Race and the prognostic influence of p53 in women with breast cancer.

BACKGROUND: Prior study suggests that p53 status behaves as an independent marker of prognosis in African American (AA) women with breast cancer. We investigate whether the influence of p53 is unique to AAs or is present in other race/ethnic groups, and how this compares with known prognostic factors. METHODS: Cox regression models [hazard ratios (HRs), 95% confidence intervals (CIs)] were used to select and evaluate factors prognostic for all-cause mortality in 331 AA and 203 non-AA consecutively treated women. RESULTS: Statistically significant baseline prognostic factors were as follows. For AAs: stage [(III/I) HR 5.57; 95% CI 3.08-10.09], grade [(higher/low) HR 1.55; 95% CI 1.14-2.11], estrogen receptor (ER)/progesterone receptor (PR) status [(-/+) HR 2.01; 95% CI 1.38-2.93], triple negative (ER-, PR-, HER2-) subtype [(+/-) HR 1.95; 95% CI 1.33-2.85], and p53 status [(+/-) HR 1.69; 95% CI 1.10-2.58]. For non-AAs: stage [HR 11.93; 95% CI 2.80-50.84], grade [HR 1.61; 95% CI 0.96-2.71], and ER/PR status [HR 2.13; 95% CI 1.19-3.81]. There was a differential effect of race within p53 groups (P=0.05) and in multivariate modeling p53-positive status remained an adverse prognostic factor in AAs only [HR 1.82; 95% CI 1.04-3.17]. Compared to non-AAs, 5-year unadjusted survival was worse for AAs overall (73.4% vs. 63.6%; P=0.032), and also for AAs with p53-positive status (80.3% vs. 54.2%; P=0.016), but not for AAs with p53-negative disease (68.4% vs. 67.9%; P=0.81). CONCLUSIONS: Among women with breast cancer of different race/ethnicity, an adverse prognostic effect as a result of p53 positivity was only observed in AA women.

Poor radiotherapy compliance predicts persistent regional disease in advanced head/neck cancer.

OBJECTIVE: To determine if poor compliance to chemoradiation results in an increased rate of persistent neck disease. STUDY DESIGN: Retrospective, cohort study in an urban, tertiary-care medical center. METHODS: The study included patients with N+ stage III/IV squamous cell carcinoma of the upper aerodigestive tract treated with curative-intent chemoradiation, who underwent subsequent planned neck dissection. Main outcome measure was persistent regional disease evidenced by identifiable carcinoma in neck dissection specimens. Variables including age, gender, race, primary site, initial T, N staging, imaging results, and treatment compliance were assessed and correlated to positive neck dissection pathology. RESULTS: Of 40 patients, 18 (45%) had persistent carcinoma in neck dissection specimens while 22 (55%) demonstrated complete response in the neck. There were 14 patients (35%) who were poorly compliant to radiotherapy (>or=14 days treatment interruption) and the remaining 26 patients (65%) were considered compliant (<14 missed days). Only 23% of compliant patients had positive pathology while 79% of noncompliant patients had positive pathology (hazard ratio: 9.9). Noncompliance was the only variable that had a statistically significant correlation to positive pathology results (P = .002). Multivariate logistic regression showed all other variables to be insignificant in predicting pathology. CONCLUSIONS: This study found that poorly compliant patients are at significantly higher risk of persistent neck disease. Poor compliance may help identify patients who will most benefit from neck dissection after chemoradiation. This variable was more predictive than pretreatment variables and posttreatment CT scan. Further studies investigating patterns of failure after chemoradiotherapy in the poorly compliant patient population are warranted.

Patient compliance to radiation for advanced head and neck cancer at a tertiary care county hospital.

BACKGROUND: Combined chemotherapy and radiotherapy are routinely used to treat advanced-stage head and neck squamous cell carcinoma (HNSCC). Patient compliance is often difficult given increased toxicities. Medically underserved or uninsured patients may lack the necessary support to complete such treatment. OBJECTIVE: To evaluate compliance to radiation therapy for patients with advanced stage HNSCC at an urban tertiary-care county hospital. STUDY DESIGN: Retrospective review. METHODS: Data were extracted from the charts of 136 consecutive patients who had been advised to undergo chemoradiotherapy for newly diagnosed HNSCC from 2004 to 2006. Demographic and tumor-related information was collected, as was patient compliance with radiation treatment. Total dose, length of treatment, and theoretical "loss of loco-regional control" was calculated. Benchmark compliance data were obtained from select publications. RESULTS: Of 136 patients, 55 did not begin treatment or transferred care elsewhere, leaving 81 study patients. Twenty-eight patients (35%) had unacceptable overall treatment courses. Forty-eight patients (59%) received less than the effective dose of 65 Gy after accounting for missed treatment days. Fifty-one patients (63%) had a greater than 10% calculated loss in loco-regional control. Univariate and multivariate analysis yielded no predictive value for gender, ethnicity, node status, stage, or primary site on compliance. CONCLUSION: Compared with other institutions, HNSCC patients in this setting are less likely to complete a prescribed therapeutic regimen. Patient and tumor characteristics measured in this study do not predict compliance. Organ preservation protocols require further evaluation in populations where compliance is suspect. Future research must examine interventions to improve compliance and assessment of its impact on survival.

Advanced stage of head and neck cancer at a tertiary-care county hospital.

BACKGROUND: Public hospitals provide health care for uninsured and medically underserved patients in large metropolitan areas. Outcomes for head and neck cancer patients within this population are perceived as being worse than outcomes for the general population, perhaps because of advanced stage at presentation. OBJECTIVE: This study assesses the initial cancer stage in patients with head and neck carcinoma presenting to an urban tertiary-care county hospital compared with data for the general population. STUDY DESIGN: Prospective study of 209 consecutive patients newly diagnosed with head and neck cancer by the Division of Otolaryngology/Head and Neck Surgery from October 2003 to April 2005. METHODS: Clinical and pathologic data were obtained as patients presented and underwent treatment. Demographic data were obtained retrospectively. Staging analysis was performed on 186 patients with squamous cell carcinoma. Normative data were obtained from the National Cancer Database. RESULTS: The mean age was 55, with a 4:1 male to female ratio. Over 95% of patients reported being unemployed. The racial composition was white 27%, African American 52%, Hispanic 11%, Asian 7%, and 3% "other." Staging revealed that 68% of patients were stage IV, and 85% would be considered "advanced" disease (stage III/IV). This is significantly worse than what national data demonstrates, where only 39% are stage IV, and 55% have advanced stage of disease at presentation. CONCLUSION: Although the perceived poor outcome of uninsured and underserved cancer patients is multifactorial, advanced stage at presentation is a critical factor. These statistics demonstrate the need for increased patient education and screening for this underserved population as an initial step to improve outcome.

Assessment and management of cutaneous reactions with amifostine administration: findings of the ethyol (amifostine) cutaneous treatment advisory panel (ECTAP).

PURPOSE: To review reports of severe skin reactions during amifostine treatment. METHODS AND MATERIAL: The expert panel reviewed postmarketing reports of skin reactions and discussed strategies for evaluation and management. RESULTS: Between 1994 and April 2002, 35 events were classified as severe skin reactions worldwide: erythema multiforme (8), Stevens-Johnson syndrome (10), toxic epidermal necrolysis (11), toxicoderma (3), and bullae (3). Unadjusted incidences were 6-9 per 10,000 radiotherapy patients and 0.8-1 per 10,000 chemotherapy patients. In 10 patients (29%) amifostine was continued after cutaneous signs and symptoms appeared. CONCLUSIONS: Practical recommendations for practicing clinicians were developed. Cutaneous evaluation for rash, ulceration, or lesions-particularly on lips/mucosa, palmar/plantar surfaces, and the trunk-should be performed before amifostine administration. Reactions can be classified as local injection site/radiation port reactions or non-injection site reactions; and non-injection site reactions with associated fever or constitutional symptoms must be differentiated from radiation-induced dermatitis or cutaneous reaction with another etiology. Amifostine should be permanently discontinued for severe skin reactions or reactions associated with constitutional symptoms not known to be due to any other etiology. Increased physician awareness, proper patient management, monitoring before administration, and early intervention/discontinuation for non-injection site reactions may reduce the incidence of cutaneous reactions and enhance amifostine safety.