Abstract P4-17-06: First posts: A content analysis of an online breast cancer community user's initial postings

Introduction: Online breast cancer communities provide users with both information and emotional support. Members of these communities include both patients and caregivers. We aimed to characterize the differences in content between patients' and caregivers' first posts.

Methods: 20189 posts were downloaded from a public online breast cancer community. Posts were sorted by user name and date to identify unique posters and coded for user demographics and content. Descriptive statistics (e.g. chi-square test) characterized differences between patients and caregivers in terms of topics and content.

Results: Of the 1827 unique posters, 83% were identified as the patient (n=1277, 70%) and 13% were identified as a caregiver (n=230). 835 (69%) patients had been previously diagnosed with breast cancer. Chemotherapy was the most common topic among cancer patients. Patients tended to seek information about physical concerns more often than psychosocial concerns. In contrast, caregivers used the community significantly more often as a source of emotional support (p<.001), although they also sought information on how to best support patients.

Breast Cancer Patients' Topics of ConversationTopicN(%)ExplanationExampleChemotherapy296 (36)Patients discussing the decision for chemotherapy, or their experiences with it.“I was allergic to some of the chemo meds”Radiation255 (31)Patients discussing the decision for radiation, or their experiences with it.“I wanted to answer your query about radiation…”Estrogen Modulating Therapy156 (19)Patients discussing the decision to take estrogen modulating medications (e.g. Tamoxifen) or their experiences with it.“I don't know if I'm going to take this with all the side effects I read.”Surgery55 (7)Patients discussing surgical options for breast cancer treatment (not reconstruction) or experiences with the procedures.“I don't want them to leave half of my breast with a chance for a new diagnosis”Reconstruction49 (6)Patients discussing reconstruction options or experiences with the procedures.“I recently had a TE recon and it went fine but a week later i developed an infection…”

Thematic Content of Posts: Patients v. CaregiversDomainPatients n(%)Caregivers n(%)Chi-Square p-valueExplanationExampleDiscussing Physical Issues234 (29)25 (11)<.001Discussing physical symptoms as a result of cancer or treatment.“I was allergic to some of the chemo meds”Seeking Emotional Support113 (14)34 (15)<.001Poster discusses feeling upset, or directly asks for support.“Thanks for listening to my pity party...”Discussing Psychosocial Issues89 (11)21 (9).165Poster mentions psychological issues including depression or anxiety, or with social sequelae of cancer such as marital difficulties.“I also found help through the use of an antidepressant…I feel like a fog has lifted.”

Conclusion: First post content varied depending on if the poster was a patient or a caregiver. Patients' first posts were often information-seeking about physical concerns, whereas caregivers tended to use the forum as a source of emotional support. By analyzing the frequency of topics and content of posts, clinicians may better understand the educational needs of patients and caregivers.

Citation Format: Marmor RA, Ward EP, Epstein E, Reghunathan M, Schoenbrunner A, Unkart JT, Blair SL, Huh J. First posts: A content analysis of an online breast cancer community user's initial postings [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-17-06.

Abstract OT2-02-03: Magnetic nano-device for identification of the breast sentinel nodes – A novel method

Breast sentinel node biopsy (SNB) is a well-established procedure that has supplanted traditional axillary dissection for most clinically node-negative breast cancer patients. Techniques to identify the draining lymph nodes include colored dyes and radioactive compounds. The Sentimag system uses a non-radioactive magnetic tracer and a handheld magnetic probe to identify sentinel nodes (SNs). The Sentimag Intraoperative Comparison (SentimagIC) study compares the magnetic technique with the standard combination of radioisotope and isosulfan blue dye.

Methods: SiennaXP is a nano device composed of coated iron oxide nanoparticles designed to optimize lymphatic uptake and SN retention. The Sentimag breast SNB technique involves injection of 2cc of SiennaXP fluid into Sappey's subareolar plexus followed by 5 minutes of breast massage and an additional 15 minutes of time to optimize drainage prior to beginning the procedure. The Sentimag hand held probe is then used to identify a magnetic 'hotspot' through the skin of the axilla. The usual transverse axillary incision is made and the magnetometer is used to identify the SNs. The SentimagIC study involves utilizing the Sentimag technique in combination with the 'standard' techniques of isosulfan blue dye and 99technetium sulfur colloid. All blue, radioactive and magnetic SNs are removed and identified as stained blue (from isosulfan blue dye) or black/brown (from SiennaXP) or not, and both radioactive and magnetic counts are taken ex vivo on each node. Currently there are 6 active sites with a total of 60 patients enrolled.

Trial design: This is a pivotal, prospective, open label, multicenter, paired comparison of the magnetic technique with the standard of care for lymph node localization in patients with breast cancer.

Primary endpoints: The lymph node detection rate with SentiMag / SiennaXP and the detection rate with the standard of care; and the safety of Sentimag / SiennaXP as indicated by adverse events.

Eligibility: Diagnosis of primary breast cancer or pure ductal carcinoma in situ (DCIS); Scheduled for sentinel lymph node biopsy; Clinical negative node status (i.e. T0-3, N0, M0).

Statistical methods: The primary hypothesis is that the magnetic technique is non-inferior to the standard technique. Based on an expected detection rate of 95% for both techniques and a non-inferiority margin of 5%, 140 subjects will be required to show non-inferiority with 85% power.

Discussion: SNB for breast cancer is a robust procedure, able to identify the draining lymph nodes of the breast in essentially all patients. Many techniques have been used including radioactive tracers (utilized on most cases) and colored dyes. SentiMag utilizes a unique nano device that can identify the same draining nodes but without the radioactivity used in most procedures. Radioactive dyes must be handled carefully to minimize radiation exposure to healthcare providers and the patient from the manufacturing process, delivery to facility, injection under a nuclear physician license, and the surgical procedure. This novel technique may supplant radioactive tracers allowing SNs to be removed without the patient/healthcare providers being exposed to radiation or the scheduling inconvenience of pre-procedure injection.

Citation Format: Beitsch PD, Hunt KK, Bold RJ, Gittleman MA, Blair SL, Alvarado MD, Harmer QJ. Magnetic nano-device for identification of the breast sentinel nodes – A novel method. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT2-02-03.

Children's participation in household labor: Child socialization versus the need for household labor

Despite the scarcity of studies of children's participation in housework, it has been established that children contribute a significant amount of total household labor. However, research on why some children contribute more than others has yielded ambiguous results. Using data from the National Survey of Families and Households(J. A. Sweet, L. Bumpus, and V. Call [1988], working paper NSFH-1, Center for Demography and Ecology, University of Wisconsin, Madison), this study tests two competing theories of children's labor participation. The first, dealing with child socialization,proposes that parents assign household chores to children as a socializing experience (e.g., to promote responsibility). The second posits that children are used as a labor source whenever structural constraints prevent adults from performing the necessary chores, and alter the demand for household labor.The results indicate that children average 7 hours of housework per week, representing 12% of all household labor. Both theories receive support, yet the pragmatic aspects of households (e.g., adult labor force participation) receive greater confirmation.

Abstract P4-01-13: Practice patterns of MRI utilization for breast cancer treatment within the University of California system as part of the Athena initiative

Background: The appropriate utilization of Breast MRI in breast cancer care remains controversial. As part of a quality improvement initiative for breast cancer screening and treatment, we sent out a survey to physicians who treat breast cancer patients. All respondents are participants in the ATHENA initiative, a program which unites physicians, researchers, and patients at the five University of California medical centers.

Objective: To use the ATHENA infrastructure to perform a qualitative analysis of variations in breast cancer care.

Methods: Surveys were sent to 50 physicians in the ATHENA network whose practices are focused on breast cancer. Respondents were presented with clinical scenarios, and asked whether they would recommend MRI always/usually or sometimes/never. Differences were compared by Chi square.

Results: 39 physicians completed the survey (78% response rate). Of these physicians 29% were surgeons, 26% radiation oncologists and 45% medical oncologists. Athena physicians were more likely to order MRI for high risk screening of mutation carriers than not (85% yes vs. 15% no, p < 0.003) but not based on breast density alone or previous history of breast cancer. They were also more likely to order it for monitoring neo-adjuvant chemotherapy (70% yes vs. 30% no, p < 0.03). Although the majority answered that they would order a Breast MRI for new breast cancer the difference between responses was not significantly different (56% yes vs. 44%, p = 0.07).

Conclusion: Athena physicians follow established published guidelines which demonstrate a benefit for Breast MRI screening for BRCA mutation carriers but not based on density or previous history of breast cancer. The Athena network allows a forum for new practice guidelines to be implemented as data becomes available to improve patient outcomes and utilize the best evidence for patient care, where both the patterns of MRI use as well as the outcomes of practice patterns will be evaluated prospectively.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-01-13.

Advanced age does not contribute to increased risks or poor outcome after major abdominal operations

Elderly patients are still frequently denied major operations out of concerns over increased morbidity. The impact of advanced age on morbidity, mortality, and late outcomes after major gastric and pancreatic resections was studied by retrospective review with Chi square and regression analysis. Between July 1987 and June 2000, 179 patients underwent a major gastrectomy or pancreatectomy procedure at the City of Hope Cancer Center. There were 96 males and 83 females with a median age of 64 years (range 17-97) and elderly subsets more than 70 (n = 53) and more than 80 (n = 18) years of age. Diagnoses included gastric cancer (n = 83, 46%), pancreatic or periampullary cancer (n = 78, 44%), and benign pancreatic (n = 11, 6%) or gastric (n = 7, 4%) conditions. Age >70 years was correlated with more complex underlying medical conditions (P = 0.001) and gastrectomy for cancer (P = 0.01). None of four in-hospital deaths or 11 90-day lethal events occurred in patients >70 years of age (P = 0.005). Overall complications (35% vs 49%) and major complications (25% vs 37%) were less frequent in the older patient group [P = not significant (NS)]. Median intensive care unit stay (3 vs 2 days) and hospital stay (12 vs 12.5 days) were similar (P = NS). Pancreatoduodenectomy, gastrectomy for "benign" indications, and splenectomy--but not age--were significant prognostic variables for increased complications and longer hospital stay (at P < 0.05). At a median follow-up of 13 months (20 for survivors) the median survival after resection for gastric cancer (30 vs 16 months) or pancreatic/periampullary cancer (30 vs 23 months) was not inferior in elderly patients (P = NS). Five-year disease-free survival was superior in gastric cancer patients >70 years (59% vs 26%, P = 0.03) but not for pancreatic cancer. Advanced age under current clinical selection criteria does not impose increased hazards beyond disease- and procedure-related risk factors for patients undergoing gastrectomy or pancreatectomy; no patient should be denied these operations on the basis of age criteria alone.

Outcome of palliative operations for malignant bowel obstruction in patients with peritoneal carcinomatosis from nongynecological cancer

BACKGROUND

Malignant bowel obstruction (MBO) secondary to peritoneal carcinomatosis carries a grave prognosis. We evaluated clinicopathologic factors that predict outcomes after palliative operations for MBO.

METHODS

Data on patients undergoing laparotomy for palliation of gastrointestinal MBO at City of Hope between 1995 and 2000 were retrospectively collected. Successful palliation was defined as the ability to tolerate solid food (TSF).

RESULTS

Sixty-three patients underwent operative treatment. In 20 patients, MBO was the first presentation of disease; for others, the median disease-free interval was 15 months. The complication rate was 44%, and postoperative mortality was 15%. The median length of stay was 12 days. Twenty-nine patients (45%) were discharged from the hospital on a regular diet; 22 (76%) continued to eat until their last follow-up. Median survival was 90 days. Univariate factors for longer survival were TSF on discharge, colorectal primary, and nonmetastatic status at first diagnosis. Patients with ascites and whose cancer first presented with MBO had an inferior survival. Noncolorectal primary remained a multivariate predictor for decreased survival. TSF was predicted by the absence of ascites, an obstruction not involving the small bowel, and a preoperative albumin of >3.0 mg/dl. Multiple logistic regression analysis yielded presence of ascites and small-bowel obstruction as predictors of inability to TSF.

CONCLUSIONS

Only one third of patients with MBO from peritoneal carcinomatosis will have prolonged postoperative palliation with significant, but acceptable, treatment-related morbidity. TSF at discharge is a useful predictor of continued palliation for most patients. Patients with colorectal cancer may have superior survival outcome and better palliation; others are at risk for poor outcomes, especially in the presence of ascites and MBO of small bowel. In these patients, highly selective use of laparotomy is recommended.

Critical care of patients with cancer. Surgical considerations

Surgical evaluation of and therapy for the critically ill cancer patient continue to present significant challenges despite, or perhaps in part because of, an ongoing technologic refinement of therapeutic modalities within a modern ICU.

Pretreatment with IFN-gamma decreases infectious complications after partial hepatectomy in the rat

Infectious postoperative complications occur commonly after hepatectomy and may lead to a long hospital stay or death. The potential beneficial effects of interferon-gamma (IFN-gamma) in this setting were evaluated in a model of hepatectomy and sepsis in rodents. Incidence of bacterial translocation was measured in animals on days 1, 2, and 5 after partial hepatectomy. Macrophage function was quantified by in vitro tumoricidal activity and superoxide anion (O2-) production. Survival after partial hepatectomy and cecal ligation and puncture (CLP) was recorded. After partial hepatectomy, bacterial translocation was decreased on days 1 and 2 in animals pretreated with IFN-gamma (p < 0.05). Macrophages from animals treated with IFN-gamma had higher in vitro tumoricidal activity and production of O2- (p < 0.05). Hepatectomized animals pretreated with IFN-gamma had an increased survival after CLP (p < 0.05). IFN-gamma may be useful in decreasing the incidence of infectious complications after partial hepatectomy.

Surgeon variability in treating nonpalpable breast cancer: surgical oncology as a value-added specialty

BACKGROUND

Several studies have demonstrated a relatively low rate of breast conservation surgery (BCS) in the United States. Few have analyzed the impact of individual surgeon variability on the outcome of the procedure, and none have contrasted surgical oncologists versus general surgeons in the treatment of nonpalpable breast cancer.

METHODS

A blinded review was done of 409 excisions for nonpalpable breast cancer performed by 11 board-certified general surgeons (GS, n = 221) and one surgical oncologist (SO, n = 185) in a teaching institution. We compared surgical margins, need for reexcision, and breast conservation rates.

RESULTS

Although there were no significant differences in patient and tumor characteristics, there were surprising differences between the GS and SO, especially related to surgical margins and final treatment. The SO has a significantly higher rate of frozen section compared to GS (81% vs. 64%, P < 0.01) and a lower rate of positive margin at the time of original biopsy (25% vs. 41%, P < 0.01). These differences translated into lower necessity for reexcision of tumor (18% vs. 48%, P < 0.01) and higher rate of BCS (88% vs. 70%, P < 0.01).

CONCLUSION

This study demonstrates marked differences among trained general surgeons. The additional experience of a surgical oncologist is valuable, because fewer positive margins lead to a higher likelihood of breast preservation and decreased costs related to fewer additional operative procedures.

Multifocal extremity sarcoma: an uncommon and controversial entity

BACKGROUND

The primary site of metastasis from extremity sarcomas is the lung. When patients with extremity sarcoma present with the disease in more than one site but not in the lung, the question of whether the disease is multifocal or metastatic is difficult to resolve.

METHODS

We reviewed 1423 patients admitted with extremity sarcoma from 1982 through 1996. Patient demographics, primary site, other sites, local recurrence, distant metastasis, and survival were analyzed. Statistics were by Fischer exact test, chi 2, Kaplan-Meier method, and log-rank test where appropriate.

RESULTS

Sixteen (1%) patients were identified with multifocal disease out of 1423 patients with extremity sarcoma. There was no difference in sex, age, size, grade, depth, and margins between multifocal and unifocal disease. In a mean follow-up time of 57 months, 50% had local recurrence of primary tumor, 80% had distant metastasis, and only 30% were alive at the time of the analysis. Whereas 21% of all patients with solitary disease develop lung metastasis, 63% of patients with apparent multifocal disease develop lung metastasis. The 5-year disease-specific survival of patients with multifocal disease was not different from that of all patients presenting with metastatic disease to lung.

CONCLUSION

Whether multifocal disease exists or is merely a form of metastasis is unproven by this analysis, but the outcome is the same. Management algorithms should suggest treating patients with multifocal disease as if it is metastatic disease.

Glutathione metabolism in patients with non-small cell lung cancers

Non-small cell lung cancer (NSCLC) is the leading cause of cancer death in the United States. Because NSCLC is highly chemoresistant, it is, usually not treatable. Altered glutathione (GSH) metabolism is thought to be one major mechanism of chemoresistance, and GSH levels are reported to be elevated in NSCLC. The main objective of this study is to delineate the potential mechanisms involved in elevation of tissue GSH, including extraction from the circulation by NSCLC. Twenty consecutive patients with NSCLC were enrolled. At the time of lobectomy, pulmonary artery and vein were identified, and blood flow was measured by an electromagnetic probe. Subsequently, blood samples were drawn from pulmonary artery, the vein draining the tumor-bearing lobe, and a normal lobe. Immediately after lobectomy, tumor and lung specimens were snap frozen. NSCLC tumor specimens had higher levels of GSH compared with lung tissue (20.8 +/- 9.4 versus 11.6 +/- 3.0 nmol/mg protein, respectively; P < 0.05). The tumor demonstrated higher activity of the enzyme gamma-glutamyl transpeptidase, a membrane-bound enzyme involved in transmembrane uptake of GSH, than lung tissue (41.9 +/- 26.4 versus 22.4 +/- 12.3 units/mg protein, respectively; P < 0.05). Also, the tumor-bearing lobe showed elevated extraction of GSH and two of its component amino acids compared with lung tissue (GSH uptake: 0.60 +/- 0.67 versus 0.20 +/- 0.40 microM/min, respectively; P < 0.05). NSCLC tumors are able to extract circulating GSH and its constituent amino acids to synthesize intracellular GSH. Increased activity of gamma-glutamyl transpeptidase may be one mechanism underlying increased GSH uptake by NSCLC.

Oral L-2-oxo-4-thiazolidine reduces bacterial translocation after radiation in the Fischer rat

Glutathione (GSH) is important in protecting rapidly dividing intestinal cells against free radicals generated following radiation. L-2-Oxo-thiazolidine (OTZ) promotes GSH synthesis through increased cysteine delivery. We hypothesize that oral supplementation with OTZ will augment GSH levels and decrease the incidence of bacterial translocation after abdominal radiation, and these effects will be abrogated by treating with a blocker of GSH synthesis, buthionine sulfoximine (BSO). Fischer rats received by oral gavage either OTZ (OTZ/rad), OTZ plus BSO (OTZ/BSO/rad), or saline (sal/rad) 4 hr prior to and 18 hr after radiation. One group underwent saline gavage and no radiation (ctl/sal). On Day 4, animals were sacrificed and mesenteric lymph nodes (MLN) were cultured. Liver and jejunum were removed for GSH analysis by HPLC. Nonradiated, ctl/sal had higher levels of hepatic and jejunal GSH than ctl/rad (13.0 +/- 1.2 vs 9.7 +/- 1.5, 11.2 +/- 1.0 vs 7.8 +/- 2.5 micromol/g dry wt, P < 0.05). Supplementation with OTZ (OTZ/rad) increased hepatic and jejunal GSH levels but treatment with OTZ and BSO (OTZ/BSO/rad) eliminated this benefit (12.0 + 2.6 vs 9.5 + 1.7, 10.1 + 2.4 vs 5.9 + 1.3 micromol/g dry wt, P < 0.05). Ctl/rad had a high rate of positive MLN cultures (80%) compared to ctl/sal and OTZ/rad (10 and 30%, P < 0.05). Treatment with OTZ and BSO (OTZ/BSO/rad vs OTZ/rad, 70 and 30%, P < 0.05) reversed the benefit of OTZ supplementation. This study demonstrated whole abdominal radiation depleted both hepatic and jejunal levels of GSH. Uniquely, OTZ supplementation restored hepatic and jejunal levels of GSH and decreased rate of bacterial translocation.