How Canadian Oncologists Use Oncotype DX for Treatment of Breast Cancer Patients.

BACKGROUND: The literature suggests that medical oncologists differ on how they use the Oncotype DX (ODX) genomic assay for making decisions about systemic therapy in breast cancer patients. Given the emergence of data supporting the use of genomic profiling for the prognosis and predicting benefit of chemotherapy, we surveyed medical oncologists in Canada to assess their usage and perception of the ODX assay. METHODS: A 34-item survey was distributed to Canadian medical oncologists via the Canadian Association of Medical Oncologists. Data was collected on physician demographics, ODX usage patterns, and physicians' perception of the impact clinical and pathologic characteristics make on ODX utilization. RESULTS: Response rate was 20.6% with 47 responses received from 228 survey sent. Forty-five responses were eligible for analysis. Sixty-two percent (28/45) of respondents treated predominantly breast cancer, and 60% (27/45) have been in practice for at least 10 years. The most cited reason for using ODX was to avoid giving patients unnecessary chemotherapy (64%; 29/45). Sixty-seven percent (30/45) deferred making treatment decisions until ODX testing was completed. Factors most strongly impacting ODX utilization included: patient request, medical comorbidities and tumor grade. In clinical scenarios, ODX was more frequently selected for patients aged 40-65 (vs. <40 or >65), grade 2 tumors (vs. grade 1 or 3), and Ki-67 index of 10-20% (vs. <10% or >20%). CONCLUSIONS: This survey demonstrated that Canadian medical oncologists are preferentially using ODX to avoid giving patients unnecessary chemotherapy. The utilization of ODX is mainly in patients with intermediate clinical and pathologic features.

Testing a novel account of the dissociation between self-reported memory problems and memory performance in chemotherapy-treated breast cancer survivors.

BACKGROUND: A puzzling observation pertaining to the impact of breast cancer on memory is the frequently reported dissociation between breast cancer survivors' self-reported memory problems and memory performance. We evaluated the hypothesis that the dissociation is related to the fact that the objective memory measures previously used assessed retrospective memory (RM) and did not tap prospective memory (PM), a domain about which survivors are complaining. METHODS: In a case-healthy-control (N = 80) cross-sectional study, the Memory for Intention Screening Test was used to assess PM and the Wechsler Logical Memory Test was used to evaluate RM. Self-reported problems were assessed with the Prospective and Retrospective Memory Questionnaire. Measures of depression (Center for Epidemiologic Studies Depression Scale) and fatigue (Functional Assessment of Cancer Therapy: Fatigue) were also administered. RESULTS: Both groups reported more PM than RM problems (P < .001). Survivors reported more fatigue and depression symptoms and more memory problems than controls (all P < .001). Importantly, the group difference in self-reported problems was no longer observed after adjusting for depression and fatigue. Survivors performed worse than controls on both PM and RM tasks. In neither group, however, were associations between self-reported RM and PM problems and RM and PM objective performance observed. CONCLUSIONS: Breast cancer survivors exhibit PM and RM deficits, which do not correlate with self-reported memory problems. Although unrelated to performance, memory complaints should not be dismissed, as they are closely associated with depression and fatigue and reveal an important facet of the cancer experience.

Empowering cancer survivors to meet their physical and psychosocial needs: An implementation evaluation.

Our Wellness Beyond Cancer Survivorship Program was established and evaluated as a quality improvement project. Individualized survivorship care plans for survivors and primary care providers included cancer surveillance recommendations and survivors' self-reported physical and psychosocial needs. At the discharge visit, an oncology nurse reviewed the care plan and symptom management strategies with survivors. We assessed the physical and psychosocial needs and feelings of empowerment of 70 breast and 53 colorectal cancer survivors on entry into the program and one year after discharge to primary care. Survivors were months to 10 or more years since the end of active treatment, with colorectal cancer survivors referred sooner (average 1.2 years). At baseline, colorectal cancer survivors reported little concern about their needs (scores <1.0 out of 5.0) and breast cancer survivors reported some concern about sleep disturbances, weight changes, memory/concentration changes, and fear of recurrence (scores 1.0 to 1.5 out of 5.0). All survivors reported feeling empowered (>3.0 out of 4.0). Needs and empowerment levels were mostly unchanged one year later. Colorectal cancer survivors showed a statistically significantly increased fear of recurrence at one year. In summary, cancer survivors with a survivorship care plan continued to feel empowered one year following discharge.

Metamemory function in chemotherapy-treated patients with breast cancer: an explanation for the dissociation between subjective and objective memory measures?

BACKGROUND: The purpose of this study was to determine if a deficit in metamemory could account for the disparity between subjective and objective measures of memory function commonly observed in patients with breast cancer (BC). Metamemory refers to the awareness and management of one's own memory function. It is considered an aspect of executive functioning, one of the most common areas of cognitive compromise associated with BC and its treatment. METHODS: Fifty-four women with early stage BC who had recently completed chemotherapy were compared with 54 healthy women matched on age and education. Cognitive function was objectively assessed with a neuropsychological test battery and subjectively assessed with the Functional Assessment of Cancer Therapy Cognitive Scale. Metamemory was assessed with a Feeling of Knowing (FOK) paradigm. RESULTS: The patients with BC scored significantly lower than the controls on both the objective and subjective cognitive measures, as well as on free recall and recognition conditions of the FOK, suggesting some decline in primary memory functions such as working memory, encoding, and retrieval. The discrepancy between the objective and subjective measures was larger in the patients with BC than in the controls, but there was no difference between the groups on the FOK metamemory index. CONCLUSIONS: Discrepancy in objective and subjective measures of cognition in patients with BC cannot be accounted for in terms of a deficit in meta-cognition. Objective and subjective measures are complementary, and a comprehensive cognitive assessment in patients with BC requires both. Copyright © 2015 John Wiley & Sons, Ltd.

An exploratory study of patients' views about being at high-risk for breast cancer and risk management beliefs and intentions, before and after risk counselling: Preliminary evidence of the influence of beliefs on post-counselling prevention intentions.

OBJECTIVES: 1) To describe how women at high-risk for breast cancer (BC) perceive their at-risk status and the options available to manage this risk, before and after risk counselling; 2) to explore the contributions of pre-counselling demographic, clinical, cognitive and emotional factors to post-counselling risk management intentions. METHODS: 58 of 173 eligible patients (34%) enrolled and were asked to fill surveys including measures of 1) subjective risk, 2) illness (being at high-risk for BC) and 3) treatment (surveillance, lifestyle modifications, and chemoprevention) cognitions, 4) BC fear and 5) future risk management intentions, prior to and 3 months after risk consultation. RESULTS: 48 of 58 participants (83%) completed both surveys. Beliefs and emotions about their condition and its management were stable over time. Surveillance and lifestyle were associated with stronger intentions, higher perceived need, and lower concerns than chemoprevention (all ps <0.001). The strongest predictors of intentions strengths were the women's beliefs about the risk reduction methods, especially for lifestyle and chemoprevention (all ps <0.01). CONCLUSIONS: The findings emphasize the importance of patients' beliefs in risk management decisions. PRACTICAL IMPLICATIONS: Patients' treatment beliefs appear to influence their choice of BC risk reduction strategies and should be discussed during risk reduction consultations.

Prospective memory impairment in chemotherapy-exposed early breast cancer survivors: Preliminary evidence from a clinical test.

We report the results of a secondary analysis of a cross-sectional study (Paquet et al., 2013 ) to evaluate the cognitive operations involved in prospective memory (PM) deficits exhibited by chemotherapy-exposed breast cancer (BC) survivors. PM was assessed with the memory for intentions screening test administered to 80 patients and 80 healthy controls. Patients performed worse than controls on the PM tasks and had more "omission" errors (indices of the prospective component of the tasks) than the controls. No group differences emerged on a recognition test. Although further studies will be needed to disentangle the multiple cognitive operations involved in PM, these findings are consistent with the notion that self-initiated retrieval processes rather than encoding are implicated in PM impairment among BC survivors.

Factors influencing Oncotype DX use in the management of early breast cancer: a single centre experience.

BACKGROUND: Oncotype DX recurrence score is a multi-gene assay which quantifies the risk of distant recurrence in patients with hormone receptor-positive (HR+) early breast cancer (EBC) treated with tamoxifen, and predicts the magnitude of clinical benefit of adjuvant chemotherapy. This retrospective study examined factors that were associated with use of Oncotype DX assay at a tertiary care cancer centre in Ottawa, Canada. METHODS: One hundred consecutive patients (pts) diagnosed with HR+, HER2/neu negative EBC (stage I-II), who underwent Oncotype DX testing (Test Group) between 1st April 2010, and 30th June 2011 were included in the study. A second cohort of 100 randomly selected patients with HR+, HER2/neu negative EBC diagnosed from the same time period who did not receive Oncotype DX testing were used as the control group (Control Group). Demographic and clinicopathologic data were obtained from review of charts. Logistic regression was performed to identify variables associated with Oncotype DX usage. FINDINGS: Median age was 58 years (r: 26-77) in Test Group and 63 years (r: 30-81) in Control Group. Sixty-two patients in the Test Group had T1 tumours, compared with 71 in the Control Group. The median 10-year recurrence risks from Adjuvant! Online were 19% and 12% in the Test Group and Control Group, respectively. Factors significantly associated with the utilisation of Oncotype DX assay on multivariate analysis include age 50-64 (p=0.049), tumour size 10.1-20mm (p=0.008) and grade 2 histological grade (p=0.004). INTERPRETATION: Usage of Oncotype DX assay is associated with several clinicopathological factors. These factors reflect the clinical uncertainty of benefit from chemotherapy in these subpopulations of patients and suggest how Oncotype DX assay could complement clinicopathological factors in helping clinicians on treatment selection.

The impact of endocrine therapy on sexual dysfunction in postmenopausal women with early stage breast cancer: encouraging results from a prospective study.

The goal of this project was to investigate the contentious issue of a possible effect of endocrine therapy (ET) on sexual dysfunction (SD) in postmenopausal early stage breast cancer survivors. To date, few studies have assessed sexual functioning prior to initiating ET and none have taken sexual distress into account when reporting the prevalence of ET-induced SD. We report the findings of a study on the change in SD (defined as experiencing sexual problems causing distress) during the first 6 months of ET usage. Between January 2009 and May 2011, 118 patients entered the study and 66 completed questionnaires prior to initiation of ET and after 6 months of use. Sexual functioning (SF) was evaluated with the female sexual function index while sexual distress was assessed with the female sexual distress scale (FSDS-R). Gynecological symptoms were measured with the FACT-B ES subscale. Over time, the level of gynecological symptoms increased (p < 0.001), whereas no decline in SF was observed. The percentage of women who reported experiencing at least one sexual problem (85 %) and the percentage who were sexually distressed (30 %) remained the same across time. Importantly, the change in the prevalence of SD between baseline (24 %) and 6 months (29 %) was not statistically significant. Women experiencing SD at baseline were more likely to experience SD after 6 months of ET usage (OR = 7.4, 95 % CI = 1.5-36.9) than women who had no SD prior to initiating ET. The observation that SF remained stable across time is encouraging news. However, longer follow-up and the inclusion of women who were premenopausal at diagnosis are needed to determine the potential influence of extended duration of ET (e.g., at least 5 years) on SD. Further studies, including assessing the impact of early identification of patients at risk of developing SD and timely intervention, are warranted.

A pilot study of prospective memory functioning in early breast cancer survivors.

AIMS: To evaluate prospective memory (PM) functioning in early breast cancer (BC) survivors and its association with fatigue and depression. METHODS: The Memory for Intention Screening Test, the Center for Epidemiologic Studies Depression Scale and the Functional Assessment of Cancer Therapy-Fatigue subscale were administered to 80 patients and 80 aged-matched healthy controls. RESULTS: Patients performed more poorly than controls on the memory test (p < 0.001) and had a higher rate of impairment (odds ratio = 5.5, p < 0.01). Fatigue mediated the relationship between Group membership and PM performance. CONCLUSIONS: BC survivors exhibited a clear pattern of PM deficit and fatigue was a major contributor to this deficit. This suggests that a common mechanism may be involved in fatigue symptoms and memory disturbances experienced by patients. Further research is needed to evaluate the role of adjuvant therapy in PM deficits and to explore whether interventions targeted at improving fatigue may also improve memory functioning in BC survivors.

Trust in physician in relation to blame, regret, and depressive symptoms among women with a breast cancer experience.

Following a diagnosis of breast cancer women experience considerable distress and often present with elevated symptoms of depression. A woman's relationship with her oncologist, and particularly trust in the physician, might influence depressive symptoms, as well as emotional and cognitive reactions to medical decisions made concerning treatment. To assess these relationships, women currently undergoing treatment for breast cancer (n = 40) and women who had previously been treated for breast cancer (n = 74) were asked about (1) trust in their physician, (2) who they blamed for negative events during treatment, (3) who made the treatment decisions, (4) regret, and (5) depressive symptoms. As well, community participants (n = 146) without breast cancer were asked about trust in their physician, levels of depression, and questions regarding blame if they hypothetically had breast cancer. Depression was greatest among women in treatment, and trust in physician was greatest among women posttreatment. However, trust in physician was neither related to depressive symptoms, decision making, nor responsibility for presence of metastases/relapse. Paradoxically, greater trust in physician was related to increased blame of the doctor for other negative events that had occurred. Furthermore, depressive scores were higher among women who blamed their doctor for negative events in comparison to women who ascribed blame to no one. As well, individuals who blamed themselves for negative events reported greater regret than individuals who blamed no one. Thus, though a woman may not hold her physician directly responsible for health outcomes, this relationship may be important to consider in other aspects of her psychological well-being.