Demographic, clinical, and geographical factors associated with lack of receipt of physician recommended chemotherapy in women with breast cancer in Texas.

PURPOSE: Identifying demographic, clinical, and geographical factors that contribute to disparities in the receipt of physician recommended chemotherapy in breast cancer patients. METHODS: The Texas Cancer Registry was used to identify women aged ≥ 18 years with invasive breast cancer diagnosed from 2007 to 2011 who received a recommendation for chemotherapy. Multivariable logistic regression was performed to determine associations between demographic and clinical factors and the receipt of chemotherapy. Cox proportional regression was used to estimate the hazard ratio (HR) for overall survival. Spatial analysis was conducted using Poisson models for breast cancer mortality and receipt of chemotherapy. RESULTS: Age ≥ 65 years, residence in areas with > 20% poverty index, and early disease stage were associated with lack of receipt of chemotherapy (all p < 0.001). Lack of receipt of chemotherapy was associated with decreased overall survival (HR 1.33, 95% CI 1.12-1.59, p = 0.001). A 38-county cluster in West Texas had lower receipt of chemotherapy (relative risk 0.88, p = 0.02) and increased breast cancer mortality (p = 0.03) compared to the rest of Texas. CONCLUSION: Older age, increased poverty and rural geographical location are barriers to the receipt of chemotherapy. Interventions that target these barriers may reduce health disparities and improve breast cancer survival.

Diagnosis and Management of High-Risk Breast Lesions.

Atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS) are nonmalignant breast lesions that confer a 4- to 10-fold increased risk for breast cancer in women. Often, AH and LCIS are diagnosed through breast biopsy due to a mammographic or palpable finding. Although AH and LCIS are benign breast disease, further management is necessary due to their high-risk nature and premalignant potential. Over the decades, management of AH and LCIS has changed as more is learned about these disease processes. This review explores the studies evaluating the risk for breast cancer in women with AH or LCIS and the clinical management of these lesions, which can include a combination of surgical excision, surveillance, and risk-reduction therapy.

Why Breast Cancer Risk by the Numbers Is Not Enough: Evaluation of a Decision Aid in Multi-Ethnic, Low-Numerate Women.

BACKGROUND: Breast cancer risk assessment including genetic testing can be used to classify people into different risk groups with screening and preventive interventions tailored to the needs of each group, yet the implementation of risk-stratified breast cancer prevention in primary care settings is complex. OBJECTIVE: To address barriers to breast cancer risk assessment, risk communication, and prevention strategies in primary care settings, we developed a Web-based decision aid, RealRisks, that aims to improve preference-based decision-making for breast cancer prevention, particularly in low-numerate women. METHODS: RealRisks incorporates experience-based dynamic interfaces to communicate risk aimed at reducing inaccurate risk perceptions, with modules on breast cancer risk, genetic testing, and chemoprevention that are tailored. To begin, participants learn about risk by interacting with two games of experience-based risk interfaces, demonstrating average 5-year and lifetime breast cancer risk. We conducted four focus groups in English-speaking women (age ≥18 years), a questionnaire completed before and after interacting with the decision aid, and a semistructured group discussion. We employed a mixed-methods approach to assess accuracy of perceived breast cancer risk and acceptability of RealRisks. The qualitative analysis of the semistructured discussions assessed understanding of risk, risk models, and risk appropriate prevention strategies. RESULTS: Among 34 participants, mean age was 53.4 years, 62% (21/34) were Hispanic, and 41% (14/34) demonstrated low numeracy. According to the Gail breast cancer risk assessment tool (BCRAT), the mean 5-year and lifetime breast cancer risk were 1.11% (SD 0.77) and 7.46% (SD 2.87), respectively. After interacting with RealRisks, the difference in perceived and estimated breast cancer risk according to BCRAT improved for 5-year risk (P=.008). In the qualitative analysis, we identified potential barriers to adopting risk-appropriate breast cancer prevention strategies, including uncertainty about breast cancer risk and risk models, distrust toward the health care system, and perception that risk assessment to pre-screen women for eligibility for genetic testing may be viewed as rationing access to care. CONCLUSIONS: In a multi-ethnic population, we demonstrated a significant improvement in accuracy of perceived breast cancer risk after exposure to RealRisks. However, we identified potential barriers that suggest that accurate risk perceptions will not suffice as the sole basis to support informed decision making and the acceptance of risk-appropriate prevention strategies. Findings will inform the iterative design of the RealRisks decision aid.

Alternative dosing regimen of exemestane in a randomized presurgical trial: the role of obesity in biomarker modulation.

In a 3-arm presurgical trial, four-six weeks exemestane 25 mg three times/week (TIW) was non-inferior to 25 mg/day (QD) in suppressing circulating estradiol in postmenopausal women with ER-positive breast cancer. Since obesity may decrease exemestane efficacy, we analyzed changes in sex steroids, adipokines, Ki-67, and drug levels in relation to obesity. Postmenopausal women with early-stage ER-positive breast cancer were randomized to either exemestane 25 mg QD (n = 57), 25 mg TIW (n = 57), or 25 mg/week (QW, n = 62) for 4-6 weeks before breast surgery. Serum and tissue pre- and post-treatment biomarkers were stratified by body mass index (BMI)< or ≥30 kg/m2. Post-treatment median exemestane and 17-OH exemestane levels were 5-6 times higher in the QD arm compared to the TIW arm. For obese women, TIW maintained comparable reductions to QD in systemic estradiol levels, although the reduction in estrone was less with the TIW regimen. There was less suppression of SHBG with the TIW versus the QD dose schedule in obese women which should result in less systemic bioavailable estrogens. Metabolically, the effect of the TIW regimen was similar to the QD regimen for obese women in terms of leptin suppression and increase in the adiponectin-leptin ratio. Reduction in tissue Ki-67 was less for obese women on the TIW regimen than QD, although changes were similar for non-obese women. Our findings suggest that TIW exemestane should be explored further for primary cancer prevention in both normal weight and obese cohorts.

Drug and biomarker tissue levels in a randomized presurgical trial on exemestane alternative schedules.

The drug's activity at the target tissue could help to define the minimal effective dose to promote cancer preventive therapy. Here we present exemestane and sex hormone concentrations within breast tissue from a pre-surgical study of alternative exemestane schedules. Postmenopausal women candidate for breast surgery for estrogen receptor-positive breast cancer were randomized to exemestane 25 mg once daily (QD), 25 mg three times/week (TIW), or 25 mg per/week (QW) for 4-6 weeks before surgery. Drug and sex hormones were analyzed from homogenized frozen tissue using a QTRAP 6500+ LC-MS/MS System. Tissue drug concentrations were detectable only in the QD arm with higher concentrations in non-malignant tissue. Estradiol was nearly suppressed in all groups in the non-malignant tissue (QD vs TIW p = .364 and QD vs QW p = .693). In contrast, a dose-response trend was observed in cancer tissue. Based on estradiol suppression in non-malignant tissue, lower exemestane schedules should be explored for breast cancer preventive therapy.

Phase I Dose Escalation Study of Topical Bexarotene in Women at High Risk for Breast Cancer.

PREVENTION RELEVANCE: Bexarotene is a rexinoid that has been shown to prevent mammary tumors in mouse models but oral dosing has toxicities. This phase I study evaluates topical bexarotene, as a potential chemoprevention agent, for safety and toxicity in high-risk women for breast cancer.

Clinical factors associated with adherence to aerobic and resistance physical activity guidelines among cancer prevention patients and survivors.

Physical activity (PA) is a known behavior to reduce cancer risk and improve cancer survivorship, yet adherence to PA guidelines is poor among the general population and cancer survivors. The purpose of this study was to determine the extent to which patients referred for exercise consultation within a clinical cancer prevention setting were meeting aerobic and resistance physical activity (PA) guidelines and to identify factors associated with guideline adherence. Between 2013 and 2015, cancer prevention patients and cancer survivors were interviewed by an exercise physiologist within an Integrative Health Program at The University of Texas MD Anderson Cancer Prevention Center. PA adherence was defined as at least 150-minutes of moderate-intensity or 75-minutes of vigorous-intensity PA per week, along with resistance training at least 2 days per week. Logistic regression was used to determine factors associated with meeting or not meeting PA guidelines for aerobic exercise, resistance exercise, and aerobic and resistance exercise combined. Among 1,024 cancer prevention patients and survivors, 9% of patients adhered to guideline-based PA. Adherence to aerobic and resistance guidelines were 20% and 12%, respectively. Overweight or obesity was associated with not meeting guideline-based PA in both cancer prevention patients and cancer survivors. Among breast cancer survivors, combination treatment with surgery, radiation, and chemotherapy ('multimodal therapy') was robustly associated with not meeting aerobic guidelines (OR 2.20, 95% CI: 1.17 to 4.16). BMI and breast cancer treatment history are key determinants of PA behavior among cancer prevention patients and survivors. Poor adherence to PA guidelines is a key issue for cancer prevention patients and survivors, particularly obese patients and women who receive multimodal therapy for breast cancer. Identifying and connecting patients at highest risk of poor PA adherence with exercise programs is needed to improve PA, a key modifiable cancer risk factor.

Whole body magnetic resonance imaging (WB-MRI) and brain MRI baseline surveillance in TP53 germline mutation carriers: experience from the Li-Fraumeni Syndrome Education and Early Detection (LEAD) clinic.

Individuals with Li-Fraumeni syndrome (LFS) have a significantly increased lifetime cancer risk affecting multiple organ sites. Therefore, novel comprehensive screening approaches are necessary to improve cancer detection and survival in this population. The objective of this study was to determine the diagnostic performance of whole body MRI (WB-MRI) and dedicated brain MRI screening as part of a comprehensive screening clinic called Li-Fraumeni Education and Early Detection (LEAD) at MD Anderson Cancer Center. Adult (≥21 year old) and pediatric (<21 year old) patients were referred to the LEAD clinic by healthcare providers or self-referred and screened at 6 month intervals. During the study period, 63 LFS individuals were seen in the LEAD clinic including 49 adults (11 male, 38 female) and 14 children (7 male, 7 female). Fifty-three of 63 potentially eligible individuals underwent baseline WB-MRI (41 adults and 12 children) with primary tumors detected in six patients, tumor recurrence in one patient and cancer metastases in one patient. Thirty-five of 63 patients (24 adults and 11 children) underwent baseline brain MRI with primary brain tumors detected in three individuals, also noted on subsequent WB-MRI scans. Three additional tumors were diagnosed that in retrospect review were missed on the initial scan (false negatives) and one tumor noted, but not followed up clinically, was prospectively found to be malignant. The high incidence of asymptomatic tumors identified in this initial screening (13%), supports the inclusion of WB-MRI and brain MRI in the clinical management of individuals with LFS.

Barriers and Facilitators to Patient-Provider Communication When Discussing Breast Cancer Risk to Aid in the Development of Decision Support Tools.

The purpose of this study was to identify barriers and facilitators to patient-provider communication when discussing breast cancer risk to aid in the development of decision support tools. Four patient focus groups (N=34) and eight provider focus groups (N=10) took place in Northern Manhattan. A qualitative analysis was conducted using Atlas.ti software. The coding yielded 62.3%-94.5% agreement. The results showed that 1) barriers are time constraints, lack of knowledge, low health literacy, and language barriers, and 2) facilitators are information needs, desire for personalization, and autonomy when communicating risk in patient-provider encounters. These results will inform the development of a patient-centered decision aid (RealRisks) and a provider-facing breast cancer risk navigation (BNAV) tool, which are designed to facilitate patient-provider risk communication and shared decision-making about breast cancer prevention strategies, such as chemoprevention.