco smoking in relation to survival in 22,870 female residents of Wisconsin, Massachusetts, or New Hampshire who were diagnosed with incident, invasive breast cancer between 1988–2008 at ages 20–79. All women reported pre-diagnosis tobacco use, as well as other known and suspected breast cancer risk factors. Information on breast cancer staging was obtained from state cancer registries. Proportional hazards regression with baseline hazard stratified on state of residence and study phase was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cause-specific death according to current smoking (at the time of the breast cancer diagnosis) and long-term (&gt;30 years) smoking (prior to the diagnosis) adjusting for age at diagnosis, stage of disease at diagnosis, family history of breast cancer, age at first birth, menopausal status, hormone therapy use, body mass index, alcohol consumption, education, and mammography. RESULTS: During a median follow-up of 11.3 years from diagnosis, 7,807 deaths occurred, including 3,483 attributed to breast cancer, 328 to lung cancer, 415 to respiratory disease, and 1,553 to cardiovascular disease. Compared to nonsmokers, the HR were 1.2 (1.1–1.3. P = trend = 0.0003) for current smokers and 1.2 (1.1–1.3, P trend = 0.01) for &gt;30 years of smoking. Current smoking was also associated with increased mortality from lung cancer, HR = 14.5 (10.1–20.8), cardiovascular disease, HR = 2.2 (1.9–2.5), and respiratory disease HR = 6.3 (4.8–8.2). CONCLUSIONS: In this large population-based sample of breast cancer cases, current and long-term smokers at the time of diagnosis were 20% more likely to die from breast cancer than never smokers adjusting for breast cancer stage. The elevated mortality risk observed here for known smoking-related diseases adds confidence to the breast cancer findings.Smoking history is associated with increased risk of most cancers, including breast cancer. Given the persistent effects of tobacco carcinogens, smoking history may also influence breast cancer survival. The few previous studies assessing this association were hindered by limited numbers of outcomes. METHODS: We assessed pre-diagnosis tobacco smoking in relation to survival in 22,870 female residents of Wisconsin, Massachusetts, or New Hampshire who were diagnosed with incident, invasive breast cancer between 1988–2008 at ages 20–79. All women reported pre-diagnosis tobacco use, as well as other known and suspected breast cancer risk factors. Information on breast cancer staging was obtained from state cancer registries. Proportional hazards regression with baseline hazard stratified on state of residence and study phase was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cause-specific death according to current smoking (at the time of the breast cancer diagnosis) and long-term (&gt;30 years) smoking (prior to the diagnosis) adjusting for age at diagnosis, stage of disease at diagnosis, family history of breast cancer, age at first birth, menopausal status, hormone therapy use, body mass index, alcohol consumption, education, and mammography. RESULTS: During a median follow-up of 11.3 years from diagnosis, 7,807 deaths occurred, including 3,483 attributed to breast cancer, 328 to lung cancer, 415 to respiratory disease, and 1,553 to cardiovascular disease. Compared to nonsmokers, the HR were 1.2 (1.1–1.3. P = trend = 0.0003) for current smokers and 1.2 (1.1–1.3, P trend = 0.01) for &gt;30 years of smoking. Current smoking was also associated with increased mortality from lung cancer, HR = 14.5 (10.1–20.8), cardiovascular disease, HR = 2.2 (1.9–2.5), and respiratory disease HR = 6.3 (4.8–8.2). CONCLUSIONS: In this large population-based sample of breast cancer cases, current and long-term smokers at the time of diagnosis were 20% more likely to die from breast cancer than never smokers adjusting for breast cancer stage. The elevated mortality risk observed here for known smoking-related diseases adds confidence to the breast cancer findings.Smoking history is associated with increased risk of most cancers, including breast cancer. Given the persistent effects of tobacco carcinogens, smoking history may also influence breast cancer survival. The few previous studies assessing this association were hindered by limited numbers of outcomes. METHODS: We assessed pre-diagnosis tobacco smoking in relation to survival in 22,870 female residents of Wisconsin, Massachusetts, or New Hampshire who were diagnosed with incident, invasive breast cancer between 1988–2008 at ages 20–79. All women reported pre-diagnosis tobacco use, as well as other known and suspected breast cancer risk factors. Information on breast cancer staging was obtained from state cancer registries. Proportional hazards regression with baseline hazard stratified on state of residence and study phase was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cause-specific death according to current smoking (at the time of the breast cancer diagnosis) and long-term (&gt;30 years) smoking (prior to the diagnosis) adjusting for age at diagnosis, stage of disease at diagnosis, family history of breast cancer, age at first birth, menopausal status, hormone therapy use, body mass index, alcohol consumption, education, and mammography. RESULTS: During a median follow-up of 11.3 years from diagnosis, 7,807 deaths occurred, including 3,483 attributed to breast cancer, 328 to lung cancer, 415 to respiratory disease, and 1,553 to cardiovascular disease. Compared to nonsmokers, the HR were 1.2 (1.1–1.3. P = trend = 0.0003) for current smokers and 1.2 (1.1–1.3, P trend = 0.01) for &gt;30 years of smoking. Current smoking was also associated with increased mortality from lung cancer, HR = 14.5 (10.1–20.8), cardiovascular disease, HR = 2.2 (1.9–2.5), and respiratory disease HR = 6.3 (4.8–8.2). CONCLUSIONS: In this large population-based sample of breast cancer cases, current and long-term smokers at the time of diagnosis were 20% more likely to die from breast cancer than never smokers adjusting for breast cancer stage. The elevated mortality risk observed here for known smoking-related diseases adds confidence to the breast cancer findings.

Lifestyle factors and the risk of a second breast cancer after ductal carcinoma in situ

BACKGROUND

Little information exists on lifestyle factors that affect prognosis after treatment for ductal carcinoma in situ (DCIS) breast cancer. Improved understanding of the role of lifestyle factors is important to survivors wishing to reduce their risk of a second breast cancer diagnosis.

METHODS

We examined the association between body mass index (BMI), physical activity, and alcohol intake, and risk of a second breast cancer diagnosis among 1,925 DCIS survivors in the Wisconsin In Situ Cohort. Exposures were self-reported during biennial patient interviews. Second breast cancer diagnoses were validated via pathology report. Cox proportional hazards regression was used to estimate the association between prediagnosis, postdiagnosis, and change in exposure levels and the risk of a second diagnosis, with adjustment for patient, tumor, and treatment factors.

RESULTS

Over a mean of 6.7 years of follow-up, 162 second breast cancer diagnoses were reported, including 57 invasive events, 60 in situ events, and 45 diagnoses of unknown stage. A significant trend of increasing risk of a second diagnosis was found over increasing categories of postdiagnosis alcohol intake (Ptrend = 0.02). Among premenopausal women, increased prediagnosis BMI was associated with a reduced risk of a second diagnosis (HR = 0.93; 95% confidence interval, 0.88-0.99).

CONCLUSION

DCIS survivors may reduce their risk of a second diagnosis by reducing postdiagnosis alcohol consumption.

IMPACT

The population of DCIS survivors is projected to surpass one million by the year 2016. Our results suggest that these women may be able to reduce their risk of a second diagnosis through moderation of alcohol consumption.

Breast cancer susceptibility loci in association with age at menarche, age at natural menopause and the reproductive lifespan

BACKGROUND

Genome-wide association studies have identified single nucleotide polymorphisms (SNPs) associated with breast cancer risk. Some of these loci have unknown functional significance and may mediate the effects of hormonal exposures on breast cancer risk. We examined relationships between breast cancer susceptibility variants and menstrual/reproductive factors using data from two population-based studies.

METHODS

The first analysis was based on a sample of 1328 women age 20-74 who participated as controls in a case-control study of breast cancer conducted in three U.S. states. We evaluated the associations between age at menarche, age at natural menopause and the reproductive lifespan with 13 previously identified breast cancer variants. Associations were also examined with a genetic score created as the sum of at-risk alleles across the 13 variants. For validation, significant results were evaluated in a second dataset comprised 1353 women age 43-86 recruited as part of a cohort study in Wisconsin.

RESULTS

Neither the genetic score nor any of the 13 variants considered individually were associated with age at menarche or reproductive lifespan. Two SNPs were associated with age at natural menopause; every increase in the minor allele (A) of rs17468277 (CASP8) was associated with a 1.12 year decrease in menopause age (p=0.02). The minor allele (G) of rs10941679 (5p12) was associated with a 1.01 year increase in age at natural menopause (p=0.01). The results were not replicated in the validation cohort (B=-0.61, p=0.14 and B=-0.01, p=.0.98, respectively).

CONCLUSIONS

The evaluated variants and reproductive experiences may work through separate pathways to influence breast cancer risk.

Disease-free survival by treatment after a DCIS diagnosis in a population-based cohort study

Randomized trials have demonstrated the efficacy of radiation and tamoxifen in reducing risk of second events after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS), but the comparative effectiveness of mastectomy, BCS, and adjuvant treatments have not been established in community practice. We examined disease-free survival (DFS) among 1,676 DCIS cases diagnosed during 1995-2006 in the population-based Wisconsin In Situ Cohort study. Information on patient and tumor characteristics, treatments, and second breast cancer events were collected via a comprehensive review of data from patient interviews, the statewide cancer registry, and pathology reports. Breast cancer DFS was evaluated according to treatment while adjusting for patient and tumor characteristics. After an average of 7.1 years of follow-up, 143 second breast cancer events occurred. Overall 5-year DFS was similar among women treated with ipsilateral mastectomy (95.6 %; 95 % CI 93.5-97.0) compared to women treated with BCS and radiation (94.8 %; 95 % CI 92.8-96.1), though women receiving BCS without radiation experienced poorer overall DFS (87.0 %; 95 % CI 80.6-91.5). Women treated with tamoxifen in addition to BCS and radiation had a similar risk of a second breast event, although the hazard ratio (HR) suggested a potential benefit (0.70, 95% CI 0.41-1.19). Women treated with BCS, radiation, and tamoxifen had comparable risk of a second event as those treated with ipsilateral mastectomy (HR = 1.20; 95 % CI 0.71-2.02). In this population-based sample, the use of BCS with radiation and tamoxifen resulted in high DFS rates comparable to those achieved by ipsilateral mastectomy.