Potential tools for predicting response to chemotherapy in OC: Assessment of immune dysbiosis, participant's self-rated health and microbial dynamics

Epithelial ovarian cancer (OC) is the deadliest female reproductive cancer; an estimated 13,270 women will die from OC in 2023. Platinum-based chemotherapy resistance mechanisms contribute to poor OC 5-year survival rates. Peripheral inflammation is linked to various disease states and we previously identified unique peritoneal microbial features predictive of OC. We hypothesized that unique peripheral immune profiles and peritoneal microbial features may be predictive of disease-free interval (time to recurrence) and response to chemotherapy in participants with OC. We also investigated self-rated health (SRH) scores in the context of peripheral inflammation as a potential screening tool for OC. Blood and peritoneal fluid were collected from participants with OC or a benign adnexal mass (BPM). Lymphocyte populations were analyzed using Fluorescence Activated Cell Sorting, serum cytokine levels were analyzed using the Human Th17 Magnetic Bead Panel assay and peritoneal fluid microbial features were analyzed using Next Generation Sequencing (NGS). Participants completed a standardized questionnaire on self-rated physical and emotional health. Participants were classified into three chemotherapy response categories: platinum-refractory, platinum-resistant or platinum-sensitive. A significant positive correlation was found between elevated inflammatory status on the day of surgery and longer disease-free interval. SRH measures did not correlate with immune status in participants with OC or a BPM. We identified a correlation between peritoneal microbial features and chemotherapy response. We conclude that immune dysbiosis may be useful in predicting OC recurrence. The immune findings reported here set the framework for additional studies utilizing immune profiles to predict platinum-based chemotherapy responsiveness in OC.

Urinary bother, Urinalysis, and Two-Year Efficacy Follow-Up Results of Phase I Trial of Intravesical Bacillus Calmette-Guérin Combined with Intravenous Pembrolizumab in Recurrent or Persistent High-Grade Non-Muscle-Invasive Bladder Cancer after Previous Bacillus Calmette-Guérin Treatment

OBJECTIVE

To report urinary bother, urinalysis changes, disease-free survival (DFS), and overall survival (OS) over 2 years for subjects enrolled in a phase I dose-escalation trial (NCT02324582) of intravesical Bacillus Calmette-Guérin (BCG) in combination with systemic pembrolizumab for recurrent or persistent high-grade non-muscle invasive bladder cancer (HGNMIBC).

METHODS

Eighteen patients consented to the study. Five were screen failures. Clinical activity was determined using cystoscopy and cytology with a biopsy of suspicious lesions. Urinalysis and International Prostate symptom score were assessed at pre-treatment, Week 10 (during combined BCG and pembrolizumab treatment), and 3 and 6 months from treatment completion. IPSS was analyzed using a mixed-model repeated measures analysis. A Chi-square test was used to compare urinalysis results at each interval.

RESULTS

The pathologic disease stage after restaging transurethral resection and before treatment was pTa in 6 (46.2%), CIS in 6 (46.2%), and pT1 in 1 (7.7%). There was no increase in reported urinary bother throughout treatment. Quality of life measurements demonstrated no change in subjective burden. On urinalysis, we did not observe significant differences at 3 months compared to baseline evaluation. At 12 months, the DFS and OS were 69.23% and 92.31%, respectively. At 24 months, the DFS and OS were 38.46% and 92.31%, respectively.

CONCLUSIONS

Treatment with BCG combined with intravenous pembrolizumab is not showing increased urinary bother or adverse urinalysis changes. Two-year response data is promising and await confirmation in the phase III study (Keynote 676).

Quality of life following treatment with intra-arterial cisplatin with concurrent radiation and erlotinib for locally advanced head and neck cancer

OBJECTIVES

Studies that focus on the feasibility of using erlotinib plus chemoradiation to treat locally advanced head and neck cancer have given hints of improved survival outcomes compared to chemoradiation alone. However, the influence of this treatment regimen on the quality of life of the patients has not been documented. We conducted a study of this triple combination and now have documented follow-up survival data as well as long-term quality of life (QoL) measures.

METHODS

Three sets of QoL questionnaires were given to patients with a diagnosis of head and neck cancer at two time points, pre- and post-treatment, to assess differences in quality of life after receiving chemotherapy with intra-arterial (IA) cisplatin (150 mg/m2), concomitant radiation (70 Gy), and oral erlotinib (150 mg/day). Additionally, patients were followed for a total of 5 years.

RESULTS

Treatment had a detrimental effect on appearance, taste, and saliva domain scores in their QoL questionnaires. Nonetheless, fewer patients reported pain and anxiety.

SIGNIFICANCE OF RESULTS

The combination of erlotinib with chemoradiation produced similar adverse effects on the QoL scores of patients with head and neck cancer as compared to chemoradiation alone.

Impact of cytotoxic chemotherapy on aldo-keto reductase family 1 member B10 expression

OBJECTIVE

Aldo-keto reductase family 1 member B10 (AKR1B10) is a protein that is produced and secreted by a significant number of breast cancers. However, a potential confounder to the use of AKR1B10 as a tumor marker is its elevation in patients given cytotoxic chemotherapy. We therefore conducted a prospective study to analyze AKR1B10 levels in patients with breast cancer receiving neoadjuvant cytotoxic chemotherapy.

METHODS

The study enrolled 10 patients from November 2015 to July 2017. All patients had locally advanced, but non-metastatic, breast cancer, and they received neoadjuvant chemotherapy followed by surgery. Serum AKR1B10 levels and tumor imaging were assessed before, during, and after chemotherapy.

RESULTS

No increase in serum AKR1B10 levels was noted in patients receiving chemotherapy whose levels were elevated at diagnosis.

CONCLUSION

The findings are complex, but the overall data suggest that AKR1B10 is suitable as a tumor marker in patients with elevated levels at the time of diagnosis.

Urban-rural kidney cancer disparities: The role of health literacy, cancer literacy, smoking status, and urinary bother

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Background: Kidney cancer (KCa) does not currently have efficacious screening methods, therefore targeting modifiable risk factors is a strong approach to primary prevention. Prior research from our group identified a significant difference in KCa incidence and mortality between the urban and rural populations in Illinois, but the reason(s) for this geographic variation were unclear. The objective of this pilot study was to investigate KCa-relevant knowledge and health behaviors in order to explain our observed urban-rural differences in KCa incidence and mortality, and to inform approaches to KCa prevention. Methods: A convenience sample was surveyed from five study sites between June 2016 and February 2018. These included 207 urban and 53 rural patients presenting at urology and primary care clinics. Four outcome measures related to KCa were assessed using validated measures: 1) health literacy, 2) cancer health literacy, 3) smoking status and knowledge of its association with KCa, and 4) degree of bother caused by urologic symptoms. Multivariate logistic regression models were used to examine these outcome measures between the two populations. Smoking history, personal and family history of cancer, and socio-demographic characteristics were controlled for in the analysis. Results: The overall model for predicting health literacy was significant (Wald Pvalue = 0.0269). When accounting for all covariates, rural versus urban residence was not a significant predictor of adequate health literacy (p = 0.4871). However, participants with higher levels of education (p = 0.0005), higher household income (p = 0.0395), and participants who were female (p = 0.0104) were all more likely to have adequate vs. low health literacy. We did not identify a statistically significant difference in cancer health literacy, knowledge of smoking as a KCa risk factor, or measurement of urinary bother between urban and rural residents in this population. Conclusions: The analyses revealed significant differences in health literacy by education, income, and gender, but not by geographic location. While there were no statistically significant geographical differences found in three of our four domains, this may have been attributed to the low proportion of rural-residing clinic patients recruited in this study. With potential limitations of using RUCA as a measure of rurality, future work is needed to better reach this population and validate results to understand the disparity of improving KCa outcomes in rural areas.

Assessment of changes in the international prostate symptom score for patients enrolled in a phase I trial of intravesical bacillus Calmette-Guérin combined with intravenous pembrolizumab for recurrent or persistent high-grade non-muscle-invasive bladder cancer after previous bacillus Calmette-Guérin treatment

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Background: We conducted the first phase I dose-escalation trial (NCT02324582) of intravesical Bacillus Calmette-Guérin (BCG) in combination with systemic pembrolizumab in patients with high-grade non-muscle-invasive bladder cancer who had persistent or recurrent disease after prior intravesical therapy with BCG. The International Prostate Symptom Score (IPSS) were administered to assess subjects’ urinary bother during the trial. Methods: Eighteen subjects were consented for the study, 13 were treated. The study population was comprised of 11 males, 2 females, with age range 42 - 92 years. The IPSS was assessed at pre-treatment, Week 10 (during combined BCG and pembrolizumab treatment), and at 3 and 6 months from treatment completion. IPSS outcomes were analyzed using a mixed-model repeated measures analysis with p-value < 0.05 considered statically significant. Results: For each time point, there was no significant change in any of the component variables of the IPSS. There was no increase in reported bother symptoms over the course of treatment, given median IPSS scores of 9, 11, 7, and 8 (IQR 1.75) for each time point, respectively. Furthermore, quality of life measurements demonstrated no significant change in subjective burden with 75% of subjects reporting that they were “mostly satisfied” with treatment outcomes, followed by 13% reporting “delighted” or “pleased” at 6 month follow-up. Conclusions: There is no significant change in quality of life or the perceived bother of symptoms indicated in the component variables of the IPSS for our study population before, during or after treatment.

Comparison of Using Intraoperative Computed Tomography-Based 3-Dimensional Navigation and Fluoroscopy in Anterior Cervical Diskectomy and Fusion for Cervical Spondylosis

OBJECTIVE

Anterior cervical diskectomy and fusion (ACDF) is a highly successful procedure to treat spinal cord or nerve root compression; however, complications can still occur. With advancements in imaging, 3-dimensional (3D) reconstruction allows real-time instrument tracking in a surgical field relative to the patient's anatomy. Here, we compare plate positioning and short-term outcomes when using 3D navigation to fluoroscopy in ACDF for degenerative spine disease.

METHODS

All ACDFs for cervical spondylosis performed by 6 surgeons at a single center between 2010 and 2018 were included. ACDFs were divided into those performed using 3D navigation or fluoroscopy. Records were assessed for patient demographics, American Society of Anesthesiology score, number of operated interspaces, operative time, length of stay, perioperative complications, and 90-day readmissions. Postoperative images were reviewed for lateral and angular plate deviations.

RESULTS

A total of 193 ACDFs performed with 3D navigation and 728 performed with fluoroscopy were included. After controlling for demographics and surgical characteristics, using 3D navigation was associated with less lateral plate deviation (P = 0.048) and longer operative times per interspace (P < 0.001) but was not associated with angular plate deviation (P = 0.724), length of stay (P = 0.393), perioperative complications (P = 0.844), and 90-day readmissions (P = 0.539).

CONCLUSIONS

Using 3D navigation in ACDF for degenerative disease is associated with slightly more midline plate positioning and comparable short-term outcomes as using fluoroscopy and can be a suitable alternative. Advantages of using this technology, such as improved visualization of anatomy, should be weighed against disadvantages, such as increased operative time, on a per-patient basis.

AKR1B10 as a Potential Novel Serum Biomarker for Breast Cancer: A Pilot Study

Background

Aldo-keto reductase 1B10 (AKR1B10) is a secretory protein that is upregulated in breast cancer.

Objective

This case-controlled pilot study evaluated the serum level of AKR1B10 in healthy women and patients with a localized or metastatic breast cancer.

Methods

AKR1B10 levels were measured by ELISA and IHC in several patient cohorts.

Results

Our data showed that serum AKR1B10 was significantly elevated in patients with localized (6.72 ± 0.92 ng/ml) or metastatic (7.79 ± 1.13 ng/ml) disease compared to cancer-free healthy women (1.69 ± 0.17 ng/ml) (p<0.001); the serum AKR1B10 was correlated with its expression in tumor tissues, but not with the tumor burden, molecular subtypes or histological stages. After surgical removal of primary tumors, the serum AKR1B10 was rapidly decreased within 3 days and plateaued at a level similar to that of healthy controls in most patients. ROC curve analysis suggested the optimal diagnostic cut-off value of serum AKR1B10 at 3.456 ng/ml with AUC 0.9045 ± 0.0337 (95% CI 0.8384 - 0.9706), sensitivity 84.75% (95% CI 73.01% to 92.78%), and specificity 93.88% (95% CI 83.13% to 98.72%).

Conclusions

These data indicate the potential value of serum AKR1B10 as a biomarker of breast cancer.

Cell-free stem cell-derived extract formulation for treatment of knee osteoarthritis: study protocol for a preliminary non-randomized, open-label, multi-center feasibility and safety study

Background

Musculoskeletal conditions are highly prevalent, and knee OA is most common. Current treatment modalities have limitations and either fail to solve the underlying pathophysiology or are highly invasive. To address these limitations, attention has focused on the use of biologics. The efficacy of these devices is attributed to presence of growth factors (GFs), cytokines (CKs), and extracellular vesicles (EVs). With this in mind, we formulated a novel cell-free stem cell-derived extract (CCM) from human progenitor endothelial stem cells (hPESCs). A preliminary study demonstrated the presence of essential components of regenerative medicine, namely GFs, CKs, and EVs, including exosomes, in CCM. The proposed study aims to evaluate the safety and efficacy of intraarticular injection of the novel cell-free stem cell-derived extract (CCM) for the treatment of knee OA.

Methods and analysis

This is a non-randomized, open-label, multi-center, prospective study in which the safety and efficacy of intraarticular CCM in patients suffering from grade II/III knee OA will be evaluated. Up to 20 patients with grade II/III OA who meet the inclusion and exclusion criteria will be consented and screened to recruit 12 patients to receive treatment. The study will be conducted at up to 2 sites within the USA, and the 12 participants will be followed for 24 months. The study participants will be monitored for adverse reactions and assessed using Numeric Pain Rating Scale (NPRS), Patient-Reported Outcomes Measurement Information System (PROMIS) Score, Knee Injury and Osteoarthritis Outcome Score Jr. (KOOS Jr.), 36-ietm short form survey (SF-36), Single Assessment Numeric Evaluation (SANE), physical exams, plain radiography, and magnetic resonance imaging (MRI) with Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for improvements in pain, function, satisfaction, and cartilage regeneration.

Discussion

This prospective study will provide valuable information into the safety and efficacy of intraarticular administration of cell-free stem cell-derived extract (CCM) in patients suffering with grade II/III knee OA. The outcomes from this initial study of novel CCM will lay the foundation for a larger randomized, placebo-controlled, multi-center clinical trial of intraarticular CCM for symptomatic knee OA.

Trial registration

Registered on July 21, 2021. ClinicalTrials.gov NCT04971798

Developing a Novel, At-Home Procedure Curriculum for Fourth-Year Medical Students in Response to the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic provided our institution a unique opportunity to develop a new procedural curriculum for our fourth-year, emergency medicine-bound medical students. A significant portion of our ED’s fourth-year elective has traditionally been centered in our simulation center, using high-fidelity simulation models to practice important emergency medicine procedures. Due to the pandemic, the simulation center was unavailable for our use, and this new curriculum was created in an effort to fill this gap in procedural education.

Addressing Unmet Basic Needs to Improve Colposcopy Adherence Among Women With Abnormal Cervical Cancer Screening

OBJECTIVES

The aims of the study were to identify unmet basic needs (BNs) among women referred to colposcopy, to assess patient acceptability/satisfaction with assistance from a navigator to address unmet BNs, and to estimate adherence to colposcopy.

METHODS

Women were recruited between September 2017 and January 2019 from 2 academic colposcopy centers, one serving a rural and one an urban area. Basic needs were assessed by phone before colposcopy appointments and considered unmet if unlikely to resolve in 1 month. Colposcopy adherence prestudy and poststudy implementation was abstracted over 4-6 months from administrative records. After a lead-in phase of 25 patients at each site, a BN navigator was offered to new participants with 1 or more unmet BNs. Primary outcome was adherence to initial appointment.

RESULTS

Among 100 women, 59% had 1 or more unmet BNs, with similar prevalence between urban and rural sites. Adherence to initial colposcopy was 83% overall, 72% at the rural clinic, and 94% at the urban clinic (p = .006). These adherence rates were improved from 4 months before study launch (30/59 [51%] rural clinic and 68/137 [50%] urban clinic). Although acceptability of BN navigation was greater than 96% and women felt that it helped them get to their colposcopy visit, having a navigator was not associated with adherence. Women reporting no unmet BNs had the lowest adherence compared with women with 1 or more unmet BNs, regardless of navigator assistance (p = .03).

CONCLUSIONS

Disadvantaged women who need colposcopy have unmet BNs and value navigator assistance for initial appointments. However, when appointment scheduling includes telephone reminders and inquiring about BNs, a navigator may not add value.

Absent hyperdense middle cerebral artery sign is associated with poor functional outcome after mechanical thrombectomy

BACKGROUND

The hyperdense middle cerebral artery sign on computed tomography indicates proximal middle cerebral artery occlusion. Recent reports suggest an association between the hyperdense sign and successful reperfusion. The prognostic value of the hyperdense middle cerebral artery sign in patients receiving mechanical thrombectomy has not been extensively studied.

AIMS

Our study aims to evaluate the association between the hyperdense middle cerebral artery sign and functional outcome in patients with M1 occlusions that had undergone mechanical thrombectomy.

METHODS

We conducted a single-center retrospective observational cohort study of 102 consecutive patients presenting with acute M1 occlusions that had undergone mechanical thrombectomy. Patients were stratified into cohorts based on the presence of hyperdense middle cerebral artery sign visually assessed on computed tomography by two readers. The outcomes of interests were functional disability measured by the ordinal Modified Rankin Scale (mRS) at 90 days, mortality, reperfusion status and hemorrhagic conversion.

RESULTS

Out of the 102 patients with M1 occlusions, 71 had hyperdense middle cerebral artery sign. There was no significant difference between the cohorts in age, baseline mRS, NIHSS, ASPECTS, and time to reperfusion. The absence of hyperdense middle cerebral artery sign was associated with increased odds of being dependent or dying (higher mRS) (OR: 3.24, 95% CI: 1.30-8.06, p = 0.011) after adjusting for other significant predictors, including age, female sex, hypertension, presenting serum glucose, ASPECTS, CTA collateral score, and successful reperfusion.

CONCLUSION

The absence of hyperdense middle cerebral artery sign is associated with worse functional outcome in patients presenting with M1 occlusions undergoing thrombectomy.

Riluzole attenuates glutamatergic tone and cognitive decline in AβPP/PS1 mice

We have previously demonstrated hippocampal hyperglutamatergic signaling occurs prior to plaque accumulation in AβPP/PS1 mice. Here, we evaluate 2-Amino-6-(trifluoromethoxy) benzothiazole (riluzole) as an early intervention strategy for Alzheimer's disease (AD), aimed at restoring glutamate neurotransmission prior to substantial Beta amyloid (Aβ) plaque accumulation and cognitive decline. Male AβPP/PS1 mice, a model of progressive cerebral amyloidosis, were treated with riluzole from 2-6 months of age. Morris water maze, in vivo electrochemistry, and immunofluorescence were performed to assess cognition, glutamatergic neurotransmission, and pathology, respectively, at 12 months. Four months of prodromal riluzole treatment in AβPP/PS1 mice resulted in long-lasting procognitive effects and attenuated glutamatergic tone that was observed six months after discontinuing riluzole treatment. Riluzole-treated AβPP/PS1 mice had significant improvement in long-term memory compared to vehicle-treated AβPP/PS1 mice that was similar to normal aging C57BL/6J control mice. Furthermore, basal glutamate concentration and evoked-glutamate release levels, which were elevated in vehicle-treated AβPP/PS1 mice, were restored to levels observed in age-matched C57BL/6J mice in AβPP/PS1 mice receiving prodromal riluzole treatment. Aβ plaque accumulation was not altered with riluzole treatment. This study supports that interventions targeting the glutamatergic system during the early stages of AD progression have long-term effects on disease outcome, and importantly may prevent cognitive decline. Our observations provide preclinical support for targeting glutamate neurotransmission in patients at risk for developing AD. Read the Editorial Highlight for this article on page 399.

Survival outcomes in post-menopausal patients with underlying cardiovascular disease receiving endocrine therapy for the treatment of breast cancer

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Background: Breast cancer remains the number one threat to women’s health while cardiovascular disease (CVD) continues to be the leading cause of mortality in women worldwide. Adjuvant therapy with endocrine therapies (selective estrogen receptor modulators (SERM), estrogen receptor blockers (ERB), and aromatase inhibitors (AI) although known to reduce the recurrence of breast cancer in hormone receptor positive breast cancer patients, raise a concern for increased risk of cardiovascular disease. Our study aims to examine breast cancer survival outcomes on patients receiving endocrine therapy who have pre-existing CVD including heart failure. Methods: An institutional database of 478 patients with histologically confirmed hormone receptor positive breast cancer diagnosed between 01/01/2014 to 12/31/2017 was reviewed after IRB approval. Preexisting CVD included coronary artery disease (CAD), history of myocardial infarction (MI), and prior diagnosis of heart failure (HF). Patients were divided in groups depending on treatment with endocrine therapy and underlying CVD. Statistical analysis was performed with SAS v9.4. software. Survival curves were estimated using Kaplan-Meier methodology and analyzed with a log rank test. Predictors of survival were assessed with Cox proportional hazards regression analyses. All significance was assumed at the p < 0.05 level. Results: Of 478 patients who met the inclusion criteria, 336 (70%) patients were postmenopausal. Out of those 336 patients, 62.2 % (n = 209) received at least one of the endocrine therapies consisting of AI, SERM or an ERB. Of these patients, 2.9 % (n = 6), 9.6% (n = 20) and 5.7% (n = 12) had a significant medical history of underlying MI, HF and CAD, respectively. Survival analysis was performed on 80% (n = 168) patients of the 209 patients with 2.3% (n = 4), 8.9% (n = 15) and 5.2% (n = 11) with underlying MI, HF and CAD respectively. There was no statistically significant difference in survival in these postmenopausal women who received endocrine therapy despite preexisting cardiovascular disease (HR 3; 95% CI, 0.5-16, p > 0.05). Conclusions: A commonly known toxicity related to the adjuvant therapy including endocrine therapy of breast cancer is cardiac toxicity. Patients with history of CVD might be at the highest risk for such toxicity. Our finding is reassuring that endocrine therapy in patients with preexisting CVD including heart failure did not result in reduced survival for our patient cohort.

Survival and cardiac outcomes in elderly individuals with breast cancer: A retrospective study from an academic center

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Background: Approximately 40% of females over the age of 65 are newly diagnosed with breast cancer. When considering elderly patients with breast cancer ( > 65 years old), complex decision making is required as patients have multiple cardiac comorbidities that may confound treatment goals. In this abstract, we aim to identify survival and cardiac outcomes in elderly individuals. Methods: This study was conducted using a retrospective cohort design with use electronic patient records. ICD diagnoses codes were used to identify breast cancer patients. Our initial search criteria revealed 1618 patients. Our eligibility criteria included adult patients 18 years and older with newly diagnosed breast cancer from January 1st, 2014 – January 31st, 2017 which yielded 478 patients. All data was collected through retrospective chart review. Analysis was performed with SAS v9.4 software. Qualitative variables were analyzed using Chi-Square Test. Survival curves are estimated using Kaplan-Meier methodology and analyzed with a log rank test. Predictors of survival are assessed with Cox proportional hazards regression analyses. All significance was assumed at the p < 0.05 level and reported as hazard ratios (HR). Results: Of our 478 breast cancer patients, 260 (59.5%) patients were less than age 65 and 177 (40.5%) patients were older than age 65. Of these two age groups, cardiac events including new diagnosis of heart failure (HF), heart failure (HF) hospitalization, and acute coronary syndrome were studied. For patients with age less than 65: n = 11 for new diagnoses of HF, n = 4 for HF hospitalizations, and n = 3 for ACS. For patients with age greater than 65: n = 5 for new diagnoses of HF, n = 3 for HF hospitalizations, and n = 2 for ACS. Comparing these two groups, there was no statistically significant cardiac event (p = > 0.05). Comparing survival among these two age groups also did not yield statistically significant results (p > 0.05). Conclusions: Per our data, it appears that there is no statistically significant difference in cardiac outcomes in different age groups for patients with breast cancer. Additionally, there was no difference in mortality among different age groups with breast cancer patients. Further prospective studies should be performed to confirm trends of mortality.

Effects of cardioprotective medications on breast cancer survival: A retrospective study from an academic center from Southern Illinois

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Background: Cardiovascular disease is one of the leading causes of deaths in breast cancer patients. Pre-existing cardiac conditions and cardiovascular risks associated with chemotherapy affect the overall mortality of these patients. Cardio protective medications like beta-blocker, ACEIs, ARBs, statin, and potassium-sparing diuretics have shown to increase the survival odds. In our study, we investigated the survival of breast cancer patients who were on cardio protective medications. Methods: Our retrospective cohort study included breast cancer patients from Simmons Cancer Institute, Springfield, Illinois from January 1st, 2014 to December 31st, 2017. The first step comprised of screening patients using ICD code of breast cancer. Next, a retrospective chart review led to selecting eligible patients with biopsy proven breast cancer diagnosis within the aforementioned dates. We excluded patients who were diagnosed outside the give time frame. Data on age, gender, medical comorbidities, medications, and survival status were also collected. Comparisons between categorical variables were compared with the Chi-Squared test. Survival curves were estimated using Kaplan-Meier methodology and analyzed with a log rank test. Predictors of survival are assessed with Cox proportional hazards regression analyses. Results: Screening using ICD codes resulted in 1618 patients. Of those, 478 had biopsy proven diagnosis within the dates mentioned. 301 out of 478 patients were on some kind of cardio protective medication (88 on beta-blockers, 73 on ACEIs, 41 on ARBs, 87 on statins, and 12 on potassium sparing diuretics). We looked into survival analysis in patients on different cardioprotective medications. ARBs and potassium sparing diuretics showed increased likelihood of survival as the hazard ratio (HR) was found to be 0.512 (95% Cl: 0.068-3.832, p-value:0.0919) and HR 0.390 (95% CI: 0.130-1.66, p-value:0.514) respectively. In contrast, other cardio protective medications showed decreased trends for survival. The HR of beta blocker was 1.734 (95% CI: 0.508-5.919, p-value: 0.379) and of ACEIs was 1.350 (95% CI: 0.395-4.613, p-value: 0.632). Similarly, statins had a hazard ratio of 1.534 (95% CI: 0.512- 4.594, p-value:0. 444). Conclusions: We found that the cardio protective medications showed no statistically significant difference in survival in breast cancer patients. Given the smaller sample size and single center study, further multi-center clinical trial is warranted to establish a stronger association.

Breast cancer frequency and survival by molecular subtype in central Illinois

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Background: Breast cancer is the most common female malignancy. In 2019, it is estimated that there were 268,000 new cases of female breast cancer. The most common subtype was HR+/HER2 based on 2012-2016 cases, a much higher rate than triple negative breast cancer. Best survival rates are found among women with HR+/HER2- subtype followed by HR+/HER2+ and HR-/HER+ subtypes. Triple negative subtype comparatively had a poorer survival.Our objective was to determine breast cancer rate and survival by molecular subtype in the central Illinois population. Methods: A cohort of 478 patients diagnosed with breast cancer between January 2014 and December 2017 was identified by using ICD codes. Eligibility criteria included pathology confirmed breast cancer.Categorical variables were summarized as frequencies and percentages. Predictors of survival were assessed with Cox proportional hazards regression analyses.All significance was assumed at the p < 0.05 level. Results: Luminal A breast cancer was the most common type in our population. In the cohort of 478 patients, 208 patients (74%) were found to have Luminal A. whereas, 37 patients (13.21%) had Basal subtype, 20 patients (7.14%) had Luminal B and 13 patients (5.36%) had Her2 enriched subtype. However, there was no statistical difference in survival between the subtypes. Conclusions: Although the frequency of cancer subtypes in our population is comparable to the national epidemiology data,we observed that there is no statistical difference in survival as compared to NCI SEERS data. This could be due to optimum care and patient’s adherence to chemo-radiation or due to small sample size. This could be an important area of future research to investigate if we can increase survival of poor prognosis subtypes (as triple negative) by following the same measures. Long term follow up for the patients in the study might also be necessary.

Comorbidities and survival in breast cancer: A retrospective cohort study from an academic institution in southern Illinois

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Background: Breast cancer is the most common malignancy in females. Early detection and advances in treatment modalities have resulted in decreasing rates of breast cancer related death. While breast cancer survival has improved, risks of death from cardiovascular comorbidities have increased. Our study aims to evaluate survival among breast cancer patients with cardiac comorbidities. Methods: This study was conducted using a retrospective cohort design with use of de-identified hospital electronic patient records. ICD diagnoses codes were used to identify breast cancer patients. Our initial search criteria revealed 1618 patients. Our eligibility criteria included adult patients 18 years and older with newly diagnosed breast cancer from January 1st, 2014 – January 31st, 2017 which yielded 478 patients. All data was collected through retrospective chart review. Analysis was performed with SAS v9.4 software. Qualitative variables were analyzed using Chi-Square Test. Survival curves are estimated using Kaplan-Meier methodology and analyzed with a log rank test. Predictors of survival are assessed with Cox proportional hazards regression analyses. All significance was assumed at the p < 0.05 level and reported as hazard ratios (HR). Results: Of our 478 patients, the following comorbidities were noted: diabetes n = 98 (21.17%), myocardial infarction (MI) n = 14 (2.98%), heart failure (HF) n = 36 (8.38%), coronary artery disease (CAD) n = 26 (5.75%), hypertension (HTN) n = 261 (55.77%), peripheral vascular disease (PVD) n = 9 (1.95%), hyperlipidemia (HLD) n = 230 (49.15%). Survival analysis was completed on patients with CAD (p = 0.49), HLD (p = 0.40), HTN (p = 0.15), MI (p = 0.52), and HF HR = 6.35 (95% CI 2.40-16.7, p = 0.0002). Pre-existing HF had a higher risk of mortality, which was statistically significant; however, all other single comorbidities were not. Overall survival (OS) in patients with more than one comorbidity HR = 1.36 (1.08-1.69, p = 0.006), was statistically significant. Conclusions: Patients with only one comorbidity be it MI, CAD, HTN, HLD did not have statistically significant results in OS. However, breast cancer patients with pre-existing HF are at 6.35-fold higher risk of mortality than those without HF. Patients with more than one comorbidity listed above were at 1.36-fold higher risk of mortality. Our results indicate that risk factor reduction may help improve survival in patients with breast cancer. Prospective validation of these findings is warranted.

Cardiac events and breast cancer survival analysis in caucasians and minorities: A retrospective study in central Illinois

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Background: Breast cancer is the most prevalent malignancy affecting the female population in the United States and poses a significant mortality risk. In central Illinois, our objective was to analyze cardiac events (described as a new diagnosis of heart failure, heart failure hospitalizations, and acute coronary syndrome) in patients diagnosed with breast cancer and overall survival. Methods: A retrospective analysis completed in February 2020 identified patients (n = 1618) based on ICD diagnosis codes with a primary diagnosis of breast cancer. The inclusion criteria comprised of confirmed pathology report with diagnosis of breast cancer between January 2014 and December 2017. A cohort of 478 patients was identified as having met the inclusion criteria. Baseline characteristics and qualitative information were obtained from retrospective chart review. Continuous variables were described with measures of central tendency (mean, median) and dispersion (range, standard deviation). Categorical variables were summarized as frequencies and percentages. Furthermore, comparison between categorical variables were analyzed using Chi-Square test. Survival curves were estimated using kaplan-meier methodology and analyzed with a log rank test. Qualitative variables were analyzed using chi-square test and reported as hazard ratio using SAS software. All significance was assumed at the p < 0.05 level. Results: Of the 478 patients that were included as part of the analysis, 425 (89.6%) were of caucasian background and 49 (10.34%) were minorities (Asian, African American, and Hispanic). In regards to heart failure, our data demonstrated increased heart failure hospitalizations in minorities (7.89%) compared to caucasians (1.22%) which was a significant association (p = 0.026). In the overall survival among caucasian and minority groups there was no statistically significant difference (hazard ratio 0.939 with a 95% CI between 0.218-4.048), however it showed slight trend suggesting improved survival in the caucasian population. Conclusions: Our data illustrates that minorities with breast cancer experienced a higher incidence of heart failure when compared to the caucasian population. This supports closer observation at cardiac risk factors of such patients and medical optimization in an effort to prevent cardiac complications. While we did not see a significant difference in overall survival, further studies may be warranted in such population.

Breast cancer, cardiac events, and survival: Do outcomes differ in urban and rural populations? A retrospective analysis of a midwest population

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Background: Breast cancer is the most common female malignancy diagnosed in the US. According to the CDC and WWAMI Rural Health Research Center, rural areas have a lower incidence of cancer than urban areas, yet have higher breast cancer related death rates (1,2). Adverse cardiac outcomes may contribute to decreased survival in rural populations. In this abstract, we discuss how environment impacts survival and cardiac outcomes in patients with breast cancer. Methods: An IRB-approved retrospective study was performed utilizing ICD codes to analyze patients diagnosed with biopsy-confirmed breast cancer between January 1, 2014 and December 31, 2017. 478 of 1618 de-identified patients qualified for this study. Statistical analysis was performed with SAS v9.4. Descriptive statistics were computed for all study variables. Continuous variables were described with measures of central tendency (mean, median) and dispersion (range, standard deviation). Categorical variables were summarized as frequencies and percentages. Comparisons between categorical variables were compared with the Chi-Square test (or Fisher’s Exact) where appropriate. Survival curves were estimated using Kaplan-Meier methodology and analyzed with a log rank test. Predictors of survival were assessed with Cox proportional hazards regression analyses. All significance is assumed at the p < 0.05 level. Results: Of 478 eligible patients, the calculated HR was 0.323 with 95% CI between 0.074 and 1.397 (p = 0.130), suggesting greater likelihood of survival in the urban population as compared to the rural population. Cardiac events like heart failure and ACS resulted in Fisher’s Exact p-value of 1, suggesting no significant difference in cardiac outcomes between the two populations. While results were not statistically significant, the trend of decreased survival in the rural population is noteworthy. Conclusions: Per our study, urban populations may have higher propensity for survival as compared to rural populations. There was no statistically significant difference in cardiac events among the two different population. Socioeconomic factors may play a large role in improved survival outcomes in the urban population, which may include but are not limited to travel to/from appointments and cost of medical care. Further large-scale, prospective studies should be performed to confirm the aforementioned trends with respect to survival outcomes in urban and rural populations.

Single center retrospective study on cardiac safety of anti-HER2 agents and anthracyclines

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Background: Chemotherapy-induced cardiotoxicity has been associated with certain breast cancer therapy regimens, such as anthracyclines. With the development of newer therapies, just as the anti HER2 agents,another association with cardiotoxicity has been recognized in these drug groups. We report the cardiac safety of anti-HER2 agents and anthracyclines. Methods: A retrospective chart review was conducted of patients diagnosed with breast cancer between January 1st 2014 and December 31st 2017, treated with chemotherapy were identified from a large cancer center database. Heart failure, ACS, and other comorbidities were identified using billing codes. Primary outcome was cardiac event,defined by New York Heart Association class II, III or IV heart failure, ACS and heart failure hospitalization. Fisher's exact test was used to test associations between medication categories and cardiac events. Results: A total of 478 patients were included in our study.Our results indicated a significant association of anti HER2 agents with new heart failure with 12.24% (6/49) of patients, compared to 4.04% (12/297) in the control group (p = 0.0288). For the compound of all cardiac events, patients on the anti HER2 arm did not have a significant association, representing 12.50%(6/48) (p = 0.117).Regarding anthracyclines, results demonstrated a significant association of cardiac events, with an incidence of 17.46%(11/63) compared to 4.59%(14/305) in the control group (p = 0.001). We also found that specifically for new onset heart failure, the anthracycline group had a proportion of 13.64%(9/66), in comparison to the control group which had an incidence of 3.21%(9/280) (p = 0.0023). Conclusions: These findings are comparable to rates reported in studies evaluating cardiac safety of anthracyclines and anti-HER2 agents,calling attention to the importance of novel techniques and treatments for the management of chemotherapy-induced cardiotoxicity.

Development of cardiac events in postmenopausal breast cancer patients treated with Aromatase inhibitor (AI) and Selective estrogen receptor modulator (SERM)

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Background: Breast cancer is the most common cancer diagnosed in women. Cardiovascular diseases (CVD), alternatively, is the leading cause of mortality in women worldwide. Adjuvant endocrine therapy including AI and SERM is offered to almost 75% of patients with estrogen receptor–positive (ER+) disease and potentially raises concerns for negative effects in cardiovascular health. Our study aims to evaluate cardiac events including acute coronary syndrome (ACS) and heart failure requiring hospitalization (HF) in post-menopausal patients treated with AI and SERM. Methods: An institutional database of 478 patients with histologically confirmed hormone receptor positive breast cancer diagnosed between 01/01/2014 to 12/31/2017 was reviewed after IRB approval. Development of ACS and heart failure requiring hospitalization upon initiating AI or SERM was considered an adverse cardiac event. Statistical analysis was performed with SAS v9.4. software. Chi Square (or Fisher’s Exact test) was used to test associations between various medication and cardiac events. Student’s T-test (or non-parametric equivalent when violations occurred) was used to assess if there was a difference in delta between those on and those not on medication categories. All significance was assumed at the p < 0.05 level. Results: Of 478 patients who met the inclusion criteria, 336 (70%) patients were postmenopausal. Of the 336 patients, 55% (n = 185) and 22% (n = 77) were offered therapy with AI and SERM, respectively. 6.49 % (n = 12) developed cardiac event with AI compared to 7.10 % (n = 13) who were not on AI therapy, (p = 0.814). Similarly, 6.49 % (n = 5) developed cardiac event with SERM compared to 6.87 % (n = 20) who were not on SERM therapy, (p = 0.9064). Moreover, an interesting finding in patients treated with SERM therapy compared to those not on SERM therapy was the delta of left ventricular ejection fraction (LVEF). Median LVEF of 3.5% (0 to 21%) was noted in patients treated with SERM compared to a median LVEF of 5% (0 to 55%) in patients who were not treated with SERM, p = 0.048. Conclusions: Our findings revealed AI and SERM therapy did not increase adverse cardiac events in our patient cohort. Cardiac safety of the patients is less likely to be compromised with AI and SERM therapy and therefore, should be initiated early in the course of treatment for better patient outcome. Furthermore, since SERM therapy can possibly have an effect in the LVEF of patients, a frequent evaluation LVEF is warranted to prevent any unwarranted complications.

Radiation and cardiotoxicity: A retrospective analysis of a midwest population

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Background: The most common female malignancy diagnosed in the US is breast cancer. Early breast cancer therapy is often treated with radiation therapy; one of the unfortunate side effects of radiotherapy in the past has been cardiotoxicity, especially coronary artery disease. Recent usage of dose reduction techniques have helped reduce these effects. Here, we present our analysis of breast cancer patients that received radiation therapy and the likelihood of cardiotoxicity. Methods: An IRB-approved retrospective study was performed utilizing ICD codes to analyze patients diagnosed with biopsy-confirmed breast cancer between January 1, 2014 and December 31, 2017. 478 of 1618 de-identified patients qualified for this study. Statistical analysis was performed with SAS v9.4. Descriptive statistics were computed for all study variables. Continuous variables were described with measures of central tendency (mean, median) and dispersion (range, standard deviation). Categorical variables were summarized as frequencies and percentages. Comparisons between categorical variables were compared with the Chi-Square test (or Fisher’s Exact) where appropriate. Survival curves were estimated using Kaplan-Meier methodology and analyzed with a log rank test. Predictors of survival were assessed with Cox proportional hazards regression analyses. All significance is assumed at the p < 0.05 level. Results: Of the 478 eligible patients, heart failure (HF), HF hospitalizations, acute coronary syndrome and overall cardiac events were compared among breast cancer patients. Patients who received radiation experienced HF 6.02% compared to 4.61% without radiation (p = 0.574). HF hospitalization was recorded as 2.27% in radiotherapy compared to 1.23% in non-radiotherapy patients (p = 0.686). Patients who radiation experienced ACS 2.27% of the time as compared to 1.21% in patients who were not treated with radiation. Of note, 9.25% receiving radiation experienced cardiac events compared to 4.24% in patients without radiation (p = 0.068). While results were not statistically significant, the trend of elevated cardiac events in breast cancer patients receiving radiation is noteworthy. Conclusions: Per our study, although statistically insignificant, radiation therapy may result in higher incidence of cardiac events in breast cancer patients. Further large-scale, prospective studies should be performed to confirm the aforementioned trends with respect to survival outcomes in urban and rural populations.

The effect of the urinary and faecal microbiota on lower urinary tract symptoms measured by the International Prostate Symptom Score: analysis utilising next-generation sequencing

OBJECTIVE

To examine the correlation between urinary and faecal microbial profiles and the different aspects of lower urinary tract symptoms (LUTS) in men, as there is accumulating evidence that variations in the human microbiota may promote different benign disease conditions.

PATIENTS AND METHODS

We extracted total DNA from urine and faecal samples of a group of men, under an Institutional Review Board-approved protocol. At the same time, International Prostate Symptom Score (IPSS) data were collected. We then amplified the extracted DNA and sequenced it using bacterial 16S ribosomal RNA gene high-throughput next-generation sequencing platform, and analysed the microbial profiles for taxonomy to examine the correlation between the different operational taxonomy units (OTUs) and LUTS represented by the total IPSS, the different symptom levels of the IPSS (mild, moderate, and severe) and its subcomponents of storage, nocturia, voiding, and bother.

RESULTS

We included 30 patients (60 samples; one urine and one faecal per patient). In all, 48 faecal OTUs showed a significant correlation with one or more of the IPSS components; 27 with nocturia, 19 with bother, 16 with storage symptoms, and nine with voiding symptoms. The most substantial negative (protective) correlation was between Lachnospiraceae Blautia, a bacteria that increases the availability of gut anxiolytic and antidepressant short-chain fatty acids, and bother (correlation coefficient 0.702; P = 0.001). The abundance of L. Blautia continued to have a protective correlation against LUTS when looking at the different levels of IPSS severity (moderate and severe vs mild, correlation coefficient 0.6132; P = 0.002). Ten unique urinary OTUs showed significant correlation with LUTS; eight with nocturia, one with bother, three with storage, and one with voiding, but no faecal OUT had more than a low correlation with the outcomes of interest in this study.

CONCLUSIONS

Our prospective work finds a plausible correlation between L. Blautia and LUTS. Additional studies are needed to determine if the correlations found in the present research are applicable to the general population of patients affected by LUTS.

Mirabegron improves sleep measures, nocturia, and lower urinary tract symptoms in those with urinary symptoms associated with disordered sleep

INTRODUCTION

The role of organized sleep in overall health and quality-of-life (QoL) is critical. Nocturia necessarily disrupts the normal sleep cycle and negatively impacts one's health, work productivity, and QoL. We investigated, for the first time in an exploratory pilot, the effectiveness of mirabegron for improving sleep disturbance and nocturia.

MATERIALS AND METHODS

This was a prospective, open-label 12-week trial evaluating the efficacy of mirabegron in 34 men and women with disordered sleep and lower urinary tract symptoms (LUTS). Subjects received mirabegron 25 mg daily for 4 weeks, then increased to 50 mg. Subjects completed the Patient-Reported Outcome Measurement Information System Sleep Disturbance Short Form (PROMIS-SDSF), Jenkins Sleep Scale (JSS), International Prostate Symptom Score (IPSS), voiding diaries, and QoL questionnaires.

RESULTS

PROMIS-SDSF scores decreased from 26.5 points to 19.3, representing a categorical improvement from clinically 'mild' to 'none to slight' sleep disturbance (p < 0.001). JSS scores also decreased from 14.1 to 8.3 (p < 0.001). IPSS decreased from 21.0 to 12.4, denoting a categorical improvement from 'severe' to 'moderate' LUTS (p < 0.001). Voiding diaries revealed 1.9 fewer voids per day (p < 0.01) and 0.8 fewer nighttime voids (p < 0.05). QoL improved from 0% in subjects who selected 'mostly satisfied,' 'pleased,' or 'delighted' to 29.6% at follow up.

CONCLUSIONS

Mirabegron use improves nocturia and produces rapid, durable, and clinically significant improvement in sleep disturbance and LUTS in males and females with urinary symptoms associated with disordered sleep.

Deletion of Nrip1 Extends Female Mice Longevity, Increases Autophagy, and Delays Cell Senescence

Using age of female sexual maturation as a biomarker, we previously identified nuclear receptor interacting protein 1 (Nrip1) as a candidate gene that may regulate aging and longevity. In the current report, we found that the deletion of Nrip1 can significantly extend longevity of female mice (log-rank test, p = .0004). We also found that Nrip1 expression is altered differently in various tissues during aging and under diet restriction. Remarkably, Nrip1 expression is elevated with aging in visceral white adipose tissue (WAT), but significantly reduced after 4 months of diet restriction. However, in gastrocnemius muscle, Nrip1 expression is significantly upregulated after the diet restriction. In mouse embryonic fibroblasts, we found that the deletion of Nrip1 can suppress fibroblast proliferation, enhance autophagy under normal culture or amino acid starvation conditions, as well as delay oxidative and replicative senescence. Importantly, in WAT of old animals, the deletion of the Nrip could significantly upregulate autophagy and reduce the number of senescent cells. These results suggest that deleting Nrip1 can extend female longevity, but tissue-specific deletion may have varying effects on health span. The deletion of Nrip1 in WAT may delay senescence in WAT and extend health span.

Age and sex have no impact on expression levels of markers of immune cell infiltration and immune checkpoint pathways in patients with muscle-invasive urothelial carcinoma of the bladder treated with radical cystectomy

OBJECTIVES

Advanced age and female sex have been associated with worse outcomes in patients undergoing radical cystectomy for muscle-invasive bladder cancer. A reduced immune response has been implicated as a mechanism. The objective of our study was to analyze the expression patterns of various cellular proteins active in bladder cancer immune pathways, and assess the correlation between age, sex, and the expression of these immune markers.

METHODS

We obtained surgical tissue samples from equally distributed male/female patients with/without lymph node metastasis who had undergone radical cystectomy for urothelial carcinoma (UC) of the bladder (n = 50). Immunohistochemistry (IHC) for CD3 (cluster of differentiation), CD4, CD8, CD56, LAG-3 (lymphocyte-activation gene), TIM-3 (T-cell immunoglobulin and mucin-domain), PD-1 (programmed death) and PD-L1 molecules was performed and scored by a single pathologist (high versus low). Spearman's correlation and Chi square tests investigated the association between age, sex, and IHC results.

RESULTS

Mean age at surgery was 67 years (range 50-78 years); all patients were Caucasians. The following percent of patients scored high for a stain: 18% CD3, 10% CD4, 0% CD8, 0% CD56, 20% LAG-3, 4% TIM-3, 0% PD-1 and 0% PD-L1. There was no association between patients' age, sex, and the expression of any of the immune markers (p > 0.05 for all).

CONCLUSIONS

The association between advanced age, female sex, and worse outcomes in bladder cancer may be independent of the immune pathways active in the disease that we examined in this study.

Analysis of AKR1B10 levels among various groups of breast cancer patients

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Background: Aldo-keto reductase 1B10 (AKR1B10) is a protein that is primarily expressed in human colon and small intestine, but induced in hepatocellular carcinoma and non-small cell lung cancer. Our recent studies have revealed that AKR1B10 is overexpressed in primary, metastatic, and recurrent cancers of the breast.

Methods: We recruited four cohorts of patients: Patients with breast cancer undergoing primary surgery from whom we procured breast cancer and matched normal adjacent tissue to evaluate AKR1B10 expression in primary tumors. The matched serum samples were collected before surgery and at various time points after the surgery (approximately 3 days, 7 days, and 1 month Patients with recurrent or advanced (metastatic) breast cancer. Serum samples were collected and serially monitored for up to 2years before and during metastatic therapy and correlated with RECIST measurements. Patients with locally advanced disease undergoing neoadjuvant chemotherapy. AKR1B10 serum levels were monitored during therapy and correlated with RECIST measurements. Healthy individuals with normal mammograms were recruited and submitted serum samples for AKR1B10 serum measurements. Results: AKR1B10 rapidly cleared the serum of early stage breast cancer patients with an estimated half-life of 24-30 hours. Serum AKR1B10 levels correlated strongly with tissue IHC staining and PR positivity but not with RECIST levels or Oncotype Dx scores. Neoadjuvant chemotherapy did not affect serum AKR1B10 levels. Individuals with normal mammograms displayed substantially lower levels of AKR1B10 than breast cancer patients. Patients with DCIS also displayed elevated serum AKR1B10 levels.

Conclusions: AKR10 may serve as tumor marker to independently identify high risk patients whose tumors have intermediated risk Oncotype Dx scores and may also identify early breast cancers in patients with equivocal breast biopsies.

Variations in compliance with different endocrine therapies in ER-positive breast cancer in elderly females in a rural population

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Background: Compliance is a serious issue for breast cancer patients on endocrine therapy. There are various factors that may alter compliance across different age groups e.g. side effects, cognitive impairment, socioeconomic status etc. Noncompliance to therapy leads to early discontinuation and poor longterm outcome. The purpose of this study was to examine compliance rates with endocrine therapy i.e. aromatase inhibitors & tamoxifen in different age groups of geriatric breast cancer patients and determine its tolerability and impact on survival. Methods: An institutional database of a total of 269 patients with histologically confirmed invasive or in-situ breast cancer with age 65 years or older at the time of diagnosis was reviewed in an IRB approved fashion. Adjuvant endocrine therapy included tamoxifen, letrozole, anstrozole and fulvestrant. Patients were further subdivided into age groups. Compliance was measured as an early termination of therapy. Fisher’s exact test was used to calculate statistical difference. Results: Out of 266 eligible patients, 221 (83.1%) were offered endocrine therapy. 216 (81.2%) accepted endocrine therapy and 5 (1.9%) declined treatment. Distribution of each therapy was as follows:Anastrozole n = 90, (33.5%), Letrozole n = 88, (32.7%), Fulvestrant n = 6,( 2.3%), Tamoxifen n = 64, (23.8%). Early termination n = 44, (21.4%). Between the ages 65-70, n = 17,(18.had an early termination or noncompliance to therapy, in the age group from 71-80 age group,n = 24,(26.4%) had an early termination, and ages 81 and above,n = 3 (12.5%) had an early termination. There were no statistical differences between Anastrozole, Letrozole, Tamoxifen & Fulvestrant (P = 0.8275, P = 0.4589, P = 0.6136). There was also no statistical difference between age groups (P = 0.2742). Overall survival was worse with early termination,n = 20 vs not n = 6 but did not reach statistical significance ( P = 0.7). Conclusions: In breast cancer patients 65 and older, age can be a factor in noncompliance. However, in our study there were no correlation between age groups and compliance or with which drug used. Tolerability was similar between each endocrine therapy, across different age groups in this geriatric breast cancer population, in a rural setting.

Bisphosphonate use in geriatric breast cancer patients on aromatase inhibitors in a rural population

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Background: Aromatase inhibitors (AIs) are commonly used in treatment of ER & PR + breast cancer in postmenopausal women. It is well known that AIs can lead to bone loss. Bisphosphonates have been used to counteract bone loss due to AI use. The objective of this study was to evaluate the use of bisphosphonates in elderly females above 65 years, with ER + breast cancer on AIs, in a rural setting, and to examine the effects of oral vs. IV bisphosphonates on overall survival (OS) in geriatric patients. We also examined the effects of alcohol use on bone health in this population. Methods: An institutional database of 269 patients with histologically confirmed invasive or in-situ breast cancer with age 65 or older at the time of diagnosis was reviewed in an IRB approved fashion. 176 patients were ER+ and had DEXA diagnosed osteoporosis or osteopenia.They were treated with anastrozole n = 88 (50)% or letrozole n = 88 (50%). Type of bisphosphonate treatments used ,impact of alcohol consumption & data on OS were collected from the database. Results: 176 patients (65.4%) were ER+ and had DEXA diagnosed osteoporosis or osteopenia. Alendronate was used in 15 patients (8.5%), ibandronate was used in 3 patients (1.7%), risedronate was used in 1 patient (0.6%), and zoledronate was used in 44 patients (25%). IV bisphosphonates were used in 44 patients (69.8%) and oral were used in 19 patients (30.2%). Majority of patietns were on calcium + D supplementation.10% of non-alcohol users had osteopenia/osteoporosis compared to 15% of former alcohol users and 29% of current alcohol users. LogRank testing found no significant difference between survival based on bisphosphonate use . Similar statistical analysis found no significant difference between survival based between IV and oral bisphosphonates. Conclusions: Our study showed that geriatric patients with ER + breast cancer on AI therapy were adequately managed for osteopenia and osteoporosis with the use of bisphosphonates (oral and IV) in a rural setting. There was no significant effect on overall survival (OS) , with use of bisphosphonates during AI therapy. No significant difference in OS was identified for patients taking IV vs. oral bisphosphonates,but this was attributed to very small number of patients that experienced death as an event in this population. Bisphosphonates were also well tolerated, with only 1 patient noting ONJ and one patient with renal toxicity. Current and former alcohol use was found to be correlated with increased rates of osteopenia/osteoporosis in this population.

Chemotherapy and trastuzumab-induced cardiotoxicity in geriatric breast cancer patients

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Background: Cardiotoxicity is a known side effect of anthracyclines & trastuzumab. Dilated cardiomyopathy is the most common form of cardiotoxicity associated with this treatment. Cardiovascular disease & cancer are common conditions in the geriatric populations. These comorbidities complicate the treatment of geriatric breast cancer patients. The purpose of this study was to determine the cardiotoxic effects of chemotherapy & trastuzumab in a geriatric population of breast cancer patients. Methods: An institutional database of a total of 269 patients with histologically confirmed invasive or in-situ breast cancer with age 65 years or older at the time of diagnosis was reviewed in an IRB approved fashion. Patients were divided in groups depending on the therapy (AC/TAC, CMF, TC and Trastuzumab) they received. Fisher’s exact test was used to calculate overall survival (OS). Results: Of the 269 patients, 72 (26.8%) were offered chemotherapy & 197 (73.2%) were not. Of the patients offered chemotherapy, 58 (21.6%) accepted treatment & 14 (5.2%) declined. 17 (6.7%) had an early termination, AC n = 11,( 4.1%), TAC n = 13, (4.8%), CMF n = 0, (0%), Trastuzumab n = 12, (4.5%), TC n = 11, (4.1%). Cardiovascular risk factors taken into consideration were, CAD n = 30, (13.8%), HLD n = 23, (10.6%), HTN n = 98, (45.2%), HTN/HLD n = 66, (30.4%), DM (N = 45, (16.7%), Smoking n = 121, (46.4%) & BMI > 30, n = 116,( 48.1%). Patients completing chemotherapy had higher OS than patients who had early termination (P = 0.017). Of the 24 patients who received Anthracycline containing regimen, 1 experienced cardiotoxicity. There was no statistically significant difference in OS between AC, TAC & Trastuzumab (P = 0.570, P = 0.547, P = 0.614). A decrease in OS was seen for patient who received TC (P = 0.002). Of the 12 who received trastuzumab, 1 experienced cardiotoxicity. There was a significant association between patients with a high BMI ( > 30) & increased cardiovascular comorbidities (P = 0.0009) but had no impact early on termination of chemotherapy or OS, NS (P = 0.7). Conclusions: The cardiotoxic effect of anthracyclines and trastuzumab are well known, however in our study, only 2 elderly breast cancer patients who received chemotherapy experienced cardiotoxicity. As would be expected, those who completed chemotherapy had improved OS. There were no difference in OS between AC, TAC and Trastuzumab, however TC treatment was associated with a decrease in OS.BMI had an impact on cardiovascular comorbidities but not on early termination of chemotherapy or OS.

Are elderly breast cancer patients offered appropriate therapy i.e. surgery, chemotherapy, radiation, and endocrine therapy, in a rural population?

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Background: The NCI SEER data demonstrated that age adjusted incidence rate of geriatric breast cancer is 427.5 per 100,000. Mortality rates for breast cancer have improved over the last 20 years,but the risk of breast cancer death has decreased 3 fold more rapidly in younger vs. geriatric population. Comorbid illnesses are more prevalent in elderly & therapy offered is often less aggressive. The objective of this study was examine practice patterns in a rural geriatric breast cancer population. The patients were divided into groups with life expectancies (LE) > 10 years or not. Analysis was also performed in groups based on age ranges. Methods: An institutional database of 269 patients with histologically confirmed invasive or in-situ breast cancer with age 65 or older at the time of diagnosis was reviewed in an IRB approved fashion. Data was collected on age at diagnosis, LE, and the rates of chemotherapy, surgery, radiation therapy, multidisciplinary discussion, clinical trials, Adjuvant Online!, & endocrine therapy offered. LE data was divided into patients with greater than 10 years of life expectancy or not at the time of diagnosis. A separate analysis examined the rates of the above in age ranges of 65-70, 71-80, and 81 plus. Variations in significance were identified using Fishers Exact Test. Results: 44 patients (16.4%) had a LE at diagnosis of < 10 years. Surgery was offered in n=262 patients (97.4%). Radiation therapy was offered in n=170 patients (64.9%). Endocrine therapy was offered in n= 221 patients (83.1%). Chemotherapy was offered in n= 72 patients (27.2%). In the greater than or less than 10 year LE group, statistically significant variations were noted in the rates of radiation (p=0.0047) & chemotherapy (p=0.0067) treatments offered to patients based on their life expectancy. When patients were grouped by age range, statistically significant variations were noted in the rates of radiation treatment (p=0.0221), endocrine treatment (p=0.032), chemotherapy (p≤0.0001), & participation in clinical trials (p=0.0218). Conclusions: Our study identified statistically significant differences in the rates of radiation & chemotherapy offered to patients based on their life expectancy. Statistically significant differences in rates of radiation, endocrine therapy, chemotherapy, and participation in clinical trials were observed based on the age ranges of patients. No differences were noted in the rates of surgery offered, use of Adjuvant Online, and multidisciplinary discussion based on LE & age range.

Effect of age and gender on expression levels of markers of immune cell infiltration and immune checkpoint pathways in patients with muscle-invasive transitional cell carcinoma of the bladder: A retrospective study of 50 patients treated with radical cystectomy

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Background: Older age and female gender have been associated with worse outcomes in patients with muscle invasive bladder cancer undergoing radical cystectomy. Reduced immune response has been implicated in disease metastasis and worse survival. The objective of our study was to determine the expression patterns of various cellular proteins active in immune pathways in bladder cancer patients, and assess the correlation between age, gender, and expression of these immune markers. Methods: Tissue samples were obtained from equally distributed male/female patients with/without lymph node metastasis on final pathology after undergoing radical cystectomy for transitional cell carcinoma (TCC) of the bladder from 2009-2011 (n = 50). Immunohistochemistry (IHC) for CD3, CD4, CD8, LAG3, CD56, TIM3, PD-1 and PD-L1 were performed and scored by a single pathologist (scoring was on 0 to 100% scale). Statistical analyses investigated association between age, gender, lymph node metastasis, and IHC results. Results: Mean age at surgery was 67 yrs (range 50 to 78 yrs); all patients were Caucasians. Statistical analyses showed no association between patients' age, gender, and the expression of any of the immune markers (p > 0.05). Similarly, the staining scores for the immune markers were not noted to be correlated with LN metastasis. Correlation between stains showed a negative correlation between CD56 and PD-L1 (-0.286, p = 0.047) and between PD-1 and PD-L1 (-0.381, p = 0.007). Conclusions: Although age and female gender have been associated with worse outcomes in bladder cancer, this association may be independent of the immune pathways active in the disease. Increased expression of PD-L1 is associated significantly with suppression of anti-tumor natural killer cells in the transitional cell carcinoma of the bladder.

Guidelines for Reporting of Statistics for Clinical Research in Urology

Investigators submitting clinical research to European Urology are encouraged to follow guidelines for the reporting of statistics. Adoption of the guidelines will not only increase the quality of published papers, but also improve statistical knowledge in urology in general.

Guidelines for reporting of statistics for clinical research in urology

In an effort to improve the quality of statistics in the clinical urology literature, statisticians at European Urology, The Journal of Urology, Urology and BJU International came together to develop a set of guidelines to address common errors of statistical analysis, reporting, and interpretation. Authors should 'break any of the guidelines if it makes scientific sense to do so', but would need to provide a clear justification. Adoption of the guidelines will in our view not only increase the quality of published papers in our journals but improve statistical knowledge in our field in general.

A Review of the FAERS Data on 5-Alpha Reductase Inhibitors: Implications for Postfinasteride Syndrome

OBJECTIVE

To quantify reports made to the Food and Drug Administration Adverse Event Reporting System (FAERS), create a demographic of patient reports, and examine the cluster of symptoms to correlate consistency of postfinasteride syndrome (PFS) complaints. PFS is a provisional diagnosis encompassing a cluster of sexual, physical, and psychological and/or neurologic symptoms associated with 5-alpha reductase inhibitor use that emerge or continue after discontinuation of medication.

MATERIALS AND METHODS

FAERS dataset of 5-alpha reductase inhibitors from April 2011 to October 2014 was obtained. Each FAERS report had 16 categories for completion, but not every report was fully completed. Statistical analysis compared variables of interest between the 2 doses of finasteride (1 mg vs 5 mg).

RESULTS

From FAERS, 2048 monotherapy cases were identified: 1581 of finasteride 1 mg, 240 of finasteride 5 mg, and 226 of unreported doses. Possibly related to labeling changes, from 2011 to 2014, there was a significant increase in adverse events (AEs) reported involving 1 mg dosing. Finasteride use was reported with many sexual AEs including diminished libido, erectile dysfunction, and ejaculatory complaints. Other common AEs included dermatologic, metabolic, and psychological and/or neurologic complaints. There were more AE reports with the 1 mg dose than the 5 mg dose. One case of dutasteride reported back pain, not generally attributed to PFS.

CONCLUSION

FAERS data suggests that finasteride exposure is reported with a diverse collection of symptoms, particularly in younger men on 1 mg dosage compared to older men on 5 mg. Many of these complaints fall well out of the realm of previously established AEs from long-term controlled studies.

Immune characterization of the programmed death receptor pathway in high-risk prostate cancer

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Background: Programmed Death 1 (PD-1) is a T cell inhibitory receptor critical to a major immunomodulation pathway which has been implicated in tumor evasion of immune response. PD-1 and its ligand PD-L1 have been found to be expressed in many tumor types, and this expression has led to the development of drugs targeting the PD-1 pathway. The goal of this study was to understand the expression of PD-1, and PD-L1 in high grade prostate cancer tissue, and correlate the expression with disease and patients characteristics. Methods: Immunohistochemistry for PD-1 (CD279), PD-L1 (B7-H1), and CD3 was performed on prostatectomy/biopsy tissue samples taken from 25 men with high grade (Gleason 8-10) prostate cancer using anti-PD-L1 clone 22C3 (Merck) and anti-PD-1 clone NAT105 (Cell Marque) . CD3 was used as a specific marker for T cell infiltration. Charts were then retrospectively reviewed for patient and disease characteristics including age at diagnosis, race, Gleason score, prostatic specific antigen (PSA) level at diagnosis, number of positive cores at biopsy, volume of tissue on biopsy and/or prostatectomy involved by cancer, clinical TNM stage, pathologic TNM stage, biochemical recurrence, or metastasis. Statistical analyses were done to correlate these patient and disease characteristics with PD-1, PD-L1, and CD3 expression. Results: A score of 3-5 on the semi-quantitative 0-5 score was deemed “high” expression whereas a score of 0-2 was deemed “low” expression. Of the 25 samples, 2 (8%) scored high for PD-1 expression, 2 (8%) scored high for PD-L1 expression, and 18 (72%) scored high for CD3 expression. With independent t-tests there was found to be no statistically significant correlation between any of the variables we collected and expression of PD-1, PD-L1, or CD3. Conclusions: We found an overall low expression of PD-1 and PD-L1, and a concurrent high expression of CD3+ T cells in high risk prostate cancer tissue. No significant correlations were made between expression of PD-1, PD-L1, or CD3 and patient and disease characteristics. The elevated T cell content in high risk prostate cancer is particularly interesting with the continued emergence of new drugs focused on enhancing efficacy of the immune response in cancer.

Blended Learning in Obstetrics and Gynecology Resident Education: Impact on Resident Clinical Performance

PROBLEM

Effects of residents' blended learning on their clinical performance have rarely been reported. A blended learning pilot program was instituted at Southern Illinois University School of Medicine's Obstetrics and Gynecology program. One of the modules was chronic hypertension in pregnancy. We sought to evaluate if the resident blended learning was transferred to their clinical performance six months after the module.

INTERVENTION

A review of patient charts demonstrated inadequate documentation of history, evaluation, and counseling of patients with chronic hypertension at the first prenatal visit by Obstetrics and Gynecology (OB/GYN) residents. A blended learning module on chronic hypertension in pregnancy was then provided to the residents. A retrospective chart review was then performed to assess behavioral changes in the OB/GYN residents.

CONTEXT

This intervention was carried out at the Department of Obstetrics and Gynecology, Southern Illinois University. All 16 OB/GYN residents were enrolled in this module as part of their educational curriculum. A query of all prenatal patients diagnosed with chronic hypertension presenting to the OB/GYN resident clinics four months prior to the implementation of the blended learning module (March 2015-June 2015) and six months after (July 20, 2015-February 2016) was performed. Data were collected from outpatient charts utilizing the electronic medical record. Data were abstracted from resident documentation at the first prenatal visit.

OUTCOME

The residents thought that the blended learning module was applicable to performance improvement in the real-world setting. Patients evaluated before (n = 10) and after (n = 7) the intervention were compared. After the intervention, there was an increase in assessment of baseline liver enzymes, referral for electrocardiogram, and early assessment for diabetes in the obese patients. More patients were provided a blood pressure cuff after the module (71.4% vs. 20%). Data were provided to the residents in an informal setting. Discussion during this session suggested that inconsistent use of the algorithm and incomplete documentation were reasons for the findings.

LESSONS LEARNED

This study suggests that blended learning may be a viable tool to support sustained changes in the performance of OB/GYN residents. Scheduled follow-up should be employed to facilitate and ensure continued learning and behavioral changes.

A Blended Approach to Learning in an Obstetrics and Gynecology Residency Program: Proof of Concept

PROBLEM

Graduate medical education programs are expected to educate residents to be able to manage critically ill patients. Most obstetrics and gynecology (OB/GYN) graduate medical education programs provide education primarily in a didactic format in a traditional face-to-face setting. Busy clinical responsibilities tend to limit resident engagement during these educational sessions. The revision of the training paradigm to a more learner-centered approach is suggested.

INTERVENTION

A blended learning education program was designed and implemented to facilitate the teaching and learning of obstetric emergencies, specifically diabetic ketoacidosis and acute-onset severe hypertension in pregnancy. The program incorporated tools to foster a community of inquiry. Multimedia presentations were also utilized as the main modality to provide instruction. The blended learning course was designed in accordance with the cognitive theory of multimedia learning.

CONTEXT

This intervention was carried out in the Department of Obstetrics and Gynecology, Southern Illinois University. All 15 OB/GYN residents were enrolled in this course as part of their educational curriculum. First, face-to-face instructions were given in detail about the blended learning process, course content, and online website. The residents were then assigned tasks related to completing the online component of the course, including watching multimedia presentations, reading the resources placed online, and participating in online asynchronous discussions. The course culminated with a face-to-face session to clarify misconceptions. Pre- and postcourse quizzes were administered to the residents to assess their retention and understanding.

OUTCOME

Objective analysis demonstrated significant improvements in retention and understanding after participating in the course. The blended learning format was well received by the residents. Resident perception of social presence in the asynchronous online discussions was demonstrative of low scores relating to peer-to-peer interaction. The multimedia presentations and the availability of learning resources were well received.

LESSONS LEARNED

Outcomes of this study suggest that blended learning is a viable tool to support teaching and learning of obstetric emergencies in an OB/GYN residency program.