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Lewinsohn R, Zheng Y, Rosenberg SM, Ruddy KJ, Tamimi RM, Schapira L, Peppercorn J, Borges VF, Come S, Snow C, Ginsburg ES, Partridge AH. Fertility Preferences and Practices Among Young Women With Breast Cancer: Germline Genetic Carriers Versus Noncarriers. Clin Breast Cancer 2023; 23:317-323. [PMID: 36628811 DOI: 10.1016/j.clbc.2022.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Young women with breast cancer who carry germline genetic pathogenic variants may face distinct fertility concerns, yet limited data exist comparing fertility preferences and practices between carriers and noncarriers. PATIENTS AND METHODS Participants in the Young Women's Breast Cancer Study (NCT01468246), a prospective cohort of women diagnosed with breast cancer at ≤40 years, who completed a modified Fertility Issues Survey were included in this analysis. RESULTS Of 1052 eligible participants, 118 (11%) tested positive for a pathogenic variant. Similar proportions (P = .23) of carriers (46%, [54/118]) and noncarriers (37%, [346/934]) desired more biologic children prediagnosis, and desire decreased similarly postdiagnosis (carriers, 30% [35/118] vs. noncarriers, 26% [244/934], P = .35). Among those desiring children postdiagnosis (n = 279), concern about cancer risk heritability was more common among carriers (74% [26/35] vs. noncarriers, 36% [88/244], P < .01). Carriers were more likely to report that concern about cancer risk heritability contributed to a lack of certainty or interest in future pregnancies (20% [16/81] vs. noncarriers, 7% [49/674], P = .001). Similar proportions (P = .65) of carriers (36% [43/118]) and noncarriers (38% [351/934]) were somewhat or very concerned about infertility post-treatment; utilization of fertility preservation strategies was also similar (carriers, 14% [17/118] vs. noncarriers, 12% [113/934], P = .78). CONCLUSION Carriers were similarly concerned about future fertility and as likely to pursue fertility preservation as noncarriers. Concern about cancer risk heritability was more frequent among carriers and impacted decisions not to pursue future pregnancies for some, underscoring the importance of counseling regarding strategies to prevent transmission to offspring, including preimplantation genetic testing.
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Affiliation(s)
- Rebecca Lewinsohn
- Harvard Medical School, Boston, MA; Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
| | - Yue Zheng
- Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | - Jeffrey Peppercorn
- Harvard Medical School, Boston, MA; Massachusetts General Hospital, Boston, MA
| | | | - Steven Come
- Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - Craig Snow
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
| | | | - Ann H Partridge
- Harvard Medical School, Boston, MA; Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA.
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Rosenberg SM, Zheng Y, Gelber S, Ruddy KJ, Poorvu P, Sella T, Tamimi RM, Wassermann J, Schapira L, Borges VF, Come S, Peppercorn J, Sepucha KR, Partridge AH. Adjuvant endocrine therapy non-initiation and non-persistence in young women with early-stage breast cancer. Breast Cancer Res Treat 2023; 197:547-558. [PMID: 36436128 PMCID: PMC10233447 DOI: 10.1007/s10549-022-06810-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/09/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Characterizing oral adjuvant endocrine therapy (ET) non-initiation and non-persistence in young women with breast cancer can inform strategies to improve overall adherence in this population. METHODS We identified 693 women with hormone receptor-positive, stage I-III breast cancer enrolled in a cohort of women diagnosed with breast cancer at age ≤ 40 years. Women were classified as non-initiators if they did not report taking ET in the 18 months after diagnosis. Women who initiated but did not report taking ET subsequently (through 5-year post-diagnosis) were categorized as non-persistent. We assessed ET decision-making and used logistic regression to identify factors associated with non-initiation/non-persistence and to evaluate the association between non-persistence and recurrence. RESULTS By 18 months, 9% had not initiated ET. Black women had higher odds and women with a college degree had lower odds of non-initiation. Among 607 women who initiated, 20% were non-persistent. Younger age, being married/partnered, and reporting more weight problems were associated with higher odds of non-persistence; receipt of chemotherapy and greater hot flash and vaginal symptom burden were associated with lower odds of non-persistence. Adjusting for age and clinical characteristics, non-persistence was associated with lower odds of recurrence. Women who initiated were more likely to report shared decision-making than non-initiators (57% vs. 38%, p = 0.049), while women who were non-persistent were less likely to indicate high confidence with the decision than women who were persistent (40% vs. 63%, p < 0.001). CONCLUSION Interventions to improve ET decision-making may facilitate initiation and address barriers to adherence in young breast cancer survivors. TRIAL REGISTRATION www. CLINICALTRIALS gov , NCT01468246.
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Affiliation(s)
- Shoshana M Rosenberg
- Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67St LA-0005, New York, NY, 10065, USA.
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Yue Zheng
- Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Shari Gelber
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | | | - Philip Poorvu
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tal Sella
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rulla M Tamimi
- Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67St LA-0005, New York, NY, 10065, USA
| | - Johanna Wassermann
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Department of Medical Oncology, Sorbonne Université, IUC, Pitié-Salpêtrière University Hospital, Paris, AP-HP, France
| | - Lidia Schapira
- Department of Medicine, Division of Medical Oncology, Stanford University, Stanford, CA, USA
| | - Virginia F Borges
- Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Steven Come
- Harvard Medical School, Boston, MA, USA
- Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeffrey Peppercorn
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Karen R Sepucha
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Division of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ann H Partridge
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Borstelmann NA, Gray TF, Gelber S, Rosenberg S, Zheng Y, Meyer M, Ruddy KJ, Schapira L, Come S, Borges V, Cadet T, Maramaldi P, Partridge AH. Psychosocial issues and quality of life of parenting partners of young women with breast cancer. Support Care Cancer 2022; 30:4265-4274. [PMID: 35091846 PMCID: PMC9701537 DOI: 10.1007/s00520-022-06852-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Data are lacking about the association between quality of life (QOL) and psychosocial issues of partners of young women with breast cancer who co-parent dependent children. METHODS We conducted a cross-sectional analysis of partners of women with breast cancer diagnosed at age ≤ 40. Among those partners reporting at least one dependent child under 18 years old at the time of diagnosis, we used multiple linear regression to examine associations between partner QOL and sociodemographic and psychosocial factors, and the patient's cancer stage and time since diagnosis. RESULTS Of the 219 parenting partners, all identified as male with a median age of 44 years; 96% (204/213) reported working full-time at the time of the survey. Fifty-four percent endorsed behaviors indicating maladaptive coping. In adjusted analyses, less than full-time employment (β = - 8.76; 95% CI = - 17.37, - 0.14), younger age (β = - 0.35; 95% CI = - 0.069, - 0.02), greater parenting concerns (β = 0.56; 95% CI = 0.36, 0.75), clinically relevant anxiety symptoms (β = 13.79; 95% CI = 10.24, 17.35), lower post-traumatic growth score (β = - 0.33; 95% CI = - 0.51, - 0.16), lower social support (β = - 0.21; 95% CI = - 0.29, - 0.12), lower sexual satisfaction (β = - 0.40; 95% CI = - 0.62, - 0.19), and breast cancer stages 3 (β = 7.61; 95% CI = 0.19, 15.02) and 4 (β = 12.63; 95% CI = 1.91, 23.34), when compared to stage 0, were associated with lower partner QOL. CONCLUSION Parenting partners of young women with breast cancer have substantial unmet psychosocial needs. Interventions are needed to enhance QOL and promote adaptive coping for this population.
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Affiliation(s)
| | - Tamryn F Gray
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.,Harvard Medical School, Boston, MA, USA
| | - Shari Gelber
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Shoshana Rosenberg
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.,Harvard Medical School, Boston, MA, USA
| | - Yue Zheng
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Meghan Meyer
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | | | | | - Steven Come
- Harvard Medical School, Boston, MA, USA.,Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Tamara Cadet
- Simmons College School of Social Work, Boston, MA, USA
| | - Peter Maramaldi
- Simmons College School of Social Work, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ann H Partridge
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.,Harvard Medical School, Boston, MA, USA
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Gray TF, Borstelmann N, Rosenberg S, Gelber S, Meyer ME, Ruddy KJ, Schapira L, Come S, Borges V, Cadet T, Maramaldi P, Partridge AH. Abstract PS9-08: The psychosocial impact of caregiving on partners of young women with breast cancer in treatment. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps9-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BackgroundCancer diagnosis and early treatment may have wide-ranging consequences for a woman’spartner (ie. spouse or significant other). In general, younger caregivers have been found to havegreater unmet needs and higher levels of distress compared to those who are older. To date,there is little known about the unmet needs and experiences of partners who care for youngwomen with breast cancer during active treatment.Trial Design: Cross-sectional survey of partners of young women with breast cancer.Eligibility Criteria: The current analysis focuses on a subset of respondent partners of womenwith breast cancer participating in the Young Womens Breast Cancer Study (NCT01468246)who met the following criteria: diagnosed at age < 40 years; time since diagnosis <12 months;and/or Stage IV disease (at diagnosis or in metastatic setting); and/or local recurrent disease< 12 months.Specific Aims: To explore the experience of partners of women in active treatment or havingvery recently completed treatment for breast cancer.Statistical Methods: We employed descriptive statistics to present sample characteristics,including means or medians for continuous variables and proportions for categorical variables.We assessed partners’ responses re: sociodemographics, perceived social support (MOS-Social Support Survey, Cancer Perceived Agents of Social Support), quality of life (QOL)(Caregiver QOL Index-Cancer), coping (Brief COPE), perceived financial security, perceivedparenting concerns (Parenting Concerns Questionnaire), anxiety and depression symptoms(Hospital Anxiety and Depression Scale), sexual satisfaction (Global Measure of SexualSatisfaction), posttraumatic growth (Posttraumatic Growth Inventory-Short Form), and an open-ended question to explore their experiences and needs.Accrual: 25 participants were included.Results: All partners were male (25/25; 100%), and most were white (n=23/25; 92%), workingfull-time (n=21/25; 91%); and college educated (n=19/25; 86%). Eighteen partners (n=18/25;72%) were parenting children <18 years old and 40% (n=10/25) were partnered with womenwith Stage 4 breast cancer. At the time of the survey, the median age of partners was 44 years(range, 28-69) and of patients was 38 years (range, 25-40). Many partners (57%) reportedsymptoms of anxiety (>8 on the HADS anxiety subscale), fewer (22%) were categorized ashaving symptoms of depression (>8 on the HADS depression subscale). Additionally, 39%reported not being sexually active; 41% reported maladaptive coping; 30% reported financialstrain;30% reported relationship strain. Reported caregiver QOL ranged from 22-116, with amean score of 52.5 (SD, 23.9), similar to population norms, with higher scores indicating lowerquality of life. Parenting concerns scores were generally low indicating less concern, with arange of 12-35, and mean of 20.5 (SD, 7.6). Post-traumatic growth ranged from 4-33, with amean score of 20.7 (SD, 7.4), with higher scores indicating greater personal growthexperienced. 44% (11/25) responded to the open-ended experiences and needs question.Common responses included feeling a lack of support, need for tailored and titrated information,and desire to connect with other men who faced similar experiences. Partners also reportedtheir struggles with uncertainty about the future.
Discussion: A subset of partners of young women in active treatment for breast cancerexpressed concerns related to relationship strain, sexuality, need for support, and finances.Future work designed to meet the needs of partners of breast cancer patients includinginformational and psychosocial supports may benefit them and the patients as they manage theprocess of ongoing treatment and challenges about the future.
Citation Format: Tamryn F Gray, Nancy Borstelmann, Shoshana Rosenberg, Shari Gelber, Meghan E Meyer, Kathryn J. Ruddy, Lidia Schapira, Steven Come, Virginia Borges, Tamara Cadet, Peter Maramaldi, Ann H. Partridge. The psychosocial impact of caregiving on partners of young women with breast cancer in treatment [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-08.
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Affiliation(s)
| | | | | | | | | | | | | | - Steven Come
- 4Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Tamara Cadet
- 6Simmons College School of Social Work, Boston, MA
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Rosenberg SM, Zheng Y, Poorvu P, Ruddy K, Gaither R, Tamimi R, Schapira L, Peppercorn J, Come S, Borges V, Partridge A. Abstract PD2-08: Endocrine therapy non-persistence and recurrence in young women with early stage breast cancer. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd2-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Young age at diagnosis is an independent risk factor for recurrence and death from breast cancer (BC), with the greatest impact of young age demonstrated in hormone receptor positive (HR+) disease. Younger women are less likely to be adherent to endocrine therapy (ET), which may contribute to disparate outcomes. Methods: As part of a prospective cohort that enrolled women with BC diagnosed at age ≤40 between 2006-2016, we identified women with HR+, Stage I-III BC. Serial surveys with items assessing socio-demographic and treatment information including medication use are administered 1-2 times per year. Medical record review was used to ascertain stage and HR status and to confirm recurrent disease (locoregional, distant, or new primary breast cancer). Women who initiated ET but discontinued it <5-years post-diagnosis without resumption were classified as non-persistent. Univariable and multivariable regression models were fit to identify predictors of non-persistence and recurrence.Results: Among 607 women who initiated ET (median age at diagnosis: 36, range:17-40; 38%, 45%, 17% were Stage 1, 2, and 3, respectively).16% (99/607) were non-persistent, of whom 30% (30/99) discontinued ET ≤2 years post-diagnosis and over half had discontinued (54%, 54/99) by 3 years. In multivariable regression, those who were younger at diagnosis (age ≤30 vs. 36-40: OR: 3.39, 95% CI: 1.84-6.24; age 31-36 vs. 36-40: OR: 2.81 95% CI: 1.70-4.64) were more likely to discontinue ET while those with a higher stage at diagnosis were less likely to discontinue ET (Stage 2 vs. 1: OR: 0.46, 95% CI: 0.29-0.74; Stage 3 vs 1: OR: 0.32, 95% CI: 0.15-0.68). At a median follow-up time from diagnosis of 7.8 years (range 1-13 years), 15% of women (88/607) recurred or developed a new primary BC at a median time from diagnosis of 3.5 years (range 1-12 years). Of these, 66% (58/88) were distant recurrences, 32% (28/88) loco-regional, and 2% (2/88) new primary BCs. Rates of recurrence were higher among women who were persistent (81/508, 16%) vs. non-persistent (7/99, 7%, p=0.02). In multivariable regression, those who were non-persistent were less likely to recur (OR: 0.43, 95% CI: 0.19-0.98) while those with a higher stage were more likely to recur (Stage 3 vs. 1: OR: 2.36, 95% CI: 1.03-5.41). Sociodemographic, patient, and other treatment factors did not predict recurrence. Conclusions: Approximately 16% of young women with HR+ BC stop ET earlier than indicated, however non-persistence was not a risk factor for BC recurrence a median of 8 years following diagnosis in our cohort. Importantly, women with higher risk disease who are likely to benefit most from adherence to ET were less likely to discontinue treatment. Extended follow-up will further inform the impact of non-persistence on the incidence of late recurrences for which women with HR+ BC are at increased risk.
Citation Format: Shoshana M Rosenberg, Yue Zheng, Philip Poorvu, Kathryn Ruddy, Rachel Gaither, Rulla Tamimi, Lidia Schapira, Jeffrey Peppercorn, Steven Come, Virginia Borges, Ann Partridge. Endocrine therapy non-persistence and recurrence in young women with early stage breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD2-08.
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Affiliation(s)
| | - Yue Zheng
- 1Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | - Steven Come
- 6Beth Israel Deaconess Medical Center, Boston, MA
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Rosenberg SM, Dominici LS, Gelber S, Poorvu PD, Ruddy KJ, Wong JS, Tamimi RM, Schapira L, Come S, Peppercorn JM, Borges VF, Partridge AH. Association of Breast Cancer Surgery With Quality of Life and Psychosocial Well-being in Young Breast Cancer Survivors. JAMA Surg 2021; 155:1035-1042. [PMID: 32936216 DOI: 10.1001/jamasurg.2020.3325] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Importance Young women with breast cancer are increasingly choosing bilateral mastectomy (BM), yet little is known about short-term and long-term physical and psychosocial well-being following surgery in this population. Objective To evaluate the differential associations of surgery with quality of life (QOL) and psychosocial outcomes from 1 to 5 years following diagnosis. Design, Setting, and Participants Cohort study. Setting Multicenter, including academic and community hospitals in North America. Participants Women age ≤40 when diagnosed with Stage 0-3 with unilateral breast cancer between 2006 and 2016 who had surgery and completed QOL and psychosocial assessments. Exposures (for observational studies) Primary breast surgery including breast-conserving surgery (BCS), unilateral mastectomy (UM), and BM. Main Outcomes and Measures Physical functioning, body image, sexual health, anxiety and depressive symptoms were assessed in follow-up. Results Of 826 women, mean age at diagnosis was 36.1 years; most women were White non-Hispanic (86.7%). Regarding surgery, 45% had BM, 31% BCS, and 24% UM. Of women who had BM/UM, 84% had reconstruction. While physical functioning, sexuality, and body image improved over time, sexuality and body image were consistently worse (higher adjusted mean scores) among women who had BM vs BCS (body image: year 1, 1.32 vs 0.64; P < .001; year 5, 1.19 vs 0.48; P < .001; sexuality: year 1, 1.66 vs 1.20, P < .001; year 5, 1.43 vs 0.96; P < .001) or UM (body image: year 1, 1.32 vs 1.15; P = .06; year 5, 1.19 vs 0.96; P = .02; sexuality: year 1, 1.66 vs 1.41; P = .02; year 5, 1.43 vs 1.09; P = .002). Anxiety improved across groups, but adjusted mean scores remained higher among women who had BM vs BCS/UM at 1 year (BM, 7.75 vs BCS, 6.94; P = .005; BM, 7.75 vs UM, 6.58; P = .005), 2 years (BM, 7.47 vs BCS, 6.18; P < .001; BM, 7.47 vs UM, 6.07; P < .001) and 5 years (BM, 6.67 vs BCS, 5.91; P = .05; BM, 6.67 vs UM, 5.79; P = .05). There were minimal between-group differences in depression levels in follow-up. Conclusions and Relevance While QOL improves over time, young breast cancer survivors who undergo more extensive surgery have worse body image, sexual health, and anxiety compared with women undergoing less extensive surgery. Ensuring young women are aware of the short-term and long-term effects of surgery and receive support when making surgical decisions is warranted.
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Affiliation(s)
| | | | - Shari Gelber
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Julia S Wong
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Steven Come
- Beth Israel Deaconess, Boston, Massachusetts
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Borstelmann NA, Rosenberg S, Gelber S, Zheng Y, Meyer M, Ruddy KJ, Schapira L, Come S, Borges V, Cadet T, Maramaldi P, Partridge AH. Partners of young breast cancer survivors: a cross-sectional evaluation of psychosocial concerns, coping, and mental health. J Psychosoc Oncol 2020; 38:670-686. [PMID: 33000705 DOI: 10.1080/07347332.2020.1823546] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Evaluation of psychosocial concerns, coping style, and mental health in partners of young (diagnosed at ≤40 years) survivors of early-stage breast cancer (BC). DESIGN Cross-sectional; partners participated in a one-time survey. SAMPLE 289 participants; most were male, white, working full-time, college educated, with median age of 43 years, parenting children <18 years old. METHODS Logistic regression was used to explore associations with anxiety and depression (≥8 on Hospital Anxiety and Depression sub-scales). FINDINGS Overall, 41% reported symptoms of anxiety, 18% reported symptoms of depression, and 44% identified maladaptive coping. Multivariable regression analyses revealed: lower social support and poorer quality of life significantly associated with depression (p < .05); maladaptive coping, fulltime employment, poorer caregiver QOL, and less education significantly associated with anxiety. CONCLUSIONS Partners of young BC survivors who use more maladaptive coping strategies, report less social support, work fulltime, and/or who have lower education levels experience negative mental health outcomes. IMPLICATIONS FOR PSYCHOSOCIAL ONCOLOGY Enhancing constructive coping and ensuring all partners have access to supportive resources may improve partners' emotional adjustment.
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Affiliation(s)
| | - Shoshana Rosenberg
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Shari Gelber
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Yue Zheng
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Meghan Meyer
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Lidia Schapira
- Stanford University Medical Center, Stanford, California, USA
| | - Steven Come
- Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Tamara Cadet
- Simmons College School of Social Work, Boston, Massachusetts, USA
| | - Peter Maramaldi
- Simmons College School of Social Work, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ann H Partridge
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Vazquez D, Rosenberg S, Gelber S, Ruddy KJ, Morgan E, Recklitis C, Come S, Schapira L, Partridge AH. Posttraumatic stress in breast cancer survivors diagnosed at a young age. Psychooncology 2020; 29:1312-1320. [PMID: 32515073 DOI: 10.1002/pon.5438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/08/2020] [Accepted: 05/26/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Young breast cancer patients experience greater psychosocial distress compared with older patients, which raises concern for their risk of posttraumatic stress disorder (PTSD). We sought to characterize the prevalence of clinically significant symptoms of PTSD and associated factors among breast cancer survivors diagnosed at a young age. METHODS The Young Women's Breast Cancer Study, an ongoing prospective cohort study, enrolled 1302 women diagnosed with breast cancer at age ≤ 40 between 2006 and 2016. Participants complete serial surveys, and we obtained additional information from medical record review. Socio-demographics, anxiety and depression, social support, and psychiatric co-morbidities and medications were assessed at study baseline (median, 5 months post-diagnosis). We defined a participant as having clinically significant posttraumatic stress symptoms (PTSS) by scoring ≥50 on the PTSD Checklist-Specific Version, administered on the 30-month survey. RESULTS Among 700 women with stage 1-3 disease, the prevalence of PTSS was 6.3% (95%CI = 4.5-8.1). In multivariable analyses, PTSS was significantly associated with anxiety (OR 12.43, 95%CI = 5.81-26.59, P < .0001) and stage 2 vs 1 disease (OR 2.26, 95%CI = 1.04-4.93, P = .04). PTSS was inversely associated with having a college degree (OR 0.29, 95%CI = 0.13-0.62, P = .002) and greater social support (OR 0.44, 95%CI = 0.21-0.94, P = .03). CONCLUSIONS We found similar rates of cancer-related PTSS in breast cancer survivors diagnosed at a young age compared with the general breast cancer population despite their well-documented increased risk of overall distress. Nevertheless, factors associated with posttraumatic stress should be considered at diagnosis and in survivorship to identify young patients who may benefit from psychosocial resources.
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Affiliation(s)
- Danny Vazquez
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Shoshana Rosenberg
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Shari Gelber
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Evan Morgan
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christopher Recklitis
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Steven Come
- Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Ann H Partridge
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Brigham and Women's Hospital, Boston, Massachusetts, USA
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9
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Rosenberg SM, Vaz-Luis I, Gong J, Rajagopal PS, Ruddy KJ, Tamimi RM, Schapira L, Come S, Borges V, de Moor JS, Partridge AH. Employment trends in young women following a breast cancer diagnosis. Breast Cancer Res Treat 2019; 177:207-214. [PMID: 31147983 DOI: 10.1007/s10549-019-05293-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/21/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Little is known about how a breast cancer diagnosis and treatment affects job-related outcomes in young women with breast cancer, who are an integral part of the workforce. We sought to describe employment trends among young breast cancer survivors. METHODS 911 women with non-metastatic breast cancer were surveyed about employment-related outcomes 1 year post-diagnosis. Participants were enrolled in the Young Women's Breast Cancer Study an ongoing, multi-center cohort of women diagnosed with breast cancer at age ≤ 40. RESULTS Among 911 women, median age at diagnosis was 36 years (range 17-40). Most women (80%, n = 729) were employed 1 year post-diagnosis. Among the 7% (n = 62) employed before diagnosis but who reported unemployment at 1 year, approximately half reported they were unemployed for health reasons. Among employed women, 7% said treatment affected their ability to perform their job. Women with stage-three disease (vs. stage 1 disease, odds ratio (OR): 3.73, 95% CI 1.39-9.97) and those who reported having money to pay bills after cutting back or difficulty paying bills at baseline (vs. having enough money for special things, OR 2.70, 95% CI 1.32-5.52) at baseline were more likely to have transitioned out of the workforce. CONCLUSIONS Our results suggest an impact of disease burden and socioeconomic status on employment in young breast cancer survivors. There is a need to ensure young survivors who leave the workforce following diagnosis are sufficiently supported given the potential adverse psychosocial and financial impacts of unemployment on survivors, their families, communities, and society.
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Affiliation(s)
- Shoshana M Rosenberg
- Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA. .,Harvard Medical School, Boston, MA, USA.
| | | | | | | | | | - Rulla M Tamimi
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | | | - Steven Come
- Harvard Medical School, Boston, MA, USA.,Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Janet S de Moor
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Ann H Partridge
- Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.,Harvard Medical School, Boston, MA, USA
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10
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von Hippel C, Rosenberg SM, Austin SB, Sprunck-Harrild K, Ruddy KJ, Schapira L, Come S, Borges VF, Partridge AH. Identifying distinct trajectories of change in young breast cancer survivors' sexual functioning. Psychooncology 2019; 28:1033-1040. [PMID: 30817075 DOI: 10.1002/pon.5047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To identify and characterize distinct trajectories of change in young women's sexual functioning over the first 5 years following breast cancer diagnosis. METHODS Group-based trajectory modeling was applied to the sexual functioning of 896 women diagnosed with stage I-IV breast cancer at age 40 or younger. The Cancer Rehabilitation Evaluation System was used to evaluate women's symptoms of sexual dysfunction annually for 5 years. RESULTS Five distinct trajectories of sexual functioning were identified: one asymptomatic, one minimally symptomatic, two moderately symptomatic, and one severely symptomatic trajectory. Twelve percent of women were asymptomatic throughout follow-up. The plurality of women experienced stable mild symptoms (42%). Among those with moderate symptoms, some experienced improvement over time (22%) while others experienced deterioration (13%); 11% experienced stable severe symptoms that did not remit over time. Independent predictors of experiencing a symptomatic rather than asymptomatic trajectory (P < 0.05, two-sided) included diagnosis with stage 2 versus 1 disease, ER positive disease treated with oophorectomy or ovarian suppression, being partnered, having anxiety, poorer body image, and greater musculoskeletal pain. CONCLUSIONS We identified distinct trajectories that describe the reported sexual symptoms in this cohort of young breast cancer survivors. The majority of women reported various degrees of sexual dysfunction that remained stable over the study period. There is, however, potential for improvement of moderate and severe symptoms of sexual dysfunction in early survivorship.
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Affiliation(s)
- Christiana von Hippel
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Shoshana M Rosenberg
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - S Bryn Austin
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Kim Sprunck-Harrild
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Lidia Schapira
- Division of Medical Oncology, Stanford University Medical Center, Stanford, California
| | - Steven Come
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Breast Cancer Program, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Virginia F Borges
- Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado
| | - Ann H Partridge
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
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11
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Kim HJ, Dominici L, Rosenberg S, Pak LM, Poorvu PD, Ruddy K, Tamimi R, Schapira L, Come S, Peppercorn J, Borges V, Warner E, Vardeh H, Collins L, King T, Partridge A. Abstract GS6-01: Surgical treatment after neoadjuvant systemic therapy in young women with breast cancer: Results from a prospective cohort study. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-gs6-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
Young women are more likely than older women to present with higher stage breast cancer (BC) and may benefit to a greater extent from downstaging with neoadjuvant systemic treatment (NST). Young age is also associated with greater likelihood of pathologic complete response (pCR). Using a large prospective cohort of young women with BC, we investigated response to neoadjuvant therapy, eligibility for breast conserving surgery (BCS) pre- and post-NST, and surgical treatment.
Methods
The Young Women's Breast Cancer Study (YWS) is a multi-center cohort of women diagnosed with BC at age ≤40, that enrolled 1302 patients from 2006 to 2016. Disease characteristics and treatment information were obtained through medical record and central pathology review. Surgical recommendation before and after NST, conversion from BCS borderline/ineligible to BCS eligible, surgery, documented reasons for choosing mastectomy (MTX) among BCS eligible women, and final pathologic response were independently reviewed.
Results
Among 1302 women enrolled in YWS, 801 (62%) presented with unilateral stage I-III breast cancer and 317(40%) received NST. Median age was 36 years old (22-40). Pre-NST, 85/317 (27%) were BCS eligible, 49 (15%) were borderline, and 169 (53%) were not eligible (16 inflammatory breast cancer (IBC), 88 large tumor size /cosmetic, 48 diffuse calcifications, and 83 multicentricity). Among the 218 patients who were BCS ineligible/borderline pre-NST, 82 (38%) became eligible for BCS after NST. 4 patients who were BCS eligible pre-NST became ineligible. Of all patients eligible for BCS post-NST (n=163), 80 (49%) attempted BCS, 74 (93%) of whom were successful, and 83 (51%) chose MTX. Reasons for choosing MTX included: patient preference (38/83 (46%)), BRCA or TP53 mutation (31 (37%)), family history (3 (4%)), unknown (11 (13%)). On final pathology, 75 (24%) patients had pCR. Among patients who achieved a pCR, 48 (64%) underwent MTX, fewer than half (21/48 (44%)) were for anatomic indications (IBC, large tumor at diagnosis, diffuse calcifications, multicentric disease).
Conclusion
While NST doubled the proportion of young women eligible for BCS, nearly half chose MTX regardless of response to NST, mostly for personal preference or high-risk preventative reasons. These data highlight that surgical decision making among young women with breast cancer is often driven by factors beyond extent of disease and clinical response to therapy.
Table 1.Clinical-pathologic characteristicsCharacteristicsNumber%Pre NST surgical recommendation BCS eligible8526.8Borderline4915.5BCS ineligible16953.3Unknown144.4Clinical Response Complete20263.7Partial9229.0Stable30.9Progressing72.2Unknown134.1Pathologic Response pCR (No invasive or DCIS)7524No pCR24276Post NST Surgical recommendation BCS eligible16351.4BCS ineligible14445.4Unknown103.2Attempted surgery BCS8025.2MTX23674.1Unknown20.6Final Surgery BCS7423.3MTX24176unknown20.6
Citation Format: Kim HJ, Dominici L, Rosenberg S, Pak LM, Poorvu PD, Ruddy K, Tamimi R, Schapira L, Come S, Peppercorn J, Borges V, Warner E, Vardeh H, Collins L, King T, Partridge A. Surgical treatment after neoadjuvant systemic therapy in young women with breast cancer: Results from a prospective cohort study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS6-01.
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Affiliation(s)
- HJ Kim
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - L Dominici
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - S Rosenberg
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - LM Pak
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - PD Poorvu
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - K Ruddy
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - R Tamimi
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - L Schapira
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - S Come
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - J Peppercorn
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - V Borges
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - E Warner
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - H Vardeh
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - L Collins
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - T King
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
| | - A Partridge
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Palo Alto, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston; University of Colorado Cancer Center, Aurora, CO; Sunnybrook Health Science Center, Toronto, Canada
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Rosenberg SM, Hu J, Dominici LS, Poorvu PD, Ruddy KJ, Tamimi RM, Schapira L, Come S, Peppercorn JM, Borges VF, Partridge AH. Abstract P2-14-03: Longitudinal changes in psychosocial health in young women following breast cancer surgery: Results from a multi-center cohort study. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p2-14-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Young women with breast cancer (BC) are increasingly choosing contralateral prophylactic mastectomy (CPM), yet little is known about the impact of surgical choices on quality of life (QOL) and psychological health. Using a large, prospective cohort of young women with BC, we sought to evaluate psychosocial outcomes following surgery.
Methods: Among participants of the Young Women's BC Study, a multi-center cohort of women dx'd with BC at age ≤40, we identified women with Stage 0-3 unilateral BC who had surgery and completed surveys that included measures of QOL (CARES) and psychological health (HADS). Linear mixed-effects models were fit to assess changes from 1 to 3 years (yrs) post-dx in anxiety, depression, psychosocial, body image, and sexual scores. Adjusted (stage, hormone receptor status, chemotherapy, age) means were estimated and differences compared (Bonferroni adjusted p-values) between CPM vs breast conserving surgery (BCS) and unilateral mastectomy (UM) at 1, 2, and 3 yrs.
Results: Of 863 women, 30% had BCS, 24% UM, 46% CPM. Median age at dx was 37 (range: 22-40). Of women who had UM/CPM, 84% had reconstruction. Among women who had CPM, mean body image (p=.02), psychosocial (p<.0001), sexual (p<.0001), and depression p=.0007) scores decreased, indicating improvement, from yr 1 to 2 but remained stable from yr 2 to 3 (Table). Anxiety decreased from yr 1 to 2 for women who had BCS (p=.0007) and M (p=.03), and from yr 2 to 3 for women who had CPM (p=.003). Body image scores did not change significantly between any time points among women who had M or BCS. Overall change trajectories for sexual (p=.03) and anxiety scores (p=.008) differed by surgery. Compared to BCS and UM, psychosocial scores were higher in women who had CPM at 1 yr (p<.05) and remained higher compared to BCS at 2 yrs (p=.04). Anxiety was higher among women who had CPM vs UM at 1 and 2 yrs (p<.01), vs BCS at 2 yrs (p=.004). Depression was higher among women who had CPM vs UM in yr 1 (p=.05). By yr 3, there were no significant differences in anxiety, depression, and overall psychosocial scores between groups. Compared to BCS, women who had CPM had higher sexual and body image scores (p<.01), indicating worse QOL, at all timepoints. Compared to UM, women who had CPM had higher sexual scores at 1 and 3 yrs (p<.05) and body image scores at 3 yrs (p=.02).
Conclusions: While psychosocial health improves over time, differences by surgery persist, with women who have CPM experiencing more sexual and body image issues compared to women who undergo BCS or M in the years following surgery. Given that surgical choices may be affected by distress experienced before or at dx, ensuring young women receive adequate support when making surgical decisions as well as after surgery is warranted.
Mean CARES and HADS scores Year 123Psychosocial*CPM.89.78.76 UM.75.69.66 BCS.72.65.66 Sexual*CPM1.641.371.40 UM1.411.291.08 BCS1.181.071.04 Body image*CPM1.331.221.30 UM1.161.131.04 BCS.64.57.56 Anxiety**CPM7.657.406.79 UM6.505.916.39 BCS7.036.226.50 Depression**CPM3.723.213.25 UM3.022.802.70 BCS3.332.823.13**CARES range: 0-4;higher scores=worse QOL **HADS range 0-21;higher scores=more anxiety/depression
Citation Format: Rosenberg SM, Hu J, Dominici LS, Poorvu PD, Ruddy KJ, Tamimi RM, Schapira L, Come S, Peppercorn JM, Borges VF, Partridge AH. Longitudinal changes in psychosocial health in young women following breast cancer surgery: Results from a multi-center cohort study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-03.
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Affiliation(s)
- SM Rosenberg
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - J Hu
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - LS Dominici
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - PD Poorvu
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - KJ Ruddy
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - RM Tamimi
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - L Schapira
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - S Come
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - JM Peppercorn
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - VF Borges
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
| | - AH Partridge
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA; University of Colorado Cancer Center, Aurora, CO
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13
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Rosenberg SM, Ruddy KJ, Tamimi RM, Gelber S, Schapira L, Come S, Borges VF, Larsen B, Garber JE, Partridge AH. BRCA1 and BRCA2 Mutation Testing in Young Women With Breast Cancer. JAMA Oncol 2017; 2:730-6. [PMID: 26867710 DOI: 10.1001/jamaoncol.2015.5941] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE BRCA testing is recommended for young women diagnosed as having breast cancer, but little is known about decisions surrounding testing and how results may influence treatment decisions in young patients. OBJECTIVES To describe the use of BRCA testing and to evaluate how concerns about genetic risk and use of genetic information affect subsequent treatment decisions in young women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of data collected following the opening of the study to accrual from October 10, 2006, through December 31, 2014, as part of the Helping Ourselves, Helping Others: Young Women's Breast Cancer Study, an ongoing prospective cohort study. Study participants included 897 women aged 40 years and younger at breast cancer diagnosis from 11 academic and community medical centers. MAIN OUTCOMES AND MEASURES Frequency and trends in the use of BRCA testing and how genetic information is used to make treatment decisions among women who test positive vs negative for a BRCA mutation. RESULTS A total of 780 (87.0%) of 897 women reported BRCA testing by 1 year after breast cancer diagnosis (mean age at diagnosis, 35.3 vs 36.9 years for untested women; P < .001), with the frequency of testing increasing among women diagnosed from August 1, 2006, through December 31, 2013. Of 39 women who were diagnosed as having breast cancer in 2006, 30 (76.9%) reported testing. In 2007, a slightly lower percentage of women (87 of 124 [70.2%]) reported testing; however, the proportion tested increased each subsequent year, with 141 (96.6%) of 146 and 123 (95.3%) of 129 women diagnosed as having breast cancer in 2012 and 2013, respectively, reporting BRCA testing (P < .001). Among untested women, 37 (31.6%) of 117 did not report discussion of the possibility that they might have a mutation with a physician and/or genetic counselor, and 43 (36.8%) of 117 were thinking of testing in the future. A total of 248 (29.8%) of 831 women said that knowledge or concern about genetic risk influenced treatment decisions; among these women, 76 (86.4%) of 88 mutation carriers and 82 (51.2%) of 160 noncarriers chose bilateral mastectomy (P < .001). Fewer women reported that systemic treatment decisions were influenced by genetic risk concern. CONCLUSIONS AND RELEVANCE Rates of BRCA1 and BRCA2 mutation testing are increasing in young women with breast cancer. Given that knowledge and concern about genetic risk influence surgical decisions and may affect systemic therapy trial eligibility, all young women with breast cancer should be counseled and offered genetic testing, consistent with the National Comprehensive Cancer Network guidelines.
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Affiliation(s)
- Shoshana M Rosenberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Rulla M Tamimi
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shari Gelber
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lidia Schapira
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston
| | - Steven Come
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Virginia F Borges
- Division of Medical Oncology, University of Colorado Cancer Center, Denver
| | - Bryce Larsen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Judy E Garber
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Shields H, Li J, Pelletier S, Wang H, Freedman R, Mamon H, Ng A, Freedman A, Come S, Avigan D, Huberman M, Recht A. Persistence of dysphagia and odynophagia after mediastinal radiation and chemotherapy in patients with lung cancer or lymphoma. Dis Esophagus 2017; 30:1-8. [PMID: 27247116 DOI: 10.1111/dote.12498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal symptoms are common during radiation and chemotherapy. It is unclear how often these symptoms persist after therapy. We retrospectively reviewed medical records of 320 adults treated for nonmetastatic breast cancer (84), lung cancer (109), or Hodgkin and non-Hodgkin lymphoma (127) who were disease-free at 10-14 months after therapy. Treatment included chemotherapy with or without nonmediastinal radiation therapy (150 patients), chemotherapy plus sequential mediastinal radiation therapy (MRT) (48 patients), chemotherapy plus concurrent MRT (61 patients), or non-MRT only (61 patients). Proton pump inhibitor use was documented. All treatment groups had similar prevalence of the esophageal symptom of heartburn before therapy. Rates were higher during treatment in those who received MRT with or without chemotherapy, but declined by 10-14 months after treatment. However, low baseline rates of dysphagia (4%) and odynophagia (2%) increased significantly after combined chemotherapy and MRT to 72% for dysphagia and 62% for odynophagia (P < 0.01) during treatment and stayed significantly elevated over baseline with 27% of the patients having dysphagia and 11% having odynophagia at 10-14 months after treatment. The use of proton pump inhibitors by patients who had MRT with chemotherapy was significantly increased during and after treatment (P = 0.002). Dysphagia, odynophagia and the use of proton pump inhibitors were significantly more common both during and after treatment than before treatment in patients who received both chemotherapy and mediastinal radiation. Our data highlight the important challenge for clinicians of managing patients with lung cancer and lymphoma who have persistent esophageal problems, particularly dysphagia and odynophagia, at approximately 1 year after treatment.
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Affiliation(s)
- Helen Shields
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Justin Li
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Helen Wang
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rachel Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Harvey Mamon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA
| | - Andrea Ng
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA
| | - Arnold Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Steven Come
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David Avigan
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mark Huberman
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Partridge AH, Rosenberg SM, Rajagopal PS, Ruddy KJ, Tamimi RM, Schapira L, Come S, Borges V, Gelber S. Abstract P4-10-04: Employment trends in young women following a breast cancer diagnosis. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p4-10-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Workplace concerns are particularly salient for young women with breast cancer (BC), and a cancer diagnosis (dx) and treatment may affect their careers. We sought to evaluate the perceived impact of dx on employment, describe job changes, and identify factors associated with transition out of the workforce after dx of BC at a young age.
Methods: As part of an ongoing, multi-center cohort of young women diagnosed with BC at age ≤ 40, we surveyed women with early-stage BC about their pre- and post-dx employment status. Additional items assessed socio-demographic and treatment information; tumor characteristics were ascertained via pathology and medical record review. We used logistic regression to identify predictors of transitioning from pre-dx employment to unemployment at 1 year after dx. Among women employed 1 year after dx, we evaluated job satisfaction, perceived impact of dx on job performance, accommodations made by employers, and perceived likelihood of employment in the future.
Results: 76% of women (555/730) were employed both before dx and at 1 year; 13% were not employed at either time point; 7% were employed pre-dx but unemployed at 1 year; 4% were not employed prior to dx but reported employment at 1 year. Among women employed 1 year after dx, 74% (427/581) were somewhat or completely satisfied with their job. Only 6% said cancer or treatment limited their ability to perform their job quite a bit or very much; 38% said their ability was affected a little bit. Most (63%) said their employers had made accommodations for them, and almost all women (93%) said it was very likely they would be working in 1 year. In multivariable analyses (Table 1), women with stage 3 disease (vs. stage 1), were more likely to transition out of the workforce following dx, while women with a college or graduate degree (vs. no college degree) were less likely to transition out.
Conclusion: Most young women with early stage BC remain employed and report a willingness by their employer to make accommodations following a breast cancer dx. While few women reported that their dx or treatment limited their job performance, the finding that women with more advanced disease were more likely to transition out of the workforce suggests an impact of dx/treatment burden on employment. Women without a college degree were also at risk for unemployment post-dx, suggesting that job type, socioeconomic status, and environment affect employment outcomes. Attention to these subgroups of women is warranted to ensure that they are sufficiently supported given the potential adverse psychosocial and financial impacts of unemployment on patients, families, communities, and society.
Table 1. Multivariable analysis of factors associated with transition out of workforce 1year post-dx (N=634) OR (95% CI)Stage (ref=1) 04.52 (0.60-33.85)21.11 (0.48-2.58)34.05 (1.53-10.72)*White non-Hispanic (ref=non-WNH)1.47 (0.56-3.81)College graduate (ref=no college degree)0.44 (0.22-0.90)*Married/Living as married (ref=unmarried)0.95 (0.43-2.08)Parous (ref=nulliparous)1.75 (0.83-3.69)Age at diagnosis (years)0.98 (0.90-1.06)Mastectomy (ref=lumpectomy)1.74 (0.75-4.05)Endocrine therapy (ref=none)0.75 (0.41-1.39)Chemotherapy (ref=none)5.20 (0.93-29.22)Radiation (ref=none)1.38 (0.64-2.96)*p<0.05
Citation Format: Partridge AH, Rosenberg SM, Rajagopal PS, Ruddy KJ, Tamimi RM, Schapira L, Come S, Borges V, Gelber S. Employment trends in young women following a breast cancer diagnosis. [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 P4-10-04.
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Affiliation(s)
- AH Partridge
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
| | - SM Rosenberg
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
| | - PS Rajagopal
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
| | - KJ Ruddy
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
| | - RM Tamimi
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
| | - L Schapira
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
| | - S Come
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
| | - V Borges
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
| | - S Gelber
- Dana-Farber Cancer Institute; University of Pittsburgh Medical Center; Mayo Clinic; Channing Division of Network Medicine, Brigham and Women's Hospital; Massachusetts General Hospital; Beth Israel Deaconess Medical Center; University of Colorado Cancer Center
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Rosenberg SM, Sepucha K, Ruddy KJ, Schapira L, Come S, Borges V, Morgan E, Lin NU, Gelber S, Tamimi RM, Partridge AH. Abstract P2-10-03: Decision-making surrounding adjuvant chemotherapy in young women with early stage breast cancer. Cancer Res 2015. [DOI: 10.1158/1538-7445.sabcs14-p2-10-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: There is an increasing recognition that many young women with breast cancer will have favorable outcomes without chemotherapy. We sought to characterize decision-making surrounding adjuvant chemotherapy treatment (CT) in this population for whom chemotherapy has historically been a standard of care.
Methods: As part of an ongoing, multi-center, prospective cohort of young women diagnosed with breast cancer at age 40 and younger, we identified 657 women with Stage I-III breast cancer. Participants were asked to complete surveys by mail that included questions about socio-demographics, decision-making, and treatment history within the first year following diagnosis. Tumor characteristics were ascertained via pathology and medical record review. We used Chi-square tests to compare: decisional involvement (patient-driven vs. shared vs. physician-driven), degree of confidence, and feeling informed about the CT decision (the latter two measured on a 0-10 scale, categorized as follows: 0-5=low; moderate=6-8; 9-10=high) between women who did and did not receive CT. To explore clinical appropriateness of the CT decision, we used logistic regression to assess the relationship between tumor characteristics and non-receipt of CT among women with Stage I/II disease.
Results: Among women with Stage I (n=250), II (n=312), and III (n=95), disease, 66%, 95%, and 100%, received CT, respectively. A greater proportion of women who had CT were highly confident with their decision compared with women who did not have CT (80% vs. 60%, p<0.0001); women who did not have CT were more likely to report a low level of feeling informed about the CT decision compared to women who received CT (20% vs. 5%, p<0.0001). Women who did not have CT were also more likely to report the final CT decision as made by their doctor (49% vs. 28%) and less likely to report a shared decision (33% vs. 59%, p<0.0001). Non-receipt of CT in women with Stage I/II disease (n=546) was associated within having node negative disease, T1 (vs. T2 or larger), Her2- negative, and hormone receptor positive tumors.
Conclusion: Although non-receipt of CT would be expected to be viewed favorably by patients and doctors, we found that women who received CT felt more confident and better informed than those who received no CT. Given that women who did not have CT were also less likely to perceive the CT decision as shared, improved communication together with better decisional support may be beneficial, especially for women who do not receive adjuvant chemotherapy.
Citation Format: Shoshana M Rosenberg, Karen Sepucha, Kathryn J Ruddy, Lidia Schapira, Steven Come, Virginia Borges, Evan Morgan, Nancy U Lin, Shari Gelber, Rulla M Tamimi, Ann H Partridge. Decision-making surrounding adjuvant chemotherapy in young women with early stage breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-10-03.
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Borstelmann NA, Rosenberg SM, Ruddy KJ, Tamimi RM, Gelber S, Schapira L, Come S, Borges V, Morgan E, Partridge AH. Partner support and anxiety in young women with breast cancer. Psychooncology 2015; 24:1679-85. [DOI: 10.1002/pon.3780] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 01/20/2015] [Accepted: 01/29/2015] [Indexed: 01/06/2023]
Affiliation(s)
- Nancy A. Borstelmann
- Dana-Farber Cancer Institute; Boston MA USA
- School of Social Work; Simmons College; Boston MA USA
| | - Shoshana M. Rosenberg
- Dana-Farber Cancer Institute; Boston MA USA
- Dana-Farber Cancer Institute; Harvard Medical School; Boston MA USA
| | | | - Rulla M. Tamimi
- Dana-Farber Cancer Institute; Harvard Medical School; Boston MA USA
- Harvard School of Public Health; Boston MA USA
| | | | - Lidia Schapira
- Dana-Farber Cancer Institute; Harvard Medical School; Boston MA USA
- Massachusetts General Hospital; Boston MA USA
| | - Steven Come
- Dana-Farber Cancer Institute; Harvard Medical School; Boston MA USA
- Beth Israel Deaconess Medical Center; Boston MA USA
| | | | | | - Ann H. Partridge
- Dana-Farber Cancer Institute; Boston MA USA
- Dana-Farber Cancer Institute; Harvard Medical School; Boston MA USA
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Rosenberg S, Ruddy K, Tamimi R, Gelber S, Schapira L, Come S, Borges V, Larsen B, Garber J, Partridge A. PO18 BRCA1/BRCA2 (BRCA) testing in young women with breast cancer: patterns; motivations and implications for treatment decisions. Breast 2014. [DOI: 10.1016/s0960-9776(14)70028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Mayer EL, Gropper AB, Harris L, Gold JM, Parker L, Kuter I, Come S, Najita JS, Guo H, Winer EP, Burstein HJ. Long-term follow-up after preoperative trastuzumab and chemotherapy for HER2-overexpressing breast cancer. Clin Breast Cancer 2014; 15:24-30. [PMID: 25205424 DOI: 10.1016/j.clbc.2014.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy and trastuzumab is an established treatment for locally advanced HER2-positive breast cancer, providing favorable rates of clinical response and pCR. Minimal data describe long-term outcomes after neoadjuvant HER2-directed therapy. This study aimed to explore long-term efficacy and toxicity after neoadjuvant trastuzumab and chemotherapy for HER2-positive breast cancer. PATIENTS AND METHODS Eligible patients participated in 1 of 2 single-arm phase II neoadjuvant trials, receiving either paclitaxel/trastuzumab (TH) or vinorelbine/trastuzumab (NH) for stage II-III HER2-positive disease. Postoperative chemotherapy, with or without trastuzumab, was offered. Charts were reviewed to identify recurrence, death, and treatment-related toxicities. Association of long-term outcomes with baseline characteristics and pathological response to primary therapy was explored. RESULTS Eighty patients were identified; 33 (41.3%) received TH and 47 (58.8%) received NH. Fourteen (17.5%) had pCR at surgery. Most (96.3%) received anthracycline-based adjuvant chemotherapy; 78.7% of NH patients also received adjuvant trastuzumab. At a median follow-up of 8.8 years, 23 (28.8%) patients have experienced recurrence, with 16 breast cancer-related deaths. Four-year RFS in patients with pCR was 92.9% (95% confidence interval [CI], 79.4%-100%) versus 72.4% without pCR (95% CI, 63.9%-82.1%). All initial symptomatic cardiotoxicity resolved during extended follow-up. New symptomatic cardiotoxicity in long-term follow-up was rare, primarily occurring in patients requiring retreatment with a cardiotoxic agent. CONCLUSION Neoadjuvant chemotherapy and trastuzumab for HER2-positive breast cancer resulted in favorable long-term survival with minimal late toxicity. Trends in this data set suggest an association between pCR and improved long-term RFS. Retreatment with cardiotoxic agents might increase risk of late cardiotoxicity.
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Affiliation(s)
| | | | | | | | | | | | - Steven Come
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Hao Guo
- Dana-Farber Cancer Institute, Boston, MA
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Seah DS, Scott SM, Najita J, Openshaw T, Krag KJ, Frank E, Sohl J, Stadler ZK, Garrett M, Winer EP, Come S, Lin NU. Abstract P2-16-04: Attitudes of metastatic breast cancer patients towards research biopsies. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p2-16-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In the era of molecularly targeted therapy, developing an understanding of the molecular basis of cancer is a principal or secondary goal of many research studies. For this reason, studies collecting tissue for research purposes are increasingly common. Understanding patients' attitudes towards research biopsies may lead to improvement in accrual to research biopsy studies.
Methods: Patients with metastatic breast cancer from two academic and two community hospitals completed a self-administered paper survey consisting of 29 questions in clinic to evaluate their willingness to consider providing additional biopsies (additional biopsy performed with a clinically indicated biopsy) and research purposes only biopsies (RPOB) (research biopsy performed as a stand alone procedure).
Results: 160 patients (n = 80 academic, n=80 community) completed the survey, with a response rate of 98%. As expected, demographic variables differed between sites, with patients from academic sites likely to be younger (p = 0.01), more educated (p = 0.002), employed (p = 0.01), have prior trial participation (P <0.001) and have a longer travel time (P <0.0001). 64 (80%) academic patients and 51 (64%) community patients would definitely or probably consider additional biopsies. 42 (53%) academic patients and 40 (50%) community patients would consider RPOB.
In univariate analyses of patients' willingness to have additional biopsies, patients in academic sites were more likely to agree to additional biopsies than those at community sites (RR = 1.2, 95% CI 1.0–1.5, p = 0.03). Statistically significant differences based on demographic characteristics such as age, education, marital status, prior trial participation, number of prior biopsies, and travel time were not observed.
For RPOB, patients having had more prior biopsies were less likely to consider research biopsies (RR = 0.6, 95% CI 0.4–1.0, p = 0.03). The following variables did not reach statistical significance: type of practice, age, education, marital status, prior trial participation, and travel time.
Patients' willingness in both academic and community sites to consider RPOB declined with more invasive biopsies. Although differences were observed, none were statistically significant between academic and community; skin (56%, 65%), bone marrow (30%, 27%), breast (43%, 49%) or liver (24%, 19%).
Of the 13/160 (8%) patients who would not consider additional biopsies, the most common reasons cited included pain or discomfort (n = 8/13, 62%), risk of biopsy (n = 8/13, 62%) and anxiety related to the biopsy (n = 6/13, 46%). Of the 37/160 (23%) patients who would not consider RPOB, the most common reasons cited included pain or discomfort (n = 23/37, 62%), risk of biopsy (n = 15/37, 41%) and inconvenience of the procedure to the patient (n = 13/37, 35%).
Conclusions: The majority of patients in this study indicated they would consider research biopsies, with a larger proportion willing to consider additional biopsies; patients seen at academic hospitals were more likely to consider additional biopsies compared to those seen at community hospitals. Breast cancer patients' willingness to undergo research biopsies may be higher than generally expected by clinicians and may not be the primary barrier to obtaining research biopsies.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-16-04.
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Affiliation(s)
- DS Seah
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - SM Scott
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - J Najita
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - T Openshaw
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - KJ Krag
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - E Frank
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - J Sohl
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - ZK Stadler
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M Garrett
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - EP Winer
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - S Come
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
| | - NU Lin
- Dana-Farber Cancer Institute, Boston, MA; Beth Isreal Deaconness Medical Center, Boston, MA; Cancer Care of Maine, Brewer, ME; Mass General North Shore Cancer Center, Danvers, MA; Memorial Sloan-Kettering Cancer Center, New York, NY
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Jeselsohn RM, Regan MM, Werner L, Fatima A, He HH, Brown M, Iglehart JD, Richardson AL, Come S. Abstract P1-07-07: Inflammatory gene expression variations in the interval between core needle biopsy and excisional biopsy in early breast cancer. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p1-07-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Advancements in molecular biology have unveiled multiple breast cancer promoting pathways and potential therapeutic targets. Large randomized clinical trials remain the ultimate means of validating therapeutic efficacy, but they require large cohorts of patients and are lengthy and costly. An alternative approach is to conduct a window of opportunity study in which patients are exposed to a drug pre-surgically during the interval between the core needle biopsy (CNB) and the definitive surgery (excisional biopsy (EB)). These are non-therapeutic studies and the end point is not clinical or pathological response but rather evaluation of molecular changes in the tumor specimens that can predict response. However, since the end points of the non-therapeutic studies are biologic, it is critical to first define any biologic changes that occur in the absence of treatment. In this study, we compared the molecular profiles of breast cancer tumors at the time of the diagnostic biopsy versus the definitive surgery in the absence of any intervention.
Methods: The study was conducted with DFCI/HCC IRB approval and patient consent. Post-menopausal women with a breast lesion suspected to be cancerous were eligible for this study. We obtained a tissue specimen at the time of a CNB and if determined to be consistent with invasive carcinoma a second specimen was obtained at the time of the EB. We used the Nanostring Ncounter system to study the expression level of 148 transcripts. Since we expected that most of the tumors will be hormone receptor positive (HR+), the library included; genes that have been shown to be prognostic in HR+ tumors (Oncotype DX®, PAM50), estrogen receptor (ER) modulators, ER responsive genes and inflammatory genes. The Wilcoxon's signed rank test was used to evaluate for changes in gene expression levels between the paired samples.
Results: 25 patients were enrolled in this study and paired tumor tissue samples were obtained from all patients. 21 of the paired samples were successfully analyzed by the nanostring system. 86% of the patients are HR+/Her2−. We found that the gene expression levels of 14 out of the 148 genes (9%) did change between the CNB and EB without any intervention (p < 0.05). 8 of these 14 genes can be classified as inflammatory genes that also have known functions in tumor progression. The expression of these 8 genes was upregulated between the biopsies and include; CD68, ADM, CD14, IL6, VEGFA, CD52, CD44 and SNAI1. These changes may be due to an inflammatory response to the CNB. Ki67 expression did not change significantly between biopsies.
Conclusions: In this study we found significant gene expression variations between CNBs and EBs in 9% of the genes tested, without any therapeutic intervention. Our findings suggest that when conducting a “Window of Opportunity” clinical study to evaluate for biomarkers of response or resistance, changes in expression of inflammatory genes cannot be attributed to treatment and a control arm should be considered.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-07.
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Affiliation(s)
- RM Jeselsohn
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - MM Regan
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - L Werner
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - A Fatima
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - HH He
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - M Brown
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - JD Iglehart
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - AL Richardson
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - S Come
- Beth Israel Deaconess Medical Center, Boston, MA; Dana Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA
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Rosenberg SM, Tamimi RM, Gelber S, Kereakoglow S, Borges V, Come S, Schapira L, Winer E, Partridge A. PD04-05: Body Image Issues in Young Breast Cancer Patients: The Impact of Chemotherapy, Hormone Treatment, and Surgery. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-pd04-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: While there is evidence that younger women with breast cancer are more likely to experience compromised quality of life compared to older women, few studies have prospectively explored the impact of treatment, including surgery, chemotherapy, and hormone therapy, on body image, in particular, in very young women (≤40 years old). This analysis examined treatment-associated differences in self-reported body image among a large cohort of young women diagnosed with breast cancer.
Methods: 431 women enrolled in an ongoing multi-center prospective cohort study with Stage 0-Stage III breast cancer were included in this analysis. Body image was measured at baseline (1-12 months following diagnosis) using three items from the Cancer Rehabilitation Evaluation System (CARES) survey. CARES scores range from 0–4, with higher scores indicative of greater image concerns. Mean differences in CARES scores between treatment groups (chemotherapy within the last month vs. none; hormone therapy vs. none; lumpectomy vs. mastectomy alone vs. mastectomy + reconstruction) were estimated using T-tests and one-way ANOVA. To control for concurrent treatment, stage, and time since diagnosis, multiple linear regression models were fit and least squares means estimated and compared between treatment groups. Multiple comparisons were adjusted for using the Bonferroni correction.
Results: Median age at diagnosis was 37 (range: 17–40) and median time from diagnosis to study enrollment was 5 months (range: 1–12 months). In the unadjusted analysis, there were no significant differences in scores between women who had received chemotherapy within the last month and those who did not (p=0.80), while women who reported hormone treatment had higher mean CARES scores compared to women who did not (p=0.04). Among women who had undergone surgery (n=370), women who had lumpectomies had a mean CARES score of 0.95, which was significantly lower (p<.0001) compared to both women who had undergone mastectomy alone (CARES: 1.89) and women who reported mastectomy + reconstruction (CARES: 1.53). After adjusting for concurrent treatment (including radiation), time since diagnosis, and stage of disease, only differences between surgical groups remained significant (p<.0001), with mean scores among women who had either undergone mastectomy alone (CARES: 2.02) or together with reconstruction (CARES: 1.58) higher compared to those who had a breast conserving procedure (CARES: 0.92) Conclusion: To the best of our knowledge, this is the largest analysis of treatment-related body image issues in young women with breast cancer. Treatment with chemotherapy and hormonal therapy did not appear to affect short-term body image. However, women who had a breast conserving procedure had the fewest body image concerns as measured by the CARES, while women undergoing more radical surgery appear to be at increased risk for low perceived body image though this may be mitigated to a degree by reconstruction. Further analyses will explore whether differences between surgical groups persist over time as well as examine the trajectory of change over the course of follow-up.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD04-05.
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Affiliation(s)
- SM Rosenberg
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
| | - RM Tamimi
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
| | - S Gelber
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
| | - S Kereakoglow
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
| | - V Borges
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
| | - S Come
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
| | - L Schapira
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
| | - E Winer
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
| | - A Partridge
- 1Harvard School of Public Health, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; University of Colorado Cancer Center, Denver, CO; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
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Morris PG, Chen C, Steingart R, Fleisher M, Lin N, Moy B, Come S, Sugarman S, Abbruzzi A, Lehman R, Patil S, Dickler M, McArthur HL, Winer E, Norton L, Hudis CA, Dang CT. Troponin I and C-reactive protein are commonly detected in patients with breast cancer treated with dose-dense chemotherapy incorporating trastuzumab and lapatinib. Clin Cancer Res 2011; 17:3490-9. [PMID: 21372222 DOI: 10.1158/1078-0432.ccr-10-1359] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE There are no validated methods of early detection of cardiotoxicity from trastuzumab (T) following anthracycline-based chemotherapy. Currently changes in left ventricular ejection fraction (LVEF) are assessed but this approach has limited sensitivity and specificity. Within a prospective feasibility study of dose-dense (dd) doxorubicin and cyclophosphamide (AC) → weekly paclitaxel (P) with T and lapatinib (L), we included a preplanned analysis of correlative cardiac Troponin I (cTnI) and C-reactive protein (CRP) as early biomarkers of cardiotoxicity. EXPERIMENTAL DESIGN As previously described, patients received ddACx 4 → PTL → TL. LVEF was assessed at months 0, 2, 6, 9, and 18 and cTnI and CRP measured every 2 weeks during chemotherapy then at months 6, 9, and 18. These biomarkers were correlated with changes in LVEF. RESULTS Ninety-five patients enrolled. Overall, 3 (3%) patients withdrew during AC and 41 (43%) withdrew during PTL → TL, mostly due to diarrhea. Median LVEF was 68% (baseline), 69% (month 2), 65% (month 6), 65% (month 9), and 65% (month 18). The majority (67%) had a detectable cTnI during the study. The proportion of detectable cTnIs increased over time; 4% at baseline, 11% at month 2, and 50% at month 3. The timing of these detectable cTnIs preceded maximum-recorded decline in LVEF. However, overall, maximum cTnI levels did not correlate with LVEF declines. A detectable CRP was seen in 74/95 (78%) but did not correlate with LVEF declines. CONCLUSION In patients receiving ddAC → PTL, cTnIs are commonly detected. These elevations may precede changes in LVEF but, as assessed in this trial, do not predict CHF.
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24
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Dang C, Lin N, Moy B, Come S, Sugarman S, Morris P, Abbruzzi A, Chen C, Steingart R, Patil S, Norton L, Winer E, Hudis C. Dose-dense doxorubicin and cyclophosphamide followed by weekly paclitaxel with trastuzumab and lapatinib in HER2/neu-overexpressed/amplified breast cancer is not feasible because of excessive diarrhea. J Clin Oncol 2010; 28:2982-8. [PMID: 20479410 PMCID: PMC3664034 DOI: 10.1200/jco.2009.26.5900] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 02/19/2010] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Dose-dense doxorubicin and cyclophosphamide (AC) followed by paclitaxel and trastuzumab (PT) is feasible. Lapatinib is effective in the treatment of human epidermal growth factor receptor 2 (HER2) -positive metastatic breast cancer. We conducted a pilot study of dose-dense AC followed by PT plus lapatinib (PTL) followed by trastuzumab plus lapatinib (TL). PATIENTS AND METHODS Patients with stages I to III, HER2-positive breast cancer and left ventricular ejection fraction (LVEF) of > or = 50% were enrolled. Treatment consisted of AC (60 mg/m(2) and 600 mg/m(2)) for 4 cycles every 2 weeks (with pegfilgrastim 6 mg on day 2) followed by paclitaxel (80 mg/m(2)) for 12 doses weekly plus trastuzumab and lapatinib. Trastuzumab (4 mg/kg loading dose, then 2 mg/kg weekly during paclitaxel then 6 mg/kg every 3 weeks after paclitaxel) and lapatinib (1,000 mg daily) were given for 1 year. The primary end points were feasibility defined as > or = 80% patients completing the PTL phase without a dose delay/reduction and a cardiac event rate of < or = 4%. RESULTS From March 2007 to April 2008, we enrolled 95 patients. Median age was 46 years (range, 28 to 73 years). At a median follow-up of 22 months, 92 were evaluable. Of the 92 patients, 41 patients (45%) withdrew for PTL-specific toxicities. Overall, 40 (43%) of 92 patients had lapatinib dose reductions, and 27 (29%) of 92 patients had grade 3 diarrhea. Three patients (3%) had congestive heart failure; three patients dropped out because of significant asymptomatic LVEF decline during PTL followed by TL. CONCLUSION Dose-dense AC followed by PTL and then followed by TL was not feasible because of a high rate of lapatinib dose reduction, mostly caused by unacceptable grade 3 diarrhea. Lapatinib (1,000 mg/d) was not feasible combined with weekly PT.
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MESH Headings
- Adult
- Aged
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Humanized
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Breast Neoplasms/drug therapy
- Breast Neoplasms/genetics
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Cyclophosphamide/administration & dosage
- Diarrhea/chemically induced
- Dose-Response Relationship, Drug
- Doxorubicin/administration & dosage
- Feasibility Studies
- Female
- Filgrastim
- Follow-Up Studies
- Gene Amplification
- Granulocyte Colony-Stimulating Factor/administration & dosage
- Humans
- Immunoenzyme Techniques
- In Situ Hybridization, Fluorescence
- Lapatinib
- Middle Aged
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/metabolism
- Neoplasm Recurrence, Local/pathology
- Neoplasm Staging
- Paclitaxel/administration & dosage
- Pilot Projects
- Polyethylene Glycols
- Quinazolines/administration & dosage
- Receptor, ErbB-2/genetics
- Receptor, ErbB-2/metabolism
- Recombinant Proteins
- Survival Rate
- Trastuzumab
- Treatment Outcome
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Affiliation(s)
- Chau Dang
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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25
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Morris PG, Dickler M, McArthur HL, Traina T, Sugarman S, Lin N, Moy B, Come S, Godfrey L, Nulsen B, Chen C, Steingart R, Rugo H, Norton L, Winer E, Hudis CA, Dang CT. Dose-dense adjuvant Doxorubicin and cyclophosphamide is not associated with frequent short-term changes in left ventricular ejection fraction. J Clin Oncol 2009; 27:6117-23. [PMID: 19901120 PMCID: PMC3664032 DOI: 10.1200/jco.2008.20.2952] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 09/08/2009] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Doxorubicin and cyclophosphamide (AC) every 3 weeks has been associated with frequent asymptomatic declines in left ventricular ejection fraction (LVEF). Dose-dense (dd) AC followed by paclitaxel (P) is superior to the same regimen given every third week. Herein, we report the early cardiac safety of three sequential studies of ddAC alone or with bevacizumab (B). PATIENTS AND METHODS Patients with HER2-positive breast cancer were treated on two trials: ddAC followed by P and trastuzumab (T) and ddAC followed by PT and lapatinib. Patients with HER2-normal breast cancer were treated with B and ddAC followed by B and nanoparticle albumin-bound P. Prospective LVEF measurement by multigated radionuclide angiography scan before and after every 2 week AC for 4 cycles and at month 6 from all three trials were aggregated to determine the early risks of cardiac dysfunction. RESULTS From January 2005 to May 2008, 245 patients were enrolled. The median age was 47 years (range, 27 to 75 years). Median LVEF pre-ddAC was 68% (range, 52% to 82%). LVEF post-ddAC was available in 241 patients (98%) and the median was unchanged at 68% (range, 47% to 81%). Per protocol no patients were ineligible for subsequent targeted biologic therapy based on LVEF decline post-ddAC. In addition, LVEF was available in 222 patients (92%) at 6 months, at which time the median LVEF was similar at 65% (range, 24% to 80%). Within 6 months of initiating chemotherapy, three patients (1.2%; 95% CI, 0.25% to 3.54%) developed CHF, all of whom received T. CONCLUSION Dose-dense AC with or without concurrent bevacizumab is not associated with frequent acute or short-term declines in LVEF.
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Morris P, Chen C, Lin N, Moy B, Come S, Abbruzzi A, Patil S, Winer E, Norton L, Hudis C, Dang C. Dose-Dense (dd) Doxorubicin and Cyclophosphamide (AC) Followed by Weekly Paclitaxel (P) with Trastuzumab (T) and Lapatinib (L) in Early Breast Cancer (EBC); Troponin I and C-Reactive Protein as Biomarkers of Cardiotoxicity. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-09-3088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BackgroundThe early detection of cardiotoxicity and congestive heart failure (CHF) from anthracyclines and anti-HER2 agents is currently limited to measuring changes in left ventricular ejection fraction (LVEF) at arbitrary time points. This approach has limited sensitivity and specificity and has led to the investigation of putative biomarkers such as cardiac Troponin I (TnI), a highly specific marker of myocardial damage and C-reactive protein (CRP), a sensitive inflammatory marker. In a pre-planned analysis we investigated these as biomarkers of cardiotoxicity within a prospective study testing the feasibility of ddAC- followed by weekly P with T and L.Materials and MethodsPatients (pts) with HER2+ EBC enrolled at MSKCC and DF/HCC and received ddAC (A 60mg/m2 + C 600mg/m2) x 4 → weekly P (80mg/m2) x 12 + T + L (1000mg/day). T+L continued for a total of 1yr. At baseline pts had LVEF ≥50%. Pts with unstable angina, CHF, recent MI, uncontrolled arrhythmia, grade 3 QT prolongation were excluded. LVEF was assessed by MUGA scan at mths 0, 2, 6, 9 and 18. TnI and CRP were measured every 2 wks right before treatment (Rx) during ddAC-PTL, then at mths 6, 9 and 18. TnI was categorized as “undetectable” (< 0.06 ng/ml; MSKCC, <0.04 ng/ml; DF/HCC), “minimally elevated” (<0.31 ng/ml) and “elevated” (>0.31ng/ml). Elevated CRP was defined as (>0.8mg/dl; MSKCC, >0.3mg/dl; DF/HCC). Investigators were blinded to these results until pts completed 18mth follow-up (F/U).ResultsFrom Apr 07- Apr 08, 95 pts were enrolled; 39/95 (41%) withdrew due to PTL toxicities (incl. 3 with asymptomatic LVEF (aLVEF) declines and 3 with CHF). Final biomarker results were available in 84 pts (88%) and 11 pts (12%) continue on study. During Rx, minimal elevations in TnI occurred in 55 pts (65%). One pt had ↑TnI above normal range with AC#4; MUGA 1 wk later was unchanged (LVEF 75%), but she died from sepsis during subsequent Rx without evidence of CHF. Elevations in TnI occurred only during chemoRx and no pt had a ↑TnI during TL or at 18mth F/U. Of 55pts with elevated TnI, 25 (45%) had aLVEF declines (3 ↓ ≥16%, 10 ↓ 10-15%, 12 ↓ 5<10%). Of 29 pts with undetectable TnI, 7 (24%) had aLVEF declines (1 ↓ ≥16%, 4 ↓ 10-15%, 2↓ 5<10%). Elevations in CRP occurred in 61/84 (73%) pts during chemoRx but only in 22 (26%) during TL or at 18mth F/U. Three pts discontinued Rx for aLVEF ↓ at mths 4, 5 and 7 respectively; 2 (66%) had rises in CRP and 2 had minimal elevation in TnI. Three pts developed CHF at mths 3, 6, and 12 respectively, all had rises in CRP; 1 pt had a single ↑TnI of 0.08 ng/ml during chemoRx, and 2pts had no ↑TnIs.ConclusionsIn pts receiving ddAC-PTL fluctuations in TnI and CRP are common but do not persist after chemoRx (during TL). These biomarkers do not appear to predict for CHF. One possibility is that the timing of the drawing of these biomarkers (immediately preceding the specified treatment cycle and after Rx completion) may have been suboptimal. We plan to assess for potential biomarkers by assessing both immediately preceding and following therapy in a planned trial. Updated results will be presented.
Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3088.
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Affiliation(s)
| | | | - N. Lin
- 2Dana-Farber Cancer Institute, MA,
| | - B. Moy
- 3Massachusetts General Hospital, MA,
| | - S. Come
- 4Beth Israel Deaconess Medical Center, MA,
| | | | | | - E. Winer
- 2Dana-Farber Cancer Institute, MA,
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27
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Morris P, Chen C, Lin N, Moy B, Come S, Abbruzzi A, Winer E, Norton L, Hudis C, Dang C. 5034 Troponin I and C-reactive protein as biomarkers for changes in left ventricular ejection fraction in patients with early stage breast cancer treated with dose-dense doxorubicin and cyclophosphamide (AC) followed by weekly paclitaxel with trastuzumab and lapatinib. EJC Suppl 2009. [DOI: 10.1016/s1359-6349(09)70926-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
6608 Background: Current guidelines for early detection of breast cancer do not adequately address diagnosis in young women. Furthermore, a lower suspicion for malignancy in this population may cause diagnostic delays. It is unknown how much the lack of routine screening and potential diagnostic delays contribute to the poorer outcomes of younger women. Methods: We surveyed women age <40 with recently diagnosed breast cancer in a prospective multicenter cohort study started in late 2006. We evaluated initial sign/symptom of cancer, time to first seeking medical attention, time from seeking medical attention to diagnosis, and patient factors associated with delays of >30 days in either timeframe. Chi square and Fisher's Exact tests were used to compare those with and without delays. Results: The first 222 women enrolled in the cohort are included in this analysis. Median age at diagnosis was 36 years (range 17–40). 79% of women initially identified their cancers through breast self exam. Only 6% were initially identified by clinical breast exam, 14% by breast imaging, 1% by systemic symptoms. While the median time between initial sign and seeking medical attention was 10 days (range 0–3,600), 54 women had >30 days between initial sign and medical attention (median 102, range 44–3,600). Similarly, median time from seeking medical attention to diagnosis was 21 days (range 0–2,970), yet 59 women had >30 days from attention to diagnosis (median 70, range 33–2,970). Preliminary comparison of women with and without delays did not reveal significant differences in age, race, education, marital status, or gravidity. Analyses will be updated and psychosocial factors, tumor subtype, and stage at diagnosis will be evaluated. Conclusions: In this large modern cohort of young women with breast cancer, nearly 80% presented with a self-detected breast abnormality, and most were diagnosed soon after they developed a sign/symptom. However, nearly 25% delayed seeking medical attention and 25% experienced a delay in diagnosis after seeking medical attention. Further research is warranted to compare delays between younger and older women, to evaluate delays in more diverse populations, to explore predictors of delays, and to assess for prognostic implications of delays in order to improve outcomes in young women. No significant financial relationships to disclose.
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Affiliation(s)
- K. J. Ruddy
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - S. Gelber
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - R. Tamimi
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - L. Schapira
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - S. Come
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - S. Kereakoglow
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - N. U. Lin
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - E. P. Winer
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - A. H. Partridge
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
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29
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Dang C, Lin N, Moy B, Come S, Lake D, Theodoulou M, Troso-Sandoval T, Dickler M, Gorsky M, D'Andrea G, Modi S, Seidman A, Drullinsky P, Partridge A, Schapira L, Wulf G, Gilewski T, Atieh D, Mayer E, Isakoff S, Sugarman S, Fornier M, Traina T, Bromberg J, Currie V, Robson M, Burstein H, Overmoyer B, Ryan P, Kuter I, Younger J, Schumer S, Tung N, Zarwan C, Schnipper L, Chen C, Winer E, Norton L, Hudis C. Dose-dense (DD) doxorubicin and cyclophosphamide (AC) followed by weekly paclitaxel (P) with trastuzumab (T) and lapatinib (L) in HER2/neu-positive breast cancer is not feasible due to excessive diarrhea: updated results. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-2108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #2108
Background: DD q 2 weekly (w) AC → P + T x 1 year (y) has an acceptable safely profile w/ congestive heart failure (CHF) rate of 1/70 pts (Dang, JCO 2008). Lapatinib (L) is effective in HER2 (+) BC. We conducted a pilot study of dd AC → w P + T + L to determine its feasibility and cardiac safety.
 Methods: Enrolled pts had HER2 (+) BC; LVEF > 50%. Rx consisted of AC at 60/600 mg/m2 x 4 q 2 w (w/ pegfilgrastim 6 mg day 2) → P at 80 mg/m2 x 12 q w + T x 1 y; L (1000 mg daily beginning w/ P + T and continued x 1 y). MUGA is obtained at baseline and at months (mo) 2, 6, 9, and 18. Rx is considered feasible if 1) > 80% pts can complete the PTL phase without a dose delay or reduction and 2) the cardiac event rate (CHF or cardiac death) is < 4%. Pts can remain on-Rx w/ one dose reduction of L (1000 mg → 750 mg) for a G 3 event or < G 3 toxicity (unacceptable).
 Results: From March 2007 to April 2008, we enrolled 95 pts. Median (med) age was 45 years (range, 28-73). At a med follow-up of 7 months, 90 are evaluable. Of the 90 pts, 34 (37%) withdrew from study during the PTL phase; 29 for a 2nd event of G 3 or unacceptable < G 3 toxicities (15 G 3 diarrhea, 4 G 1/2 diarrhea, 1 G 3 rash, 2 G 2 rash, 1 G 3 dyspnea and also had G 3 diarrhea, 1 G 3 ↑QTc also had G 3 diarrhea, 1 G 3 ↑ALT also had G 3 diarrhea, 1 G 3 paronychia, 1 G 3 pneumonitis, 1 asymptomatic LVEF ↓, 1 myocarditis) and 5 for other reasons (2 personal reason, 1 PCP pneumonia, 1 progression, 1 P hypersensitivity). Overall, 25/90 (27%) pts had G 3 diarrhea and 31/90 (34%) pts required a dose reduction of lapatinib. Med LVEF at baseline is 67% (N=95), at mo 2 is 68% (N=90), at mo 6 is 65% (N=53), and mo 9 is 65% (N=28). To date there are no patient drop-outs due to significant LVEF declines after dd AC; one patient dropped during PTL out due to an asymptomatic LVEF decline.
 Discussion: L at 1000 mg/day is not feasible combined w/ weekly P and T by protocol stipulation (> 20% pts required L dose reduction) primarily due to excessive G 3 diarrhea. These results have led to the modification of Design 2 (Arm D) of ALTTO. We will report updated results.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2108.
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Affiliation(s)
- C Dang
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - N Lin
- 2 Medicine, Dana Farber Cancer Institute, Boston, MA
| | - B Moy
- 3 Medicine, Massachusetts General Hospital, Boston, MA
| | - S Come
- 4 Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - D Lake
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M Theodoulou
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - T Troso-Sandoval
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M Dickler
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M Gorsky
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - G D'Andrea
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - S Modi
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - A Seidman
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - P Drullinsky
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - A Partridge
- 2 Medicine, Dana Farber Cancer Institute, Boston, MA
| | - L Schapira
- 3 Medicine, Massachusetts General Hospital, Boston, MA
| | - G Wulf
- 4 Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - T Gilewski
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - D Atieh
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - E Mayer
- 2 Medicine, Dana Farber Cancer Institute, Boston, MA
| | - S Isakoff
- 3 Medicine, Massachusetts General Hospital, Boston, MA
| | - S Sugarman
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M Fornier
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - T Traina
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - J Bromberg
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - V Currie
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M Robson
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - H Burstein
- 2 Medicine, Dana Farber Cancer Institute, Boston, MA
| | - B Overmoyer
- 2 Medicine, Dana Farber Cancer Institute, Boston, MA
| | - P Ryan
- 3 Medicine, Massachusetts General Hospital, Boston, MA
| | - I Kuter
- 3 Medicine, Massachusetts General Hospital, Boston, MA
| | - J Younger
- 3 Medicine, Massachusetts General Hospital, Boston, MA
| | - S Schumer
- 4 Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - N Tung
- 4 Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - C Zarwan
- 4 Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - L Schnipper
- 4 Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - C Chen
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - E Winer
- 2 Medicine, Dana Farber Cancer Institute, Boston, MA
| | - L Norton
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - C Hudis
- 1 Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
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Keller P, Gupta PB, Klebba I, Gilmore H, Come S, Schnitt S, Lander ES, Kuperwasser C. Breast epithelial differentiation is altered in BRCA1mut/+ carriers prior to the onset of cancer and contributes to the basal tumor phenotype. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-3083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #3083
Human breast tumors are broadly divided into either luminal-like or basal-like cancers. This distinction is significant since basal-like tumors are more aggressive and afford a poor patient prognosis relative to luminal-like tumors. For reasons that are unclear, germline mutations in BRCA1 strongly predispose for poor prognosis basal-like tumors. The predisposition for basal-like tumors in BRCA1mut/+ patients could be due to (1) differences in underlying target cell populations between BRCA1mut/+ and BRCA1+/+ women or (2) differences in the genetic mutations arising within a single shared target cell type. This basic question has remained unresolved due to a lack of experimental models in which it can be addressed. We describe here a novel in vivo breast cancer system that enables the generation of tumors by introducing oncogenes into normal breast epithelium derived directly from human breast tissue. This system is unique in that it enables human-derived epithelial cells to be sorted for cell surface markers and transformed without requiring in vitro culture prior to implantation in vivo. Using this experimental system, we show that epithelial cells from BRCA1mut/+ patients give rise to tumors that exhibit multiple features of basal differentiation, in contrast to epithelial cells transformed with identical oncogenes from BRCA1+/+ patients. We show further that non-cancerous epithelial cells from BRCA1mut/+ patients already exhibit atypical differentiation even prior to the onset of cancer, in contrast to cells from BRCA1+/+ women. Remarkably, some of these differences are observable in the context of unperturbed breast tissue obtained from disease-free BRCA1mut/+ and BRCA1+/+ patients. Collectively, these findings show that the increased incidence of basal-like tumors in BRCA1mut/+ patients is a reflection of the altered differentiation of breast epithelial cells in BRCA1mut/+ patients.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3083.
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Affiliation(s)
- P Keller
- 1 Department of Anatomy & Cellular Biology, Sackler School, Tufts University School of Medicine, Boston, MA
- 2 Molecular Oncology Research Institute, Tufts Medical Center, Boston, MA
| | - PB Gupta
- 3 Department of Biology, MIT and Broad Institute of MIT and Harvard, Cambridge, MA
| | - I Klebba
- 1 Department of Anatomy & Cellular Biology, Sackler School, Tufts University School of Medicine, Boston, MA
- 2 Molecular Oncology Research Institute, Tufts Medical Center, Boston, MA
| | - H Gilmore
- 4 Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - S Come
- 5 Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - S Schnitt
- 4 Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - ES Lander
- 3 Department of Biology, MIT and Broad Institute of MIT and Harvard, Cambridge, MA
- 6 Whitehead Institute for Biomedical Research, Cambridge, MA
- 7 Department of Systems Biology, Harvard Medical School, Boston, MA
| | - C Kuperwasser
- 1 Department of Anatomy & Cellular Biology, Sackler School, Tufts University School of Medicine, Boston, MA
- 2 Molecular Oncology Research Institute, Tufts Medical Center, Boston, MA
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Miksad RA, Come S, Weinstein M. The quality-of-life impact of osteonecrosis of the jaw: Implications for bisphosphonate use in metastatic breast cancer. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.6620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6620 Background: Osteonecrosis of the jaw (ONJ) has been linked to bisphosphonates used to prevent skeletal related events (SREs) in metastatic breast cancer (MBC). The primary aim of this decision-analysis study is to determine the preference threshold at which the quality of life (QOL) impact of ONJ may change bisphosphonate treatment decisions. Methods: We developed a Markov decision- analysis model of bisphosphonate use in MBC that includes the risk of ONJ. For the base case we estimated the QOL impact of ONJ by evaluating published ONJ reports with the Oral Health Impact Profile (OHIP). OHIP scores were transformed to EQ5D utilities and adjusted for MBC (published utility for MBC=0.63). We used published utility values for SRE: 0.46 for the month in which SRE occurs. Based on published data, we estimated that bisphosphonates reduce the incidence of SREs by 41% and that the incidence of SRE rises with increased bisphosphonate exposure: year 1=0.004/month; year 2=0.022/month; year 3=0.034/month. We inspected 2 treatment strategies: treat all patients with bisphosphonates (treat all) and treat no patient with bisphosphonates (treat none). Results: 18 published cases were adequate for evaluation. The mean OHIP score=27 (possible range 14–70), s.d.=1.8. We calculated that patients with MBC and ONJ have a utility=0.53 (s.d.=0.04) for the base-case. The model predicted a mean survival of 22 months for both strategies. In the treat all strategy each patient received a mean of 19 months of bisphosphonates and suffered 2.4 SREs. In the treat none strategy each patient suffered 4.0 SREs. In the base case, the treat all strategy maximized net quality-adjusted life, although by less than 1/2 month per patient. The treat all strategy was optimal for only 33% of patients. The treat all strategy does not maximize net quality-adjusted life if the risk of ONJ is 4.5 times higher than the base case or the ratio of the utility for ONJ to the utility for SRE is less than 0.4 (base-case ratio=1.152). Conclusions: The QOL impact of ONJ alters the decision to use bisphosphonates when 1) the incidence of ONJ is 4.5 times higher than published estimates; or 2) the long-term preference for ONJ is 60% lower than the short-term preference for SRE. Further QOL research may refine these estimates. No significant financial relationships to disclose.
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Affiliation(s)
- R. A. Miksad
- Beth Israel Deaconess Medical Center, Boston, MA; Harvard University, Boston, MA
| | - S. Come
- Beth Israel Deaconess Medical Center, Boston, MA; Harvard University, Boston, MA
| | - M. Weinstein
- Beth Israel Deaconess Medical Center, Boston, MA; Harvard University, Boston, MA
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Osborne CK, Pippen J, Jones SE, Parker LM, Ellis M, Come S, Gertler SZ, May JT, Burton G, Dimery I, Webster A, Morris C, Elledge R, Buzdar A. Double-blind, randomized trial comparing the efficacy and tolerability of fulvestrant versus anastrozole in postmenopausal women with advanced breast cancer progressing on prior endocrine therapy: results of a North American trial. J Clin Oncol 2002; 20:3386-95. [PMID: 12177098 DOI: 10.1200/jco.2002.10.058] [Citation(s) in RCA: 499] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the efficacy and tolerability of fulvestrant (formerly ICI 182,780) with anastrozole in the treatment of advanced breast cancer in patients whose disease progresses on prior endocrine treatment. PATIENTS AND METHODS In this double-blind, double-dummy, parallel-group study, postmenopausal patients were randomized to receive either an intramuscular injection of fulvestrant 250 mg once monthly or a daily oral dose of anastrozole 1 mg. The primary end point was time to progression (TTP). Secondary end points included objective response (OR) rate, duration of response (DOR), and tolerability. RESULTS Patients (n = 400) were followed for a median period of 16.8 months. Fulvestrant was as effective as anastrozole in terms of TTP (hazard ratio, 0.92; 95.14% confidence interval [CI], 0.74 to 1.14; P =.43); median TTP was 5.4 months with fulvestrant and 3.4 months with anastrozole. OR rates were 17.5% with both treatments. Clinical benefit rates (complete response + partial response + stable disease > or = 24 weeks) were 42.2% for fulvestrant and 36.1% for anastrozole (95% CI, -4.00% to 16.41%; P =.26). In responding patients, median DOR (from randomization to progression) was 19.0 months for fulvestrant and 10.8 months for anastrozole. Using all patients, DOR was significantly greater for fulvestrant compared with anastrozole; the ratio of average response durations was 1.35 (95% CI, 1.10 to 1.67; P < 0.01). Both treatments were well tolerated. CONCLUSION Fulvestrant was at least as effective as anastrozole, with efficacy end points slightly favoring fulvestrant. Fulvestrant represents an additional treatment option for postmenopausal women with advanced breast cancer whose disease progresses on tamoxifen therapy.
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Affiliation(s)
- C K Osborne
- Breast Center at Baylor College of Medicine, 1 Baylor Plaza, MS 600, Houston, TX 77030, USA.
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Howell A, Osborne C, Robertson J, Jones S, Mauriac L, Ellis M, Come S, Vergote I, Budzar A, Gertler S. ICI 182,780 (Faslodex™) versus anastrozole (Arimidex™) for the treatment of advanced breast cancer in postmenopausal women — prospective combined analysis of two multicenter trials. Eur J Cancer 2001. [DOI: 10.1016/s0959-8049(01)81042-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
The ideal sequencing of CT and radiation therapy in early-stage breast cancer treated with breast-conserving surgery and RT is not known. There is evidence that delaying CT might have an adverse impact on systemic control, while delaying RT might adversely affect local control. Concurrent CT and full-dose RT might minimize the above tradeoffs, but is associated with increased toxicity. Concurrent CT and reduced-dose RT is a novel approach to address these issues, but requires additional formal evaluation before clinical use. In the absence of definitive information, clinicians should balance each patient's risk for systemic recurrence and local-regional recurrence. For example, a patient with a large number of positive nodes but clearly negative margins would be an appropriate candidate for adjuvant therapy starting with CT and continuing with RT at the completion of CT. Alternatively, a patient with node-negative disease with close or focally positive margins might be an appropriate candidate for initiating RT sooner. Current treatment regimens which deliver CT in a "short" time period [i.e., Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide) delivered in four 3-week cycles] may represent a reasonable tradeoff with regard to promptly starting systemic therapy while initiating RT within 3 months of surgery. It is possible that optimizing the way RT and CT are combined is important in achieving the highest survival rate and in reducing long-term adverse effects. There is unfortunately very little solid information from randomized clinical trials addressing this question, and considerable controversy remains regarding the optimal approach to integrating these modalities. Additional randomized clinical trials addressing this important clinical question are needed.
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Affiliation(s)
- A K Dubey
- Joint Center for Radiation Therapy, Harvard Medical School, Boston, MA 02115, USA
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Abner AL, Collins L, Peiro G, Recht A, Come S, Shulman LN, Silver B, Nixon A, Harris JR, Schnitt SJ, Connolly JL. Correlation of tumor size and axillary lymph node involvement with prognosis in patients with T1 breast carcinoma. Cancer 1998; 83:2502-8. [PMID: 9874455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND The prognosis of patients with T1 breast carcinoma remains controversial. Some studies have shown a low risk of lymph node metastasis and distant failure whereas others have not, possibly due to differences in the definition of tumor size. In this study, the authors assessed the relation between macroscopic tumor size, microscopic invasive tumor size, axillary lymph node involvement, and prognosis in a group of patients with clinically lymph node negative disease. METHODS Between 1968 and 1986, 1865 women with American Joint Committee on Cancer clinical Stage I or II infiltrating carcinoma of the breast were treated at the Joint Center for Radiation Therapy with conservative surgery and radiation therapy. The study population was limited to 118 patients with clinically negative axillary lymph nodes for whom the macroscopic pathologic tumor size was identified unambiguously as being < or = 2.0 cm, who underwent an axillary lymph node dissection with at least 6 lymph nodes sampled, and for whom the microscopic size of the invasive component could be determined. The median follow-up time for surviving patients was 134 months (range, 90-208 months). No patients with pathologically negative axillary lymph nodes received systemic therapy. RESULTS Macroscopic and microscopic tumor sizes differed by > 5 mm in 17 patients (14%), by 3-5 mm in 24 patients (20%), and by < or = 2 mm in 77 patients (65%). The macroscopic tumor size was smaller than the microscopic size in 37 patients (31%), larger in 55 patients (47%), and equal in 26 patients (22%). Pathologic axillary lymph node involvement was present in 21% of all patients. The risk of lymph node involvement was not significantly different for those patients with tumors < or = 1 cm compared with patients with tumors > or = 1.1 cm, regardless of whether tumor size was measured by macroscopic or microscopic examination. The 10-year actuarial rate of freedom from distant recurrence (FFDR) was 91% for lymph node negative patients with macroscopic tumors measuring < or = 1.0 cm compared with 77% for patients with macroscopic tumors measuring > or = 1.1 cm (P = 0.07). When measured microscopically, the rates were 96% and 72%, respectively (P = 0.001). CONCLUSIONS There often is a discrepancy between microscopic tumor size and macroscopic tumor size. T1 tumors have a substantial risk of axillary lymph node metastasis whether measured macroscopically or microscopically. Among those patients with pathologic lymph node negative tumors who are not treated with systemic adjuvant therapy, microscopic invasive tumor size is a better predictor of 10-year FFDR than macroscopic tumor size. There is a substantial risk of distant failure for patients with tumors whose invasive component microscopically measure > or = 1.1 cm, whereas the prognosis for patients with tumors that microscopically measured < or = 1 cm is excellent. These results suggest that the microscopic size of the invasive component of breast carcinomas < or = 2.0 cm routinely should be reported.
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Affiliation(s)
- A L Abner
- Joint Center for Radiation Therapy, Harvard Medical School, Boston, Massachusetts 02215, USA
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Abner AL, Collins L, Peiro G, Recht A, Come S, Shulman LN, Silver B, Nixon A, Harris JR, Schnitt SJ, Connolly JL. Correlation of tumor size and axillary lymph node involvement with prognosis in patients with T1 breast carcinoma. Cancer 1998. [DOI: 10.1002/(sici)1097-0142(19981215)83:12<2502::aid-cncr14>3.0.co;2-i] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Gage I, Schnitt SJ, Recht A, Abner A, Come S, Shulman LN, Monson JM, Silver B, Harris JR, Connolly JL. Skin recurrences after breast-conserving therapy for early-stage breast cancer. J Clin Oncol 1998; 16:480-6. [PMID: 9469331 DOI: 10.1200/jco.1998.16.2.480] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To assess the frequency and prognosis of skin recurrences after breast-conserving therapy (BCT) compared with other breast recurrences. MATERIALS AND METHODS From 1968 to 1986, 1,624 patients with unilateral stage I or II breast cancer treated with BCT at the Joint Center for Radiation Therapy (Boston, MA) underwent gross tumor excision and received a dose of > or = 60 Gy to the tumor bed. Skin recurrences (SR) were defined as breast recurrences without associated parenchymal disease. An invasive breast recurrence with any parenchymal disease noted clinically or radiographically was scored as an other breast recurrence (OBR). Median follow-up for survivors was 137 months. RESULTS SR represented 8% (18 of 229) of all breast recurrences and occurred in 1.1% of all patients. The outcome after local recurrence was different for patients with SR and invasive OBR. Patients with SR more frequently had uncontrolled local failure (50%; 9 of 18) than did patients with OBR (14%; 26 of 188) (P = .0007). Forty-four percent (8 of 18) of patients with SR had distant metastasis simultaneously or within 2 months of the recurrence compared with 5% (9 of 188) of invasive OBR patients (P < .0001). For patients without distant metastasis at the time of recurrence, the 5-year actuarial rate of development of distant metastasis was 60% for SR patients compared with 39% for invasive OBR patients (P = .07), and the corresponding 5-year actuarial survival rates beyond the time of local failure were 51% and 79%, respectively (P = .06). CONCLUSION In contrast to other types of invasive breast recurrence after breast-conserving therapy, skin recurrences are rare and are associated with a significantly higher rate of distant metastasis and uncontrolled local disease as well as a lower rate of survival.
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Affiliation(s)
- I Gage
- Joint Center for Radiation Therapy, Boston, MA, USA.
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Wong JS, Recht A, Beard CJ, Busse PM, Cady B, Chaffey JT, Come S, Fam S, Kaelin C, Lingos TI, Nixon AJ, Shulman LN, Troyan S, Silver B, Harris JR. Treatment outcome after tangential radiation therapy without axillary dissection in patients with early-stage breast cancer and clinically negative axillary nodes. Int J Radiat Oncol Biol Phys 1997; 39:915-20. [PMID: 9369141 DOI: 10.1016/s0360-3016(97)00456-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To determine the risk of nodal failure in patients with early-stage invasive breast cancer with clinically negative axillary lymph nodes treated with two-field tangential breast irradiation alone, without axillary lymph node dissection or use of a third nodal field. METHODS AND MATERIALS Between 1988 and 1993, 986 evaluable women with clinical Stage I or II invasive breast cancer were treated with breast-conserving surgery and radiation therapy. Of these, 92 patients with clinically negative nodes received tangential breast irradiation (median dose, 45 Gy) followed by a boost, without axillary dissection. The median age was 69 years (range, 49-87). Eighty-three percent had T1 tumors. Fifty-three patients received tamoxifen, 1 received chemotherapy, and 2 patients received both. Median follow-up time for the 79 survivors was 50 months (range, 15-96). Three patients (3%) have been lost to follow-up after 20-32 months. RESULTS No isolated regional nodal failures were identified. Two patients developed recurrence in the breast only (one of whom had a single positive axillary node found pathologically after mastectomy). One patient developed simultaneous local and distant failures, and six patients developed distant failures only. One patient developed a contralateral ductal carcinoma in situ, and two patients developed other cancers. CONCLUSION Among a group of 92 patients with early-stage breast cancer (typically T1 and also typically elderly) treated with tangential breast irradiation alone without axillary dissection, with or without systemic therapy, there were no isolated axillary or supraclavicular regional failures. These results suggest that it is feasible to treat selected clinically node-negative patients with tangential fields alone. Prospective studies of this approach are warranted.
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Affiliation(s)
- J S Wong
- Joint Center for Radiation Therapy, Department of Radiation Oncology, Harvard Medical School, Boston, MA 02215, USA
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Dubey AK, Recht A, Shulman L, Come S, Gelman R, Silver B, Harris JR. 2053 Outcome following concurrent chemotherapy (CT) and reduced-dose radiation therapy (RT) for patients with early stage breast cancer. Int J Radiat Oncol Biol Phys 1997. [DOI: 10.1016/s0360-3016(97)80823-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mauch PM, Kalish LA, Marcus KC, Coleman CN, Shulman LN, Krill E, Come S, Silver B, Canellos GP, Tarbell NJ. Second malignancies after treatment for laparotomy staged IA-IIIB Hodgkin's disease: long-term analysis of risk factors and outcome. Blood 1996; 87:3625-32. [PMID: 8611686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The survival of patients with Hodgkin's disease has dramatically improved over the past 30 years because of advances in treatment. However, concern for the risk of long-term complications has resulted in a number of trials to evaluate reduction of therapy. The consequences of these trials on recurrence, development of long-term complications, and survival remain unknown. One major consequence of successful treatment of Hodgkin's disease is the development of second malignant neoplasms. We sought to determine the factors most important for development of second tumors in pathologically staged and treated Hodgkin's disease patients followed for long intervals to provide background information for future clinical trials and guidelines for routine patient follow-up. Between April 1969 and December 1988, 794 patients with laparotomy staged (PS) IA-IIIB Hodgkin's disease were treated with radiation therapy (RT) alone or combined radiation therapy and chemotherapy (CT). There were 8,500 person-years of follow-up (average of 10.7 person-years per patient). Age and gender-specific incidence rates were multiplied by corresponding person-years of observation to obtain expected numbers of events. Observed to expected results were calculated by type of treatment, age at treatment, sex, and time after Hodgkin's disease. Absolute (excess) risk was expressed as number of excess cases per 10,000 person-years. Seventy-two patients have developed a second malignant neoplasm. Eight patients developed acute leukemia, 10 had non-Hodgkin's lymphoma (NHL), and 53 patients developed solid tumors at a median time of 5 years, 7.25 years, and 12.2 years, respectively, after Hodgkin's disease. One patient developed multiple myeloma 16.5 years after Hodgkin's disease. The relative risk (RR) of developing a second malignancy was 5.6. The absolute excess risk per 10,000 person-years (AR) of developing a second malignancy was 69.6 (7.0% excess risk per person per decade of follow-up). The highest RR occurred for the development of leukemia (RR = 66.2), however because of the low expected risk, the AR was only 9.3. The RR of solid tumors after Hodgkin's disease was lower (4.7); however, the AR was greater (49) than for acute leukemia. Among the solid tumors, breast, gastrointestinal, lung, and soft tissue cancers had the highest absolute excess risks. The risk for developing breast cancer after Hodgkin's disease was greatest in women who were under the age of 25 at treatment. The most significant risk factor for the development of both leukemia and solid tumors was the combined use of radiation therapy and chemotherapy. The RR following RT alone was 4.1 (AR = 51.1); for RT + CT (initially or at relapse) the RR was 9.75 (P < 0.05, nonoverlapping confidence limits, AR = 123.9). Survival following development of a second malignancy was poor in patients with leukemia, gastrointestinal tumors, lung cancer, and sarcoma. Survival from other malignancies including NHL and breast cancer was more encouraging. Second malignant neoplasms are a major cause of late morbidity and mortality following treatment for Hodgkin's disease. The most significant risk factor for the development of second tumors is the extent of treatment for Hodgkin's disease. Recommendations are presented for both prevention and early detection of these tumors.
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Affiliation(s)
- P M Mauch
- Joint Center for Radiation Therapy, Dana-Farber Cancer Institute, Boston, MA 02215, USA
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Mauch PM, Kalish LA, Marcus KC, Shulman LN, Krill E, Tarbell NJ, Silver B, Weinstein H, Come S, Canellos GP, Coleman CN. Long-term survival in Hodgkin's disease relative impact of mortality, second tumors, infection, and cardiovascular disease. Cancer J Sci Am 1995; 1:33-42. [PMID: 9166452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Despite dramatic improvements in the survival of patients with Hodgkin's disease attributable to advances in treatment over the past 30 years, concern for the risk of treatment-related deaths has led to a number of trials to evaluate reduction of therapy. The consequences of these trials on recurrence, development of long-term complications, and survival remain unknown. We determined the causes of death in a group of patients with pathologically staged and intensively treated Hodgkin's disease who were followed for long intervals. MATERIALS AND METHODS Between April 1969 and December 1988, 794 patients with laparotomy-staged IA to IIIB Hodgkin's disease were treated with radiation therapy alone or combined radiation therapy and chemotherapy. There were 8700 person-years of follow-up (average, 10.95 person-years/ patient). Causes of mortality were grouped into the categories Hodgkin's disease, second malignant tumors, cardiovascular, infection, and miscellaneous. Age- and gender-specific incidence rates were multiplied by corresponding person-years of observation to obtain expected numbers of events. Observed-to-expected results were calculated by type of treatment, age at treatment, sex, and time after Hodgkin's disease. Absolute (excess) risk was expressed as number of excess cases per 10,000 person-years. RESULTS Of 124 patients who died, 56 died of Hodgkin's disease, 36 of second malignant neoplasms, 15 of cardiac causes, 9 of infection, and 8 of miscellaneous causes. The 20-year actuarial survival rate for all patients in this study is 73%. Age 40 years or older, mixed cellularity/lymphocyte-depleted histologic type, and stage-III disease were adverse independent predictors of survival. The largest differences were seen by age. The 20-year actuarial rates of survival were 78%, 78%, and 46%, respectively, for patients aged 16 or less, 17 to 39, and 40 years or older at diagnosis. Hodgkin's disease diagnosed at age 40 or older was a significant risk factor for all causes of death. The use of combined chemotherapy/ radiotherapy was a significant risk factor for second tumor and infection-related mortality. The excess risk of death from all causes, including Hodgkin's disease, remained constant with time from treatment and was approximately 1.2% per year over the first 20 years. Deaths from Hodgkin's disease decreased with time from treatment, with no patients dying after 15 years. This decrease, combined with an increased excess mortality risk with time from other causes, especially second tumors, accounted for the constant excess mortality with time after Hodgkin's disease. CONCLUSIONS Hodgkin's disease followed by second tumors, cardiac events, and infections remain the major causes of death after treatment of Hodgkin's disease. Our findings suggest the importance of both maintaining a high disease-free survival and reducing long-term complications in designing treatments of Hodgkin's disease.
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Affiliation(s)
- P M Mauch
- Joint Center for Radiation Therapy, 50 Binney Street, Boston, MA 02115, USA
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Mauch PM, Canellos GP, Shulman LN, Silver B, Tarbell NJ, Come S, Rabin MS, Coleman CN. Mantle irradiation alone for selected patients with laparotomy-staged IA to IIA Hodgkin's disease: preliminary results of a prospective trial. J Clin Oncol 1995; 13:947-52. [PMID: 7707123 DOI: 10.1200/jco.1995.13.4.947] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE To determine the feasibility of omitting prophylactic paraaortic irradiation in selected patients with laparotomy-staged (pathologically staged [PS]) IA to IIA Hodgkin's disease. PATIENTS AND METHODS We initiated a prospective single-arm trial in October 1988 to study the role of mantle irradiation alone in selected PS IA to IIA patients with Hodgkin's disease. A total of 37 patients have been entered onto this trial. Entrance criteria included nodular sclerosis (NS) or lymphocyte predominance (LP) histology, absence of B symptoms, disease limited above the carina, and a negative laparotomy. Results of treatment of 23 patients in the prospective trial, monitored off treatment for > or = 1 year, are presented. Twenty-three additional PS IA to IIA patients, treated with mantle irradiation alone from 1970 to 1987, were analyzed as a comparison group. The median follow-up durations were 32 and 113 months, respectively, for the two groups. RESULTS The 4-year actuarial rates of freedom from relapse and overall survival are 83% and 100%, respectively, for the prospective trial. The 10-year actuarial rates of freedom from relapse and overall survival are 83% and 89%, respectively, for retrospectively studied patients. There have been five recurrences among 46 patients who received mantle irradiation alone, all with a component of relapse below the diaphragm. CONCLUSION These early results support the use of mantle irradiation alone in selected PS IA to IIA patients with NS or LP histology. Relapses, although rare, have occurred predominantly below the diaphragm. This suggests the need for continued long-term surveillance of abdominal and pelvic nodes in this group of treated patients.
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Affiliation(s)
- P M Mauch
- Dana-Farber Cancer Institute, Boston, MA, USA
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Abner AL, Recht A, Eberlein T, Come S, Shulman L, Hayes D, Connolly JL, Schnitt SJ, Silver B, Harris JR. Prognosis following salvage mastectomy for recurrence in the breast after conservative surgery and radiation therapy for early-stage breast cancer. J Clin Oncol 1993; 11:44-8. [PMID: 8418240 DOI: 10.1200/jco.1993.11.1.44] [Citation(s) in RCA: 159] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE The prognosis and factors that influence prognosis following salvage mastectomy in patients with recurrence in the treated breast after conservative surgery (CS) and radiation therapy (RT) were investigated. MATERIALS AND METHODS A total of 1,593 patients with stage I or II invasive breast cancer were treated following gross total excision of the tumor at the Joint Center for Radiation Therapy (JCRT) between 1968 and 1985. One hundred sixty-six of the 1,593 (10%) had subsequent recurrence in the breast. Of these, 123 had salvage mastectomy and constitute the study population. The recurrent tumor was predominantly invasive in 99 patients, noninvasive in 14, and focally invasive in 10. Following mastectomy, chemotherapy or hormonal therapy was administered to 29 patients. The median follow-up time was 39 months after salvage mastectomy. RESULTS The 5-year actuarial rate of further local or distant relapse for the entire group was 41%. None of the 24 patients with focally invasive or noninvasive tumors had a subsequent relapse. In comparison, the 5-year actuarial rate of further relapse in the 99 patients with a predominantly invasive recurrence was 52% (P = .001). The method of detection of the recurrence, the age of the patient at initial diagnosis, the disease-free interval, and the location of the recurrence in the breast were not found to have a statistically significant association with the risk of further relapse. CONCLUSION We conclude that the histology of the recurrent tumor is an important prognostic factor for the risk of further relapse. Patients with purely noninvasive or focally invasive tumors have an excellent prognosis following salvage mastectomy. In contrast, patients with predominantly invasive tumors are at substantial risk for further relapse.
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Affiliation(s)
- A L Abner
- Department of Radiation Oncology, Beth Isreal Hospital, Boston, MA
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Abner AL, Recht A, Vicini FA, Silver B, Hayes D, Come S, Harris JR. Cosmetic results after surgery, chemotherapy, and radiation therapy for early breast cancer. Int J Radiat Oncol Biol Phys 1991; 21:331-8. [PMID: 2061109 DOI: 10.1016/0360-3016(91)90779-4] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Adjuvant chemotherapy (CT) is increasingly being used in conjunction with radiation therapy (RT) in the treatment of early stage breast cancer. To assess the effect of CT on the cosmetic outcome of the irradiated breast, we retrospectively reviewed the cosmetic results of patients who received either cyclophosphamide-methotrexate-fluorouracil (CMF) or doxorubicin-based chemotherapy in conjunction with breast irradiation between 1968 and 1985. The overall cosmetic results were evaluated by the physician as "excellent," "good," "fair," or "poor" using a standardized scale. The CT group consisted of 170 patients treated with CT and RT administered either concurrently or sequentially (CT before RT, after RT, or both) with a minimum of 24 months of cosmetic follow-up. These were compared to an RT alone control group of 170 patients who did not receive CT and were matched by tumor size, radiation technique, and year of treatment. At 36 months, the cosmetic scores for the CT group compared to RT alone were 47% versus 71% excellent (p less than 0.01), 36% versus 19% good, and 17% versus 9% fair or poor. For the 50 patients treated with concurrent CMF and RT, the scores were 31% excellent, 45% good, and 24% fair/poor, whereas for the 118 patients treated with sequential RT and CT they were 54%, 31%, and 14%, respectively. There was no difference between those patients who received sequential CMF and those treated with doxorubicin. We conclude that adjuvant chemotherapy adversely affects the cosmetic outcome of breast irradiation, but that this effect is not clinically significant unless CMF is administered concurrently with RT. Patients treated with either sequential CMF or doxorubicin-based CT had only a slight decrement in their cosmetic result compared to patients treated without CT.
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Affiliation(s)
- A L Abner
- Department of Radiation Therapy, Harvard Medical School, Boston, MA 02115
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Abstract
In 1984, as part of a prior American Cancer Society National Conference on Breast Cancer, the authors reported on the status of conservative surgery (CS) and radiotherapy (RT) as primary local treatment for women with early stage breast cancer. Since that time, additional data have become available regarding the use of this approach and its comparability to mastectomy. In general, these data support the use of CS and RT and, as a result, this approach is now more widely employed in the United States and abroad than it was in 1984. The current focus of inquiry has shifted from whether or not CS and RT is an acceptable option for patients with early stage breast cancer to the following questions. For which patients are CS and RT suitable? What are the best techniques of surgery and RT? Are there any patients who can be treated safely with CS without RT? How should RT and systemic therapy be integrated when both are to be used? In this report, recent results on the use of CS and RT from both retrospective and prospective trials are summarized, and these current areas of inquiry are addressed.
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Affiliation(s)
- J R Harris
- Joint Center for Radiation Therapy, Boston, MA 02115
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46
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Rose MA, Henderson IC, Gelman R, Boyages J, Gore SM, Come S, Silver B, Recht A, Connolly JL, Schnitt SJ. Premenopausal breast cancer patients treated with conservative surgery, radiotherapy and adjuvant chemotherapy have a low risk of local failure. Int J Radiat Oncol Biol Phys 1989; 17:711-7. [PMID: 2777660 DOI: 10.1016/0360-3016(89)90056-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The use of adjuvant chemotherapy in premenopausal breast cancer patients with positive nodes is now routine, but the optimal local treatment of these patients is uncertain. To determine the effect of adjuvant chemotherapy on the likelihood of local recurrence as the first site of failure in premenopausal patients treated with conservative surgery (CS) and radiotherapy (RT), we examined the outcome of 74 patients treated with CS, RT, and adjuvant chemotherapy and compared it to the outcome in 192 patients treated with CS and RT alone. Adjuvant chemotherapy consisted of four or more cycles of either a doxorubicin-containing regimen or cyclophosphamide, methotrexate, and 5-fluorouracil. All patients were less than 50 years old, had UICC-AJCC Stage I or II breast cancer treated between 1968 and 1981, had gross excision of the primary tumor, and had a total radiation dose to the primary tumor bed of greater than or equal to 6000 cGy. Factors predicting for local recurrence, such as extensive intraductal carcinoma and age less than 35, were equivalent in the two groups. Women treated with adjuvant chemotherapy had significantly worse T- and N-stages than women treated with conservative surgery and radiotherapy alone: 61% versus 36% had T2 tumors (p = 0.0003), 34% versus 6% had clinically positive nodes (p less than 0.0001), and 97% versus 4% had pathologically positive nodes (p less than 0.0001). Despite the poorer prognosis of patients treated with adjuvant chemotherapy, within 5 years of diagnosis, 4% of patients who received adjuvant chemotherapy had their initial relapse in the breast and 24% had initial failure elsewhere, compared with 15% local failure first and 14% failure elsewhere first for those treated without chemotherapy (p = 0.01). We conclude that premenopausal patients with positive nodes treated with combined modality therapy (conservative surgery, radiation therapy, and adjuvant chemotherapy) have a low risk of local recurrence as a first site of failure. These results suggest a possible interaction between radiation therapy and chemotherapy in their effects on local tumor control.
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Affiliation(s)
- M A Rose
- Joint Center for Radiation Therapy, Harvard Medical School, Boston, MA
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Recht A, Schnitt SJ, Connolly JL, Rose MA, Silver B, Come S, Henderson IC, Slavin S, Harris JR. Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma. Int J Radiat Oncol Biol Phys 1989; 16:3-9. [PMID: 2912955 DOI: 10.1016/0360-3016(89)90003-5] [Citation(s) in RCA: 109] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Factors which influence patient prognosis following a breast recurrence or regional nodal recurrence after initial treatment of early-stage invasive breast carcinoma with conservative surgery and radiotherapy are not well known. Ninety patients treated at the Joint Center for Radiation Therapy treated from 1968-1981 had a recurrence in the treated breast before (84) or simultaneous with (6) distant metastases. Sixty-five patients had salvage mastectomy (median subsequent follow-up in patients without further disease, 32 months; range, 1-123 months). The five-year rate of further recurrence in this group was 37%. The most important variable associated with subsequent outcome was the histology of the recurrent tumor. There were no further recurrences among 10 patients with purely non-invasive cancer or 10 patients with predominantly non-invasive disease and only focal areas of invasion. In contrast, 17/45 patients (38%) with predominantly infiltrating tumors suffered further local-regional recurrences (6) or distant metastases (11) following mastectomy (5-year actuarial rate, 55%) (p less than 0.05). Ten patients developed regional nodal failures without evidence of simultaneous breast recurrence (1 internal mammary, 3 supraclavicular, 1 both supraclavicular and axillary, and 5 axillary). Only 3 of these 10 (all with axillary node failures) did not have simultaneous distant metastases; they remain alive without evidence of further distant or local-regional recurrence following salvage treatment 1, 59, and 87 months after recurrence. We conclude that the great majority of the patients (88% in this series) who have a breast recurrence following initial conservative surgery and radiation therapy for early stage breast carcinoma will have disease limited to the breast clinically and tumors amenable to salvage mastectomy. Salvage mastectomy appears to be effective treatment for patients with an isolated breast recurrence, especially if the recurrence is predominantly or wholly non-invasive.
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Affiliation(s)
- A Recht
- Joint Center for Radiation Therapy, Department of Radiation Therapy, Harvard Medical School, Boston, MA 02115
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48
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Abstract
The optimal local-regional treatment for patients with Stage III breast cancer has not been determined. To evaluate the effectiveness of radiation therapy as local treatment for such patients, the results of 192 patients (five with bilateral disease) treated with radiation therapy without mastectomy between July 1, 1968 and December 31, 1981 were reviewed. Excisional biopsy (gross tumor removal) was performed in only 54 of the 197 breasts. Patients typically received 4500 to 5000 cGy in 5 weeks to the breast and draining lymph nodes; a local boost to areas of gross disease was delivered to 157 patients. Multi-agent chemotherapy was given to 53 patients. The median follow-up was 65 months. The actuarial probability of survival for the entire group was 41% at 5 years and 23% at 10 years. The probability of relapse-free survival (RFS) was 30% at 5 years and 19% at 10 years. The addition of multi-agent chemotherapy was associated with a significantly improved 5-year RFS (40% versus 26%, P = 0.02). The 5-year survival rate was 51% for patients who received adjuvant multi-agent chemotherapy and 38% for patients who did not (P = 0.16). The actuarial rate of local-regional tumor control (not censored for distant failure) for all patients was 73% at 5 years and 68% at ten years, and the crude incidence of local-regional control was 78%. Local-regional tumor control was principally influenced by radiation dose. Patients who received 6000 cGy or greater to the primary site had a better 5-year rate of control in the breast than did patients who received less than 6000 cGy (83% versus 70%, P = 0.06). Significant complications were seen in 15 patients (8%); these included moderate or severe arm edema in six patients and brachial plexopathy in four patients. Cosmetic results at last evaluation were excellent or good in 56% of evaluable patients, fair in 25%, and poor in 19%. It is concluded that high-dose radiation therapy without mastectomy is an effective means of controlling local-regional tumor in patients with locally advanced breast cancer.
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Henderson IC, Hayes DF, Come S, Harris JR, Canellos G. New agents and new medical treatments for advanced breast cancer. Semin Oncol 1987; 14:34-64. [PMID: 3547667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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50
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Recht A, Connolly JL, Schnitt SJ, Cady B, Love S, Osteen RT, Patterson WB, Shirley R, Silen W, Come S. Conservative surgery and radiation therapy for early breast cancer: results, controversies, and unsolved problems. Semin Oncol 1986; 13:434-49. [PMID: 3541215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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