Contralateral prophylactic mastectomy in a rural population: A single-institution experience.

Background: The incidence of contralateral prophylactic mastectomy (CPM) for unilateral breast cancer (UBC) has continued to increase, despite an absent survival benefit except in populations at highest risk for developing contralateral breast cancer (CBC). CPM rates may be higher in rural populations but causes remain unclear. A study performed at our institution previously found that 21.8 % of patients with UBC underwent CPM from 2000 to 2009. This study aimed to evaluate the CPM trend at a single institution serving a rural population and identify the CPM rate in average-risk patients. Methods: Retrospective review of patients who underwent mastectomies for UBC at our institution from 2017 to 2021 was performed. Analysis utilized frequencies and percentages, descriptive statistics, chi-square, and independent sample t-tests. Results: A total of 438 patients were included, of whom 64.4 % underwent bilateral mastectomy for UBC (CPM). Patients who underwent CPM were significantly younger, underwent genetic testing, had germline pathogenic variants, had a family history of breast cancer, had smaller tumors, underwent reconstruction, and had more wound infections. Of CPM patients, 50.4 % had no identifiable factors for increased risk of developing CBC. Conclusions: The rate of CPM in a rural population at a single institution increased from 21.8 % to 64.4 % over two decades, with an average-risk CPM rate of 50.4 %. Those that undergo CPM are more likely to undergo reconstruction and have more wound infections. Identifying characteristics of patients undergoing CPM in a rural population and the increased associated risks allows for a better understanding of this trend to guide conversations with patients. Key message: This study demonstrates that the rate of contralateral prophylactic mastectomy for unilateral breast cancers performed at a single institution serving a largely rural population has nearly tripled over the last two decades, with half of these patients having no factors that increase the risk for developing contralateral breast cancers. Contralateral prophylactic mastectomy was significantly associated with smaller tumors, younger age, genetic testing, germline pathogenic variants, family history of breast cancer, breast reconstruction, and increased wound infections.

Overcoming Patient Pain Together: Breast Cancer Patients and Caregivers' Pretreatment Psychosocial Distress Linked to Patients' Pain Interference During the First Year of Treatment.

Breast cancer patients experience treatment-related pain from surgery, radiation, chemotherapy, and long-term hormonal treatment, which can lead to poorer outcomes. Patient and family caregivers' psychosocial distress exacerbates patient pain interference, but this has not been directly examined among breast cancer patients in dyadic models longitudinally. Guided by a biopsychosocial framework, the Biobehavioral Family Model, we explore how multiple reports of patient pain interference across the first year of treatment are linked to the patient (N = 55) and caregiver (N = 55) pretreatment psychosocial distress (eg, depression, anxiety, marital satisfaction, family relationship quality). Specifically, we find that breast cancer patients' pain interference increases and then decreases over the first year of treatment. Additionally, caregivers' pretreatment anxiety was associated with increased patient pain interference over time (B = .19, SE = .07, P = .008), while patients' pretreatment psychosocial distress was not associated with a change in their pain interference. Yet, looking at clinically specific times during the first year of treatment, we find that caregiver-reported higher marital satisfaction is associated with lower patient-reported pain interference later in treatment (6 months: B = -.58, SE = .24, P = .017; 12 months: B = -.82, SE = .23, P < .001). We conclude that, per the Biobehavioral Family Model, pretreatment patient and caregiver psychosocial distress is linked to patient pain interference during the first year of breast cancer treatment. Thus, caregivers' psychosocial distress (ie, anxiety and marital satisfaction) may be a particularly important target in future dyadic behavioral intervention strategies to reduce breast cancer patient pain. PERSPECTIVE: This article presents the link between breast cancer patients and family caregiver pretreatment psychosocial distress (anxiety, depression, marital satisfaction, and family quality) on patient pain interference during 1 year of breast cancer treatment. Findings suggest that caregiver anxiety and marital satisfaction may be important targets for future dyadic behavioral pain interventions.

The impact of rural structural and community health factors on postmastectomy complications among south central Appalachian breast cancer patients.

PURPOSE: The study examined how structural and community health factors, including primary care physicians (PCP), food insecurity, diabetes, and mortality rate per county, are linked to the number and severity of postmastectomy complications among south central Appalachian breast cancer patients depending on rural status. METHODS: Data was obtained through a retrospective review of 473 breast cancer patients that underwent a mastectomy from 2017 to 2021. Patient's ZIP Code was used to determine their rural-urban community area code and their county of residence for census data. We conducted a zero inflated Poisson regression. FINDINGS: Results demonstrated that patients in small rural/isolated areas with low (B = -4.10, SE = 1.93, OR = 0.02, p = 0.03) to average (B = -2.67, SE = 1.32, OR = 0.07, p = 0.04) food insecurity and average (B = -2.67, SE = 1.32, OR = 0.07, p = 0.04) to high (B = -10.62, SE = 4.71, OR = 0.00, p = 0.02) PCP have significantly fewer postmastectomy complications compared to their urban counterparts. Additionally, patients residing in small rural/isolated areas with high (B = 4.47, SE = 0.49, d = 0.42, p < 0.001) diabetes and low mortality (B = 5.70, SE = 0.58, d = 0.45, p < 0.001) rates have significantly more severe postmastectomy complications. CONCLUSION: These findings demonstrate that patients who reside in small/rural isolated areas may experience fewer and less severe postmastectomy when there is certain optimal structural and community health factors present compared to their urban counterparts. Oncologic care teams could utilize this information in routine consult for risk assessment and mitigation. Future research should further examine additional risks for postmastectomy complications.

Differences in Distress Between Rural and Non-rural Appalachian Breast Cancer Patient/Caregiver Dyads During the First Year of Treatment.

Introduction: Breast cancer patients and their caregivers living in rural Appalachia face substantial health disparities compared to their non-rural Appalachian counterparts. However, there is limited research on how these specific health disparities in rural Appalachian communities may impact patient psychological distress and caregiver strain during the first year of breast cancer treatment. Purpose: The purpose of the current study was to assess differences in patient psychological distress (depression and anxiety) and caregiver strain between rural non-rural Appalachian breast-cancer-affected dyads (patients and their caregivers) during the first year of treatment. Methods: A total of 48 Appalachian breast cancer patients (with a Stage I through Stage III diagnosis) and their identified caregiver (together, 'dyads') were identified from The University of Tennessee Medical Center across 2019 to 2020. Dyads completed follow-up surveys throughout the first year of treatment. In this prospective pilot study, measures on anxiety, depression and caregiver strain were self-reported and then analyzed using RM-ANOVA. Results: There was a statistically significant higher number of reports of patient depression and caregiver strain in rural-residing dyads compared to non-rural-residing dyads. However, there was not a statistically significant difference between rural and non-rural Appalachian dyads for patient-reported anxiety during the first year of treatment. Implications: The higher reported patient depression and caregiver strain among rural-residing Appalachian patients may indicate the need for implementing remote (e.g., telehealth) Cognitive Behavioral Therapy (CBT) to address the psychological needs of rural-residing dyads. Additionally, greater education from physicians to rural dyads on what to expect during treatment could alleviate caregiver strain.

The Impact of Prior Breast Augmentation on Breast Reconstruction after Mastectomy.

The risk of women developing breast cancer after augmentation mammaplasty may be lower than the general population, with minimal current literature on breast reconstruction in this population. We sought to evaluate the impact of previous augmentation on postmastectomy breast reconstruction. Methods: Retrospective review of patients who underwent mastectomies from 2017 to 2021 at our institution was performed. Analysis included frequencies and percentages, descriptive statistics, chi-square analysis, and Fisher exact test. Results: Four hundred seventy patients were included, with average body mass index of 29.1 kg/m2, 96% identifying as White, and an average age at diagnosis of 59.3 years. Twenty (4.2%) patients had a prior breast augmentation. Reconstruction was performed in 80% of the previously augmented patients compared to 49.9% of nonaugmented patients (P = 0.01). Reconstruction was alloplastic in 100% of augmented and 88.7% of nonaugmented patients (P = 0.15). All reconstructed augmented patients underwent immediate reconstruction compared with 90.5% of nonaugmented patients (P = 0.37), and two-stage reconstruction was most common (75.0% versus 63.5%; P = 0.42). Of the previously augmented patients, 87.5% increased implant volume, 75% underwent same implant plane reconstruction, and 68.75% underwent same implant-type reconstruction as their augmentation. Conclusions: Previously augmented patients were more likely to undergo reconstruction after mastectomy at our institution. All reconstructed augmented patients underwent alloplastic reconstruction, with most performed immediately in staged fashion. Most patients favored silicone implants and maintained the same implant type and plane of reconstruction, with increased implant volume. Larger studies are required to further investigate these trends.

I am feeling stressed, are you?: Breast cancer patients and caregivers' inter-psychophysiological symptoms during the first year of breast cancer treatment.

OBJECTIVE: Breast cancer treatment can be a stressful time for both the patient and their caregiver. Both patients and caregivers can experience increases psychophysiological distress (e.g., pain interference, fatigue, anxiety, depressive symptoms, perceived health); however, it is not clear how psychophysiological distress before treatment is linked to distress during the first year of treatment both interpersonally and intrapersonally. METHODS: The present study recruited 54 patient-caregiver dyads during diagnosis before breast cancer treatment started. Both patients and caregivers complete self-reported surveys at baseline (before treatment), then 6-weeks, 6-months, and 12-months after the start of treatment. Specifically, we examine trajectories of psychophysiological change using Actor-Partner Interdependence Models (APIMs) Growth Curve Models and clinically specific times of psychophysiological influence using APIM path analyses. RESULTS: Results indicate that patient and caregiver psychophysiological distress before treatment is linked to psychophysiological distress during the first year of treatment both intrapersonally and interpersonally but somewhat differently depending on the symptom. For example, for perceived health there are no interpersonal effects and for fatigue caregivers appear to experience the majority of psychophysiological distress effects. CONCLUSION: Our findings suggest that medical practitioners could evaluate patients and their caregivers for psychophysiological distress prior to breast cancer treatment and consider referrals to therapy or psychoeducation to help with symptom management throughout the first year of treatment.

The Development of Breast Cancer-Related Lymphedema After Mastectomy in a Rural Population.

Breast cancer-related lymphedema (BCRL) is a lifelong condition that can impact the quality of life, affecting approximately 20% of breast cancer patients. Risk factors for the development of BCRL after mastectomy in rural populations have not been studied.Retrospective review of mastectomy patients from 2017 to 2021 was performed at a single institution. Statistical analysis included logistic and linear regression models.475 patients were included, and 40 (8.4%) patients were diagnosed with BCRL. Increased odds of developing BCRL were significantly associated with tumor-involved lymph nodes, radiation therapy, axillary lymphadenectomy, adjuvant chemotherapy, and endocrine therapy. Postmastectomy reconstruction significantly reduced the odds of developing BCRL. There was no significant association in our population with age, body mass index, diabetes, tobacco use, cancer type, or complications.This study demonstrates that individuals underrepresented in the literature, such as patients in largely rural communities, have some differences in risk factors for developing BCRL when compared to national studies.

The Impact of Travel Distance and Income on Breast Reconstruction after Mastectomy in a Rural Population.

Factors that influence breast reconstruction after mastectomy have been previously examined in national databases. The purpose of this study was to determine the impact of patient travel distance and income on breast reconstruction after mastectomy in a rural population. Methods: Retrospective review of mastectomy patients from 2017 to 2021 was performed from our prospectively enrolled tumor registry. Analysis included frequencies and percentages, descriptive statistics, χ 2 analysis, independent sample t tests, and multivariable analysis. Results: In total, 462 patients were included. Median BMI was 27.6 kg/m2, 96.1% of patients were White, and median age at diagnosis was 60.0 years. Reconstruction rate was 52.6%, and median length of follow-up was 24.6 months. No significant difference was found in the distance traveled by patients who underwent reconstruction (16.6 versus 16.7 miles; P = 0.94). Rates of reconstruction in patients who traveled 0-10 miles, 11-30 miles, and over 30 miles did not differ significantly (P = 0.16). Median household income was significantly different in reconstructed and nonreconstructed patients ($55,316.00 versus $51,629.00; P = 0.047). Rates of reconstruction were significantly higher in patients with median household income greater than $65,000 (P = 0.024). This difference was not significant on multivariable analysis. Conclusions: Travel distance did not significantly impact reconstruction rates after mastectomy, while household income did on univariable analysis. Studies at an institutional or regional level remain valuable, especially in populations that may not be accurately represented in larger database studies. Our findings highlight the importance of patient education, resource allocation, and multidisciplinary approach to breast cancer care, especially in the rural setting.

Relationship quality and psychophysiological distress for underserved breast cancer patients and their caregiver before treatment.

OBJECTIVE: Breast cancer patients and caregivers experience biobehavioral reactivity (e.g., depression, anxiety, pain, fatigue) during breast cancer treatment which predicts cancer recurrence and mortality. High quality patient-caregiver relationships can mitigate this distress during treatment, but this association is unclear pre-treatment. Identifying early interventions that target high risk Appalachian patients could impact biobehavioral reactivity. METHODS: We recruited 55 breast cancer patient-caregiver dyads to complete a self-report survey after diagnosis but before treatment. We used a series of Actor-Partner Interdependence Models to test the hypotheses that both patient and caregiver relationship quality would be linked to their own and their partners' biobehavioral reactivity. RESULTS: Caregiver reported marital quality lower caregiver anxiety, patient anxiety, caregiver depression, patient depression, caregiver pain, and caregiver fatigue. Interestingly, patient-reported marital quality was linked with higher caregiver anxiety, higher patient anxiety, lower patient depression, and lower patient pain. Patients reported family quality was linked to lower patient and caregiver pain. CONCLUSIONS: This study demonstrates that pre-treatment marital and family quality levels are directly related to psychophysiological measures in both the caregiver and the patient, though sometimes in unexpected directions. Additionally, our findings potentially reveal an opportunity to intervene at the time of diagnosis to improve relationship quality, impacting patient and caregiver psychophysiological outcomes.

Economic disparities in Appalachia linked to risk factors for long-term health for estrogen positive breast cancer patients.

BACKGROUND: Breast cancer is the second leading cause of cancer death for women in the United States and mortality from cancer is more common among individuals in the Appalachian region compared to the rest of the country. We examined how risk factors for long-term health outcomes for Estrogen positive breast cancer patients differed by county economic status in southern Appalachia. METHODS: Data was collected through retrospective data mining of patient medical files (N = 238). Using the self-reported zipcode, patients were classified into county economic status. At-risk and distressed designations were also rural counties. Bi-variate statistical analyses were used to evaluate how demographic, behavioral, health risk factors differed across economic statuses. RESULTS: For demographic factors, fewer single individuals lived in at-risk counties and older individuals lived in distressed counties. For health behaviors, more individuals in transitional counties report drinking alcohol but more individuals in distressed counties reported adhering to medication. For morbidity, more individuals in distressed counties reported having diabetes or a circulatory disease. CONCLUSIONS: Many risk factors differed across county economic statuses. Therefore, doctors must consider the patient's context as a risk factor not just their individual characteristics. Patients from economically distressed counties may be at higher risk for treatment complications due to a larger proportion of co-morbidities and older age. Because many risk factors (eg, previous cancer, BMI) are similarly proportioned across Appalachian economic statuses, ER+ breast cancer patients in Appalachia may be at a similarly high risk for health complications compared to the rest of the country.

Immune status in very preterm neonates.

OBJECTIVES: Preterm neonates are at increased risk of sepsis compared with those born at term. We investigated immune status at birth and early neonatal life in very preterm neonates and its association with short-term outcomes. METHODS: Prospective observational study conducted at a university hospital recruiting 113 preterm neonates (23-32 weeks) and 78 controls. Monocyte major histocompatibility complex (MHC) class II expression, serum, and ex vivo lipopolysaccharide stimulated levels of six cytokines (tumor necrosis factor α, interleukin (IL)-1ß, IL-6, IL-8, IL-10, and IL-12p70) were measured in umbilical cord blood and over the first 7 days. The presence of neonatal sepsis and histologic chorioamnionitis was recorded. RESULTS: Prematurity (preterm labor and preterm premature rupture of membranes cohorts), neonatal sepsis, and histologic chorioamnionitis were associated with significant reduction in monocyte MHC class II expression. Neonates who had evidence of subsequent protracted sepsis had low levels of MHC class II expression at birth. Serial monocyte MHC class II expression revealed a fall by day 2, in all preterm neonates, with the degree being influenced by both prematurity and sepsis, and incomplete recovery by day 7, suggesting immunoparalysis in preterm premature rupture of membranes and preterm labor cohorts. Whole blood lipopolysaccharide stimulation assay showed significantly lower tumor necrosis factor α, values in preterm neonates who subsequently developed sepsis indicating a degree of immunoparalysis. CONCLUSIONS: Our data support the concept that fetal exposure to inflammation before preterm delivery leads to subsequent endotoxin hyporesponsiveness (immunoparalysis), which increases the risk of subsequent sepsis and associated organ dysfunction.

Monocyte major histocompatibility complex class II expression in term and preterm labor.

OBJECTIVE: To investigate how term and preterm labor (PTL) influence the balance between maternal proinflammatory and antiinflammatory responses as measured by expression of major histocompatibility complex (MHC) Class II on maternal monocytes and tumor necrosis factor-alpha (TNF-alpha) production by in vitro stimulation of whole blood by lipopolysaccharide (LPS). METHODS: Blood was taken from the following women (n=118): term elective cesarean delivery or in spontaneous labor, in premature labor, or with preterm premature rupture of the membranes (PROM) at less than 32 weeks, and gestation-matched reference group. Monocyte MHC Class II expression was measured by flow cytometry using a dual-staining technique. Plasma cytokine levels were assayed using a cytometric bead array system. In vitro whole blood stimulation with LPS was also performed, and cytokine production was measured. RESULTS: Term labor was associated with a fall in the percentage of monocytes expressing MHC Class II, compared with third trimester of pregnancy, P<.05 and a reduction in LPS-stimulated TNF-alpha production. This fall in MHC Class II was even more pronounced in PTL and preterm PROM groups compared with the reference group, P<.01. CONCLUSION: There was evidence of reduced expression of monocyte MHC Class II and LPS-stimulated TNF-alpha in term and preterm labor. This pattern of reduced MHC Class II expression and reduced TNF-alpha production is known as monocyte hyporesponsiveness or immune paresis. Detection of this state may provide insights into the maternal inflammatory status and be of use in the management of women with threatened PTL or preterm PROM. LEVEL OF EVIDENCE: II.

Female genital appearance: "normality" unfolds.

OBJECTIVE: To describe variations in genital dimensions of normal women. DESIGN: Observational cross-sectional study. SETTING: Elizabeth Garrett Anderson Hospital, University College Hospital NHS Trust, London, UK. POPULATION: Fifty premenopausal women having gynaecological procedures not involving the external genitalia under general anaesthetic. METHODS: A cross sectional study using digital photography and measurements of the external genitalia. MAIN OUTCOME MEASURES: Clitoral size, labial length and width, colour and rugosity, vaginal length, distance from clitoris to urethral orifice, distance from posterior fourchette to anterior anal margin. RESULTS: A wide range of values were noted for each measurement. There was no statistically significant association with age, parity, ethnicity, hormonal use or history of sexual activity. CONCLUSION: Women vary widely in genital dimensions. This information should be made available to women when considering surgical procedures on the genitals, decisions for which must be carefully considered between surgeon and woman.