Impact of the Breast Cancer Index for Extended Endocrine Decision-Making: First Results of the Prospective BCI Registry Study.

BACKGROUND: The Breast Cancer Index (BCI) test assay provides an individualized risk of late distant recurrence (5-10 years) and predicts the likelihood of benefitting from extended endocrine therapy (EET) in hormone receptor-positive early-stage breast cancer. This analysis aimed to assess the impact of BCI on EET decision-making in current clinical practice. METHODS: The BCI Registry study evaluates long-term outcomes, decision impact, and medication adherence in patients receiving BCI testing as part of routine clinical care. Physicians and patients completed pre-BCI and post-BCI test questionnaires to assess a range of questions, including physician decision-making and confidence regarding EET; patient preferences and concerns about the cost, side effects, drug safety, and benefit of EET; and patient satisfaction regarding treatment recommendations. Pre-BCI and post-BCI test responses were compared using McNemar's test and Wilcoxon signed rank test. RESULTS: Pre-BCI and post-BCI questionnaires were completed for 843 physicians and 823 patients. The mean age at enrollment was 65 years, and 88.4% of patients were postmenopausal. Of the tumors, 74.7% were T1, 53.4% were grade 2, 76.0% were N0, and 13.8% were HER2-positive. Following BCI testing, physicians changed EET recommendations in 40.1% of patients (P<.0001), and 45.1% of patients changed their preferences for EET (P<.0001). In addition, 38.8% of physicians felt more confident in their recommendation (P<.0001), and 41.4% of patients felt more comfortable with their EET decision (P<.0001). Compared with baseline, significantly more patients were less concerned about the cost (20.9%; P<.0001), drug safety (25.4%; P=.0014), and benefit of EET (29.3%; P=.0002). CONCLUSIONS: This analysis in a large patient cohort of the BCI Registry confirms and extends previous findings on the significant decision-making impact of BCI on EET. Incorporating BCI into clinical practice resulted in changes in physician recommendations, increased physician confidence, improved patient satisfaction, and reduced patient concerns regarding the cost, drug safety, and benefit of EET.

Ancillary Treatment Referrals and Visits After Breast Cancer Surgery in a Sociodemographically Diverse Population.

BACKGROUND: Ancillary therapies with rehabilitative, palliative, and survivorship specialists mitigate adverse effects of breast cancer surgery. Existing data suggest that patients from disadvantaged backgrounds may be less likely to receive these services. This study aimed to assess variations in ancillary provider referrals and patient visits at a high-volume urban cancer center. METHODS: Electronic health records of breast cancer surgical patients at the Yale-New Haven Health System between 2010 and 2017 were reviewed. The primary end points were postoperative referral to ancillary service providers and patient use of ancillary services (defined as attending ≥ 1 consultation). Associations between end points and demographic/disease variables were identified in uni- and multivariable logistic regression analyses. RESULTS: The study identified 5496 patients: 2288 patients (41.6%) referred to ancillary services and 1572 patients (28.6%) who attended one or more consultations. Referrals were highest among the patients with Hispanic (57.5%) or black (54.9%) ancestry, no health insurance (57.6%), lowest percentage of high school degrees for the zip code area (50.5%), and poorest median income bracket (50.7%). Associations remained significant in the multivariable analysis (p < 0.05). Minority race remained associated with referrals in analyses of each ancillary service individually. Visits to ancillary specialists were greatest among the patients with private insurance (70.7%), highest percentage of high school degrees (72.8%), highest median household income (72.2%), and Hispanic ethnicity (73.5%). Highest median household income (odds ratio [OR] 1.45; p = 0.02) and Hispanic ethnicity (OR, 1.50; p = 0.05) remained associated in the multivariable analysis. CONCLUSIONS: In a well-resourced health system serving a demographically diverse population, traditional markers of poor health care access were associated with referral for ancillary treatment after breast cancer surgery but not with utilization of ancillary treatment. Health care access remains a critical barrier to adjunctive therapies that target postoperative morbidity and elevate quality of life.

Delivery of Cancer Survivorship Education to Community Healthcare Professionals.

Our pilot study aimed to evaluate the needs of community oncology providers with regard to cancer survivorship education, develop a survivorship curriculum based on the needs assessment, and evaluate the acceptability of the Project ECHO® (Extension for Community Healthcare Outcomes) model for delivery of the survivorship curriculum. A needs assessment was delivered to participants in suburban community cancer practices, and a curriculum was developed based on the results. Participants were enrolled in an ECHO curriculum consisting of 6 sessions from October to December 2019. Participants included registered nurses (RN), registered dietitians (RD), clinical social workers (LCSW), advanced practice providers (APP), radiation oncologists, and medical oncologists (MD). Participants were invited to participate in exit interviews designed to better evaluate the participant experience. Ninety percent of needs assessment participants (n = 37) expressed an interest in cancer survivorship education. Eight participants from 3 community practices in suburban Connecticut enrolled in the ECHO curriculum. Four participants (50%) agreed to participate in exit interviews. Five themes emerged from the exit interviews: interest in survivorship, time, positive experience, empowerment, and community. Our Survivorship ECHO pilot demonstrated the acceptability of the Project ECHO® model for delivering cancer survivorship education to oncology providers. Further research confirming the feasibility of this model in additional oncology provider settings is needed.

Musculoskeletal Effects of Antineoplastic Agents.

Cancer remains a common disease with approximately 40% of Americans diagnosed with cancer in their lifetime. Medical advances in the field of oncology have led to an increased life expectancy and a decreased mortality rate. Antineoplastic agents such as taxanes and targeted therapies are indicated in the treatment of many cancers, and their use can be associated with various musculoskeletal complaints and adverse effects. Orthopaedic Surgeons are trained to identify primary bone tumors and metastasis to bones. It is also important for them to have an understanding of the profile of musculoskeletal adverse effects associated with the treatment of the more common neoplasms. This article reviews the current literature on the commonly used chemotherapeutic agents and their associated musculoskeletal effects.

Impacts of Early Guideline-Directed 21-Gene Recurrence Score Testing on Adjuvant Therapy Decision Making.

PURPOSE: The 21-gene recurrence score (RS) assay is used to help formulate adjuvant chemotherapy recommendations for patients with estrogen receptor-positive, early-stage breast cancer. Most frequently, medical oncologists order RS after surgery. Results take an additional 2 weeks to return, which can delay decision making. We conducted a prospective quality-improvement project to assess the impact of early guideline-directed RS ordering by surgeons before the first visit with a medical oncologist on adjuvant therapy decision making. MATERIALS AND METHODS: Surgical oncologists ordered RS testing following National Comprehensive Cancer Network guidelines at time of diagnosis or at time of surgery between July 1, 2015 and December 31, 2015. We measured the testing rate of patients eligible for RS, time to chemotherapy decisions, rates of chemotherapy use, accrual to RS-based clinical trials, cost, and physician acceptance of the policy and compared the results to patients who met eligibility criteria for early guideline-directed testing during the 6 months before the project. RESULTS: Ninety patients met eligibility criteria during the testing period. RS was ordered for 91% of patients in the early testing group compared with 76% of historical controls ( P < .001). Median time to chemotherapy decision was significantly shorter in the early testing group (20 days; 95% CI, 17 to 23 days) compared with historical controls (32 days; 95% CI, 29 to 35 days; P < .001). There were no significant differences in time to chemotherapy initiation, chemotherapy use, RS-based trial enrollment, or calculated costs between the groups. CONCLUSION: Early guideline-directed RS testing in selected patients is an effective way to shorten time to treatment decisions.

Patient preferences regarding incidental genomic findings discovered during tumor profiling.

BACKGROUND: During the process of tumor profiling, there is the potential to detect germline variants. To the authors' knowledge, there currently is no accepted standard of care for how to deal with these incidental findings. The goal of the current study was to assess disclosure preferences among patients with cancer regarding incidental genomic variants that may be discovered during tumor profiling. METHODS: A 45-item questionnaire was administered to 413 patients in ambulatory oncology clinics. The survey captured demographic and disease variables and personal and family history, and presented case scenarios for different types of incidental germline variants that could theoretically be detected during genomic analysis of a patient's tumor. RESULTS: The possibility of discovering non-cancer-related, germline variants did not deter patients from tumor profiling: 77% wanted to be informed concerning variants that could increase their risk of a serious but preventable illness, 56% wanted to know about variants that cause a serious but unpreventable illness, and 49% wanted to know about variants of uncertain significance. The majority of patients (75%) indicated they would share hereditary information regarding predisposition to preventable diseases with family and 62% would share information concerning unpreventable diseases. The most frequent concerns about incidental findings were ability to obtain health (48%) or life (41%) insurance. Only 21% of patients were concerned about privacy of information. CONCLUSIONS: Patients with cancer appear to prefer to receive information regarding incidental germline variants, but there is substantial variability with regard to what information patients wish to learn. The authors recommend that personal preferences for the disclosure of different types of incidental findings be clarified before a tumor profiling test is ordered. Cancer 2016;122:1588-97. © 2016 American Cancer Society.

Weight Gain After Breast Cancer Diagnosis and All-Cause Mortality: Systematic Review and Meta-Analysis.

BACKGROUND: Overweight and obesity are associated with breast cancer mortality. However, the relationship between postdiagnosis weight gain and mortality is unclear. We conducted a systematic review and meta-analysis of weight gain after breast cancer diagnosis and breast cancer-specific, all-cause mortality and recurrence outcomes. METHODS: Electronic databases identified articles up through December 2014, including: PubMed (1966-present), EMBASE (1974-present), CINAHL (1982-present), and Web of Science. Language and publication status were unrestricted. Cohort studies and clinical trials measuring weight change after diagnosis and all-cause/breast cancer-specific mortality or recurrence were considered. Participants were women age 18 years or older with stage I-IIIC breast cancer. Fixed effects analysis summarized the association between weight gain (≥5.0% body weight) and all-cause mortality; all tests were two-sided. RESULTS: Twelve studies (n = 23 832) were included. Weight gain (≥5.0%) compared with maintenance (<±5.0%) was associated with increased all-cause mortality (hazard ratio [HR] = 1.12, 95% confidence interval [CI] = 1.03 to 1.22, P = .01, I(2) = 55.0%). Higher risk of mortality was apparent for weight gain ≥10.0% (HR = 1.23, 95% CI = 1.09 to 1.39, P < .001); 5% to 10.0% weight gain was not associated with all-cause mortality (P = .40). The association was not statistically significant for those with a prediagnosis body mass index (BMI) of less than 25 kg/m(2) (HR = 1.14, 95% CI = 0.99 to 1.31, P = .07) or with a BMI of 25 kg/m(2) or higher (HR = 1.00, 95% CI = 0.86 to 1.16, P = .19). Weight gain of 10.0% or more was not associated with hazard of breast cancer-specific mortality (HR = 1.17, 95% CI = 1.00 to 1.38, P = .05). CONCLUSIONS: Weight gain after diagnosis of breast cancer is associated with higher all-cause mortality rates compared with maintaining body weight. Adverse effects are greater for weight gains of 10.0% or higher.

Use of neoadjuvant chemotherapy for patients with stage I to III breast cancer in the United States.

BACKGROUND: Neoadjuvant chemotherapy (NAC) is the standard of care for patients with locally advanced breast cancer and can yield clinical advantages in individuals with lower stage cancers as well. To the authors' knowledge, the extent and patterns of use of NAC remain unknown. The objective of the current study was to assess temporal trends in NAC use and to examine what clinical, demographic, and treatment site characteristics influence its use. METHODS: Data from the National Cancer Data Base regarding 395,486 patients with stage I to stage III breast cancer who received adjuvant or neoadjuvant chemotherapy in the United States from 2003 through 2011 were analyzed. Chi-square tests and logistic regression analyses were used to assess the association between NAC use and patient, tumor, and facility characteristics. RESULTS: Overall, 17.4% of patients received NAC, including 4% of patients with stage I disease, 17.8% of patients with stage II disease, and 41.6% of patients with stage III disease. NAC use increased over time from 12.2% to 24.0%, particularly among patients with more advanced cancers. Rates increased from 12.9% to 39.3% in patients with stage IIIA, from 72.3% to 86.4% in patients with stage IIIB, and from 30.1% to 59.3% in patients with stage IIIC cancers. On multivariate analysis, patients aged <60 years, African American individuals, and those treated in academic centers were more likely to receive NAC. NAC use also varied by geographic region and was the highest in the West South Central region (21%) and lowest in the Midwest (15.2%). CONCLUSIONS: Although NAC use increased between 2003 and 2011, <50% of all patients with stage III breast cancer were treated with NAC. Substantial regional and practice-related variations exist.

Systematic approach to providing breast cancer survivors with survivorship care plans: a feasibility study.

PURPOSE: This was a feasibility study with the primary purpose to identify women with a diagnosis of breast cancer for survivorship care plan (SCP) delivery at the postoperative visit and deliver an SCP after treatment. The secondary purpose was to determine if patients' knowledge about their diagnosis, treatment, and risk for future adverse events improved with the SCP. METHODS: Sixty-seven English-speaking women older than age 18 years with stage I-III breast cancer were enrolled at their postoperative appointment. The participants' treatment was tracked through the electronic medical record; SCPs were generated based on information abstracted from the records. After treatment completion, participants received an SCP during a routine follow-up appointment. Knowledge of tumor, treatments, adverse events, and screening recommendations were assessed before receiving the SCP and 2 months later. Accuracy at baseline and follow-up were compared using the McNemar test. RESULTS: One hundred twenty-nine visits were screened to identify 75 eligible participants. Seventy-five eligible participants (100%) agreed to enroll, and 71 (95%) were given an SCP. Participants were more accurate in reporting details about their history, screening recommendations, and potential adverse events at follow-up than they were at baseline for most measures, but the only statistically significant changes were found with stage (P = .0016) and increased risk of leukemia (P = .0348). CONCLUSION: It is feasible to identify and deliver SCPs to women with breast cancer who are approached during the postoperative visit in a surgical clinic. Additionally, SCPs seem to improve patient knowledge in several areas.

Palliative care across the continuum of cancer care.

Optimal oncology care requires the integration of palliative medicine into oncology care across the disease trajectory. All patients require screening for palliative care services at the initial oncologic visit and reassessment throughout the continuum of care. As a result of the increasing attention focused on palliative care nationally and internationally, the domains of palliative cancer care have been elucidated and have fostered the development of guidelines for quality palliative care. The recent recognition of palliative medicine as a subspecialty in the United States, the growing number of hospital-based palliative care programs, and the accreditation of palliative medicine fellowship programs by the Accreditation Council for Graduate Medical Education highlight the increased visibility of palliative medicine. This provides hope for the future of oncologic care. The palliative approach is subsumed in cancer care--it provides assistance with decision-making, symptom management, and access to financial, emotional, and spiritual services. A fully integrated program of oncology and palliative care provides the greatest opportunity for care and cure.

Functional recovery after hip fracture: the combined effects of depressive symptoms, cognitive impairment, and delirium.

OBJECTIVES: To measure the prevalence of depressive symptoms, cognitive impairment, and delirium in patients with hip fracture and to estimate their effect on functional recovery, institutionalization, and death after surgical repair. DESIGN: Prospective cohort. SETTING: Hospital, follow-up to community and nursing home. PARTICIPANTS: One hundred twenty-six patients aged 65 and older admitted for hip fracture repair. MEASUREMENTS: Baseline measurements: Mini-Mental State Examination, Blessed Dementia Rating Scale, Geriatric Depression Scale, prefracture activities of daily living (ADLs), ambulatory status. The Confusion Assessment Method was used to diagnose in-hospital delirium. One- and 6-month outcomes were ADL decline, loss of ambulation, and new nursing home placement or death. RESULTS: Twenty-two percent of patients had one cognitive or mood disorder, 30% had two, and 7% had three. At 1 month, each cognitive or mood disorder was independently associated with one or more adverse outcome. Considered together, each additional cognitive or mood disorder was associated with greater odds of 1 month outcomes (ADL decline: odds ratio (OR)=1.8, 95% confidence interval (CI)=1.1-2.9; decline in ambulation: OR=1.8, 95% CI=1.1-3.0; nursing home placement or death: OR=3.9, 95% CI=1.9-8.1). CONCLUSION: Cognitive and mood disorders were common in elderly hip fracture patients and were associated with greater risk of poor outcomes, both independently and in combination. Recognition and treatment of these conditions may reduce adverse outcomes in this vulnerable population.