Active shooter in emergency departments in Guanajuato State, Mexico.

Mass violence events, especially in healthcare settings, have devastating consequences and long-lasting effects on the victims and the community. The rate of violent events in Mexico, especially in hospital settings, has increased since 2006, but has become more evident in 2018. Guanajuato State, located in central Mexico, is among the states most affected by the wave of violence, especially active shooter events. The year 2019 had the highest number of incidents. Therefore, the Silver Code and the components of Safe Hospitals, in accordance with the Hartford consensus and PAHO guidelines, were implemented in the hospitals of the Institute of Public Health of the State of Guanajuato, with a focus on the actions of healthcare personnel to prevent collateral damage. Although subsequently there were still fatalities and injuries in the events involving active shooters in the hospitals, there were no casualties among healthcare personnel, according to data from the Institute of Public Health, Guanajuato State. This paper presents information from the data from General Directorate of Epidemiology to describe the hospital mass violence situation in the State of Guanajuato, Mexico and recounts the step taken to effectively manage and prevent these situations moving forward. Specific recommendations based on international consensus and our experience provided include increasing the level of security checks for people entering the hospital premises, training healthcare personnel on violence-related preparedness and improving management of active shooter events consistent with published evidence, to reduce the possibility of casualties.

Pipelle endometrial biopsy for abnormal uterine bleeding: do patient's pain and anxiety really impact on sampling success rate?

BACKGROUND: Pipelle endometrial biopsy is vital for the early diagnostics of endometrial pathology and is performed in outpatient setting in minimally invasive manner. One of the reported disadvantages of sampling with Pipelle curette is failure to collect enough tissue for histological analysis. The role of psychological factors such as anxiety and pain sensitivity in obtaining adequate samples is not well known. The study's objective was to explore whether there is relationship between severe pain, anxiety, and the rate of Pipelle failure. METHODS: Study included 158 women with median age of 42 who underwent Pipelle endometrial biopsy at Clinical Academic Department of Women's Health of the University Medical Center (UMC), Nur-Sultan City, Kazakhstan with an abnormal uterine bleeding from June 2019 to April 2021. Women were asked to fill survey on pain, anxiety before, during and after the procedure. RESULTS: 3.8%, 15.19% and 4.43% of women reported severe pain and 39.24%, 34.18% and 14.56% of women reported severe anxiety prior, during and after procedure, respectively. Women who experienced severe pain during procedure tend to be more anxious during procedure (p = 0.0001) and have higher number of sampling attempts (p = 0.0040). Pain level was higher among patients sampled by the junior OB/GYN specialist (p < 0.0001). We found no differences in Pipelle biopsy success rates in relationship to baseline, during and postprocedural pain and anxiety scores. CONCLUSION: Anxiety during procedure performance was significantly associated with severe pain during the procedure but did not represent a key element for the success of Pipelle biopsy.

Lessons Learned From a Gap Analysis of Obstetric Hemorrhage Protocols across a Health System.

INTRODUCTION: The United States has experienced a rising incidence of maternal deaths, including those attributable to obstetric hemorrhage (OBH). In response, the National Partnership for Maternal Safety developed a standardized OBH Consensus Bundle with the goal of universal adoption. In 2016 a large western Pennsylvania health system adopted the OBH Consensus Bundle across its 8 obstetrical units, with the goal to improve maternal outcomes. METHODS: Gap analysis was used to identify differences between existing OBH protocols and the OBH Consensus Bundle from January to June 2016. Identified gaps as well as existing practices of success were used to systematically develop and implement a standardized system-wide OBH improvement initiative. Hospitals were then categorized by annual birth volume as high (> 2000), medium (500-2000), and low (< 500) with analysis performed across these groups to identify potential trends. RESULTS: All hospitals had individual successes as well as gaps that were used to direct the system-wide OBH improvement initiative. In some cases, individual plans were tailored to meet hospital resources. When hospitals were compared by annual birth volume, variation existed in their preparedness for, and management of OBH, with the single low-volume hospital having the most gaps. DISCUSSION: This gap analysis identified areas for improvement among all hospitals in a health system regardless of annual birth volume. This systematic approach of evaluation of current protocols and identification of improvement targets with implementation strategies may improve maternity outcomes. Additionally, these lessons described may provide a useful framework for other hospitals and health systems as they implement their own safety bundles.

Cost-effectiveness analysis of biopsy strategies for endometrial cancer diagnosis in women with postmenopausal bleeding: Pipelle sampling curette versus dilatation & curettage.

BACKGROUND: Endometrial sampling is widely used for accurate diagnosis of endometrial cancer (EC), which is the most common gynecologic cancer in US women. The objective of this study was to explore the cost-effectiveness of two endometrial sampling procedures for diagnosing EC: (1) Pipelle endometrial sampling (Pipelle), and (2) dilatation & curettage (D&C), while accounting for sampling procedure failure rates and diagnostic accuracy in women with postmenopausal bleeding (PMB). METHOD: The decision analytic model was built to compare the cost-effectiveness of Pipelle and D&C strategies in a hypothetical cohort of PMB women. The analysis was performed from the perspective of a public healthcare payer (Medicare, US). We used 2017 Medicare reimbursement data for cost estimation. The effectiveness of these two diagnostic strategies was measured by analyzing the remaining life expectancy after EC diagnosis and subsequent treatment. RESULTS: The base case analysis suggested that Pipelle was not only equally effective (32.11 vs. 32.11 years of life), but also less costly ($1897.80 vs. $2999.11) based on Medicare reimbursement when compared to D&C. In one-way sensitivity analyses and Monte Carlo probabilistic sensitivity analysis, the Pipelle remained the more cost-effective sampling strategy even after accounting for sampling failure rate associated with each sampling strategy. CONCLUSION: The Pipelle is the more cost-effective sampling strategy compared to D&C for EC diagnosis in women with PMB. From the cost-effectiveness perspective, the higher sampling failure rate of Pipelle should not be regarded as a limitation in its clinical application.

Changes in inflammatory endometrial cancer risk biomarkers in individuals undergoing surgical weight loss.

OBJECTIVE: Obesity has been strongly linked to endometrial cancer (EC) risk. A number of potential EC risk biomarkers have been proposed, including heightened pro-inflammatory cytokines and adipokines. To evaluate if bariatric surgery can serve as a means for altering levels of such EC risk biomarkers, we investigated changes in these biomarkers after weight loss. METHODS: Blood samples were collected pre-operatively and 6months post-operatively in 107 female bariatric surgery patients aged 18-72years. Wilcoxon signed-rank tests were used to compare biomarker levels (measured using xMAP immunoassays) pre- and post-surgery. Normative comparisons were implemented to contrast 6-month post-surgery biomarker levels to levels in a sample of 74 age-matched non-obese women. Linear regression was used to evaluate the relationship between biomarker expression at baseline and 6months post-surgery and the relationship between race and biomarker levels. RESULTS: On average, participants lost 30.15kg (SD: 12.26) after the bariatric intervention. Levels of C-peptide, insulin, CRP, leptin, IL-1Rα, and IL-6 significantly decreased, while levels of SHBG, IGFBP1, and adiponectin significantly increased with weight loss. Normative comparisons showed the levels of SHBG, C-peptide, insulin, IGFBP1, adiponectin, CRP, and TNFα after bariatric intervention approached the level of markers in comparison group. Multiple regression analyses revealed significant relationships between changes in BMI and changes in biomarker levels. The changes in IL-1Rα were significantly associated with race. CONCLUSIONS: Our findings demonstrate that normalization of EC risk biomarkers can be achieved with bariatric surgery. Improved understanding of biological mechanisms associated with weight loss may inform preventive strategies for EC.

Patient and provider factors associated with endometrial Pipelle sampling failure.

OBJECTIVE: To explore risk factors associated with sampling failure in women who underwent Pipelle biopsy. METHODS: A consecutive sample of 201 patient records was selected from women who underwent Pipelle biopsy procedures for suspected uterine pathology in a large healthcare system over a 6-month period (January 2013 through June 2013). Personal and medical data including age, BMI, gravidity and parity, and previous history of Pipelle biopsy were abstracted from medical records for each patient. Logistic regression analyses were used to determine factors associated with biopsy sampling failure. RESULTS: Pipelle biopsy sampling failed in 46 out 201 women (22.89%), where 8 (17.39%) were due to inability to access the endometrium, 37 (80.43%) were inadequate samples, and 1 (2.18%) was due to unknown reasons. Personal and medical factors found to be related to sampling failure included: postmenopausal bleeding as biopsy indication (OR 7.41, 95% CI 2.27-24.14); history of prior biopsy failure (OR 23.87, 95% CI 3.76-151.61); and provider type (physician vs. midlevel provider) (OR 9.152, 95% CI 2.49-33.69). CONCLUSION: We identified several risk factors for biopsy failure that suggest the need for particular care with Pipelle sampling procedures among women with certain characteristics, including postmenopausal bleeding and a history of prior failed Pipelle biopsy. Our finding of a significantly higher risk of sampling failure based on personal and clinical data suggests that providers must take into account additional considerations to improve sampling success.

Development of an evidence-based decision pathway for vestibular schwannoma treatment options.

OBJECTIVE: To integrate multiple sources of clinical information with patient feedback to build evidence-based decision support model to facilitate treatment selection for patients suffering from vestibular schwannomas (VS). METHODS: This was a mixed methods study utilizing focus group and survey methodology to solicit feedback on factors important for making treatment decisions among patients. Two 90-minute focus groups were conducted by an experienced facilitator. Previously diagnosed VS patients were recruited by clinical investigators at the University of Pittsburgh Medical Center (UPMC). Classical content analysis was used for focus group data analysis. Providers were recruited from practices within the UPMC system and were surveyed using Delphi methods. This information can provide a basis for multi-criteria decision analysis (MCDA) framework to develop a treatment decision support system for patients with VS. RESULTS: Eight themes were derived from these data (focus group + surveys): doctor/health care system, side effects, effectiveness of treatment, anxiety, mortality, family/other people, quality of life, and post-operative symptoms. These data, as well as feedback from physicians were utilized in building a multi-criteria decision model. DISCUSSION: The study illustrated steps involved in the development of a decision support model that integrates evidence-based data and patient values to select treatment alternatives. CONCLUSIONS: Studies focusing on the actual development of the decision support technology for this group of patients are needed, as decisions are highly multifactorial. Such tools have the potential to improve decision making for complex medical problems with alternate treatment pathways.

Obesity, lymphadenectomy and survival outcomes in intermediate to high-risk, early-stage endometrial cancer patients.

AIM: Lymphadenectomy or lymph node dissection is a topic of controversy in endometrial cancer (EC) treatment. MATERIALS & METHODS: Associations between lymph node dissections and clinical factors were retrospectively examined in obese, endometrioid endometrial cancer patients with early-stage disease between 1995 and 2005. Overall, EC-specific and recurrence-free survival were also evaluated. RESULTS: Out of 192 patients, 61 (32%) did not have a lymph node examination, 55 (29%) had less than ten lymph nodes removed and 76 (39%) had ≥10 removed. Lymph node dissection count was not significantly associated with overall, EC-specific or recurrence-free survival. CONCLUSION: Analysis revealed no significant associations between ≥10 dissected lymph nodes and survival outcomes among obese, EC patients, which supports the need for additional investigation of the merit of lymphadenectomy among these patients.

Not a Humbug: the evolution of patient-centred medical decision-making.

This 'Christmas Issue'-type paper uses the framework of 'A Christmas Carol' to tell about the evolution of decision-making in evidence-based medicine (EBM). The Ghost of the Past represents paternalistic medicine, the Ghost of the Present symbolises EBM, while the Ghost of the Future serves as a patient-centred system where research data and tools of decision science are jointly used to make optimal medical decisions for individual patients. We argue that this shift towards a patient-centred approach to EBM and medical care is the next step in the evolution of medical decision-making, which would help to empower patients with the capability to make educated decisions throughout the course of their medical treatment.

Hormone receptor expression patterns in the endometrium of asymptomatic morbidly obese women before and after bariatric surgery.

OBJECTIVE: Obesity increases risk for endometrial neoplasia, but neither the pathophysiology nor the effects of weight loss on the risk are well established. We attempted to characterize the molecular profile of the endometrium of asymptomatic women with morbid obesity before and following bariatric surgery-induced weight loss. METHODS: 59 asymptomatic, morbidly obese women underwent endometrial sampling before bariatric surgery; 46 (78%) of these returned one year later for re-biopsy (median weight loss of 41kg). Duplicate samples from these specimens were scored for expression of estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), and Ki-67 by two independent, blinded pathologists using an H-score [staining intensity (0-3)×(percent of tissue involved)]. RESULTS: The prevalence of hyperplasia pre-operatively was 7% overall and 10% among patients not on an anti-estrogen. ER H-scores were similar before and after surgery overall (median 190 and 196 respectively, p=0.82), but patients with hyperplasia had higher pre-operative H-scores (median 256, p<0.001) and experienced greater H-score drops, than those without hyperplasia (-112 vs +50, p=0.028). In two patients with persistent hyperplasia at one year, ER H-scores fell to levels that were similar to those without pathology. One patient who developed hyperplasia during the study period had a rising ER H-score. Patients with hyperplasia had higher median PR H-scores pre-operatively (284 vs 188, p=0.01), which normalized through greater drops (75 vs 0, p=0.053). AR H-scores dropped significantly after surgery (13 vs 2, p=0.015), but were similar between patients with and without hyperplasia (p=0.33). Weight loss did not affect Ki-67 proliferation index. CONCLUSION: Asymptomatic morbidly obese patients have a high prevalence of occult hyperplasia, characterized by relatively high hormone receptor expression. These profiles appear to normalize with weight loss and in advance of pathologically identifiable changes. These data suggest a potential role for screening this population as well as the possibility that weight loss may be a valid treatment strategy for risk reduction.

An exploratory investigation of links between changes in adipokines and quality of life in individuals undergoing weight loss interventions: possible implications for cancer research.

OBJECTIVE: Obesity has been linked to a wide spectrum of malignancies, with the strongest association demonstrated for endometrial cancer. Although the mechanisms are not yet entirely clear, a number of risk biomarkers have been proposed, including altered adipokines. Systemic levels of these adipose derived molecules have also been linked in prior research to self-reported quality of life (QOL). The study objective was to examine the hypothesis that adipokine changes during intentional weight loss may be associated with changes in QOL. METHODS: Fifty-two female participants were selected from two behavioral weight loss trials (SMART and PREFER) on the basis of achieving successful weight loss at 6month assessment, availability of blood samples and completion of standard SF-36 QOL questionnaires. Levels of adiponectin, leptin, and resistin were measured using xMAP immunoassays. Changes in QOL were examined using linear regression models in relation to pre- and post-intervention changes in biomarker levels and BMI. RESULTS: Significant changes between pre- and post-intervention were observed for leptin. Controlling for baseline BMI, leptin was the only biomarker that predicted change in QOL (Physical Component Scale, PCS). Linear regression models demonstrated that leptin continued to be a significant predictor of change in PCS when other possible predictor variables were included in the model. CONCLUSIONS: This study is among the first to demonstrate that changes in PCS may be regulated by levels of both metabolic variables and adipokines. An improved understanding of biological mechanisms associated with weight loss and the role of QOL may help guide preventive strategies for obesity-associated cancers.

USA endometrial cancer projections to 2030: should we be concerned?

AIM: As the incidence of endometrial cancer (EC) increased considerably since 2007, this study aimed to project the burden of EC to the year 2030. METHODS: Multivariate linear regression was used to project EC incidence by modeling trends in EC incidence from 1990 to 2013, while accounting for temporal changes in obesity, hysterectomy and smoking. RESULTS: The best-fitting model predicting EC rates included a time effect plus effects for hysterectomy (12-year lag), severe obesity (3-year lag) and smoking (9-year lag). The best-fitting model projected an increase to 42.13 EC cases per 100,000 by the year 2030, a 55% increase over 2010 EC rates. CONCLUSION: The projected increase of EC over next 16 years indicates the need for close monitoring of EC trends.

Weight loss is more important than the diet type in improving adiponectin levels among overweight/obese adults.

OBJECTIVE: The study objective was to compare the effect of a standard calorie- and fat-restricted diet (STD-D) and a calorie- and fat-restricted lacto-ovo-vegetarian diet (LOV-D) on total and high-molecular-weight (HMW) adiponectin levels after 6 months of behavioral intervention. DESIGN: This study is an ancillary study to a randomized clinical trial. SUBJECTS: Subjects included 143 overweight/obese adults (STD-D = 79; LOV-D = 64). INTERVENTION: Both groups received the same standard behavioral intervention; the only difference was that LOV-D participants were instructed to eliminate meat, poultry, and fish from their diet. MEASURES: Weight, dietary intake with the 3-day food diary, and total and HMW adiponectin levels were measured. RESULTS: Both groups significantly increased total (STD-D +7.2 ± 17.8%; LOV-D +9.4 ± 21.8%) and HMW adiponectin levels (STD-D +18.5 ± 32.9%; LOV-D +15.8 ± 34.5%; ps < 0.05) with no significant differences between the groups. We found significant associations between weight loss and increases in total (ß (SE) = -.071(.27); p = 0.003) and HMW adiponectin (ß (SE) = -1.37(.47); p = 0.001) levels independent of the diet type. Weight loss at the higher quartile was associated with improvements of adiponectin levels (p < 0.05). CONCLUSION: Weight loss was associated with increased total and HMW adiponectin levels regardless of the diet type. Enhancing weight loss may be a means to improve adiponectin levels.

Survival outcomes in endometrial cancer patients are associated with CXCL12 and estrogen receptor expression.

CXCL12 is a chemotactic cytokine that has pro-metastatic functions in several malignancies through interactions with its receptor, CXCR4. CXCL12 is an estrogen-regulated gene, and notably, estrogen is a major risk factor for endometrial cancer (EC) development. As few studies examine concurrent CXCL12, CXCR4, and estrogen receptor (ER) expression in EC patients, we examined this pathway in 199 EC patients with data from the University of Pittsburgh Medical Center Cancer Registry. Immunohistochemistry (IHC) was used to detect CXCR4, CXCL12 and ER protein expression. As CXCR4 expression was positive in all cases, this investigation focused on associations between CXCL12 and ER expression, clinicopathologic factors and survival outcomes using chi-square tests, Kaplan-Meier graphs, and log-rank tests. CXCL12 expression was negative in 63 cases (32%) and positive in 136 cases (68%). Negative CXCL12 expression was borderline significantly associated with metastasis (χ(2) p = 0.07). ER expression was negative in 75 cases (38%) and positive in 124 cases (62%). Positive ER expression was significantly associated with low grade and early stage tumors (χ(2) p < 0.001). CXCL12 and ER were not significantly associated (χ(2) p = 0.11). Positive CXCL12 expression was associated with longer overall survival (OS) (log-rank p = 0.006) and longer recurrence-free survival (RFS) (log-rank p = 0.01) in ER negative patients, but not in ER positive patients. We identified a unique molecular signature associated with better OS and RFS in EC patients. In addition to pathological characteristics of the tumor, expression of CXCL12 and ER may be clinically useful for assigning adjuvant treatment to EC cases.

Factors associated with mortality after breast cancer metastasis.

BACKGROUND: It is generally accepted that patients with breast cancer metastases have very poor survival. Metastatic breast cancer patients can be considered a heterogeneous population with a varied clinical course, which underscores the need for accurate prediction of survival based on prognostic factors. The purpose of the present study was to identify factors related to survival in breast cancer patients after diagnosis with metastatic disease. POPULATIONS AND METHODS: A total of 557 patients with breast cancer metastasis diagnosis seen at one large urban practice have been followed up between 1 January, 1999 and 30 June, 2010. Demographic, tumor characteristics, clinical factors as predictors of survival were analyzed using log-rank test and Cox regression model. RESULTS: The median survival length was 39 months (range 1-138 months) with 154 (27.7%) alive and 403 (72.3%) dead at the end of follow-up period. This study demonstrated that a history of hypertension, ER/PR status, HER2 status, metastasis-free interval, metastatic location (including brain, bone and liver), and BMI at diagnosis with metastatic breast cancer were the most relevant prognostic factors for survival after metastatic disease diagnosis. CONCLUSION: Findings of this study may form a foundation for the growing corpus of knowledge explaining the outcome differences in treatment of patients with metastatic breast cancer, potentially helping to create tailored counseling and personalized treatment approaches for this vulnerable group.

Longitudinal evaluation of cancer-associated biomarkers before and after weight loss in RENEW study participants: implications for cancer risk reduction.

INTRODUCTION: Obesity is a major risk factor for the development of endometrial cancer (EC). An improved understanding of biologic mechanisms associated with weight loss, including alteration in inflammation, hormonal balance, and cancer antigens expression may lead to the development of effective cancer prevention strategies. The goal of this study was to explore longitudinal biomarker changes in obese women who underwent weight loss intervention, testing the hypothesis biomarker levels can be altered through intentional weight loss. METHODS: Serum samples from 89 participants with Class II and Class III obesity and 43 non morbidly obese comparisons were obtained in Re-Energize with Nutrition, Exercise and Weight Loss (RENEW) study as previously reported. Twenty-one bead-based xMAP immunoassays were utilized, including cancer-associated antigens, cytokines, chemokines, and hormones. One-way repeated measures ANOVA was used to examine the association between changes in biomarker expression levels over time (baseline, 6 months and 12 months). Linear mixed effects models were used to examine longitudinal relationships between biomarker expression levels. RESULTS: Mean levels of VEGF, soluble E-selectin, GH, adiponectin, IL-6, IL-7, CA-125, and IGFBP-1 significantly differed between time periods. In adjusted mixed linear models, decreasing BMI was significantly associated with lower levels of soluble E-selectin and IL-6 and increases in GH, adiponectin, and IGFBP-1. CONCLUSIONS: This is one of the first efforts to explore changes in cancer-associated biomarkers in a cohort of weight loss research participants at high risk for EC development. Our findings demonstrate that changes in the expression of markers can be achieved with weight loss intervention.

Qualitative Interview Study of Gynecologic Oncologist Utilization of Recommended Same-Day Discharge Following Minimally Invasive Hysterectomy.

Recent investigations have supported the safety and benefits of discharging women on the same day following a minimally invasive hysterectomy (MIH) for both benign and malignant indications. Not all eligible candidates for same-day discharge (SDD) are discharged the same day, and patients undergoing an MIH for malignant indications have decreased the odds of receiving SDD despite established safety. The objective of this study was to use qualitative interviews to explore physician decision making regarding SDD after an MIH for malignant indications. Six qualitative interviews of gynecologic oncologists were analyzed using recurrent theme analysis for distinct themes in physician decision making regarding SDD. Results suggest that physician-perceived barriers to SDD include patient health characteristics, patient social characteristics, and hospital-system factors. Cited factors influencing SDD include patient travel, social support, practice setting (urban vs. rural) and staff comfort with the recommendation. Obstructive sleep apnea and post-surgical oxygenation appear to be a recurring reason for unplanned admission. The utilization of SDD after an MIH in the gynecologic oncology patient population is influenced by patient, physician, and system factors. Addressing the physician's perceived barriers to SDD and catering recommendations to the gynecologic oncology population may increase utilization.

Factors Influencing on Pain in Patients Undergoing Pipelle Endometrial Biopsy for Abnormal Uterine Bleeding: Why a Personalized Approach Should Be Applied?

Objectives. Abnormal uterine bleeding (AUB) is a common complaint of women in different age groups, and endometrial biopsy is widely used to investigate the underlying causes. The aim of this observational study was to assess factors influencing pain in patients undergoing endometrial biopsy for AUB. Methods. Pain intensity before, during, and after Pipelle sampling was evaluated using the numerical rating scale (NRS), where "0" represents no pain at all, "10"­the worst pain ever possible. Pain rating was categorized as 1−6­mild to moderate, 7 and above as severe pain. Results. The study included 160 women who underwent Pipelle biopsy. The median age in the cohort was 42 (34−48) years, 18.1% of women were postmenopausal, 56.3% were either overweight or obese, 30% were nulliparous and 80% reported urban residency. The median pain score during the procedure was 2 (0−4). Pain scores of 5 (4−7) were reported with the junior gynecologist and 2 (0−4) in the senior gynecologist (p < 0.0001). Conclusion. The pain was found to have a strong association with the type of provider performing the endometrial sampling procedure. This fact suggests the need for a personalized approach and that psychological or informational interventions should be scheduled before the procedure to decrease pain and increase satisfaction.

Endometrial cancer risk factors in Singapore Chinese: a prospective cohort study.

PURPOSE: The incidence of Endometrial cancer (EC) has grown substantially in Asia over the past decade. However, few studies have addressed risk factors associated with EC incidence in Asian populations. We explored the association between reproductive and dietary risk factors and EC in the Singapore Chinese Health Study (SCHS), one of the largest prospective cohort studies in Asia. METHODS: Data were collected from 34,028 ethnically Chinese women aged 45-74 residing in Singapore, enrolled between 1993 and 1998. Baseline demographic, dietary, and reproductive factors were collected via structured questionnaires. EC cases were identified from the Singapore Cancer Registry (n = 126) up to 2010. Cox proportional hazard models were used to analyze association between EC and personal, reproductive, and dietary factors. RESULTS: The incidence of EC in this population was 28.8 per 100,000 person-years. Regardless of menopausal status, obesity (BMI ≥ 27) was associated with increased EC risk (HR = 2.22, 95% CI 1.26-3.92), while later age at menarche was associated with decreased EC risk (HR = 0.14, 95% CI 0.04-0.46). In postmenopausal women, later age at menopause was associated with increased EC risk (HR = 2.82, 95% CI 1.24-6.43). Lifestyle and nutritional factors were not associated with risk of EC in this cohort. CONCLUSIONS: This study is one of the largest cohort studies exploring EC risk factors in Asian populations. Our study identified similarities in EC risk factors for European and Asian populations, which potentially suggests that strategies developed for EC prevention in Western populations can be potentially appropriate for the Singapore Chinese population due to risk factor similarities.

The effect of delays in treatment for breast cancer metastasis on survival.

It is generally accepted that delay in receiving treatment for breast cancer results in adverse outcomes. The purpose of this study was to evaluate the impact of delay in treatment after the diagnosis of metastatic disease on survival measured from metastatic breast cancer diagnosis and from first treatment while controlling for immortal time effect among patients with metastatic breast cancer. A total of 553 patients with breast cancer metastasis diagnosis from one large urban practice have been followed between January 1, 1999 and June 30, 2008. Prognostic factors and outcomes of these patients were analyzed using log-rank test and Cox regression model. Backward stepwise selection of covariates was conducted to assess the association of treatment delay with survival. The median survival was 40 months (range 1-114 months), with 265 (47.9%) women alive and 288 (52.1%) having died at the end of the follow-up period. Treatment delays of more than 12 weeks had impact on poor survival from first treatment than the delays of 4-12 weeks with borderline significance level (HR 1.76, 95% CI 0.99-3.13, P = 0.056) in multivariate analysis, adjusted by BMI, history of hypertension, ER/PR status, HER2 status, number of metastatic sites, and liver metastasis. Moreover, the interval of 12-24 weeks, compared to the interval of 4-12 weeks was associated with greater risk of death from first treatment (HR 2.39, 95% CI 1.19-4.77, P = 0.014). The treatment delay interval of >12 weeks was not related with survival since metastatic breast cancer diagnosis, compared to the 4-12 weeks of treatment delays. This study demonstrated that delays of over 12 weeks in receiving treatment for metastatic breast cancer were related to adverse survival outcomes measured from initiation of first treatment. The findings of this study support targeted efforts to ensure prompt treatment initiation in patients diagnosed with metastatic breast cancer.