Are There Disparities in Breast Reconstruction After Contralateral Prophylactic Mastectomy?

INTRODUCTION: Despite national guidelines against contralateral prophylactic mastectomy (CPM) in low- to moderate-risk breast cancer, CPM use continues to rise. Breast reconstruction improves health-related quality of life and satisfaction among women undergoing mastectomy. Given the lack of data regarding factors associated with reconstruction after CPM and the known benefits of reconstruction, we sought to investigate whether disparities exist in receipt of reconstruction after CPM. METHODS: The 2004-2017 National Cancer Database was queried to identify women diagnosed with breast cancer who underwent unilateral mastectomy with CPM. Patients were divided into two groups: those who underwent planned reconstruction at any timepoint and those who did not. A secondary analysis comparing types of reconstruction (tissue, implant, combined) was conducted. Patient, tumor, and demographic characteristics were analyzed using chi-square test and odds ratios were calculated using generalized estimating equations. RESULTS: The cohort included 1,73,249 women: 95,818 (55.3%) underwent reconstruction and 77,431 (45.7%) did not. Both the rate CPM and the proportion of women undergoing reconstruction after CPM increased between 2004 and 2017. Of the women who had reconstruction, 40,840 (51.7%) received implants, 29,807 (37.7%) had tissue, and 8352 (10.6%) had combined reconstruction. After adjusted analysis, factors associated with reconstruction were young age, Hispanic ethnicity, private insurance, and living in an area with the highest education and median income (P < 0.01). Patients who underwent reconstruction were less likely to have radiation (P < 0.01) and chemotherapy (P < 0.01), more likely to have stage I disease (P < 0.01), and to be treated at an integrated cancer center (P < 0.01). CONCLUSIONS: Reconstruction after CPM is disproportionately received by younger women, Hispanics, those with private insurance, and higher socioeconomic status and education. While the rate of reconstruction after CPM is increasing, there remain significant disparities. Conscious efforts must be made to eliminate these disparities, especially given the known benefits of reconstruction after mastectomy.

Menopausal hormone therapy use and risk of ovarian cancer by race: the ovarian cancer in women of African ancestry consortium.

BACKGROUND: Most studies examining post-menopausal menopausal hormone therapy (MHT) use and ovarian cancer risk have focused on White women and few have included Black women. METHODS: We evaluated MHT use and ovarian cancer risk in Black (n = 800 cases, 1783 controls) and White women (n = 2710 cases, 8556 controls), using data from the Ovarian Cancer in Women of African Ancestry consortium. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of MHT use with ovarian cancer risk, examining histotype, MHT type and duration of use. RESULTS: Long-term MHT use, ≥10 years, was associated with an increased ovarian cancer risk for White women (OR = 1.38, 95%CI: 1.22-1.57) and the association was consistent for Black women (OR = 1.20, 95%CI: 0.81-1.78, pinteraction = 0.4). For White women, the associations between long-term unopposed estrogen or estrogen plus progesterone use and ovarian cancer risk were similar; the increased risk associated with long-term MHT use was confined to high-grade serous and endometroid tumors. Based on smaller numbers for Black women, the increased ovarian cancer risk associated with long-term MHT use was apparent for unopposed estrogen use and was predominately confined to other epithelial histotypes. CONCLUSION: The association between long-term MHT use and ovarian cancer risk was consistent for Black and White women.

The State of Breast Cancer Reconstruction in Virginia: An Evidence-Based Framework for Identifying Locoregional Health Disparities.

BACKGROUND: Age, race, socioeconomic status, and proximity to plastic surgeons have been shown to impact receipt of reconstruction after mastectomy in several national studies. Given that targeted outreach efforts and programs to address these discrepancies would occur locoregionally, investigation of these reconstructive trends on a state level is warranted. STUDY DESIGN: Patients diagnosed with breast cancer in Virginia between 2000 and 2018 were identified in the Virginia Department of Health Cancer Registry. Patients who underwent mastectomy breast conservation surgery, and/or breast reconstruction at the time of oncologic surgery were identified. Patient demographics were analyzed, and logistic regression analyses were used to determine the likelihood of receipt of mastectomy, receipt of mastectomy versus breast conservation surgery, receipt of mastectomy with reconstruction versus mastectomy alone, and receipt of mastectomy with reconstruction versus breast conservation surgery with respect to the demographic variables. Geographically weighted regression analyses were also performed to determine impact of geographic location on receipt of mastectomy and reconstruction after mastectomy. RESULTS: A total of 78,682 patients in Virginia underwent surgical treatment for breast cancer between 2000 and 2018. Living outside a metropolitan area, increased age, lower socioeconomic status, non-White race, and lower number of plastic surgeons within 50 miles were associated with decreased rates of postmastectomy reconstruction. Rural setting, lower socioeconomic status, and lower plastic surgeon supply were also associated with decreased rates of breast conservation surgery. Reconstruction after mastectomy was lowest in the northwest, central, and southwest regions of Virginia. CONCLUSIONS: Within the state of Virginia, programs to improve access to breast reconstruction for patients residing in rural regions, as well as non-White patients, older patients, and those in lower socioeconomic groups should be implemented. Future studies would implement and study the efficacy of such outreach programs, which could then be applied and tailored to other states or regions to address sociodemographic disparities in access to breast reconstruction.

Effects of Adjuvant Endocrine Therapy Adherence and Radiation on Recurrence and Survival Among Older Women with Early-Stage Breast Cancer.

BACKGROUND: The Cancer and Leukemia Group-B 9343 (CALGB 9343) trial demonstrated that women aged ≥ 70 years with early-stage breast cancer can safely omit radiation therapy (RT) and be treated with breast-conserving surgery (BCS) and adjuvant endocrine therapy (AET) alone. AET adherence is low, leaving an undertreated cohort who may be at increased risk of recurrence and death. We hypothesized that AET adherence and adjuvant treatment choice impact recurrence and survival among CALGB 9343 eligible women. PATIENTS AND METHODS: SEER-Medicare was used to identify CALGB 9343 eligible women who underwent BCS between 2007 and 2016. Medicare claims were used to identify AET use, and the proportion of days covered by AET was used to categorize adherent (PDC ≥ 0.80) versus nonadherent patients (PDC < 0.80). Recurrence-free, cancer-specific, and overall survival were assessed using Cox proportional hazards models. RESULTS: In total, 10,719 women were identified, of whom 780 (7.3%) underwent BCS alone, 1490 (13.9%) underwent BCS + RT, 1663 (15.5%) underwent BCS + AET, and 6786 (63.3%) had BCS + RT + AET. Among women treated with BCS + AET, adherent patients had lower recurrence than did nonadherent patients (HR = 0.65, 95% CI: 0.50-0.85). With respect to adjuvant treatment combinations, there was no recurrence difference between the BCS + RT + AET group and BCS + AET group (HR = 0.81, 95% CI: 0.54-1.21). There was equivalent cancer-specific but worse overall survival in the BCS + AET group versus the BCS + AET + RT group. CONCLUSIONS: While BCS + RT + AET may represent overtreatment for some, AET nonadherent women who omit RT are at risk for worse outcomes. Treatment decisions regarding RT omission should be tailored to the individual patient, taking into consideration the chances of AET nonadherence and the patients' own risk tolerance.

Predicting adjuvant endocrine therapy initiation and adherence among older women with early-stage breast cancer.

PURPOSE: The CALGB 9343 trial demonstrated that women age 70 or older with early-stage, estrogen receptor positive (ER +) breast cancer (BC) may safely forgo radiation therapy (RT) and be treated with breast conserving surgery followed by adjuvant endocrine therapy (AET) alone. However, most patients in this population still undergo RT in part because AET adherence is low. We sought to develop a predictive model for AET initiation and adherence in order to improve decision-making with respect to RT omission. METHODS: Women ages 70 and older with early-stage, ER + BC were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Comorbidities, socioeconomic measures, prescription medications, and demographics were collected as potential predictors. Bivariate analysis was performed to identify factors associated with AET initiation and adherence. Stepwise selection of significant predictors was used to develop logistic regression classifiers for initiation and adherence. Model performance was evaluated using the c-statistic and other measures. RESULTS: 11,037 patients met inclusion criteria. Within the cohort, 8703 (78.9%) patients initiated AET and 6685 (60.6%) were adherent to AET over 1 year. Bivariate predictors of AET initiation were similar to predictors of adherence. The best AET initiation and adherence classifiers were poorly predictive with c-statistics of 0.65 and 0.60, respectively. CONCLUSIONS: The best models in the present study were poorly predictive, demonstrating that the reasons for initiation and adherence to AET are complex and individual to the patient, and therefore difficult to predict. Initiation and adherence to AET are important factors in decision-making regarding whether or not to forgo adjuvant RT. In order to better formulate treatment plans for this population, future work should focus on improving individual prediction of AET initiation and adherence.

An Interregional, Transdisciplinary and Good Practice-Based Approach for Frailty: the Mind&Gait Project.

Social facilities such residential structures and day-centres increasingly seek integrated, structured, adapted, creative, dynamic and economic strategies to prevent frailty. The arising need of an aged and frail population requires innovative interventions and products to prevent cognitive and physical decline. The interregional MIND&GAIT project aims to promote independent living in frail older adults by improving cognition and gait ability by using assistive products. This transdisciplinary strategy within a 24-months period expects as project' deliverables: i) a structured and good practice-based combined intervention (CI) consisting of a cognitive stimulation programme and a physical exercise programme; ii) an auto-blocking mechanism for rolling walkers with biofeedback acquisition (ABMRW); iii) a randomized clinical trial to assess CI' effectiveness; and iv) a web-platform to be used as a repository that will support and disseminate the intervention materials, covering the action-line of translational research. Positive benefits are expected in prevention and maintenance of frail older adults' capacities. Preliminary results showed positive effects on the improvement of cognitive and physical functions, functionality and depressive symptomatology. The interregional geographical coverage induced by MIND&GAIT underlines the potential replicability of the project extension to the community in the Centro and Alentejo regions of Portugal. MIND&GAIT network supports actions and provides learning opportunities and emergence of locally-embedded support systems towards social innovation for older adults.

Methodology to assess quality of estimated disturbances in active disturbance rejection control structure for mechanical system.

A methodology to assess the quality of estimation of disturbances in mechanical systems, by state observers, in the control structure with active compensation of disturbances (ADRC) is presented. Evaluation is carried out by four performance indices that depend on the steady-state error between reference signals and output of the plant. These indices are related with the accuracy and precision of the closed loop system in the sense of norms L2 and L∞, for a set of reference signals representing the typical operating conditions of the mechanism. The effectiveness of the methodology is illustrated with the quality assessment of the estimated disturbance of five state observers to control of a simple pendulum and validated on a SCARA robot arm.

The dynamics of disability and functional change in an elderly cohort: results from the Alameda County Study.

OBJECTIVE: To examine changes in functional status over time by age, gender, and ethnicity in a representative sample of older persons. DESIGN: Six-year prospective cohort study. SETTING: Alameda County, California. PARTICIPANTS: 508 persons 65 years old and older at baseline in 1984. MAIN OUTCOME MEASURES: Activities of daily living (ADL) dependence, mobility impairment, and functioning on an 18-item scale. RESULTS: The prevalence of ADL dependence and mobility impairment at baseline increased with age, while function decreased. Particularly striking differences occurred for those 80 and older. Changes in function over the 6-year follow-up showed a similar pattern. While death rates for males were higher, females had poorer initial functioning, and surviving females declined more than surviving males. The incidence of ADL dependence and mobility impairment during follow-up was similar for males and females, although females survived longer with incident disability than did males. Blacks had poorer baseline functioning, more ADL dependence and mobility impairment, and declined more than non-Blacks during follow-up. Some of the baseline difference in function between Blacks and non-Blacks was due to higher rates of chronic illness and co-morbidity. In spite of the general downward trend in functioning over the 6 years, 13% of the males and 20% of the females improved. CONCLUSION: Age-related changes in function for older persons are complex and result in much heterogeneity. Clarifying the reasons for such heterogeneity is an important and challenging area of research.

Psychological distress and mortality: evidence from the Alameda County Study.

The relationship between psychological distress, in this case depression, and subsequent risk of mortality is examined using data from the Alameda County (California) Study, an 18-yr, three-wave prospective investigation of psychosocial risk factors and health. The results indicate no relationship between psychological morbidity and all-cause mortality or specific causes of death. While these results are discordant with those reported from a majority of studies of psychiatric patients, they are concordant with a majority of community-based studies of the general adult population. Possible methodologic explanations are discussed which might account for disparate results reported to date, in particular failure to control for the effects of co-morbidity of somatic disorders and socioeconomic status.

Gender differences in factors associated with change in physical functioning in old age: a 6-year longitudinal study.

We compared 356 older men and women and found that income, education, and marital status had significantly stronger associations with 6-year change in functioning for men; internal health locus of control was stronger for women. Large but not significant differences occurred for age, perceived health, and days going out per week (stronger for women) plus exercise and smoking (stronger for men). We found no difference for ethnicity, chronic conditions, and social contacts. Gender specific models incorporating factors amenable to change predicted significantly higher follow-up functioning for those with positive health behaviors, supporting the value of preventive interventions.

Factors associated with multiple sex partners among junior high school students.

Twenty-one percent of a sample of inner-city junior high school students were found to be sexually active (n = 403). Only 31% of them reported a single lifetime sexual partner, 25% reported two partners, and 43% reported three or more partners. Logistic regression analysis evaluated the influence of demographic, psychosocial, and behavioral factors on the adolescents' lifetime number of sex partners. Respondents whose sexual debut occurred before age 13 years were nine times more likely to report three or more sex partners compared with those whose first sexual intercourse was at age 15 or 16 years, blacks were four times more likely than non-Hispanic whites to report three or more sex partners; and males were four times as likely as females to report this number of sexual partners. Factors not independently associated with the number of sex partners included: age, Asian or Hispanic ethnicity, human immunodeficiency virus (HIV) knowledge, self-efficacy (belief that one can protect oneself from the virus), condom use, and alcohol and drug use. We conclude that a significant proportion of school-based middle adolescents are sexually active and that most of these are at risk for contracting HIV because of behaviors such as having multiple sexual partners. Topics often stressed in school-based HIV education, such as factual knowledge about HIV, avoiding drugs and alcohol, and condom use are not associated with adolescents' choice about their number of sex partners. Intervention programs will have to identify and then target each specific HIV risk behavior and its motivations in order to reduce adolescents' risks of contracting and transmitting the disease.

Insensible water loss during extracorporeal membrane oxygenation: an in vitro study.

To measure insensible fluid loss from silicone membrane oxygenators during extracorporeal membrane oxygenation (ECMO), an in vitro system was used. A standard neonatal ECMO circuit (Avecor) was connected to a noncompliant reservoir, which was then primed with normal saline. The experiment was conducted by using two silicone oxygenators (Avecor 0.4 and 0.8 m2), three gas flow rates (0.5, 1.0, and 2.0 L/min) (sweep), and two fluid flow rates (200 and 400 ml/min). Two methods were used to measure the water loss. One method was to replace the water to the noncompliant circuit by using a calibrated burette, and the other method was to collect condensed water after cooling the postmembrane sweep gas to 0 degrees C. The influence of the amount of sweep, fluid flow rate, size of membrane, and inlet and outlet sweep gas temperatures on measured water loss was statistically determined. The amount of water loss correlated with sweep (r2 = 0.81; p<0.00001) but was not related to the fluid flow rate, membrane size, or inlet and outlet sweep gas temperature. The average daily fluid loss measured with replacement and collection methods for each liter of sweep per minute were 72.0+/-12.6 and 62.3+/-10.0 ml, respectively. This information may be applied to clinical practice to accurately manage fluid balance in the sick neonate on ECMO.

Bilateral removal of the cauda epididymides in the neonatal pig as a technique for creating teaser boars.

Five pairs of crossbred littermate boars were used to assess the efficacy of bilateral removal of the cauda epididymides at an early age as a technique for creating teaser boars. The cauda epididymides were surgically removed in one of each litter pair; the other of the pair served as an intact control. Boars subjected to removal of the epididymides (Epid) were rendered sterile by the technique. The Epid-treated and control untreated littermate boars had similar levels of sexual aggression and libido, as measured by behavioral characteristics at semen collection. The Epid-treated boars showed a slight, but not significant, reduction in ejaculate volume. Upon slaughter at 273 d of age, Epid and control boars had similar weights for the accessory sexual organs and penis and similar penile lengths. The Epid-treated boars displayed enlarged caput epididymides and granulomata. It is suggested that bilateral removal of the cauda epididymides in the neonatal pig may prove a worthwhile alternative to the traditional vasectomy procedure to create teaser boars.

Living in fast-flowing water: morphology of the gastromyzophorous tadpole of the bufonid Rhinella quechua (R. veraguensis group).

We describe the bufonid gastromyzophorous tadpoles of Rhinella quechua from montane forest streams in Bolivia. Specimens were cleared and stained, and the external morphology, buccopharyngeal structures, and the musculoskeletal system were studied. These tadpoles show a combination of some traits common in Rhinella larvae (e.g., emarginate oral disc with large ventral gap in the marginal papillae, labial tooth row formula 2/3, prenarial ridge, two infralabial papillae, quadratoorbital commissure present, larval otic process absent, mm. mandibulolabialis superior, interhyoideus posterior, and diaphragmatopraecordialis absent, m. subarcualis rectus I composed of three slips), some traits apparently exclusive for the described species of the R. veraguensis group (e.g., second anterior labial tooth row complete, lingual papillae absent, adrostral cartilages present), and some traits that are shared with other gastromyzophorous tadpoles (e.g., enlarged oral disc, short and wide articular process of the palatoquadrate, several muscles inserting on the abdominal sucker). In the context of the substantial taxonomic and nomenclatural changes that the former genus Bufo has undergone, and despite the conspicuous morphological differences related to the presence of an abdominal sucker, the larval morphology of R. quechua supports including it in the genus Rhinella and placing it close to species of the R. veraguensis assemblage.

Effect of triploidy on turbot haematology.

This study was carried out to compare key haematological features of diploid (2n) and triploid (3n) turbot as a first step towards the assessment of the ability of 3n turbot to withstand sub-optimal culture conditions. Morphometric indices of erythrocytes were determined on blood smears by light microscopy. Triploidy significantly (P<0.001) increased all morphometric indices measured in the erythrocytes, including size, surface, and volume, except for the size of minor nuclear axis. The increase in cell size was larger for the major (31.0%) than for the minor (8.3%) axis, thus rendering erythrocytes of 3n turbot more ellipsoidal. The increase in erythrocyte volume (45.9%) was close to the theoretical expected 50% increase as a result of one extra chromosome set. Haematological indices were measured automatically by a haematological Coulter Counter. Triploid turbot had lower numbers of red blood cells (RBC: 1.84 cells pL(-1) in 2n vs. 1.27 cells pL(-1) in 3n; P<0.001) but they were of a larger size (Mean corpuscular volume [MCV]: 145.51 fL in 2n vs. 181.78 fL in 3n; P<0.001). However, the decrease in RBC was not compensated by the increase in MCV, and thus, triploidy decreased the haematocrit (Hct: 26.80% in 2n vs. 23.11% in 3n; P<0.001) and total blood haemoglobin concentration (Hb: 73.74 g l(-1) in 2n vs. 67.54 g l(-1) in 3n; P<0.05). In contrast, mean corpuscular hemoglobin (MCH: 40.27 pg in 2n vs. 53.28 pg in 3n; P<0.001) was higher for 3n turbot as a result of their larger erythrocytes although MCH concentration (MCHC: 0.28 pg fL(-1) in 2n vs. 0.29 pg fL(-1) in 3n did not significantly differ. RBC, Hct and MCV were also determined manually using light microscopy. In general, discrepancies between the two methods were small (overall approximately 7%) but the Coulter Counter tended to overestimate RBC and Hct (and thus to underestimate MCV). Nevertheless, relative differences between ploidies were very similar, thus verifying triploidy-associated changes in hematological features. These changes, as determined in the present study, are essential when evaluating the feasibility of triploid turbot for intensive aquaculture systems in which unfavorable situations may occur.

Perceived health and mortality: a nine-year follow-up of the human population laboratory cohort.

The association between perceived health ratings ("excellent," "good," "fair," and "poor") and mortality was assessed using the 1965 Human Population Laboratory survey of a random sample of 6928 adults in Alameda County, California, and a subsequent nine-year follow-up. Risk of death during this period was significantly associated with perceived health rating in 1965. The age-adjusted relative risk for mortality from all causes for those who perceived their health as poor as compared to excellent was 2.33 for men and 5.10 for women. The association between level of perceived health and mortality persisted in multiple logistic analyses with controls for age, sex, 1965 physical health status, health practices, social network participation, income, education, health relative to age peers, anomy, morale, depression, and happiness.

Alcohol consumption and mortality in Alameda County.

The association between level of alcohol consumption and 15-year mortality, focusing particularly on the possible protective effect of light drinking compared to abstention, was studied in a representative population sample of 6928 residents of Alameda County, California. Because abstainers differ from light, moderate and heavy drinkers on a number of demographic, physical, and psychosocial characteristics, the role of these as confounders of the alcohol/mortality association was examined. Using multiple logistic models, the mortality experience of abstainers, moderate drinkers, heavy drinkers and very heavy drinkers was compared with that of light drinkers. Among men only, very heavy drinkers were at significantly greater risk of death from all causes than were light drinkers (OR = 2.5, p less than 0.01). Neither abstainers nor other drinkers were at significantly higher risk of death from ischemic heart disease than were light drinkers. This pattern of results persisted with adjustment for 11 covariates of alcohol consumption in addition to age.

Poverty and health. Prospective evidence from the Alameda County Study.

To examine the reasons for the association between socioeconomic status and poor health, the authors examined the nine-year mortality experience of a random sample of residents aged 35 and over in Oakland, California. Residents of a federally designated poverty area experienced higher age-, race-, and sex-adjusted mortality over the follow-up period compared with residents of nonpoverty areas (relative risk = 1.71, 95 per cent confidence interval 1.20-2.44). This increased risk of death persisted when there was multivariate adjustment for baseline health status, race, income, employment status, access to medical care, health insurance coverage, smoking, alcohol consumption, physical activity, body mass index, sleep patterns, social isolation, marital status, depression, and personal uncertainty. These results support the hypothesis that properties of the sociophysical environment may be important contributors to the association between low socioeconomic status and excess mortality, and that this contribution is independent of individual behaviors.

Patterns of vitamin C intake from food and supplements: survey of an adult population in Alameda County, California.

Use of vitamin C in food and pills and its association with health habits and health status were investigated in a random sample of 3,119 adults in Alameda County, California. Vitamin C intakes of nearly 80 per cent of respondents met or exceeded Recommended Daily Dietary Allowances. Fourteen per cent or fewer appeared to have inadequate vitamin C intake. Vitamin C supplements were taken daily by 29 per cent, occasionally by 21 per cent. Most respondents obtained 100 mg or less of vitamin C daily; 2 per cent had more than 2000 mg. Proportionately, more women than men took vitamin C pills daily. Men aged 16 to 44 were the most likely to have neither vitamin C foods nor pills. Persons 45 years and older tended to take vitamin C pills daily, younger persons to take them occasionally. Respondents who did not eat breakfast or who smoked cigarettes had lower vitamin C intakes. People in poor health took more vitamin C than those in good health. Health status may have influenced vitamin C intake rather than vitamin C intake influencing health status.