Emergency department visits and hospitalizations in older women treated for early stage breast cancer.

INTRODUCTION: Older patients with cancer often require acute care treatment through emergency department (ED) visits and hospitalizations. This study investigates acute care utilization through ED visits and hospitalizations during treatment and in the two years following the completion of primary treatment for early stage breast cancer (EBC) in women aged 65 and older. MATERIALS AND METHODS: A retrospective analysis including descriptive statistics, univariate analysis, and relative risk analysis of 256 women with EBC was performed through medical record review of demographics, comorbidities, disease characteristics, treatment details, and causes of hospitalizations and ED visits. RESULTS: Both hospitalizations and ED visits were significantly more frequent for patients in the post-primary treatment period compared to during treatment (hospitalizations: 22% post-primary treatment vs 13% during treatment, 95% confidence interval [CI] of true difference = 2.5%-15.5; ED visits: 21% post-primary treatment vs 10% during treatment, 95% CI of true difference = 4.8%-17.2%). Both hospitalizations (79% versus 32%, 95% CI of true difference = 28.7%-65.3%) and ED visits (42% versus 12%, 95% CI of true difference = 9.1%-50.9%) were more often breast cancer related during primary treatment compared to following treatment. Following treatment, EBC related hospitalizations were most often for disease progression (42%) and EBC related ED visits were most often for post-systemic therapy complications (43%). Significant predictors for EBC related hospitalizations in the two years following treatment included stage III disease (relative risk [RR] = 8.77, 95% CI = 2.50-30.82), having underwent mastectomy (RR = 12.51, 95% CI = 2.91-53.78), and having received chemotherapy (RR = 3.95, 95% CI = 1.18-13.23). However, chemotherapy does not appear to be a significant predictor for hospitalization when controlling for stage III disease (RR = 2.22, 95% CI = 0.61-8.05), whereas stage III disease remains a significant risk factor when controlling for chemotherapy (RR = 6.09, 95% CI = 1.58-23.52). DISCUSSION: Our findings suggests that stage III disease, undergoing mastectomy, and chemotherapy treatment predict higher likelihood of EBC related hospitalization following primary treatment in older EBC patients, with stage III disease likely the strongest risk factor.

Does walking during chemotherapy impact p16INK4a levels in women with early breast cancer.

BACKGROUND: Increased p16INK4a (p16) expression is directly related to cellular senescence and is a robust biomarker of aging in humans. Prior studies have shown that levels of p16 dramatically increase in breast cancer patients who have received adjuvant chemotherapy. This study investigated whether moderate physical activity during chemotherapy would attenuate the expected rise in p16 expression. METHODS: Participants were women with Stage I-III breast cancer enrolled in a walking study for the duration of their chemotherapy (NCT02167932, NCT02328313, NCT03761706). Participants were asked to walk at least 30 min or 6200 steps/day following a structured walking program and to wear an activity tracker. p16 mRNA levels were measured in peripheral blood T-cells before chemotherapy initiation and at approximately 6 months after last chemotherapy treatment (mean 200 days, SD 40 days). RESULTS: In total, 141 participants met inclusion criteria and 10% (n = 14) averaged > 6200 steps/day. There was no significant association of daily steps with change in p16 levels pre- to post-chemotherapy (Pearson correlation coefficient = 0.11, p = 0.17). After adjusting for age, stage, anthracycline-based chemotherapy, and baseline p16, the change in log2 p16 for each 1000 steps was estimated to be 0.03 (p = 0.35). Most participants were sedentary prior to chemotherapy and achieved modest levels of physical activity during treatment. CONCLUSION: A self-guided walking program achieved only modest levels of physical activity and was unable to ameliorate chemotherapy-induced change in p16 levels in women undergoing chemotherapy for early-stage breast cancer. More structured and vigorous exercise programs should be tested for a more definitive exploration of their impact on post-chemotherapy p16 levels.

Age and competing concerns in treatment selection for women with non-metastatic HR+ and HER2- breast cancer: Current clinical practice.

BACKGROUND: Newer adjuvant treatment options for non-metastatic breast cancer have increased survival. There is a need to investigate whether demographic and clinical characteristics of women with hormone receptor-positive, human epidermal growth receptor 2-negative non-metastatic breast cancer (stages I-III) differentially influence treatment decisions in older (age 65 or older) versus younger patients (under age 65). METHODS: In a retrospective electronic medical record review, prevalence ratio with 95% confidence interval for treatment decisions in older vs younger patients was calculated using log binomial regression adjusted for race, stage, and total number of comorbidities. RESULTS: In a sample of 537 patients, 66% were age < 65 and 34% age ≥ 65. Older patients included a higher proportion of White women (85% vs 75%, P = .02), higher number of comorbidities (P ≤0.0001), and lower stage tumors (P = .0004). In multivariable analysis, age ≥ 65 was independently associated with fewer mastectomies (95% CI 0.65-0.96, P = .02), more lumpectomies (95% CI 1.05-1.42, P = .01), and less receipt of radiation treatment (95% CI 0.78-0.97, P = .01) and/or chemotherapy (95% CI 0.73-0.95, P = .006). In multivariate analysis, stage was independently significant for all treatment modalities, except endocrine therapy, and race was not. CONCLUSIONS: This study suggests that age, in addition to breast cancer stage, is a predictor of treatment modality, independent of race and number of comorbidities. Treatment modality reflects a combination of patient preference and clinician assessment of fitness for current standard of care.

Effect of an Antiracism Intervention on Racial Disparities in Time to Lung Cancer Surgery.

PURPOSE: Timely lung cancer surgery is a metric of high-quality cancer care and improves survival for early-stage non-small-cell lung cancer. Historically, Black patients experience longer delays to surgery than White patients and have lower survival rates. Antiracism interventions have shown benefits in reducing racial disparities in lung cancer treatment. METHODS: We conducted a secondary analysis of Accountability for Cancer Care through Undoing Racism and Equity, an antiracism prospective pragmatic trial, at five cancer centers to assess the impact on overall timeliness of lung cancer surgery and racial disparities in timely surgery. The intervention consisted of (1) a real-time warning system to identify unmet care milestones, (2) race-specific feedback on lung cancer treatment rates, and (3) patient navigation. The primary outcome was surgery within 8 weeks of diagnosis. Risk ratios (RRs) and 95% CIs were estimated using log-binomial regression and adjusted for clinical and demographic factors. RESULTS: A total of 2,363 patients with stage I and II non-small-cell lung cancer were included in the analyses: intervention (n = 263), retrospective control (n = 1,798), and concurrent control (n = 302). 87.1% of Black patients and 85.4% of White patients in the intervention group (P = .13) received surgery within 8 weeks of diagnosis compared with 58.7% of Black patients and 75.0% of White patients in the retrospective group (P < .01) and 64.9% of Black patients and 73.2% of White patients (P = .29) in the concurrent group. Black patients in the intervention group were more likely to receive timely surgery than Black patients in the retrospective group (RR 1.43; 95% CI, 1.26 to 1.64). White patients in the intervention group also had timelier surgery than White patients in the retrospective group (RR 1.10; 95% CI, 1.02 to 1.18). CONCLUSION: Accountability for Cancer Care through Undoing Racism and Equity is associated with timelier lung cancer surgery and reduction of the racial gap in timely surgery.

Anticipating mental health needs after chemotherapy in early-stage breast cancer using patient-reported symptom screening.

PURPOSE: Many patients with breast cancer experience depression and anxiety for years after completing systemic chemotherapy, which negatively impact overall symptom burden, quality of life, and treatment outcomes. The objective of this study was to examine the utility of patient-reported outcome (PRO) measures to predict mental health needs in patients with breast cancer during post-chemotherapy follow-up care. METHODS: In a sample of women with non-metastatic breast cancer, associations between patient-reported depression and anxiety at end of chemotherapy and post-chemotherapy mental health needs were evaluated using log-binomial regression adjusted for functional status, social activity limitations, and time from chemotherapy. RESULTS: In a sample of 149 women, 40% reported at least mild depressive symptoms and 52% reported at least mild anxiety at the end of chemotherapy. Over an average 3.2 years post-chemotherapy (range: 0.7-5.6 years), 23% received new psychiatric diagnoses, 21% engaged in mental health specialty care, and 62% were prescribed psychotropic medications. End of chemotherapy depression and anxiety were associated with future prescription of psychotropic medications (RR 1.52; 95% CI 1.14-2.03), as well as greater number of psychotropics. Associations were strongest with serotonin-norepinephrine reuptake inhibitors [(depression: RR 4.75; 95% CI 2.06-10.95); (anxiety: RR 3.68; 95% CI 1.62-8.36); (depression and anxiety: RR 2.98; 95% CI 1.65-5.36)]. CONCLUSION: Diagnosis of and treatment for depression and anxiety are common among women with breast cancer after completing chemotherapy. Prescriptions for psychotropic medications during the initial years after systemic chemotherapy can be anticipated by depression and anxiety screening at end of chemotherapy.

Social support and outcomes in older adults with lung cancer.

BACKGROUND: Insufficient social support is associated with increased mortality among older adults. Lung cancer is primarily a disease of older adults and is the leading cause of all cancer deaths. We assessed the association of social support with outcomes among older adults with lung cancer. MATERIALS AND METHODS: Adults age 65 and older with lung cancer with a completed geriatric assessment (GA) were assessed. Emotional social support (ES) and tangible (material, instrumental) support (TS) measures and patient characteristics were obtained from the GA. The electronic health record was used to extract clinical variables. Simple linear regression models evaluated the association between social support scales with patient and clinical factors. RESULTS: 79 adults were assessed. White race was positively associated with ES score (p=.04), while higher BMI (p=.03), depression (p=.03) and anxiety (p=.02) were associated with worse ES. Higher BMI was associated with higher/better TS score (p=.02) while living alone was associated with lower/worse TS score (p=.03). Completion of platinum-based doublet chemotherapy with immunotherapy as planned was associated with higher ES scores (p=.02) and higher TS scores (p=.02). Disease progression was associated with lower ES scores (p=.03). CONCLUSION: Social support may influence clinical outcomes in older adults with lung cancer. As lung cancer often portends to poor prognosis, social support may be an important prognostic indicator.

Obesity, comorbidities, and treatment selection in Black and White women with early breast cancer.

BACKGROUND: This study investigates obesity and comorbidity in Black and White women with early breast cancer (stages I-III) and their potential impact on treatment decisions for patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) tumors. METHODS: In this retrospective chart review, comparisons of frequencies for Black and White patients were calculated with the Fisher exact test. Log binomial regression was used to estimate prevalence ratios (PRs) with 95% confidence intervals for total and individual comorbidities, and multivariable modeling was used to estimate PRs adjusted for age and body mass index (BMI). RESULTS: In a sample of 548 patients, 26% were Black, and 74% were White. Sixty-two percent of Black patients and 32% of White patients were obese (BMI ≥ 30 kg/m2 ; P < .0001). Seventy-five percent of Black patients and 87% of White patients had HR+ tumors (P = .001). Significant intergroup differences were seen for 2 or more total comorbidities (62% of Blacks vs 47% of Whites; P = .001), 2 or more obesity-related comorbidities (33% vs 10%; P < .0001), hypertension (60% vs 32%; P < .0001), diabetes mellitus (23% vs 6%; P < .0001), hypercholesterolemia or hyperlipidemia (28% vs 18%; P = .02), and hypothyroidism (4% vs 11%; P = .012). In women with HR+/HER2- tumors, there were no intergroup differences in treatment decisions regarding the type of surgery, chemotherapy regimen, radiation, or endocrine treatment despite significant differences in the prevalence of obesity and comorbidities. CONCLUSIONS: This study documents significant disparities between Black and White women with early breast cancer with regard to high rates of obesity, overall comorbidities, and obesity-related comorbidities, and it highlights the prevalence of competing risks that may complicate outcomes in breast cancer.