bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementation of team training in outpatient breast oncology.
Authors: Bunnell Craig A. , Gross Anne , Kalfin Michael , Partridge Ann H. , Lane Sharon , Burstein Harold J. , Fine Barbara , Hilton Nancy , Sullivan Clare , Colicchio Lynn , Hagemeister Erin , Kelly Anne , Szabatura Audrea , Winer Eric P. , Mann Susan , Weingart Saul
Published: February 2017

83

Background: Team Training (TT) principles, used in high-risk industries to reduce errors and improve communication and task coordination, have been applied in several areas of medicine, but not in outpatient oncology. We piloted a TT program in a large, academic, clinical breast cancer program. Methods: Observations, interviews, and anonymous adverse event reporting systems were used to identify areas of vulnerability for intervention: Communication of changes in same-day chemotherapy orders (“change orders”); Missing treatment orders on days patients were not also scheduled with physician (“unlinked” visits); Follow-up and communication to other team members on important patient issues (e.g., pending test results or changes in patient status); Conflict resolution between providers and staff. Agreements about roles, responsibilities, and behaviors were made to address vulnerabilities. Using a train-the-trainer model, clinical leaders trained all providers and staff in TT principles, behavioral agreements, and the tools to support them. Results: The program was assessed six months after implementation. There was insufficient power to detect a significant difference in communication of change orders because of infrequency of events (< 2% pre- and post-training). However, 100% of providers reported it was easier to communicate change orders and 87% of infusion nurses reported a decrease in non-communicated changes. The incidence of missing orders for unlinked visits decreased from 38%to 2%. Press-Ganey patient satisfaction scores highlighted improvements in perception of care coordination. Providers, infusion nurses, and support staff all reported strongly positive perceptions of improvement in the efficiency (75%, 86%, 90%), quality (82%, 93%, 93%) and safety (92%, 92%, 90%) of patient care. Similarly, all groups reported improved relationships and more respectful behavior among team members (91%, 85%, 93%). Conclusions: Team Training improved communication, task coordination and perceptions of efficiency, quality, safety, and interactions among team members and patients’ perceptions of care coordination. Widespread implementation of TT across the entire Adult Service is ongoing at our institution.
Patient understanding and impression of hematology/oncology fellows.
Authors: Curley Brendan F. , Truong Quoc Van , Curley Anjaly Belur , Culp Mark , Hu Yanqing , Almubarak Mohammed
Published: February 2017

9

Background: Hematologists/oncologists spend years training in a fellowship program. At academic centers, patients receiving treatment are often seen by fellows. It has not been established what patients understand about fellowship training, therefore our purpose was to explore their understanding and if they are content with fellows taking part in their care. Methods: At West Virginia University/Mary Babb Randolph Cancer Center we drafted a survey. This anonymous and voluntary survey abstracted patient data that included: age, sex, race, level of education, type of cancer diagnosis, amount of time being treated for cancer, experience being cared for by fellows and basic knowledge of a hematology/oncology fellowship. Multiple-choice questions were drafted with 4 to 6 answer choices with no option for unknown. Surveys were collected over a three-week period from July 3, 2012 through July 24, 2012. Patients were surveyed at outpatient appointments, infusion center visits, and laboratory draws. Results: 226 surveys were collected. Statistical analysis was performed and a binomial regression was fit to the data. There is evidence that higher levels of education are more likely to give correct answers (p value 0.035). Patients who stated they had not seen a fellow or were unsure they had seen a fellow were more likely to select incorrect answers (p value 0.001). There is no statistical significance differentiating between cancer types in likelihood of getting answers correct (Table). 1.77% of those surveyed felt they completely understand the role of a fellow in their care, while 84.51% desired further information about fellows. Only 2.21% disliked having a fellow involved in their care. Conclusions: Patients at academic centers being seen by hematology/oncology fellows appear to have a lack of knowledge of a fellow’s role and background but have a desire to be educated. Educational initiatives can be introduced to teaching institutions to help patients better understand the role of a fellow. [Table: see text]
Wait time reduction for patients awaiting chemotherapy infusion using a formal process improvement approach and sequential.
Authors: Norden Andrew David , Buswell Lori A. , Amorati Meg , Arthur Lois , Bernard Antoinette , Constantine Michael , Dalby Carole , Farrar Wendy , Fuller Frances , Kerivan Dawn , Lacourse Kristin , McNulty Brendan D. , Racicot Adonica , Spinks Melissa , Jacobson Joseph O. , Ponte Patricia Reid , Shulman Lawrence N.
Published: February 2017

92

Background: At a community hospital satellite of an academic cancer center, baseline data indicated that 49% of patients waited longer than 30 minutes from arrival in the treatment chair until treatment was started, resulting in dissatisfaction and decreased chair turnover. Methods: A team was assembled, including physicians, nurses, pharmacists, and administrative staff. The team constructed a detailed process flow map and performed a cause-and-effect analysis. Wait time data were collected using the electronic scheduling system and time sheets. Additionally, nurses used a structured data collection sheet to categorize the reasons for prolonged wait times. A p-type statistical process control chart was constructed to track the proportion of infusion visits per day with wait times longer than 30 minutes. The team brainstormed process improvements and selected ones to implement by employing a priority/pay-off matrix. Results: Baseline data were assessed for 403 visits over a 3 week period. Of 232 visits with wait times longer than 30 minutes, 98 (42%) involved excessive waiting for the physician to see the patient or write orders. One of 4 physicians was responsible for 56 (57%) of these. This physician’s patients were seen exclusively in the infusion room, while the other physicians saw patients in the exam room before sending them to the infusion area. Three PDSA cycles were conducted: (1) All physicians started seeing patients in the exam room before sending them to infusion chairs, (2) Specific treatments were selected that could be routinely administered without the physician seeing the patient, and (3) A reminder system prompted physicians to enter treatment orders within 24 hours of each patient’s visit. After 6 months, 29% of patients waited longer than 30 minutes, down from 49% at baseline. Conclusions: These interventions implemented using PDSA cycles successfully reduced wait times. Measurement and presentation of data were critical in persuading physicians to practice in a more homogeneous fashion.
Using a disease pathway management (DPM) approach to improve the quality of lung cancer care in Ontario.
Authors: Evans William K. , Ung Yee , Sawka Carol Anne , Assouad Nathalie
Published: February 2017

93

Background: Cancer Care Ontario (CCO) is mandated to oversee quality of cancer care in Ontario and began its Lung Cancer (LC) DPM initiative in 2009. DPM has 4 objectives: align provincial quality improvement (QI) initiatives by disease site; map the patient journey and identify gaps in evidence/quality in clinical practice that impact care or the patient experience; set and manage regional quality indicators across the pathway; and leverage tools to model the impact of policy decisions. Methods: The LC DPM drafted a disease pathway map and established 5 multidisciplinary working groups (WGs) each focussed on a phase of the LC patient journey: prevention, screening, and early diagnosis; diagnosis; treatment; palliative care; the patient experience. WGs held 25 two-hour meetings and developed ideas for 17 QI projects. 8 were selected for discussion at a provincial consensus conference and yielded a Priorities for Action Report. Regional “roadshows” were held in all 14 regions of the province at which region-specific data on incidence, stage at diagnosis, compliance of treatment with guidelines and wait times, amongst other metrics relevant to LC, were shared with the regional care providers. Funding was provided by CCO for regional QI based on the data and identified priorities. Results: Completed diagnostic and treatment pathways are posted on CCO’s website as are educational materials on dyspnea management, including a patient video and a document prepared by patients for patients “Understanding Lung Cancer.” Lung diagnostic assessment units/programs have been initiated in 14 regions. An audit is underway to better understand the barriers to the uniform uptake of evidence-based practices across the province. The percent of LC patients whose symptoms are assessed at least once a month using a standardized symptom assessment instrument (ESAS) has improved. Conclusions: Regional cancer programs are now aware of their performance on a range of LC specific quality metrics. Standardized diagnostic and treatment pathways have been developed and assessment units have been implemented across the province.
Morbidity, mortality, and improvement (MM&I) conference leading to change.
Authors: Moore Andrew Jacob , Coyne Tracy , Cardin Dana Backlund , Gilbert Jill
Published: February 2017

94

Background: During quarterly MM&I Conferences, a recurrent systems problem identified was the underreporting of chemotherapy infusion reactions. Attendees acknowledged difficulty in obtaining accurate data regarding adverse events and justifications for treatment cessation, which may lead to under dosing of effective therapies. Methods: MM&I conference is an interactive multidisciplinary forum that emphasizes discussion to improve system-based problems. Attendees include faculty, fellows, residents, nursing staff, informatics and pharmacy representatives. Participants used the Ickwaka Fishbone Diagram to identify issues that led to underreporting of reactions. Through discussion of the issues and identification of potential improvement activities, participants recognized that improved nursing documentation could accurately capture data related to adverse drug events. Representatives from the informatics department identified a report that could be generated automatically when infusions are stopped that would require nursing staff to identify the type of reaction and give justification for not completing the infusion. Reports would also include actions taken and patient responses. Results: Implementation of electronic nursing documentation revealed that the prevalence of infusion reactions were much higher than previously identified. During the first 6 months of electronic documentation there were 71 identified reactions compared to 46 reactions documented during the 6 months prior to implementation. Paclitaxel (22%) and Rituximab (39%) were identified as the two most common agents associated with infusion reactions. Twenty (28%) infusion reactions resulted in cessation of that particular chemotherapy. Conclusions: The format of the MM&I Conference engaged members of a multidisciplinary team to promote collaboration for system-based improvements in patient care and safety. Electronic nursing documentation has put a mechanism in place to capture data related to infusion reactions that will allow us to evaluate the effectiveness of future interventions to decrease the prevalence of infusion reactions, as well as the number of therapies that are stopped indefinitely due to these reactions.
Patient retention and costs associated with a pancreatic multidisciplinary clinic.
Authors: Elnahal Shereef M. , Wild Aaron Tyler , Pawlik Timothy M. , Wang Hao , Gavney Deann , Snyder Tammy , Biedrzycki Barbara A. , Jaffee Elizabeth M. , Langbaum Terry , Fishman Elliott K. , Hruban Ralph H. , Laheru Daniel A. , Hacker-Prietz Amy , Schulick Richard D. , Makary Martin , Edil Barish H. , Wolfgang Christopher Lee , Herman Joseph M.
Published: February 2017

96

Background: Multidisciplinary clinics (MDC) are a burgeoning method of administering timely and comprehensive oncologic care. The continuity of care achievable with MDCs, in addition to their costs, are not well-described. We compared retention rates and charges for MDC patients to patients with individual referrals at the same academic center. Methods: The geographic origins of 482 MDC patients and 3,766 non-MDC patients, all referred for pancreatic cancer treatment between 2008-2010, were defined as “local,” “adjacent states,” and “non-adjacent states.” Proportions of patients in each group who presented initially and subsequently returned were compared using chi-squared tests. Multivariate adjustment was performed for disease stage and other clinical risk factors. Gross charges per patient were determined using billing data. Results: Overall, the MDC retained a higher percentage of patients for subsequent treatment than the non-MDC group (60.8% vs. 53.6%; p=0.003), as well as all three individual regions. Multivariate adjustment results are not yet available, but will be at the time of the meeting. Mean charges per patient were 11% higher for the non-MDC group. Conclusions: The MDC achieved higher patient retention, suggesting improved continuity of care. Total charges were higher for the non-MDC group, suggesting that MDCs may be more cost-effective. [Table: see text] [Table: see text]
Impact of oncology drug shortages.
Authors: Emanuel Ezekiel J. , Shuman Katie , Chinn Derek , Gogineni Keerthi
Published: February 2017

CRA6510

Background: Drug shortages of common chemotherapeutics have been reported. What is the prevalence and consequence of these shortages? Methods: Between 9/2012 and 1/2013, a self-administered questionnaire was sent to a random sample of 455 board-certified U.S. oncologists selected from the American Society of Clinical Oncology directory to assess the prevalence of shortages and impact on therapeutic decision-making. 245 responses were received (response rate 55%), of whom 210 were practicing medical oncologists/hematologists. Results: Due to drug shortages in the prior 6 months, 92% (163) of oncologists reported that their patients’ treatment was affected and 83% (174) were unable to prescribe standard chemotherapy. The five chemotherapy agents most commonly reported in shortage were: leucovorin (68%), liposomal doxorubicin (63%), 5-FU (19%), bleomycin (18%), and cytarabine (17%). Physicians adapted in many ways. 38% of the time, oncologists substituted more expensive branded drugs for those in shortage, such as levoleucovorin for leucovorin. Nearly 13% of the time, shortages prevented enrollment, delayed administration of a study drug, or suspended involvement of patients on clinical trials. Despite the prevalence of scarcities, 70% (146) of oncologists reported their cancer centers or practices lacked formal guidance for allocation decisions. Conclusions: Drug shortages in oncology are very common, compromise the delivery of standard care, impede research, and lead to higher costs by using branded drugs instead of generics. Oncologists also seem to lack formal guidance on how to address these shortages. [Table: see text]
Randomized, open-label, phase III study of pemetrexed plus carboplatin (PemC) followed by maintenance pemetrexed versus paclitaxel/carboplatin/bevacizumab (PCB) followed by maintenance bevacizumab in patients with advanced nonsquamous (NS) non-small cell lung cancer (NSCLC).
Authors: Zinner Ralph , Ross Helen J. , Weaver Robert , Govindan Ramaswamy , Holden Viran R. , Chowhan Naveed Mahfooz , Beck J. Thaddeus , Waterhouse David Michael , Modiano Manuel , Rao Vijay Phooshkooru , Liu Jingyi , Koustenis Andrew , Melemed Symantha , Guba Susan C. , Ortuzar Waldo Feliu , Desaiah Durisala , Spigel David R. , Obasaju Coleman K.
Published: February 2017

LBA8003

Background: PemC and PCB are regimens used for first-line treatment of advanced NS-NSCLC. The primary objective was to compare progression-free survival without Grade 4 toxicity (G4PFS) between two vs three drug regimen arms. Methods: Patients ≥18 years, Stage IV NS NSCLC, AJCC (v7.0), and ECOG PS 0/1 were enrolled. Patients were randomized (1:1); received 4 cycles of induction (PemC: Pem, 500 mg/m2 and C, AUC = 6; PCB: P, 200 mg/m2, C, AUC = 6, and B, 15 mg/kg) followed by Pem (PemC Arm) or B (PCB Arm) maintenance therapy in the absence of progressive disease or discontinuation. Secondary endpoints were PFS, overall survival (OS), overall response rate (ORR), and disease control rate (DCR). The study was powered for G4PFS; assuming hazard ratio (HR) of 0.75; there was 80% power to detect superiority of PemC over PCB with a 2-sided type I error of 0.10. Efficacy data were analyzed by intent-to-treat principle using the log-rank test for time-to-event variables, and an exact test for ORR and DCR. Safety data were evaluated using CTCAE v3 for patients who received ≥1 dose of study treatment. Results: Patients were randomized to PemC (N = 182) or PCB (N = 179). Baseline factors were balanced between arms: median age 66/66 years; % female 42/42; % PS=0, 47/47; % stage IV M1a 29/30; for PemC vs PCB, median G4PFS (months) was 3.91/2.86 (HR = 0.85, 90% CI 0.7, 1.04, p = 0.176); PFS and OS had HR = 1.06 (95% CI 0.84, 1.35), p = 0.610, and HR = 1.07 (95% CI 0.83, 1.36), p = 0.616, respectively. The ORR (%) 23.6/ 27.4 and DCR (%) 59.9/57.0 were for PemC vs PCB, respectively. Significantly more drug-related grade 3/4 anemia (18.7% vs 5.4%), and thrombocytopenia (24.0% vs 9.6%) were seen on PemC; significantly more grade 3/4 neutropenia (48.8% vs 24.6%) and grade 1/2 alopecia (28.3 % vs 8.2%) were seen on PCB. Conclusions: PemC was not superior to PCB in G4PFS; no difference in PFS or OS was observed for the two- vs three-drug regimens. There were no unexpected toxicities; the toxicity profiles demonstrated distinctions by arm, and both regimens demonstrated tolerability. Clinical trial information: NCT00948675.
Recurrence score along the continuum of increasing nodal burden in breast cancer.
Authors: Smith Franz Omar , Lee Marie Catherine , Acs Geza , Fulp William J. , Lee Ji-Hyun , Khakpour Nazanin , Kiluk John , Laronga Christine
Published: February 2017

101

Background: The Oncotype Dx (ODX) Recurrence Score (RS) stratifies breast cancer patients (pts) by risk of recurrence and potential benefit of adjuvant chemotherapy. Pts with early stage, estrogen receptor (ER) positive, lymph node-negative breast cancer were included in the initial validation studies. Limited data exists on the application of ODX in node positive pts. We review our experience with RS along the continuum of nodal burden. Methods: A prospective database of pts with breast cancer for whom ODX RS was obtained for treatment planning was reviewed by final surgical pathology. Patients were grouped into four pathologic categories: negative sentinel lymph node [N0(i-)], isolated tumor cells [N0(i+)], micro-metastasis [N1mic] and macro-macrometastasis [N1, 1-3 + nodes]. P values were calculated using the exact Wilcoxon Rank Sum Test. Results: 637 pts were identified in the study period: 521 (81.8%) pts had negative sentinel lymph nodes; 54 (8.5%) pts had isolated tumor cells (N0(i+)); 29 (4.6%) pts had N1mic, and 33 (5.2%) had N1 disease (Table). Median age overall was 58yrs, median invasive tumor size was 1.5cm; 475 (91.2%) had ductal histology. Median RS for the study pts was 17 (range 0-85), and increasing RS had no correlation to increasing nodal burden (p=0.23). Pathologic factors associated with nodal status were lymphovascular invasion (LVI) and histology. The frequency of LVI was higher with increasing nodal burden (p<0.0001). Ductal histology was significantly associated with abnormal nodal findings. (p = 0.002). Age, mitotic rate, grade and degree of ER-positive staining on IHC were not significantly associated with sentinel lymph node status (p > 0.05). Conclusions: Tumor size, histology and LVI were significant predictors of increased nodal burden. However, ODX RS was neither predictive nor reflective of increasing nodal disease. RS is a potentially useful tool in adjuvant systemic treatment decisions in patients with positive lymph nodes but should not impact decisions regarding local-regional therapy. [Table: see text]
Evaluating the prevalence of cardiovascular risk factors among breast cancer survivors and the outcomes of cardio-oncology referrals by a breast cancer survivorship clinic.
Authors: Klemp Jennifer R. , Ranallo Lori , Knight Catie , Fabian Carol J. , Befort Christie A.
Published: February 2017

107

Background: Breast cancer survivors have a 4x increased incidence of cardiovascular disease (CVD) compared to women never treated for breast cancer and cardiac events are the 2nd most common cause of death in long-term survivors. Attention to reducing the risk of CVD should be a priority for the long-term care of breast cancer survivors. This study was undertaken to describe cardiovascular risk factors in breast cancer survivors, and the cardio-oncology referral patterns and outcomes from cardio-oncology screening visits. Methods: 356 female breast cancer survivors seen at the University of Kansas Breast Cancer Survivorship Center between 2006 and 2012 who completed an initial intake visit were evaluated for cardiovascular risk factors and referrals to cardio-oncology. An expanded list of cardiovascular factors was used: BMI > 25, Diabetes, HTN, HLD, Current/Past Smoker, Family Hx of MI < 60 years, Exercise < 150 min/wk, Ejection Fraction < 50%, and exposure to cardio-toxic breast cancer treatment. Breast cancer survivors without evidence of metastatic disease were on average 57.8 +/-11.0 years old, underwent standard treatment regimens, and were approximately 7.5 years from their initial diagnosis. Results: 13% were already followed by a cardiologist, 21% were referred to cardio-oncology, and 66% were not referred at their initial survivorship visit. There were significant differences in the average number of risk factors between those not referred to cardio-oncology (4.36 +/-1.89), and those referred to cardio-oncology (5.68+/-1.8), and between those already followed by cardiologist (5.91+/-1.75), p < 0.001 and p < 0.0001, respectively. The most common risk factors were BMI >25, elevated HDL, exercise <150 min/wk, and exposure to an anthracycline. The most common outcomes following a cardio-oncology visit included further diagnostic tests, medication changes, or a return visit. Conclusions: These findings demonstrate the need to determine how to include treatment related risk factors along with traditional cardiovascular risk factors in assessing and managing cardiovascular risk in breast cancer survivors.
Taking control of cancer: Why women are choosing mastectomy.
Authors: Covelli Andrea Marie , Baxter Nancy N. , Fitch Margaret , Wright Frances Catriona
Published: February 2017

108

Background: Rates of both unilateral (UM) and contralateral prophylactic mastectomy (CPM) for early stage breast cancer (ESBC) have been increasing since 2003. More extensive surgery is not a benign procedure without the risk of complications. Studies suggest that the increase is due to women choosing UM and CPM; we do not know what factors are influencing the choice for more extensive surgery. Methods: We conducted a qualitative study using grounded theory to identify factors for the choice of mastectomy. Purposive sampling was used to identify women across the Toronto Area (Ontario, Canada), who were suitable candidates for breast conserving surgery (BCS) but underwent UM or CPM. Data were collected through semi-structured interviews. Constant comparative analysis identified key concepts and themes. Results: Data saturation was achieved after 29 in-person interviews. 12 interviewees were treated at academic cancer centers, 6 at an academic non-cancer center and 11 at community centers. 15 women underwent UM; 14 underwent UM+CPM. Median age was 55. ‘Taking control of cancer’ was the dominant theme. Fear of breast cancerwas expressed at diagnosisand remains throughout decision making. Fear translates into the overestimated risk of local recurrenceand contralateral cancer. Despite discussion of the equivalence of BCS and UM, patients chose UM due to fear of recurrence and misperceived survival advantage. Similarly, patients chose CPM to eliminate the risk of contralateral cancer and misperceived survival advantage. Women were actively trying to Control Outcomes, as more surgery was seen as greater control. Conclusions: Women seeking UM and CPM for treatment of their early stage breast cancer manage their fear of cancer by undergoing more extensive surgery which in turn drives mastectomy rates. It is important to understand this process so that we may improve our ability to discuss issues of importance to women and facilitate informed decision-making.
Webinars as a tool for breast cancer survivorship education.
Authors: Bantug Elissa Thorner , Duffey Katherine E. , Peairs Kimberly S. , Lee Linda A. , Gould Jeffery M. , Brown Mary-Eve , Wolff Antonio C.
Published: February 2017

109

Background: Survivorship education may facilitate coordination of care between the patient and health care providers, increase adherence to health maintenance recommendations, and improve outcomes. Approximately 80% of Americans regularly use the internet. Interactive seminars (webinars) may offer an efficient tool to reach a diverse audience of cancer survivors, caregivers, and providers. Methods: From September 2012-April 2013, we offered 3 free 1-hour webinars advertised via social media, print flyers, email, newsletters, and advocacy and support groups. Topics included next steps after breast cancer treatment, integrative medicine, and nutrition. Participants registered online or by phone. Format consisted of a 30-minute lecture followed by live Q&A with electronically submitted questions. Demographic data were collected at registration and participants were asked to complete a brief 9-question survey after the webinar. Results: 728 participants registered for at least 1 webinar (median age 56, range 18-81 years; 14% African American). 681 participants were U.S.-based and 47 joined from 21 other countries. Participants self-identified as a cancer survivor (71%), provider (20%), caregiver (8%), or other (2%). Most (79%) had at least a high school education. Among the 184 (25%) who completed the post-webinar survey, 86% reported that information was relevant to situation, 85% said they had the opportunity to ask questions, 94% felt speakers were knowledgeable, and 90% were satisfied with the information quality. Participants ranked one-on-one care followed by webinars as their preferred way to receive survivorship information, above other tools like videos, websites, and handouts. Conclusions: As part of a multidisciplinary approach to breast cancer survivorship care, webinars are a feasible modality to deliver quality health information. Limitations include overall generalizability with a potential selection bias of those who may be more educated than the general population, have access to the internet, and feel comfortable with this technology. Nonetheless, data suggest that this format may allow us to reach a diverse audience that appears receptive and satisfied with survivorship education provided in an electronic format.
Assessing the need for a nurse-led breast cancer telephone follow-up clinic in Alberta, Canada.
Authors: Lupichuk Sasha M. , Railton Cindy , Ko Jenny J. , McCormick Jennifer , Zhong Lihong , Joy Anil Abraham , Walley Barbara , Giese-Davis Janine
Published: February 2017

111

Background: Routine follow-up of breast cancer (BC) patients is largely transferred to primary care due to limited tertiary care resources and evidence supporting the acceptability and safety of this approach. It is unknown how BC survivors are faring in the community with treatment and surveillance goals, and if there is an unmet need for access to specialist care. Objectives of this cross-sectional study of BC survivors were to examine: concordance with endocrine therapy and follow-up recommendations; perceived need for help with achieving these recommendations; and, perceived need for a telephone follow-up clinic. Methods: Eligible participants were women with stage I-III BC diagnosed June 2006-September 2009 who had been seen in consultation at a tertiary cancer centre (TCC) in Alberta, Canada. 960 potentially eligible women were invited to participate via mail-out from the Alberta Cancer Registry. Consenting participants completed a structured telephone interview. Further patient, disease, endocrine therapy and surveillance data were obtained from the electronic chart and pharmacy databases. Results: 240 participants completed the telephone interview. 68.8% had been discharged from a TCC. 87.1% reported having had a clinical breast examination, and 97.1% with remaining breast tissue reported having had a surveillance mammogram within the past year. Concordance with endocrine therapy varied between pharmacy dispensing records (95.4%) versus self-report (82.0%). Top participant-identified gaps in post-treatment services were: side effect management, achieving body weight and physical activity goals, psychosocial health, and sexual health. 71.7% of participants reported that they would have used a telephone follow-up clinic. Factors associated with telephone follow-up clinic use included younger age, no endocrine therapy, fatigue, and non-urban residence. Conclusions: Concordance with measurable follow-up goals (exam, mammography, endocrine therapy) was better than expected. Despite this, interest in a nurse-led BC telephone follow-up clinic was high. Perceived needs included management of symptoms plus support for life-style behavior change.
A comparison of rates and predictors of hospital readmission: Outpatient versus inpatient mastectomy for breast cancer.
Authors: Uyeno Lori , Streja Leanne , Yim John H. , Chen Steven L. , Kruper Laura
Published: February 2017

116

Background: The odds of readmission have been reported to be slightly higher with outpatient (OP) compared to inpatient (IP) mastectomy, although overall rates are low. While OP mastectomy procedures have become more common, predictors of readmission and current rates are unknown. Methods: Observational study of women 18+ years who underwent mastectomy in California from 2005-2009 from the Healthcare Cost and Utilization Project (HCUP) linked state database. Associations of readmission and post-mastectomy complications with length of stay (LOS) were assessed using Jonkheere – Terpstra test for trend. Multivariate logistic regression was used to test the association of LOS with readmission to hospital within 30 days, adjusting for patient, clinical, and hospital factors. Results: Readmission rates for OP compared to IP mastectomy was 3.3 % vs. 5.6% (p<0.0001). OP mastectomy had the highest hematoma/seroma and chemotherapy related anemia/ neutropenia readmissions (19% p=0.0112; 2.9% p=0.0009). Readmits for cardiopulmonary events were higher for the longest LOS. Multivariate analysis showed increased readmission rates by LOS, race, payer, comorbidities (all p-values <0.0001). Odds of readmission were higher with increasing LOS vs. OP (1d OR 1.13 95% CI 0.99-1.3; 2d OR 1.6 95%CI 1.4-1.8; ≥3d OR 3.0 95%CI 2.6-3.4). Increased odds of readmission was associated with African-Americans (OR 1.5 95%CI 1.2-1.9) and Whites (OR 1.4 95%CI 1.2-1.7) vs. Asians. Revisit rates were higher with Medicare (OR 1.7 95%CI 1.4-1.9) and Medicaid (OR 1.6 95%CI 1.3-1.8) compared to private insurance. The highest readmission rates were ≥ 3 comorbidities (OR 2.7 95%CI 2.2-3.2). Conclusions: In California, readmission rates increase with increasing LOS. Risks of readmission following IP mastectomy are higher compared to OP. Low readmission rates suggest appropriate selection of patients for OP mastectomy. However, subsets of patients are at higher risk of readmission. Additional studies of patients with extended LOS; racial disparities in access to services; and evaluation of payer policies are needed to improve care and decrease hospital readmissions.
Social support as a determinant of health-related quality of life in breast cancer survivors in California.
Authors: Rab Faiza
Published: February 2017

118

Background: To evaluate the relationship between perceived social support and HRQOL (physical and emotional) in low SES (Socio economic status) breast cancer survivors. Methods: A cross-sectional study design was used to measure perceived social support at 18 months and HRQOL at 3 years after breast cancer diagnosis using MOS SS and MOS SF-36, respectively. Multiple regression analyses were used to evaluate the relationship. Results: Menopause at the time of diagnosis, adjunct chemotherapy, adjunct radiation therapy, co-morbidities, treatment side effects and depression were negatively associated with PCS scores (p < 0.01). Treatment side effects, anxiety and depression were negatively associated with MCS scores (p < 0.01). Conclusions: Perceived social support was not associated with HRQOL in low SES breast cancer survivors in our study. Menopause, co-morbidities, treatment side effect, adjunct chemotherapy and radiation therapy adversely affect physical HRQOL. Feelings of anxiety, depression and treatment side effects have a negative impact on emotional HRQOL.
Referral trends for reproductive-age patients with breast cancer to a reproductive endocrinology clinic for fertility preservation counseling between 2004 and 2012.
Authors: Kort Jonathan David , Seiger Kira , Henry Solomon , Westphal Lynn
Published: February 2017

129

Background: As of October 2012, both embryo and oocyte cryopreservation are considered non-experimental fertility preservation (FP) options for cancer patients facing potentially gonadotoxic therapy. This study aims to assess the historical referral frequency of reproductive aged breast cancer patients from a major cancer center to an associated reproductive endocrinology and infertility (REI) clinic for counseling regarding FP and also assess how frequently these patients underwent FP after referral. Methods: Using the Stanford Cancer Center Research Database in conjunction with our EMR, a query was made for patients of reproductive age (13-45) who were seen at the Stanford Cancer Center for a new breast cancer diagnosis between 2004 and 2012. These patients’ records were then searched for referral encounters in the REI department. Those who were seen by REI were assessed for having undergone FP via embryo or oocyte cryopreservation prior to starting chemotherapy. Results: 420 women, ages 20 to 45, were seen at our cancer center for a new diagnosis of breast cancer between 2004 and 2012. Sixty (14.3%) of these patients, ages 20 to 42 at diagnosis, were referred to the REI department for FP counseling. Patients who were referred for FP counseling were 5.1 years younger at diagnosis than those who were not (p<.005). Of those referred, 33.3% underwent FP with embryo (77%) or oocyte cryopreservation (23%) under an experimental protocol. Among breast cancer patients ≤35 years old, 35% were referred to our REI department for FP counseling and 53.5% of those referred underwent FP. Conclusions: Despite advances in FP technology, the majority of reproductive aged breast cancer patients are still not referred for FP counseling by a reproductive endocrinologist. This trend was also seen among patients younger than 35—a subgroup who is more likely to undergo and benefit most from FP. This study does not reflect patients who decline this opportunity or seek FP elsewhere, however additional study and outreach is needed to improve referral rates, which are now a measure of the Quality Oncology Practice Initiative (QOPI).
The use of bioimpedance spectroscopy to monitor response to treatment interventions with breast cancer-related lymphedema.
Authors: Shah Chirag , Vicini Frank , Beitsch Peter D. , Anglin Beth , Laidley Alison Lisa , Ridner Sheila H. , Lyden Maureen
Published: February 2017

138

Background: Currently, limited tools are available to assess response to therapy in patients with breast cancer related lymphedema (BCRL). The purpose of this study was to perform an exploratory analysis to determine if, in clinical settings, bioimpedance spectroscopy (BIS) can detect changes in extracellular fluid volume in response to treatment of BCRL. Methods: Three centers that had experience with BIS (L-Dex U400, ImpediMed Limited, Brisbane, Australia) provided retrospective data on 50 patients with breast cancer who were evaluated with BIS at baseline and following loco-regional procedures. Patients had a pre-surgical L-Dex measurement as well as at least 2 post-surgical measurements (before and after BCRL intervention). Decisions regarding intervention were made by physicians with no L-Dex score cut-off utilized. An analysis was performed comparing changes in L-Dex scores for those patients undergoing treatment for BCRL (n=13) versus those not undergoing intervention (n=37). A second analysis was also performed on all patients with elevated L-Dex scores compared to baseline prior to intervention (n=32). Results: The mean age was 54 years old. Fifty four percent of patients underwent SLN biopsy with a mean of 7.9 nodes removed. The mean change in L-Dex score from baseline (pre-treatment) to the first post-surgical L-Dex score measurement was 3.3 +/- 6.8. When comparing the cohort treated for BCRL to those not treated, L-Dex scores were significantly reduced (-4.3 v. 0.1, p=0.005) following intervention. For the subset of patients with elevated L-Dex scores post-surgery, the change in L-Dex score following BCRL intervention was significantly reduced (-5.8 v. 0.1, p=0.001) compared with those observed. Conclusions: These results confirm that BIS can detect increases in L-Dex scores following breast surgery and can also detect reductions in L-Dex scores following intervention for early onset lymphedema. These results demonstrate that BIS has significant clinical utility as it can be used to monitor patients with early BCRL who undergo intervention and to follow these patients (through serial measurements) to document their short and long-term response to these treatments.
Secondary cancers after breast-conserving therapy in Tokyo database.
Authors: Shiraishi Kenshiro , Nakagawa Keiichi , Kawamori Jiro , Ibukuro Kenji , Fukuuchi Atsushi , Nishi Tsunehiro , Shinozaki Tomohiro
Published: February 2017

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Background: The more patients overcome early breast cancer and become cancer survivors as a result of modern sophisticated approach, the more secondary cancers inevitably arise. The second malignancies after breast conserving therapy (BCT) are well-known sticky dilemma because of additional anxiety and need for medical care for longer-time. However, it is unclear whether secondary cancers negatively affect prognosis of breast cancer survivors. Methods: We performed a retrospective study of long-term cancer survivors after BCT for locoregional invasive or noninvasive breast cancer diagnosed between 1982 and mid-2012. Actuarial rates of overall (OS) and cause-specific survival (CSS) were calculated by using the Kaplan-Meier method. We compared between-group differences using the log-rank test. Results: Eight hundred sixty patients (32%) were followed-up for more than 10 years. At a median follow-up of 90 months, 146 patients had developed a second malignancy. The greatest increases in risk were for leukemia (Standardized incidence ratio (SIR): 4.24 (1.52–8.31)), ovarian cancer (SIR: 4.12 (2.40–6.31)), reno-ureteral cancer (SIR: 3.18 (1.14–6.23)), endometrial cancer (SIR: 2.48 (1.27–4.08)), and pancreatic cancer (SIR: 2.32 (1.11–3.99)). No increased risk was observed for other gastrointestinal and genitourinary cancer, malignant melanoma, lymphoma, thyroid or head and neck cancer. Overall 10-year cumulative incidence of OS without secondary cancer was 93.3%, and 10-year cumulative incidence of OS with secondary cancer was 81.5%. (p<0.001)Overall 10-year cumulative incidence of CSS without secondary cancer was 94.2%, and 10-year cumulative incidence of CSS with secondary cancer was 92.8%. (p=0.749). This likelihood of survival disadvantage is similar to that with ipsilateral breast tumor recurrecnce. Conclusions: Secondary cancers after BCT negatively impact on OS. Given the life-threatening nature to cancer survivors, lifetime caution such as smoking cessation, alcohol intake abstention, weight control, physical activity, and other healthy lifestyle must be paid.
Characterization of patients who received prior chemotherapy for advanced breast cancer (ABC) in BOLERO-2.
Authors: Yardley Denise Aysel , Campone Mario , Lebrun Fabienne , Noguchi Shinzaburo , Pritchard Kathleen I. , Burris Howard A. , Beck J. Thaddeus , Ito Yoshinori , Bachelot Thomas , Pistilli Barbara , Melichar Bohuslav , Petrakova Katarina , Arena Francis P. , Erdkamp Frans , Harb Wael A. , Litton Jennifer Keating , Brechenmacher Thomas , El-Hashimy Mona , Taran Tanya , Gnant Michael
Published: February 2017

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Background: In patients with hormone receptor–positive (HR+) breast cancer, endocrine therapy is the standard of care both in the adjuvant setting and as front-line therapy for ABC. Chemotherapy (CT) is commonly used for HR+ ABC patients if disease burden is high and rapid symptom control is required (Barrios CH. GAMO. 2010). In the phase III BOLERO-2 study (NCT00863655), first-line of prior CT in the ABC setting was allowed. This subset analysis examined disease characteristics and the efficacy of everolimus (EVE) + exemestane (EXE) in patients who received CT for ABC prior to BOLERO-2 study entry. Methods: In BOLERO-2, 724 patients with HR+, human epidermal growth factor receptor 2–negative (HER2–) ABC whose disease recurred or progressed during/after a nonsteroidal aromatase inhibitor were randomized 2:1 to EVE (10 mg/d) + EXE (25 mg/d) or placebo (PBO) + EXE. The primary endpoint was progression-free survival (PFS) by local investigator review (confirmed by blinded independent central review). Results: A total of 186 patients (26%) received prior CT for ABC (125 in the EVE + EXE group and 61 in PBO + EXE). In this subset, 54% (67 of 125) of EVE+ EXE patients received prior CT in the advanced setting only while 46% (58 of 125) of EVE + EXE patients received prior CT in both the neoadjuvant/adjuvant and advanced settings. Visceral metastases (67% vs. 56%), multiple metastases (79% vs. 66%), and ≥ 4 metastatic sites (18% vs. 15%) were more frequent in ABC patients with prior CT for ABC at study entry compared with those with no prior CT for ABC. History of disease recurrence <6 months from initial diagnosis was recorded in 32% (n = 60) of prior CT patients versus 17% (n = 93) of patients with no prior CT. Median PFS (by local assessment) in patients who received prior CT for ABC was substantially longer with EVE + EXE versus PBO + EXE (6.1 vs. 2.7 mo; hazard ratio = 0.38; 95% CI, 0.27-0.53). PFS by central review showed similar results (7.1 vs. 2.8 mo, respectively; hazard ratio = 0.42; 95% CI, 0.27-0.65). Conclusions: These results demonstrate that patients with HR+, HER2 ABC who received previous CT in the advanced setting had a higher tumor burden but derived significant and clinically meaningful benefit from combination therapy with EVE + EXE. Clinical trial information: NCT00863655.
Association of bone mineral density with breast cancer and histopathologic features of the tumor.
Authors: Sharma Anurag , Youssef Elias , Roche Meaghan , Maroules Michael
Published: February 2017

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Background: High bone mineral density (BMD) has been associated with increased incidence of breast cancer. We studied the differences in BMDs between females with and without breast cancer as well as the association between BMD and the histopathological features of breast cancer. Methods: Data on BMDs and Tscores of hip and spine were collected for 311 breast cancer patients from Dexa Scans available from 5 years before or within 1 year of diagnosis. The same information was collected for 1,047 females without breast cancer (age matched with study group). The following additional data was collected for breast cancer patients: TNM staging, Histology, Estrogen receptor (ER), Progesterone receptor (PR), Ki-67 and HER-2 percentages, Tumor size, and Tumor differentiation. Results: As expected, breast cancer patients were found to have higher hip/spine BMDs than women without breast cancer (p < 0.001). PR percentage was positively associated with hip BMD/Tscore and spine BMD/Tscore ([rsp=0.166/0.165, 0.145/0.164, respectively], p<0.05 for all [Spearman Correlation Analysis]). Tumor size was negatively associated with spine BMD/Tscore ([rsp=-0.134, p=0.06], [rsp=-0.136, p=0.04], respectively, [Spearman Correlation Analysis]). A negative trend was seen between Ki-67 percentages and BMD (although no significance was achieved). Patients with lymphovascular invasion had lower spine Tscores than patients without lymphovascular invasion (-1.22±1.45 vs. -0.84±1.37, p=0.04, [One-way ANOVA]). Conclusions: Amongst all women studied, women with breast cancer were likely to have a higher BMD. However, higher BMD in breast cancer patients was associated with favorable tumor characteristics. Higher BMD was also associated with higher percentage of PR while no significant association was seen with ER. Greater cumulative estrogen exposure in females with higher BMD might explain these results. Estrogens are known to affect proliferation of breast cancer cells and to alter their phenotypic and cytoarchitechtural features, including enhanced induction of PR and possible downregulation of ER. Future studies are needed to explore these underlying pathways, their effect on tumor behavior, and treatment implications.