Disparities in OncotypeDx Testing and Subsequent Chemotherapy Receipt by Geography and Socioeconomic Status

BACKGROUND

OncotypeDx is a prognostic and predictive genomic assay used in early-stage hormone receptor-positive, HER2- (HR+/HER2-) breast cancer. It is used to inform adjuvant chemotherapy decisions, but not all eligible women receive testing. We aimed to assess variation in testing by demographics and geography, and to determine whether testing was associated with chemotherapy.

METHODS

For 1,615 women in the Carolina Breast Cancer Study with HR+/HER2-, Stage I-II tumors, we estimated prevalence differences (PD) and 95% confidence intervals (CI) for receipt of OncotypeDx genomic testing in association with and sociodemographic characteristics. We assessed associations between testing and chemotherapy receipt overall and by race. Finally, we calculated the proportion of eligible women receiving OncotypeDx by county-level rurality, census tract-level socioeconomic status, and Area Health Education Center regions.

RESULTS

38% (N = 609) of potentially eligible women were tested, with lower testing prevalences in Black (31%; PD, -11%; 95% CI, -16%-6%) and low-income women (24%; PD, -20%; 95% CI, -29% to -11%) relative to non-Black and higher income women. Urban participants were less likely to be tested than rural participants, though this association varied by region. Among women with low genomic risk tumors, tested participants were 29% less likely to receive chemotherapy than untested participants (95% CI, -40% to -17%). Racial differences in chemotherapy were restricted to untested women.

CONCLUSIONS

Both individual and area-level socioeconomics predict likelihood of OncotypeDx testing.

IMPACT

Variable adoption of OncotypeDx by socioeconomics and across geographic settings may contribute to excess chemotherapy among patients with HR+/HER2- cancers. See related In the Spotlight, p. 635.

Anti-racism bystander training: A critical need in medical schools

Despite increasing acknowledgment of racism in both the curricular and clinical spaces, it continues to pervade the medical field, with clear detrimental impacts to the health of our patients. The introduction of anti-racism bystander training (ARBT) may provide a unique opportunity to reduce inequitable care and health disparities that occur secondary to racism in healthcare. ARBT, in its various forms, has been shown to be an effective method to increase participants' confidence and efficacy in intervening on observed racist encounters. This training can take numerous forms, and the authors provide one successful template used with medical students at their own institution. If medical centers, educators, and leaders in the field of medicine truly hope to mitigate the individual racist behaviors that remain in healthcare, ARBT must be employed to a much wider degree in medical education.

Simulating the population impact of interventions to reduce racial gaps in breast cancer treatment

BACKGROUND

Inequities in guideline-concordant treatment receipt contribute to worse survival in Black breast cancer (BCa) patients. Inequity-reduction interventions (eg, navigation, bias training, tracking dashboards) can close such treatment gaps. We simulated the population-level impact of statewide implementation of inequity-reduction interventions on racial BCa inequities in North Carolina.

METHODS

Using registry-linked multi-payer claims data, we calculated Black/White inequities in endocrine (ET; n = 12,033) and chemotherapy (CTx; n = 1,819) receipt. We then built cohort- (ET and CTx), and race-stratified Markov models to simulate the potential increase in the proportion of patients receiving ET or CTx and subsequent improvements in BCa outcomes if inequity-reducing intervention were implemented statewide. We report uncertainty bounds representing 95% of simulation results.

RESULTS

75.6% and 72.1% of Black patients received ET and CTx over the 2006-2015 and 2004-2015 periods (vs 79.3 and 78.9% of White patients, respectively). Inequity-reduction interventions could increase ET and CTx receipt among Black patients to 89.9% (85.3, 94.6%) and 85.7% (80.7, 90.9%). Such interventions could also decrease 5-and 10-year BCa mortality gaps from 3.4 to 3.2 (3.0, 3.3) and from 6.7 to 6.1 (5.9, 6.4) percentage points in the ET cohorts and from 8.6 to 8.1 (7.7, 8.4) and from 8.2 to 7.8 (7.3, 8.1) percentage points in the CTx cohorts.

CONCLUSIONS

Inequity-focused interventions could improve cancer outcomes for Black patients. However, they would not fully close the racial BCa mortality gap. Addressing other inequities along cancer continuum (eg, screening, pre-and post-diagnosis risk factors) is required to achieve full equity in BCa outcomes.

Differential response to neoadjuvant endocrine therapy for Black/African American and White women in NCDB

PURPOSE

Compared to White women, there are higher mortality rates in Black/African American (BAA) women with hormone receptor-positive breast cancer (HR + BC) which may be partially due to differences in treatment resistance. We assessed factors associated with response to neoadjuvant endocrine therapy (NET).

METHODS

The National Cancer Database (NCDB) was queried for women with clinical stage I-III HR + BC diagnosed 2006-2017 and treated with NET. Univariate and multivariate analyses described associations between the sample, duration of NET, and subsequent treatment response, defined by changes between clinical and pathological staging.

RESULTS

The analytic sample included 9864 White and 1090 BAA women. Compared to White women, BAA women were younger, had more co-morbidities, were higher stage at presentation, and more likely to have > 24 weeks of NET. After excluding those with unknown pT/N/M, 3521 White and 365 BAA women were evaluated for NET response. On multivariate analyses, controlling for age, stage, histology, HR positivity, and duration of NET, BAA women were more likely to downstage to pT0/Tis (OR 3.0, CI 1.2-7.1) and upstage to Stage IV (OR 2.4, CI 1.002-5.6). None of the women downstaged to pT0/Tis presented with clinical stage III disease; only 2 of the women upstaged to Stage IV disease presented with clinical Stage I disease.

CONCLUSION

Independent of NET duration and clinical stage at presentation, BAA women were more likely to experience both complete tumor response and progression to metastatic disease. These results suggest significant heterogeneity in tumor biology and warrant a more nuanced therapeutic approach to HR + BC.

Barriers to Care Among Sexual and Gender Minority Individuals With Chronic Inflammatory Skin Diseases in the US

Importance

Research on the prevalence of barriers to care among sexual and gender minority (SGM) patients with chronic inflammatory skin diseases (CISDs) in the US is limited.

Objective

To compare the prevalence of cost and noncost barriers to care among SGM and non-SGM patients with CISDs and to analyze the prevalence of barriers based on SGM status and race and ethnicity.

Design, Setting, and Participants

A cross-sectional study of health care access and utilization survey data collected by the National Institutes of Health's All of Us Research Program between May 31, 2017, and July 1, 2022, was conducted. Participants were adults aged 18 years or older with CISDs who enrolled in All of Us directly online or through partner health care practitioner organizations located across the US.

Exposures

Chronic inflammatory skin diseases, sexual orientation and gender identity, and race and ethnicity.

Main Outcome and Measures

The main outcome was the experience of cost and noncost barriers to health care among SGM patients with CISDs. Multivariable logistic regression was used to examine the association of SGM status with experiencing barriers to care.

Results

This study included 19 743 patients with CISDs; 1877 were SGM patients (median age, 40.5 years [IQR, 28.7-57.9 years]; 1205 [64.2%] assigned female sex at birth) and 17 866 were non-SGM patients (median age, 57.1 years [IQR, 40.8-68.1 years]; 13 205 [73.9%] assigned female sex at birth). Compared with non-SGM patients, SGM patients with CISDs were significantly more likely to delay specialist care (adjusted odds ratio [AOR], 1.23; 95% CI, 1.03-1.47), mental health care (AOR, 1.62; 95% CI, 1.37-1.91), and filling a prescription (AOR, 1.30; 95% CI, 1.11-1.52) because of cost. In addition, SGM patients with CISDs were significantly more likely than non-SGM patients to delay care because of transportation issues (AOR, 1.49; 95% CI, 1.22-1.80) and not having a health care practitioner who shares the same background with regard to race and ethnicity, religion, native language, sexual orientation, and gender identity (AOR, 1.39; 95% CI, 1.19-1.62). Sexual and gender minority patients with CISDs were also significantly more likely than non-SGM patients to report not always being treated with respect by their health care practitioners (AOR, 1.47; 95% CI, 1.30-1.65).

Conclusions and Relevance

The findings of this cross-sectional study of survey data suggest that SGM patients with CISDs may be disproportionately affected by cost and noncost barriers to health care. Dermatologists and other health care practitioners caring for SGM patients with CISDs have an important role in helping to address these barriers and larger systemic issues for SGM patients at both the patient and system levels.

Re-imagining metastatic breast cancer care delivery: a patient-partnered qualitative study

PURPOSE

While significant progress in metastatic breast cancer (MBC) treatment has prolonged survival and improved prognosis, there remain substantial gaps in providing patient-centered supportive care. The specific care delivery needs for metastatic cancer differ from that of early-stage cancer due to the incurable nature and lifelong duration of the condition. The objective of this study was to assess how patients living with MBC would re-imagine cancer care delivery.

METHODS

This qualitative study was conducted in partnership with patient-led organizations Guiding Researchers and Advocates to Scientific Partnerships (GRASP) and Project Life, a nonprofit, online wellness community founded by patients with MBC for patients living with MBC. Virtual semi-structured interviews (n = 36) were conducted with Project Life members purposively sampled from the groups' overall membership. The interview guide contained items surrounding patients' lived experiences of MBC, greatest unmet needs related to care, and perspectives on virtual wellness community involvement. Interviews were coded using two-stage deductive and inductive analysis.

RESULTS

Three major themes for re-imagining cancer care delivery were identified, including holistic care, information needs, and conceptual shifts. Within these several subthemes emerged with patients re-imagining referrals to non-oncological services, caregiver support, acceptance of integrative medicine, streamlined clinical trial enrollment, curated quality patient resources, MBC-specific terminology and approaches, long-term life and goal-of-care planning, and patient-centered voice throughout.

CONCLUSION

People living with metastatic cancers have specific supportive care needs. These findings highlight patient-driven areas for re-imagination that are most salient for individuals with MBC.

From Race to Racism and Disparities to Equity: An Actionable Biopsychosocial Approach to Breast Cancer Outcomes

PURPOSE

Racial disparities in outcomes of breast cancer in the United States have widened over more than 3 decades, driven by complex biologic and social factors. In this review, we summarize the biological and social narratives that have shaped breast cancer disparities research across different scientific disciplines in the past, explore the underappreciated but crucial ways in which these 2 strands of the breast cancer story are interwoven, and present 5 key strategies for creating transformative interdisciplinary research to achieve equity in breast cancer treatment and outcomes.

DESIGN

We first review the key differences in tumor biology in the United States between patients racialized as Black versus White, including the overrepresentation of triple-negative breast cancer and differences in tumor histologic and molecular features by race for hormone-sensitive disease. We then summarize key social factors at the interpersonal, institutional, and social structural levels that drive inequitable treatment. Next, we explore how biologic and social determinants are interwoven and interactive, including historical and contemporary structural factors that shape the overrepresentation of triple-negative breast cancer among Black Americans, racial differences in tumor microenvironment, and the complex interplay of biologic and social drivers of difference in outcomes of hormone receptor positive disease, including utilization and effectiveness of endocrine therapies and the role of obesity. Finally, we present 5 principles to increase the impact and productivity of breast cancer equity research.

RESULTS

We find that social and biologic drivers of breast cancer disparities are often cyclical and are found at all levels of scientific investigation from cells to society. To break the cycle and effect change, we must acknowledge and measure the role of structural racism in breast cancer outcomes; frame biologic, psychosocial, and access factors as interwoven via mechanisms of cumulative stress, inflammation, and immune modulation; take responsibility for the impact of representativeness (or the lack thereof) in genomic and decision modeling on the ability to accurately predict the outcomes of Black patients; create research that incorporates the perspectives of people of color from inception to implementation; and rigorously evaluate innovations in equitable cancer care delivery and health policies.

CONCLUSIONS

Innovative, cross-disciplinary research across the biologic and social sciences is crucial to understanding and eliminating disparities in breast cancer outcomes.

Breast Cancer Germline Genetic Counseling and Testing for Populations of African Heritage Globally: A Scoping Review on Research, Practice, and Bioethical Considerations

PURPOSE

Despite the disproportionately high risk of breast cancer among women of African heritage, little is known about the facilitators and barriers to implementing germline genetic testing and counseling (GT/C).

METHODS

This scoping review followed guidelines recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Published manuscripts from database inception through 2021 were sourced from PubMed, Cumulative Index to Nursing and Allied Health Literature via EBSCO, Embase, Cochrane Library, and Scopus. Search terms were used to retrieve articles addressing (1) African heritage, (2) breast cancer, and (3) GT or GC. The screening involved abstract and title review and full-text review. Data were extracted for all articles meeting the inclusion criteria.

RESULTS

A total of 154 studies were included. Most studies that took place were conducted in the United States (71.4%), and most first authors (76.9%) were from the United States. GT was conducted in 73 (49.7%) studies. BRCA1/BRCA2 were the most commonly studied genes for germline mutations. GC was conducted in 49 studies (33.3%), and perspectives on GC were evaluated in 43 (29.3%). The use of racial/ethnic categories varied broadly, although African American was most common (40.1%). Racism was mentioned in three studies (2.0%).

CONCLUSION

There is a growing body of literature on GT/C for breast cancer in women of African heritage. Future studies on GT/C of African populations should consider increased clarity around racial/ethnic categorizations, continued community engagement, and intentional processes for informed consent.

Risk of Mortality After a Diagnosis of Melanoma In Situ

Importance

The incidence of melanoma in situ (MIS) is increasing more rapidly than any invasive or in situ cancer in the US. Although more than half of melanomas diagnosed are MIS, information about long-term prognosis following a diagnosis of MIS remains unknown.

Objective

To evaluate mortality and factors associated with mortality after a diagnosis of MIS.

Design, Setting, and Participants

This population-based cohort study of adults with a diagnosis of first primary MIS from 2000 to 2018 included data from the US Surveillance, Epidemiology, and End Results Program, which were analyzed from July to September 2022.

Main Outcomes and Measures

Mortality after a diagnosis of MIS was evaluated using 15-year melanoma-specific survival, 15-year relative survival (ie, compared with similar individuals without MIS), and standardized mortality ratios (SMRs). Cox regression was used to estimate hazard ratios (HRs) for death by demographic and clinical characteristics.

Results

Among 137 872 patients with a first-and-only MIS, the mean (SD) age at diagnosis was 61.9 (16.5) years (64 027 women [46.4%]; 239 [0.2%] American Indian or Alaska Native, 606 [0.4%] Asian, 344 [0.2%] Black, 3348 [2.4%] Hispanic, and 133 335 [96.7%] White individuals). Mean (range) follow-up was 6.6 (0-18.9) years. The 15-year melanoma-specific survival was 98.4% (95% CI, 98.3%-98.5%), whereas the 15-year relative survival was 112.4% (95% CI, 112.0%-112.8%). The melanoma-specific SMR was 1.89 (95% CI, 1.77-2.02); however, the all-cause SMR was 0.68 (95% CI, 0.67-0.7). Risk of melanoma-specific mortality was higher for older patients (7.4% for those 80 years or older vs 1.4% for those aged 60-69 years; adjusted HR, 8.2; 95% CI, 6.7-10.0) and patients with acral lentiginous histology results (3.3% for acral lentiginous vs 0.9% for superficial spreading; HR, 5.3; 95% CI, 2.3-12.3). Of patients with primary MIS, 6751 (4.3%) experienced a second primary invasive melanoma and 11 628 (7.4%) experienced a second primary MIS. Compared with patients without a subsequent melanoma, the risk of melanoma-specific mortality was increased for those with a second primary invasive melanoma (adjusted HR, 4.1; 95% CI, 3.6-4.6) and was decreased for those with a second primary MIS (adjusted HR, 0.7; 95% CI, 0.6-0.9).

Conclusions and relevance

The results of this cohort study suggest that patients with a diagnosis of MIS have an increased but low risk of melanoma-specific mortality and live longer than people in the general population, suggesting that there is significant detection of low-risk disease among health-seeking individuals. Factors associated with death following MIS include older age (≥80 years) and subsequent primary invasive melanoma.

Abstract 1939: Evaluating treatment data concordance among young Black women diagnosed with breast cancer

Background: There have been renewed calls for greater inclusivity of populations most prominently affected by cancer health inequities across the cancer research enterprise, particularly Black and African American populations. In cancer health services research there are myriad methodologies and data sources to study cancer treatment outcomes including medical records, cancer registries, and primary data collection. These different methodologies have varying levels of resource intensity that may affect the recruitment of marginalized populations. Little is known about how much concordance between data sources may exist among marginalized populations with cancer, which has substantial implications for cancer inequities research.

Objective: To evaluate the data concordance between medical records, cancer registries, and self-reported survey data among an underrepresented population in cancer population sciences research.

Methods: This investigation used a population-based sample of self-identified Black women recruited through the Tennessee and Florida Cancer registries who were diagnosed with invasive breast cancer at or below the age of 50. Participants completed medical records release forms and questionnaires about their cancer treatment trajectories. Comparing data contained in the cancer registries, medical records, and self-reported data, we quantitatively assessed the concordance between data sources for receipt of surgery, chemotherapy, and radiation, using medical records as the gold standard.

Results: In total, 558 Black women at or below 50 with invasive breast cancer had available registry data and also completed a medical records release. In terms of missing data for receipt of surgery, chemotherapy, and radiation, self-report was the most complete, followed by the registry and then the medical records. Among those with complete data, comparing the medical records to the cancer registry, accuracy was high for surgery (94.6% ; 95% CI 92.2, 96.4) and chemotherapy (89.7%; 95% CI: 85.7, 92.8) , but low for radiation (55.4%, 95% CI: 48.5, 62.2) with the cancer registry missing the receipt of radiation that was noted in the medical records. Comparing medical records to self-report data, accuracy was >90% for surgery, chemotherapy, and radiation. Comparing the cancer registry to self-report, accuracy was high for surgery (94.5%; 95% CI: 92.0, 96.4), moderate for chemotherapy (88.2; 95% CI: 85.1,90.9), and low for radiation (67.2%; 95% CI 62.9, 71.3).

Conclusion: For receipt of surgery and chemotherapy, there was high concordance between medical records, cancer registries, and self-reported data. The receipt of radiation was inconsistently reported in the cancer registry and medical records. When considering inclusivity in the study of cancer services delivery among marginalized populations, tradeoffs of data validity and resource intensity must be weighed.

Citation Format: Mya L. Roberson, Lindsay Venton, Anne Weidner, Sonya Reid, Tuya Pal. Evaluating treatment data concordance among young Black women diagnosed with breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1939.

Receipt of Bilateral Mastectomy Among Women With Hereditary Breast Cancer

This case series study examines differences in surgical treatment among adult females with invasive breast cancer who have pathogenic or likely pathogenic variants in genes with high vs moderate breast cancer penetrance.

A Qualitative Study of the Impact of the COVID-19 Pandemic on Metastatic Breast Cancer Care

The COVID-19 pandemic substantially impacted the delivery of oncology care, particularly for individuals with metastatic cancers. The objective of this study was to qualitatively evaluate the impacts of COVID-19 on metastatic breast cancer (MBC) care among patients. This study consisted of 36 semi-structured qualitative interviews conducted virtually with people living with MBC, who were members of a patient support organization called Project Life. Project Life is an MBC patient-led, web-based wellness community. Responses were analyzed using Phronetic Iterative Analysis. Interviews were conducted from March 14, 2022, to May 31, 2022. Analysis from 36 individual in-depth qualitative interviews revealed the following themes during COVID-19: (1) variable preferences for telehealth (2) disruptions to care, (3) virtualization of social care. Wide variations existed in preferences surrounding telehealth, centered around ideas of convenience. Disruptions to care included delays to diagnostic care, isolation from caregivers, and interruptions associated with COVID-19 infection. These results call for adaptability in oncology care given wide-ranging preferences on telehealth and the shifting of available support services.

Reimaging metastatic breast cancer care delivery: A patient-partnered qualitative investigation

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Background: Treatment advances for metastatic breast cancer (MBC) have markedly increased survival over the last several decades. Despite the clinical innovation that has occurred, there remains substantial fragmentation of care and lack of focused attention on MBC survivorship care. This study partnered with Project Life, an MBC-survivor led patient wellness community to assess MBC patient experiences with treatment experiences and social support services. Methods: We conducted, virtual, in-depth semi-structured qualitative interviews among people who were members of the Project Life Wellness community. The interview guide and study materials were developed in collaboration with Project Life leadership. A study flyer was distributed by Project Life to members that included a link to an eligibility survey. Participants were eligible if they self-identified as having MBC, were a member of the Project Life community, and could complete the interview in English. As part of the interview, we asked, “How would you re-imagine medical care for people with metastatic breast cancer?” We then systematically processed responses with phronetic iterative analysis, using the mixed-methods research software MAXQDA, to uncover contextually grounded, emergent themes through synthetic coding. Results: We interviewed 36 women with MBC who were members of the Project Life Wellness Community in Spring 2022. In terms of age, 8 (22%) participants were 30-45, 15 (42%) were 46-59, and 13 (36%) were 60+. Overall, 22% of participants identified as people of color (Black, Latina, or Asian). In response to how they would reimagine MBC care delivery, all participants touched upon dimensions of care coordination. Aspects of care coordination that participants specifically raised included 1) Organized referral processes for non-oncology care like mental health services, sexual health care, and palliative care; 2) The need for MBC-specific support services within the care setting; 3)Patient connection to psychosocial aspects of care including social work and patient navigation; 4) Streamlined processes for identifying and enrolling in clinical trials. Conclusions: In our investigation, when asked how they would reimagine MBC care delivery, participants overwhelmingly endorsed the need for more care coordination along several key domains. Responses highlighted the unique needs of care coordination specific to MBC patients. Future care innovations should center patient voices to ensure optimal impact.

Structural Racism and Cancer: Calls to Action for Cancer Researchers to Address Racial/Ethnic Cancer Inequity in the United States

As leaders with the American Society of Preventive Oncology (ASPO) Cancer Health Disparities Special Interest Group, we describe the role of structural racism in perpetuating cancer health inequity historically, and potential implications of COVID-19 in exacerbating the effects of structural racism on patients with cancer seeking screening, diagnostic care, treatment, and survivorship support. As a strategy to reduce cancer inequities in the United States, we provide the following calls to action for cancer researchers to help alleviate the burden of structural racism: (i) identify and name structural racism while describing its operation within all aspects of scientific research; (ii) comprehensively integrate discussions on structural racism into teaching, mentoring, and service activities; and (iii) understand and support community actions to address structural racism.

Validity of breast cancer surgery treatment information in a state-based cancer registry

PURPOSE

Surgery is an important part of early stage breast cancer treatment that affects overall survival. Many studies of surgical treatment of breast cancer rely on data sources that condition on continuous insurance coverage or treatment at specified facilities and thus under-sample populations especially affected by cancer care inequities including the uninsured and rural populations. Statewide cancer registries contain data on first course of cancer treatment for all patients diagnosed with cancer but the accuracy of these data are uncertain.

METHODS

Patients diagnosed with stage I-III breast cancer between 2003 and 2016 were identified using the North Carolina Central Cancer Registry and linked to Medicaid, Medicare, and private insurance claims. We calculated the sensitivity, specificity, positive predictive value, negative predictive value, and Kappa statistics for receipt of surgery and type of surgery (breast conserving surgery or mastectomy) using the insurance claims as the presumed gold standard. Analyses were stratified by race, insurance type, and rurality.

RESULTS

Of 26,819 patients who met eligibility criteria, 23,125 were identified as having surgery in both the claims and registry for a sensitivity of 97.9% (95% CI 97.8%, 98.1%). There was also strong agreement for surgery type between the cancer registry and the insurance claims (Kappa: 0.91). Registry treatment data validity was lower for Medicaid insured patients than for Medicare and commercially insured patients.

CONCLUSIONS

Cancer registry treatment data reliably identified receipt and type of breast cancer surgery. Cancer registries are an important source of data for understanding cancer care in underrepresented populations.

Justice-Involved Women and Cervical Cancer Disparities: Issues of Surveillance, Education, and Policy

Incarceration affects an increasing number of women in the United States. For current and formerly incarcerated women (justice-involved women), incarceration has implications for health, particularly the reproductive health of women, long after incarceration is over. Currently, justice-involved women have a high cervical cancer burden relative to the general population, resulting in substantial disparities in incidence and outcomes. In this article, we review the surveillance, education, and resulting policy issues that contribute to incarceration being a determinant of cervical cancer disparities and present a potential model for continuity of care to reduce such inequity.

Performance of ABCD-10 and SCORTEN mortality prediction models in a cohort of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis

BACKGROUND

Age, bicarbonate, cancer, dialysis, 10% body surface area risk model (ABCD-10) has recently been proposed as an alternative to the SCORe of toxic epidermal necrolysis (SCORTEN) model for predicting in-hospital mortality in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). In contrast to SCORTEN, ABCD-10 incorporates prior dialysis and upweights the impact of cancer.

OBJECTIVE

To determine the performance of ABCD-10 compared with that of SCORTEN in mortality prediction at a large, tertiary burn center.

METHODS

A retrospective analysis of 192 patients with SJS/TEN admitted to the North Carolina Jaycee Burn Center from January 1, 2009, to December 31, 2019, was conducted. Data on these patients were collected using the burn registry and a manual chart review. The performance of both the mortality prediction models was assessed using univariate logistic regression and the Hosmer-Lemeshow test.

RESULTS

The overall mortality was 22% (n = 43). Nine (5%) patients had cancer, and 7 (4%) had undergone prior dialysis; neither factor was associated with mortality (P = .11 and P = .62, respectively). SCORTEN was well calibrated to predict inpatient mortality (P = .82), whereas ABCD-10 appeared to have a poorer fit (P < .001) in these patients. Both the models showed good discrimination.

LIMITATIONS

Small sample size.

CONCLUSION

SCORTEN was a better predictor of inpatient mortality than ABCD-10 in a North American cohort of patients treated at the tertiary burn center.

Abstract C052: Premenopausal oophorectomy and survival among women with breast cancer: Evidence of effect measure modification by family history status

In the US, bilateral oophorectomies are frequently performed before menopause for one of two reasons: 1) in concert with hysterectomy for benign gynecologic conditions or 2) prevention of breast or ovarian cancer risk and mortality. Prior literature has consistently shown a reduction in breast cancer-specific mortality among women who had premenopausal hysterectomy with bilateral oophorectomy (H +BO) prior to their breast cancer diagnosis. The present study sought to assess whether the relationship between prediagnosis premenopausal H + BO and breast cancer-specific mortality differed by family history status in women with breast cancer. It is hypothesized that women who may have prognostically different breast cancer due to having family history disproportionately benefit from premenopausal H+ BO compared to more average-risk women with no family history. This study analyzed data from Phases 1 and 2 of the Carolina Breast Cancer Study (CBCS), a population-based study of Black and White women prospectively identified in central and eastern North Carolina with newly diagnosed breast cancer between 1993 and 2001. Women with invasive breast cancer with known gynecologic surgical status were included (n=1,723). Gynecologic surgery was defined as: no surgery; hysterectomy with bilateral oophorectomy (H+BO); hysterectomy with conservation of ≥1 ovary (H + OC). Cause-specific mortality was ascertained using the National Death Index, last updated in 2016. Hazard ratios (HR) and 95% confidence intervals (CI) for breast cancer-specific mortality were estimated with Cox proportional hazard models. Models were then stratified by family history status, the self-reporting of one or more first-degree relatives with a family history of breast cancer. Models were adjusted for race, age at diagnosis, smoking, alcohol use, menopausal hormone therapy use and reproductive history factors. All participants still living at the end of follow-up were right censored. Among 1,723 women in the sample, 44% (n=759) were Black and 56% (n=964) were White. There were 836 deaths, of which 447 were from breast cancer. In this population, 74.1% (n=1,276) of women reported having no previous premenopausal gynecologic surgery, 8.8% (n=152) reported having H + BO and 17.1% (n=295) reported H + OC. Compared to women who had not had premenopausal gynecologic surgery, the overall adjusted HR for breast cancer-specific mortality associated with H+BO was 0.68 (95% CI: 0.49,0.96) and 0.90 (95% CI: 0.72,1.12) for women with H+OC. In models stratified on family history, the HR for women with H+BO was 0.11 (95% CI: 0.03,0.42) for those with family history and 0.90 (95% CI: 0.63, 1.29) for those without. The HR for women with family history who had H+ OC was 0.77 (95% CI: 0.45, 1.29) and 0.90 (95% CI: 0.63,1.29) for women without. This study suggests that the overall protective relationship observed between premenopausal hysterectomy with bilateral oophorectomy and breast-cancer specific mortality may be driven by a small subset of especially high-risk women.

Citation Format: Mya L. Roberson, Whitney R. Robinson, Hazel B. Nichols, Andrew F. Olshan, Melissa A. Troester. Premenopausal oophorectomy and survival among women with breast cancer: Evidence of effect measure modification by family history status [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C052.

The influence of peer and parental norms on first-generation college students' binge drinking trajectories

INTRODUCTION

First-generation college students are those whose parents have not completed a four-year college degree. The current study addressed the lack of research on first-generation college students' alcohol use by comparing the binge drinking trajectories of first-generation and continuing-generation students over their first three semesters. The dynamic influence of peer and parental social norms on students' binge drinking frequencies were also examined.

METHODS

1342 college students (n = 225 first-generation) at one private University completed online surveys. Group differences were examined at Time 1, and latent growth-curve models tested the association between first-generation status and social norms (peer descriptive, peer injunctive, parental injunctive) on binge drinking trajectories.

RESULTS

Overall, binge drinking frequency tended to decline over the first three semesters of college. After controlling for demographics, substance-free dormitory residence, parental alcohol problems and norms, first-generation status was associated with steeper declines in binge drinking frequency. During the first semester, the association between parental injunctive norms and binge drinking frequency was stronger for first-generation students than for continuing-generation students; this influence declined over time for first-generation students. The influence of peer descriptive norms on binge drinking increased for continuing-generation students; while this influence remained stable over time for first-generation students.

CONCLUSIONS

First-generation student status appears to be protective against binge drinking. Substance-free dormitory residence, and perceived parental and peer norms likely play a role in first-generation students' tendency to engage in binge drinking less often over the first year of college.

Premenopausal gynecologic surgery and survival among black and white women with breast cancer

PURPOSE

In the United States, hysterectomies and oophorectomies are frequently performed before menopause for benign conditions. The procedures are associated with reduced breast cancer-specific mortality among White women. The relationship between premenopausal gynecologic surgery and mortality in Black women with breast cancer is unknown.

METHODS

This investigation used incident invasive cases of breast cancer from Phases 1 and 2 of the Carolina Breast Cancer Study a population-based study that recruited Black and White women in North Carolina between 1993 and 2001. Premenopausal gynecologic surgery was operationalized in three categories: no surgery; hysterectomy with bilateral oophorectomy; hysterectomy with conservation of ≥ 1 ovary. Mortality was ascertained using the National Death Index, last updated in 2016. Multivariable-adjusted Cox Proportional Hazard Models were used to estimate the effect of premenopausal surgery on breast cancer-specific and all-cause mortality RESULTS: Hysterectomy with bilateral oophorectomy was associated with reduced breast cancer-specific mortality (HR 0.68; 95% CI 0.49, 0.96). White and Black women had a similar reduction in breast cancer-specific mortality. (HR among white: 0.66; 95% CI 0.43, 1.02), (HR among Black: 0.67; 95% CI 0.37, 1.21).

CONCLUSIONS

There was a similar reduction in breast cancer-specific mortality following premenopausal, pre-diagnosis hysterectomy with bilateral oophorectomy across both Black and White women.

Reported use of autotransfusion systems in initial resuscitation areas by one hundred thirty-six United States hospitals

INTRODUCTION

The purpose of this study was to determine autotransfusion system availability and use in the initial resuscitation area.

METHODS

A 22-item questionnaire was mailed to 290 facilities across the country; 136 (46.8%) were returned. Questions included availability and use of the autotransfusion system, patient population, resistance to the system, frequency of in-service programs, use of anticoagulants, and recommendations regarding the use of autotransfusion systems.

RESULTS

One hundred seven hospitals (79%) reported autotransfusion system availability. Frequency of autotransfusion system initiation was as follows: always, 17 (15.9%); most of the time, 34 (31.8%); occasionally, 41 (38.3%); and never, 15 (14%). Not all patients who had an autotransfusion system initiated received shed blood. The most frequent reasons for not using an autotransfusion system were as follows: "not requested by medical staff," n = 50; "no need for autotransfusion system," n = 33; "preferred banked blood," n = 25; and "did not use [often] enough to maintain skill," n = 21. Those with more than one in-service program per year were more likely to use an autotransfusion system than those with one in-service program per year.

DISCUSSION

The majority of hospitals surveyed had autotransfusion system availability; however, autotransfusion system use was inconsistent. Two major areas influencing autotransfusion system use were having specific criteria for use and educational factors.