Population Of Breast Cancer Survivors Research Articles

Abstract PS02-04: Associations of sleep health with quality of life among women with newly diagnosed breast cancer: baseline results from the AMBER cohort study

Abstract Background High incidence, ageing, and advancements in early detection and clinical treatment have led to a growing breast cancer survivor population, particularly in developed countries. Sleep problems are common and persist in this population, affecting over 50% of breast cancer survivors. Good sleep health is characterized by sleep duration, sleep timing and sleep quality, and these three dimensions do not necessarily correlate with each other. This analysis aimed to investigate the associations of sleep health, characterized by sleep duration, sleep timing, and a range of metrics for sleep quality (latency, efficient, disturbance, medication, daytime dysfunction) with physical and mental well-being in women with newly diagnosed breast cancer. Methods Newly diagnosed breast cancer patients, with early-stage disease were recruited between 2012-2019 in Edmonton and Calgary, Canada, and completed the Pittsburg Sleep Quality Index (PSQI) to assess the habitual sleep duration and timing, as well as sleep latency, efficiency, disturbance, medication and daytime dysfunction. To measure quality of life, participants completed the SF-36 version-2 to assess their physical and mental well-being. Multivariable linear regressions were used to estimate the association of sleep characteristics with physical and mental well-being, adjusting for socio-demographic, disease, clinical and lifestyle behaviour factors. Results Among 1409 breast cancer survivors, 41% reported short or long sleep duration ( < 6 or ≥9 h/d), 41% reported habitual bedtimes after 11pm, 56% reported sleep efficiency being < 85%, 80% reported fairly good (vs. very good) sleep disturbance, 35% reported taking sleep medication in the past month, and 71% reported fairly good, fairly bad or very bad (vs. very good) daytime function. In the multivariable model, short sleep (≤6/d) was associated with worse mental well-being (-3.6, 95%CI: -4.7,-2.4) but not physical well-being (-1.5, 95%CI: -2.3,-0.7). No clinically meaningful differences in quality of life were found for sleep timing. Metrics characterizing suboptimal sleep quality were associated with poorer physical and mental well-being, with stronger associations observed for mental health well-being. Notably, only 20% and 29% women were classified as “very good” in sleep disturbance and daytime dysfunction measures, respectively. Nevertheless, even “fairly good” sleep disturbance and daytime dysfunction were associated with statistically and clinically meaningful significant poorer physical (-3, 95%CI: -3.8,-2.2) and mental (-8, 95%CI: -9,-7) well-being. Conclusion Sleep timing does not appear to affect the quality of life in a clinically meaningful manner in women newly diagnosed with breast cancer. In contrast, short sleep duration and worse sleep quality were strongly associated with poorer mental well-being in these women. Targeted interventions to improve sleep may lead to improvements in the quality of life among women with newly diagnosed breast cancer. Table 1. Association of Sleep Characteristics with SF-36 Measured Quality of Life, Physical Well-Being. Table 2. Association of Sleep Characteristics with SF-36 Measured Quality of Life, Mental Well-Being. Citation Format: Lin Yang, Qinggang Wang, Jessica McNeil, Charles Matthews, Leanne Dickau, Jeff Vallance, Margaret McNeely, S. Nicole Culos-Reed, Karen Kopciuk, Kerry Courneya, Christine Friedenreich. Associations of sleep health with quality of life among women with newly diagnosed breast cancer: baseline results from the AMBER cohort study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS02-04.

Strategies to increase survey participation: A randomized controlled study in a population of breast cancer survivors

BackgroundData collection by mailing questionnaires to the study population is one of the main research methods in epidemiologic studies. As participation rates are decreasing, easy-to-implement and cost-effective strategies to increase survey participation are needed. In this study, we tested the effect of a pragmatic combination of evidence-based interventions. MethodsWe conducted a two-armed randomized controlled trial, nested in a cohort of breast cancer survivors (n = 1000) in the setting of a health outcomes survey. The intervention arm received a postal pre-notification, a non-monetary incentive (ballpoint with the study logo) and an alternative invitation letter in which several lay-out and textual adjustments were implemented according to behavioural science techniques. The alternative invitation letter also contained a QR-code through which an information video about the study could be accessed. The control arm was invited according to standard practice. Participants had the option to fill-out a questionnaire either on paper or online. A questionnaire with more than 50% of the questions answered classified as participation. ResultsOverall participation rate was 62.9%. No significant difference in participation rate was observed between intervention and control arm (64.5% vs 61.3%, Risk Ratio (RR) 1.05, 95% CI [0.96 – 1.16]). Older age at study (>65 vs <51 years), and high socio-economic status (highest vs lowest quartile) were associated with higher participation rates (RR 1.30, 95% CI [1.07 – 1.57] and 1.24, 95% CI [1.09 – 1.42] respectively). In-situ carcinoma compared to invasive cancer and longer interval since treatment were associated with lower participation (RR 0.86, 95% CI [0.74 – 0.99] and RR 0.92, 95% CI [0.87 – 0.99] per 5 year increase, respectively). ConclusionOverall, the combination of four interventions tested in this study did not improve survey participation among breast cancer survivors. The overall participation rate was relatively high, possibly due to the study population of cancer survivors.

Abstract LB151: Association of radiotherapy with the risk of subtype-specific lung cancer among breast cancer survivors in the United States

Abstract Background Breast cancer survivors face an elevated risk of subsequent primary lung cancer (SPLC), especially those who received radiotherapy. Nevertheless, the association of radiotherapy for breast cancer and the risk of subtype-specific lung cancer is unknown. Methods Females diagnosed with first primary breast cancer at ages 20-84 years from 1992-2020 were identified from 12 Surveillance, Epidemiology, and End Results registries. Follow-up began at 2 months from breast cancer diagnosis and ended at subsequent lung cancer diagnosis, last known vital status, death, or December 31, 2020. Standardized incidence ratios (SIRs) and excess absolute risks (EARs, per 10,000 women) were calculated for each histological subtype of lung cancer (adenocarcinoma, squamous cell carcinoma, small cell carcinoma, large cell carcinoma, and others) using expected rates of each subtype in the SEER population. Subgroup analyses were conducted by treatment for breast cancer (radiotherapy yes or no/unknown), overall and stratified by the relative position (ipsilateral and contralateral) of the breast and SPLC. Results Of all 550,007 breast cancer survivors (&amp;gt;50 years old, 74%; non-Hispanic Whites, 67%; localized, 51%), 8,014 SPLCs were diagnosed during a mean follow-up of 9.7 years. 52.6% of the participants received radiotherapy treatment. Compared with the general population, breast cancer survivors had a statistically significantly higher risk of lung cancer with subtype-specific SIR being greatest for adenocarcinoma (Observed N=4337; SIR=1.20, 95% Confidence Interval [CI]=1.16-1.24; EAR=1.35), followed by squamous cell carcinoma (Observed N=1368; SIR=1.11, 95% CI=1.05-1.17; EAR=0.26) and small cell carcinoma (Observed N=1026; SIR=1.08, 95% CI=1.02-1.15; EAR=0.14). When stratified by radiotherapy receipt, the increased risk associated with adenocarcinoma did not vary across strata. In contrast, the increased risk for squamous and transitional cell carcinoma and small cell carcinoma were confined to those who received radiotherapy (SIR=1.16, 95% CI=1.08-1.24 vs SIR=1.06, 95% CI=0.98-1.15 for squamous and transitional cell carcinoma; SIR=1.15, 95% CI=1.06-1.25 vs SIR= 1.00, 95% CI=0.91-1.09 for small cell carcinoma). Further analysis by laterality showed that associations of treatment receipt with increased risk of lung cancer were confined to ipsilateral SPLC for these two subtypes. Conclusion Different subtypes of lung cancer may have distinct associations with prior radiation treatment in individuals who have survived breast cancer. The findings have implications for evaluating risks and implementing surveillance for subsequent primary lung cancer in the growing population of breast cancer survivors. Citation Format: Chenxi Jiang, Rachel A. Freedman, Ahmedin Jemal, Hyuna Sung. Association of radiotherapy with the risk of subtype-specific lung cancer among breast cancer survivors in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB151.

Abstract 3474: Racial disparities in receipt of surveillance mammography after breast cancer diagnosis

Abstract Background: The 5-year survival rate for breast cancer (BC) stands at an estimated 91%, with approximately 3.8 million BC survivors in the U.S. This large population of breast cancer survivors remains at risk of loco-regional recurrence, with variations noted across racial groups. White survivors face a locoregional breast cancer recurrence rate of 1.8%, whereas Black, Asian, and Hispanic survivors experience higher rates of 3.9%, 3.6%, and 3.1%, respectively. Notably, Black BC survivors with recurrent breast cancer exhibit a median survival time of 1.8 years compared with 3.6 years observed for White BC survivors. Current recommendations from the U.S. Preventative Services Task Force and the American College of Radiology advocate for surveillance through annual mammography and routine clinical visits following breast-conserving surgery and lumpectomies. However, there are gaps in the data available regarding disparities in the utilization of surveillance mammography by race/ethnicity. Thus, the goal of this study is to estimate race/ethnic disparities in surveillance mammography utilization and its impact on survival among breast cancer survivors at a large comprehensive cancer center. Methods: A retrospective cohort study of female breast cancer survivors ≥19 years diagnosed and/or treated at the Duke Cancer Institute (DCI) between 2014 and 2022 was conducted. Data was abstracted on patient socio-demographics, cancer type (invasive ductal and ductal in situ carcinomas) and utilization of surveillance mammography within 2-5 years post initial breast cancer diagnosis. Chi-squared testing will be used to analyze rates of mammography surveillance receipt among different races presenting with BC at DCI. Kaplan-Meier estimates will be used for analysis on survival. Results: A total of 10,904 women with a mean age of 43.7 years were included in the study. The study cohort is comprised of 69% non-Hispanic (NH) White, 24% NH Black, 2.2% Hispanic, 0.5% NH Native American, 1% NH other, and 3.2% NH Asian women. There were 1,791 cases of ductal in situ carcinomas and 9,113 invasive ductal carcinoma cases. NH Black women had the lowest 5-year relative survival rate (81.5%) of all represented racial groups: NH White 89.1%, Hispanic 95.3%, NH Native 87.8%, Asian 97.9%, and NH Other 88.0%. Ongoing analysis will be completed to estimate disparities in the use of post-treatment surveillance mammography amongst breast cancer survivors. Conclusions: This study will inform efforts to increase post-treatment surveillance and improve adherence to survivorship guidelines with the ultimate goal of reducing mortality disparities among breast cancer survivors. Citation Format: Jasmine G. Wilkerson, Frances Wang, Yadurshini Raveendran, Tomi Akinyemiju. Racial disparities in receipt of surveillance mammography after breast cancer diagnosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3474.

The voice of the breast cancer survivor: Implementation of survivorship needs assessment in an integrated health system.

488 Background: The population of breast cancer survivors in the US has reached 3.8 million in 2022, underscoring the importance of understanding survivor needs. To address whether assessment of patient needs is feasible and leads to actionable findings, we implemented a breast cancer survivor needs assessment with standardized documentation of actions taken in the electronic medical record. Methods: An adapted NCCN evaluation tool (Coleman Tool) was used in survivorship visits to assess the feasibility of needs assessment from January 2022 to June 2022 as part of a quality improvement project. The assessment was done either electronically via secure health portal prior to the visit or in person at the time of the visit. Patient, tumor, treatment characteristics as well as needs identified, and actions taken were abstracted from the electronic medical record. Fisher’s exact test used for comparisons. Results: Patients were ethnically diverse (43% White, 39% Asian, 13% Hispanic, African American 4%), English speaking (82%), and employed (50.5%). The median time from cancer diagnosis to needs assessment was 884 days. Most of the patients had Stage 1A (38.2%), were ER (91.7%) and PR (77.8%) positive and HER2 negative (73.7%). The majority underwent lumpectomy (66.4%), had radiation therapy (67.7%) and hormonal therapy (81.6%). Only 32.3% received chemotherapy. Most patients received some form of needs assessment (202 of 217, 94.0%), with 59 (29.2%) receiving pre-appointment electronic assessments with a 42.4% response rate. Major domains of needs reported by patients and actions taken are mentioned below in the table. Both pre and at visit assessments noted a high degree of treatment and physical needs that lead to subsequent actions (p value of 1.00 and 0.04 respectively). Conclusions: An adapted NCCN Needs Assessment Tool (Coleman Tool) is a practical and feasible method of assessing breast cancer survivors’ needs. The assessment can be done pre or at visit and can lead to actions which improve survivorship care.[Table: see text]

THU485 The Impact Of Cured, Fried Bacon On The Reemergence From Breast Cancer Dormancy

Abstract Disclosure: C.P. Schane: None. A. Nelczyk: None. C. Chen: None. H. Vidana Gamage: None. M. Kadiri: None. M.T. McHenry: None. S. Bendre: None. N. Krawczynska: None. M.A. Henn: None. D.C. Castro: None. J. Chen: None. R.I. Tejeda: None. S. Hsiao: None. N.J. Engeseth: None. J.V. Sweedler: None. M.K. Wendt: None. T. Fan: None. W.G. Helferich: None. E.R. Nelson: None. One in eight women will develop breast cancer in her lifetime, with metastasis being the leading cause of mortality. Once the cells colonize the metastatic site, they do not always immediately begin to proliferate, but remain dormant. These dormant cells reside in the tissue, until mechanisms, which remain unknown, awaken the dormant cells and they resume malignant proliferation. Due to the large and growing population of breast cancer survivors at risk of metastatic recurrence, there is an urgent need to elucidate the mechanisms of dormancy and develop therapeutics to prevent reemergence. Elevated levels of circulating cholesterol are a risk factor for breast cancer recurrence. Preclinical work has demonstrated that oxysterol cholesterol metabolites such as 27-hydroxycholesterol (27HC) can promote tumor metastasis. Here, we show that exogenous 27HC lead to a more rapid reemergence from dormancy, using the syngeneic mouse D2.0R model of mammary cancer dormancy. Since it would be expected that cooking high cholesterol foods, such as bacon, under oxidative conditions, such as pan-frying, would produce fat containing cancer-promoting cholesterol metabolites, we hypothesized that consumption of such cooked foods would also promote reemergence from dormancy. Interestingly, consumption of cured, fried bacon fat (cfBF), but not uncured fried bacon fat (ufBF) resulted in reemergence. When metastatic tissues were assessed, it was found that consumption of cfBF dramatically reduced mast cell numbers. Since mast cells (MC) are major contributors to local histamine production, we next tested whether various anti-histamines could alter dormancy. This led to the striking finding that H2 antagonists promoted the breaking of dormancy. Our ongoing work is aimed at further elucidating this novel metastatic axis: Diet - MC - H2 - Dormancy, with the ultimate goal of leveraging it to develop novel therapeutic targets or lifestyle interventions. Therefore, our results are expected to provide the foundation for dietary and medical approaches to reduce the risk of recurrence among breast cancer survivors. This work was supported by the American Institute for Cancer Research grant (713063), the National Cancer Institute (R01CA234025) and Department of Defense Breast Cancer Research Program Era of Hope Scholar Award (BC200206). Further support awarded to ATN from a National Institutes of Environment Health Sciences and Research Training in Toxicology and Environmental Health (T32) Fellowship (ES007326). Presentation: Thursday, June 15, 2023

Diabetes mellitus in breast cancer survivors: metabolic effects of endocrine therapy.

Breast cancer is the most common invasive malignancy in the world, with millions of survivors living today. Type 2 diabetes mellitus (T2DM) is also a globally prevalent disease that is a widely studied risk factor for breast cancer. Most breast tumours express the oestrogen receptor and are treated with systemic therapies designed to disrupt oestrogen-dependent signalling. Since the advent of targeted endocrine therapy six decades ago, the mortality from breast cancer has steadily declined; however, during the past decade, an elevated risk of T2DM after breast cancer treatment has been reported, particularly for those who received endocrine therapy. In this Review, we highlight key events in the history of endocrine therapies, beginning with the development of tamoxifen. We also summarize the sequence of reported adverse metabolic effects, which include dyslipidaemia, hepatic steatosis and impaired glucose tolerance. We discuss the limitations of determining a causal role for breast cancer treatments in T2DM development from epidemiological data and describe informative preclinical studies that suggest complex mechanisms through which endocrine therapy might drive T2DM risk and progression. We also reinforce the life-saving benefits of endocrine therapy and highlight the need for better predictive biomarkers of T2DM risk and preventive strategies for the growing population of breast cancer survivors.

Curcumin for Aromatase Inhibitor-Induced Joint Pain in Breast Cancer Survivors - The CurPain Trial: A Randomized, Double-Blind, Phase III, Multicenter Clinical Trial

Introduction: Adjuvant treatment with aromatase inhibitors (AIs) is extremely important in hormone-positive breast cancer survivors, reducing the early recurrence of the disease. Arthralgia and musculoskeletal symptoms resulting from AIs-toxicity can be observed in approximately one-third of the treated patients and are the leading cause of AIs-treatment discontinuation. However, there is no sufficient standard treatment. Analgesic and anti-inflammatory effects of curcumin in chronic joint pain are reported. This study protocol will determine whether curcumin supplementation reduces joint pain in breast cancer survivors under AIs therapy. Methods: This study protocol is a phase III, randomized, blinded, placebo-controlled, multicentric, parallel arm design. The study population targets post-menopause women with stage I, luminal, unilateral, non-metastatic, receptor-positive breast cancer after breast-conserving surgery healed per primary intention. 160 participants will be enrolled. Daily curcumin supplementation (500 mg thrice daily) for twelve weeks is planned. Brief Pain Inventory-Worst Pain (Δ BPI-WP) will assess joint pain change after twelve weeks of follow-up as the primary outcome. Secondary outcomes include Quality of Life assessed by Functional Assessment of Cancer Therapy-Breast, further Brief Pain Inventory-Short Form items, Patient Health Questionnaire-8, and Quantitative Analgesic Questionnaire at six and twelve weeks. Discussion: We present a randomized clinical trial to provide scientific evidence that supports the efficacy of curcumin supplementation on joint pain alleviation, pain-relieving medication reduction, and AIs-treatment adherence improvement in a predefined breast cancer survivor population.

Racial disparities in major cardiovascular and cerebrovascular adverse events in breast cancer survivors: A nationwide analysis

Background: Improved survival outcomes in breast cancer has brought attention to major cardiovascular and cerebrovascular adverse events (MACCE). Racial disparities in these events among breast cancer survivors are understudied. Methods: Using National Inpatient Sample datasets (October 2015-December 2017, ICD-10-CM), we investigated racial disparities in the hospitalized breast cancer survivors for MACCE. They were further sub-categorized on the basis of prior chemotherapy or radiation therapy (CT/RT). Results: Of 1,301,320 breast cancer survivor women, 75.8% were White, 11.3% were Black, and 16.1% had prior CT/RT. All-cause in-hospital mortality was highest in Asian or Pacific Islanders (3.2%) in the whole breast cancer survivor population; and in Native Americans (4.7%) in CT/RT subgroup. Native Americans (4.1%) had the highest incidence of acute myocardial infarction (AMI) in the overall population, whereas White patients (2.9%) predominated in CT/RT subgroup. White patients (29.6%) had the highest prevalence of arrhythmia, regardless of the prior CT/RT. For strokes, Asian or Pacific Islanders (3.9%) and Black patients (3.8%) had a higher prevalence. All-cause mortality, AMI, arrhythmia, and stroke had the highest adjusted odds in Asian or Pacific Islanders (1.19), Native Americans (1.31), White patients (1), and Black patients (1.12) respectively. Black patients had the lowest quartile income and a longer median stay. White patients had the highest transfer to nursing facilities, whereas Asian or Pacific Islanders had the highest mean hospital expenditures. Conclusions: Racial disparities exist in MACCE among breast cancer survivors. Further research, especially pooling and analyzing real-world data is needed on the prevalence of MACCE in breast cancer survivors, particularly in subgroups with different cancer-related treatments.

The voice of the breast cancer survivor: Implementation of survivorship needs assessment in an integrated health system.

e24180 Background: The population of breast cancer survivors in the US has reached 3.8 million in 2022. In times of standardized and guideline driven oncologic treatment, individual patients continue to have multitude of unique needs that may impact their long-term survival outcomes. To address whether assessment of patient needs is feasible and leads to actionable findings, we implemented a breast cancer survivor needs assessment with standardized documentation of actions taken in the electronic medical record. Methods: An adapted NCCN evaluation tool (Coleman Tool) was used in survivorship visits to assess the feasibility of needs assessment from January 2022 to June 2022 as part of a quality improvement project. The assessment was done either electronically via secure health portal prior to the visit or in person at the time of the visit. Patient, tumor, treatment characteristics as well as needs identified, and actions taken were abstracted from the electronic medical record. Fisher’s exact test used for comparisons. Results: Patients were ethnically diverse (43% White, 39% Asian, 13% Hispanic, African American 4%), English speaking (82%), and employed (50.5%). The median time from cancer diagnosis to needs assessment was 884 days. Most of the patients had Stage 1A (38.2%), were ER (91.7%) and PR (77.8%) positive and HER2 negative (73.7%). The majority underwent lumpectomy (66.4%), had radiation therapy (67.7%) and hormonal therapy (81.6%). Only 32.3% received chemotherapy. Most patients received some form of needs assessment (202 of 217, 94.0%), with 59 (29.2%) receiving pre-appointment electronic assessments with a 42.4% response rate. Major domains of needs reported by patients and actions taken are mentioned below in the table. Both pre and at visit assessments noted a high degree of treatment and physical needs that lead to subsequent actions (p value of 1.00 and 0.04 respectively). Conclusions: An adapted NCCN Needs Assessment Tool (Coleman Tool) is a practical and feasible method of assessing breast cancer survivors’ needs. The assessment can be done pre or at visit and can lead to actions which improve survivorship care. [Table: see text]

Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors.

Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors. During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity. The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed. In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Abstract P3-03-23: Breast Cancer and Subsequent Risk of Type 2 Diabetes Mellitus: A systematic review and Meta-Analysis

Abstract Introduction Due to improvements in breast cancer (BC) diagnostics and treatment, the population of BC survivors is growing. BC treatments may have adverse effects that lead to an increased risk of developing type 2 diabetes mellitus (T2D). It is therefore important to investigate the risk of T2D in patients with BC in general and according to type of adjuvant BC treatment. Objectives To conduct a systematic review and meta-analysis investigating the association between early BC and the risk of subsequent T2D diagnosis. A secondary aim was to examine this association according to type of adjuvant BC treatment––chemotherapy and endocrine therapy (ET). Methods We searched PubMed and Embase using variations of the search terms breast cancer (population), ET, tamoxifen, aromatase inhibitors (AIs) and chemotherapy (exposures), and diabetes mellitus (outcome). Two authors screened papers for eligibility by title and abstract using Covidence and reviewed full texts of eligible papers. Guided by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist, study data were extracted. Using random-effects models, we calculated relative risks (RRs) and associated 95% confidence intervals (CIs) for the association between BC, adjuvant BC treatment (ET overall, tamoxifen, and AIs), and subsequent T2D. We used funnel plots to assess publication bias in the analyses. Results Among 16 eligible studies, 11 reported on T2D risk after BC, chemotherapy, or ET; five studies investigated more than one association. Compared with patients without BC, those with BC had elevated risk of T2D overall (RR=1.27, 95%CI=1.15-1.41), particularly those who received any ET (RR=1.23, 95% CI=1.16-1.32). Among BC patients only, risk of T2D was higher for those who received tamoxifen compared with those who did not receive tamoxifen (RR=1.19, 95% CI=1.13-1.25). Due to few studies, analyses investigating T2D risk after treatment with AIs and chemotherapy were inconclusive. Conclusion Our findings support an association between BC and subsequently elevated risk of T2D, particularly after tamoxifen use. Further research is needed to determine the impact of ET overall, AIs and chemotherapy on the incidence of T2D in patients with early BC. Funding This project was funded from the following source: The Novo Nordisk Foundation (NNF20OC0065928) Citation Format: Nanna Jordt, Kasper Kjærgaard, Signe Borgquist, Reimar W. Thomsen, Deirdre Cronin-Fenton. Breast Cancer and Subsequent Risk of Type 2 Diabetes Mellitus: A systematic review and Meta-Analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-03-23.

Risk Factors, Patterns, and Distribution of Bone Metastases and Skeletal-Related Events in High-Risk Breast Cancer Patients

More than a quarter of breast cancer patients are at risk to develop recurrent metastases to the bone. This study was designed to identify risk factors and predilections of bone metastasis and skeletal-related events (SRE) in a population of breast cancer survivors initially diagnosed in advanced stages and with high-risks of relapse. Associated risk factors, distribution, and attainable treatment of bone metastasis and SRE were analyzed in a cohort of 1,329 breast cancer patients. The association with dependent variables was subsequently analyzed using multivariable logistic regression. Sociodemographic and adverse clinical characteristics were included as covariates of progression into bone metastasis and SREs. Of 1329 breast cancer patients, 246 patients (18.5%) were diagnosed as metastatic breast cancer in which 232 of them (94.3%) had bone metastases. Spines were the most common sites of bone metastases (25.6%). In multivariable analysis, advanced stage at diagnosis (OR=1.840, 95%CI:1.198-2.826, P=0.005), luminal subtype (OR=1.788, 95%CI:1.206-2.652, P=0.045), lobular histology (OR=1.795, 95%CI:1.012-3/184, P=0.046), positive axillary lymph node (OR=1.771, 95%CI:1.087-2.886, P=0.022), multiple metabolic comorbidities (OR=2.193, 95%CI:1.371-3.508, P=0.001), early menopause (OR=2.136, 95%CI:1.116-4.464, P=0.046) were significantly associated with risk of recurrent bone metastases. SREs occurred in 89 (68.5%) patients. Several risk factors for SREs were early menopausal age (OR=2.342, P=0.024), advanced stages (OR=1.404, P=0.039), lobular histology (OR=2.279, P=0.007), and having multiple metabolic comorbidities (OR=1.728, P=0.039). Bone metastases and SREs are relatively high in breast cancer patients diagnosed in advanced stages. Luminal subtypes, having multiple metabolic comorbidities, and lobular histology are associated with higher risks of recurrent bone metastases. Living in rural areas and advanced stage at diagnosis as a risk factors for bone metastases might represent a social gradient of care delivery.

Body composition changes in a 12-week exercise intervention for breast cancer patients.

e12500 Background: Evidence has linked weight gain and obesity to increased breast cancer risk, poorer outcomes, decreased survivorship, and increased risk of recurrence. Adjuvant therapies can increase weight gain, making tailored exercise interventions beneficial in maintaining a healthy weight. In this study, body composition changes were examined after a 12-week exercise program in a cohort of breast cancer survivors. Methods: The Breast Cancer Exercise Rehabilitation Research Study recruited breast cancer survivors to undergo a 12-week exercise program (NCT04013568) and examine body composition changes. Measurements taken included anthropometry (waist circumference, waist-to-hip ratio, BMI), DXA body composition measurements (fat mass-visceral and subcutaneous, trunk to limb, muscle mass-appendicular, and whole body), and BIA (Bio-electrical Impedance Analysis-muscle, fat, and water). 34 participants completed the exercise program and baseline and post-12-week measurements were obtained. Descriptive statistics and a paired t-test analysis was done to analyze changes in body composition using SAS onDemand. A correlation analysis between measurements simple to do in clinic and DXA measurements were run to determine proxy use for DXA. Results: After a 12-week exercise program, reductions in body fat via DXA scan, BIA, and InBody (whole body fat, whole body fat %, trunk fat, leg fat, body fat %, hip width at maximum girth, body fat mass, and percent body fat) were observed. Additionally, increases in lean mass (Appendicular Lean Mass (ALM)/height2, Appendicular Lean/height2, ALM index, and lean body mass), whole body mass measured by DXA, basal metabolic rate, water retention (extracellular water and total body water), and skeletal muscle mass were observed. Correlation analysis revealed BMI can be used as a surrogate measure for whole body mass measured by DXA (r=0.91, p&lt;0.001) and can be utilized to measure change over time. Skinfold sum showed moderate correlation for measuring subcutaneous fat mass by DXA (r=0.45, p=0.0096). Conclusions: In our population of breast cancer survivors, a 12-week exercise program did show various changes in body composition according to InBody, DXA, and BIA measurements. DXA and InBody measurements were feasible, making it readily available for patients. Additionally, simple measures such as BMI and skinfold sum showed moderate to strong correlation with DXA measurements, validating use of these measurements in routine practice. Clinical trial information: NCT04013568. [Table: see text]

Work ability 8 years after breast cancer: exploring the role of social support in a nation-wide survey

IntroductionAs the 5-year survival rate after breast cancer in Norway is 92%, the population of breast cancer survivors (BCSs) is increasing. Knowledge of work ability in this population is scarce. In a population-based cohort of BCSs, we explored work ability 8 years after diagnosis and the association between work ability and social support, and cancer-related variables including late effects and lifestyle factors.MethodsIn 2019, all Norwegian women < 59 years when diagnosed with stage I–III breast cancer in 2011 or 2012, were identified by the Cancer Registry of Norway and invited to participate in a survey on work life experiences. Work ability was assessed using the Work Ability Index (scale 0–10). Factors associated with excellent work ability (score ≥ 9) were identified using univariate and multivariate logistic regression analyses, and adjusted for socioeconomic-, health- and cancer-related variables.ResultsOf the 1951 eligible BCSs, 1007 (52.8%) responded. After excluding survivors with relapse (n = 1), missing information on work ability score (n = 49), or work status (n = 31), the final sample comprised 926 BCSs within working age at survey (< 67 years).Mean age at survey was 56 years and 8 years (SD 0.7) had passed since diagnosis. Work ability had been reduced from 8.9 (SD 2.3) at diagnosis to 6.3 (SD 3.1). One in three BCSs reported poor work ability (WAS ≤ 5), and seven out of ten reported that their physical work ability had been reduced due to cancer. Social support from colleagues during cancer therapy was associated with excellent work ability, which was not observed for social support provided by supervisors or the general practitioner. Cognitive impairment and fatigue were inversely associated with work ability. None of the cancer-related variables, including treatment, were associated with work ability 8 years after diagnosis.ConclusionIn this population-based sample, one in three BCSs reported poor work ability 8 years after diagnosis. Collegial social support during cancer therapy appears to be a protective factor for sustained work ability, whilst survivors struggling with fatigue and cognitive impairments may represent a particularly vulnerable group for reduced work ability.

Abstract P4-11-25: Burden of financial toxicity in an underserved population of breast cancer survivors

Abstract Background: The impact of financial toxicity (FT) on cancer patients is significant in terms of lost productivity and poor quality of life (QoL). Past studies have reported negative influence of high FT on patients actively undergoing treatment for breast cancer. However, existing data largely comes from quaternary referral centers, and the populations surveyed may not be generalizable in terms of income and insurance status across the United States. There is also limited understanding regarding the relationship between FT measured throughout the continuum of cancer care, demographics, disease factors, and QoL indicators in breast cancer survivors, particularly those from underserved communities. Methods: Breast cancer survivors who received treatment between 2015 and 2019 at Loma Linda University Cancer Center located in San Bernardino County, CA were invited to complete an anonymous online survey assessing demographics, disease history, FT, and QoL. A modified version of the Comprehensive Score for Financial Toxicity (COST) survey was used to assess FT at baseline and after treatment. The patient-reported outcomes measurement information system (PROMIS) survey was used to assess QoL. Demographic data were summarized using descriptive statistics. Associations between disease factors and FT measured at baseline and after treatment were analyzed using multivariable linear regression. Positive COST score coefficients indicate lower FT, while negative COST score coefficients indicate higher FT. Correlations between FT and QoL were evaluated using the Pearson correlation. Results: A total of 407 surveys were sent to breast cancer survivors who met study criteria, of whom 16% responded. Amongst 65 patients included in this analysis, the median age was 64 (IQR 56, 70), 68% were white (n = 44), 18% were unemployed, 13% had a high school or lower level of education, and 16% had an annual income &amp;lt; $30,000. Mean COST score at baseline and after treatment were 21.6 ± 9.6 and 12.9 ± 7.8, respectively. During treatment, 21% of patients turned down or skipped treatment, 23% quit their job, and 15% reported family members quit their job. At baseline, lower FT was significantly associated with age &amp;gt; 80 (6.2 95% CI: 4.1 to 8.3), presence of a college (4.5 95% CI: 1.4 to 10.4) or graduate degree (5.2 95% CI: 4.7 to 6.2), current employment (2.7 95% CI: 2.0 to 3.4), retiree status (6.7 95% CI: 0.4 to 13.0), and household income &amp;gt; $30,000 (5.9 95% CI: 2.7 to 9.1) (p &amp;lt; 0.05), while higher FT was significantly associated with Hispanic ethnicity (-4.1 95% CI: -6.7 to -1.5), Medicare (-1.6 95% CI: -5.2 to -2.0), and Medicaid insurance (-6.9 95% CI: -12.5 to -1.2) (p &amp;lt; 0.05). After treatment, higher FT was significantly associated with receiving 3 or more combined modality treatments (-5.6 95% CI: -9.7 to -1.5) and having 5 or more treatment-related side effects (-6.0 95% CI: -10.4 to -1.6) (p &amp;lt; 0.05). Finally, FT after treatment overall correlated positively with physical and mental health (Pearson coefficient 0.63 and 0.60 respectively, p &amp;lt; 0.01). Conclusions: These findings suggest a significant association between FT, baseline demographics, treatment modalities, side effects, and quality of life in an underserved population of breast cancer survivors. In the future, FT should be assessed at baseline and throughout the continuum of breast cancer care to provide individualized assistance to patients facing financial strain, as it affects compliance to treatment which in turn can adversely affect cancer-related outcomes and QoL. Additional policies are needed to address the increasing cost of breast cancer care. Citation Format: Akhil Mehta, Jukes Namm, Ellen D'Errico, Eric Lau, Sharon Lum, Gayathri Nagaraj. Burden of financial toxicity in an underserved population of breast cancer survivors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-25.

Current practice patterns and gaps in guideline-concordant breast cancer survivorship care

PurposeBreast cancer-specific survivorship care guidelines for the more than 3.8 million survivors in the U.S. are available, but implementation in clinical practice remains challenging. We examined current practice patterns and factors associated with guideline-concordant survivorship care among oncologists.MethodsA national sample of medical oncologists, recruited using two databases, participated in a survey focused on practice patterns for breast cancer survivorship care. A “survivorship care composite score” was calculated for each respondent based on provision of services recommended in the survivorship guidelines. Descriptive statistics and multivariable linear regression analyses examined associations between physician and practice characteristics and composite scores.ResultsThe survey was completed by 217 medical oncologists, with an overall response rate of 17.9% and eligibility rate of 56.9% for those who responded. Oncologists reported high engagement in evaluation of disease recurrence (78%). Performed less frequently were the provision of survivorship care plans (46%), assessment of psychosocial long-term and late effects (34%), and screening for subsequent cancers (34%). Lack of survivorship care training (p = 0.038) and not routinely informing patients about potential late effects (p = 0.003) were significantly associated with poorer survivorship care composite scores.ConclusionsDespite the availability of disease-specific survivorship care guidelines, adherence to their recommendations in clinical practice is suboptimal. Survey results identified key gaps in survivorship care for breast cancer survivors, particularly related to subsequent primary cancers and psychosocial long-term and late effects.Implications for Cancer SurvivorsImproving the delivery of comprehensive survivorship care for the growing population of breast cancer survivors is a high priority. Disease-specific clinical guidelines for cancer survivorship provide valuable recommendations, but innovative strategies are needed to integrate them into the care of long-term breast cancer survivors.

Impact of diabetes and other comorbidities on cardiovascular mortality in elderly breast cancer patients

Breast cancer (BC), like most cancer, is a disease of aging. According to the Surveillance Epidemiology and End Results registry, the median age of BC diagnosis is 62 with 40% > 65 years, among whom 16% additionally suffer from diabetes mellitus (DM). As survival time increases with more effective treatment, CVD risk factors (CVDRF) are now increasing in this aging population. The aim of this study was to assess the impact of DM and other CVDRF on cardiovascular disease (CVD) mortality in elderly BC patients. This retrospective study included women aged > 55 who were initially diagnosed with BC recruited from the registry of the cardio-oncology unit of Casablanca, Morocco, from January 2014 to March 2021. Patients were divided into 4 categories: no comorbidity, DM only, DM and other comorbidity or other comorbidity without DM. Overall, 1843 patients with non-metastasized BC were included. Mean age of our series was 61.3 years, comorbidities at baseline prior to BC were: hypertension in 19.3%, DM in 9.8%, dyslipidemia in 11.8% and obesity in 10.4%. In our series, the short-term Overall survival (OS) was higher in patients with DM only compared with patients without comorbidity (HR: 1.16, 95% CI: 0.85–1.88) ( P = 0.037) and similar with those with other comorbidity without DM (HR: 0.76, 95% CI: 0.48–0.92) ( P = 0.066), while patients with DM and additional comorbidity had the worst short-term OS (HR: 1.82, 95% CI: 1.54–2.16) ( P < 0.001) especially in patients aged ≥ 75 years ( P = 0.028). In our study, among elderly BC patients, diabetes mellitus is associated with poorer prognosis and shorter OS compared to patients without any comorbidity, especially if associated with additional comorbidities such as hypertension, dyslipidemia and obesity. Larger registries to better understand the true incidence of CVD and the utility of current treatments would be invaluable for this growing population of breast cancer survivors.

Assessment of the prognostic role of body mass index on breast cancer survivors: A Moroccan center experience

Positive association between elevated body mass index (BMI) and reduced survival in breast cancer (BC) women was demonstrated in previous meta-analyses of published data. Meanwhile, recent studies have reported that low BMI was associated with BC recurrence and overall mortality, which is paradoxical. The aim of our study was to evaluate the impact of BMI on mortality risk in a population of BC survivors. This retrospective study included 2284 female BC survivors recruited from the registry of the cardio-oncology unit of Casablanca between 2014 and 2021. BMI defined by the WHO criteria as follow: underweight (UW; BMI < 18.5 kg/m 2 ), normal weight (NW; BMI = 18.5–24.9 kg/m 2 ) and overweight or obese (OW; BMI ≥ 25 kg/m 2 ). We performed to evaluate the association between low BMI and clinical outcome in BC patients. The clinicopathological characteristics and clinical outcomes of patients after BC diagnosis were analyzed. In our study, 9.2% patients were UW and 23.9% were OW. OW group was associated with older age, larger size tumors, and higher cardiotoxicity ( P = 0.032, 0.025, P < 0.001, respectively). The overall survival (OS) decreased in OW patients ( P = 0.014), and both OW and obesity were independent predictors for increased risks of BC relapse and death ( P = 0.028). On the other hand, UW was more prominent in young women ( P = 0.018) and no significant association was found between BC recurrence rate and the UW group ( P = 0.082 and 0.056, respectively). However, multivariate regression analysis found that low BMI was an independent OS prognostic factor in young patients [HR: 1.72 (95% CI: 1.18–2.32), P = 0.029]. Our results demonstrate the prognostic role of BMI on BC survivors that might depend on patients’ age and clinical stage. Both overweight and underweight might be independently associated with poorer prognosis in BC patients. Efforts should be made to maintain BC patients in normal weight in order to improve survival.

Late effects in a high-risk population of breast cancer survivors.

To better understand the impact of cancer and treatment on outcomes and guide program development, we evaluated breast cancer survivors at risk for long-term medical and psychosocial issues who participated in survivorship care visits (SVs) at Johns Hopkins Hospital. We conducted a prospective survey study of women with stage I-III breast cancer who participated in SVs from 2010-2016. The same 56-item questionnaire administered at SV and follow-up included an assessment of symptoms, social factors, demographics, anxiety, depression, and comorbidities. We added the Godin Exercise questionnaire to the follow-up. In 2018, 74 participants were identified as disease-free and mailed a follow-up survey; 52 (70.3%) completed the survey. At a median follow-up time of 3.1years after diagnosis, participants were less likely to be employed (54% vs. 67%) than at the SV. About two-thirds were sedentary, and this was associated with high body mass index (p = 0.02). Sufficiently active participants (≥ 150min per week of moderate-intensity activity) were less likely to report pain (p = 0.02) or fatigue (p = 0.001). Although 19% had moderate/severe anxiety or depression at follow-up, participants who reported employment satisfaction were less likely to be depressed (p = 0.02). Awareness of issues faced by survivors is critical for enhancing care and developing models to identify patients who might benefit most from targeted long-term interventions. Interventions to address physical activity, persistent symptoms, and mental health are critical for breast cancer survivors.