Population Of Breast Cancer Survivors Research Articles

Development of phase-specific breast cancer survivorship care plans (SCPs).

61 Background: There are nearly 3 million breast cancer (BC) survivors in the US. Among the recently diagnosed, accrediting organizations (e.g., Commission on Cancer) now require SCPs at the completion of curative therapy. Within the Oncology Care Model, the preparation and delivery of SCPs is recognized as one of the 13 quality metrics. SCPs, combining treatment summaries (TS) and follow-up care plans (FUCPs), assist patients and providers in the delivery of high quality long-term care. BC presents a unique challenge, as the risk of recurrence extends decades past initial treatment; adjuvant risk reduction may extend up to 15 years. Periodic FUCPs provide a mechanism to review updated information and may allow providers to catch up with longer term BC survivors whose care was delivered prior to SCPs. We explored the role of phase-specific SCPs within the heterogeneous BC survivor population. Methods: Oncologists and nurse practitioners (NPs) from the Breast Health and Survivorship Programs at Tufts MC, an academic medical center in Boston, and New England Cancer Specialists, a community-based private oncology practice in Maine--together caring for more than 2,000 BC survivors--convened to develop and test phase-specific survivorship tools. Using an adapted ASCO template for BC, TS were completed at the end of initial therapy by trained NPs. FUCPs for initial, 5-year, and 10-year visits were designed with clinical input, literature reviews, and existing guidelines. Results: FUCPs were pilot tested and refined before incorporation into the electronic health record. Further testing is planned to identify barriers to effective survivorship care, particularly involving documentation of changes in recommendations and the transition from oncologist to primary care physician. Conclusions: SCPs are critical for providing quality health care to BC survivors, but a single SCP, written at the conclusion of curative treatment, might not be sufficient to address changing needs of individuals as they progress through survivorship. Thus, phase-specific SCPs enable providers to focus on salient aspects of care that may change over time. Despite growing recognition of the value of SCPs, implementation remains a challenge across cancer programs.

Interventions to Manage Uncertainty and Fear of Recurrence in Female Breast Cancer Survivors: A Review of the Literature.

Fear of cancer recurrence (FCR) is one of the largest unmet needs in the breast cancer survivor population. This review addresses this unmet need with the question. The purpose of this article is to better understand potential interventions to manage FCR when caring for breast cancer survivors. Databases used were PubMed, CINAHL®, Google Scholar, EMBASE, and Scopus. Articles published in English from 2009-2014 with female breast cancer survivors and interventions that address FCR as an endpoint or outcome measure or objectively illustrate an improvement in FCR were included. One hundred ninety-eight articles were initially identified in this literature review search. Upon detailed review of content for relevance, seven articles met criteria to be included in this review. This literature review provided current evidence of published interventions to manage uncertainty in the female breast cancer survivor population, as well as future research recommendations. Interventions surrounding being mindful, managing uncertainty, having more effective patient-provider communication, and handling stress through counseling are options for managing FCR.

Identification of potential compensatory muscle strategies in a breast cancer survivor population: A combined computational and experimental approach

BackgroundBiomechanical models are often used to estimate the muscular demands of various activities. However, specific muscle dysfunctions typical of unique clinical populations are rarely considered. Due to iatrogenic tissue damage, pectoralis major capability is markedly reduced in breast cancer population survivors, which could influence arm internal and external rotation muscular strategies. MethodsAccordingly, an optimization-based muscle force prediction model was systematically modified to emulate breast cancer population survivors through adjusting pectoralis capability and enforcing an empirical muscular co-activation relationship. Model permutations were evaluated through comparisons between predicted muscle forces and empirically measured muscle activations in survivors. FindingsSimilarities between empirical data and model outputs were influenced by muscle type, hand force, pectoralis major capability and co-activation constraints. Differences in magnitude were lower when the co-activation constraint was enforced (−18.4% [31.9]) than unenforced (−23.5% [27.6]) (p<0.0001). InterpretationThis research demonstrates that muscle dysfunction in breast cancer population survivors can be reflected through including a capability constraint for pectoralis major. Further refinement of the co-activation constraint for survivors could improve its generalizability across this population and activities. Improving biomechanical models to more accurately represent clinical populations can provide novel information that can help in the development of optimal treatment programs for breast cancer population survivors.

Relative validity of a brief Fat and Fibre Behaviour Questionnaire in a population of overweight and obese breast cancer survivors: A note of caution.

Dietary intake assessment is often difficult in research contexts because of time and resource constraints and participant burden. Valid, reliable and brief assessments of dietary behaviour are needed. Additionally, examination of instrument performance in a variety of populations is needed. This study assessed relative validity and responsiveness to change of the Fat and Fibre Behaviour Questionnaire (FFBQ) in a population of breast cancer survivors compared with dietary intake measured by 24-hour recalls. Data were collected at baseline and six months after baseline of a six-month, randomised controlled trial that evaluated a telephone-based behavioural weight loss intervention (n = 45) compared to usual care (n = 45) among overweight and obese breast cancer survivors. The FFBQ's total index, fat index and fibre index were assessed for relative validity against two 24-hour recalls (Pearson's correlations). Responsiveness to change was assessed as intervention group change divided by standard deviation of usual care group change. Pearson's correlations of the fat index with fat intake measures ranged from -0.09 to -0.30 (P < 0.05) at baseline and from -0.19 to -0.28 (P < 0.05) for dietary change. Correlations of the fibre index with unadjusted and energy-adjusted fibre intake measures (0.25-0.32, P < 0.05) were significant at baseline only. Both the FFBQ and 24-hour recall were responsive to fat-related dietary changes and not responsive to fibre-related changes. The FFBQ showed small to medium relative validity against 24-hour dietary recall for assessing fat and fibre dietary behaviours and changes in dietary fat, and was responsive to fat-related dietary changes in this population.

Worry about recurrence in a multi-ethnic population of breast cancer survivors and their partners.

The objectives of this study are to describe racial/ethnic differences and clinical/treatment correlates of worry about recurrence and examine modifiable factors in the health care experience to reduce worry among breast cancer survivors, partners, and pairs. Women with non-metastatic breast cancer identified by the Detroit and Los Angeles SEER registries between 6/05 and 2/07 were surveyed at 9months and 4years. Latina and Black women were oversampled. Partners were surveyed at time 2. Worry about recurrence was regressed on sociodemographics, clinical/treatment, and modifiable factors (e.g., emotional support received by providers) among survivors, partners, and pairs. The final sample included 510 pairs. Partners reported more worry about recurrence than survivors. Compared to Whites, Latinas(os) were more likely to report worry and Blacks were less likely to report worry (all p<0.05). Partners of survivors who received chemotherapy reported more worry (OR=2.47 [1.45, 4.22]). Among modifiable factors, survivors and pairs who received more emotional support from providers were less likely to report worry than those survivors and pairs who did not receive such support (OR=0.56 [0.32, 0.97]) and (OR=0.45 [0.23,0.85]), respectively. Early identification of survivors and partners who are reporting considerable worry about recurrence can lead to targeted culturally sensitive interventions to avoid poorer outcomes. Interventions focused on health care providers offering information on risk and emotional support to survivors and partners is warranted.

The Importance of Awareness and Education in Patients with Breast Cancer-Related Lymphedema.

Upper extremity lymphedema occurs in one of five women after breast cancer treatment and causes significant morbidity. Women often report being uninformed regarding awareness of lymphedema and other side effects after the cancer surgery. The aim of the study was to assess the postoperative information and education about lymphedema in patients with lymphedema related to breast cancer surgery in the rehabilitation unit of a tertiary hospital. One hundred eighty patients who had admitted to lymphedema rehabilitation unit between September 2013 and February 2015 were recruited to the study. The demographic properties of women, duration, and grade of lymphedema were recorded. The patients were asked whether they had received any information about awareness of lymphedema or whether they have been educated for reducement of the risk of lymphedema after the breast cancer surgery. One hundred eighty women with a mean age of 52.9 ± 10.7years (27-53) and with a mean lymphedema duration of 19.8 ± +39.4months were included. Ninety-eight (54.4%) patients had grade 1, 80 (44.4%) patients had grade 2, and 2 (1.11%) patients had grade 3 lymphedema. Among the participants, only 35 (19.5%) had reported that they had received information or education about lymphedema. One hundred forty-five patients (80.5%) were not informed or trained about the development of lymphedema. The degree and duration of lymphedema were lower in patients that had been informed or educated about lymphedema as compared to the patients who had not been informed or educated, but the difference was not statistically significant (p = 0.052). Only a minor group of patients (19%) had received information and education about lymphedema and there is an unmet need for education or information about lymphedema after breast cancer treatment, especially in developing countries. The nonsignificant correlation between education and the degree and duration of lymphedema was thought to be related with the incongrous numbers of the subgroups. In conclusion with the growing population of breast cancer survivors, patient awareness and education about postoperative lymphedema risk after the cancer surgery is warranted.

Variation among local health units in follow-up care of breast cancer patients in Emilia-Romagna, Italy.

This study examines the patterns of follow-up care for breast cancer survivors in one region in Italy. This retrospective analysis included 10,024 surgically treated women, with incident cases of breast cancer in the years 2002-2005 who were alive 18 months after their incidence date. Rates of use of follow-up mammograms, abdominal echogram, bone scans and chest x-rays were estimated from administrative data and compared by Local Health Unit (LHU) of residence. Logistic regression analyses were performed to assess possible "overuse", accounting for patient age, cancer stage, type of surgery and LHU of residence. A total of 7168 (72.1%) women received a mammogram within 18 months of their incidence date, while 6432 (64.2%) had an abdominal echogram, 3852 (38.4%) had a bone scan and 5231 (52.2%) had a chest x-ray. The rates of use of abdominal echograms, bone scans and chest x-rays were substantially higher in the population of breast cancer survivors than in the general female population. Taking account of patient age, cancer stage at diagnosis and type of surgery, multivariate analyses demonstrated significant variation in the use of these tests by LHU of residence. The observed variation in the use of abdominal echograms, bone scans and chest x-rays supports the conclusion that there is substantial misuse of these tests in the population of postsurgical breast cancer patients in the Emilia-Romagna region in Italy. In the absence of a documented survival benefit, overtesting has both a human and financial cost. We recommend additional review of the methods of follow-up care in breast cancer patients in the LHUs of Emilia-Romagna, with the aim of developing, disseminating and evaluating the implementation of specific guidelines targeting primary care physicians and oncologists providing care to breast cancer survivors. Patient education materials may also help to reduce unnecessary testing.

An e-health strategy to facilitate care of breast cancer survivors: A pilot study.

Innovative e-health strategies are emerging, to tailor and provide convenient, systematic and high-quality survivorship care for an expanding cancer survivor population. This pilot study tests the application of an e-health platform, "Healthy.me," in a breast cancer survivor cohort at Liverpool and Macarthur Cancer Therapy Centres, New South Wales, Australia. Fifty breast cancer patients were recruited to use the Healthy.me website, designed by the Centre of Health Informatics at the University of New South Wales, over a 4-month period. Telephone and online questionnaires were used at 1 and 4 months and a face-to-face feedback at study completion, to gather qualitative and quantitative data regarding feasibility of Healthy.me. Healthy.me was reported to be a useful online resource by most users. Usage declined from 76% at 1 month to 48% at 4 months. Breast cancer survivors enjoyed a variety of tailored information regarding health and life-style issues. Positive aspects of Healthy.me were the convenient access to trusted information, and interaction with their peers and healthcare professionals. Barriers to usage contributing to usage decline were lack of reported patient time to re-access information, limited content updates and technical factors. This pilot study suggested the potential of an e-health strategy such as Healthy.me in addressing the needs of a growing breast cancer survivor population. Ongoing development of a more robust e-health resource and integration with primary care models is warranted.

Abstract C16: Validation of a new medical discrimination scale among a diverse population of breast cancer survivors

Abstract Introduction: Experiences of medical discrimination may impact women's decisions regarding breast cancer treatment. However, measures of perceived discrimination generally are not specific to the medical context, and none are specific to breast cancer. The objective of this study was to determine the structure and psychometric properties of a 9-item scale assessing perceived discrimination among a racially/ethnically diverse sample of women receiving breast cancer care. This scale was developed based on existing measures of general discrimination and recent qualitative research with breast cancer survivors of various racial/ethnic backgrounds. Methods: Women ages 20 and older diagnosed with a first invasive primary breast cancer between 2006 and 2009 were sampled from all available case listings in the Greater Bay Area Cancer Registry. 542 of these women completed a telephone interview in English, Spanish, Mandarin, Cantonese, or Tagalog between 2011 and 2013. Women reported how often they perceived 9 types of discriminatory experiences while receiving breast cancer care using a 4-point scale (never, rarely, sometimes, often). Item-level descriptive statistics and reliability analyses were computed. A categorical confirmatory factor analysis (CCFA) was conducted to determine whether the 9 items reflected a single discrimination construct. Logistic regression was used to evaluate differential item functioning (DIF), examining whether the items performed differently by race after controlling for the level of perceived medical discrimination. A summed medical discrimination score was calculated from the items that supported the unidimensional discrimination construct according to the CCFA and did not show evidence of DIF. Correlations between the summed score and single item measures of perceived racial/ethnic discrimination and satisfaction with breast cancer care were used to assess convergent validity. Results: Reports of medical discrimination were fairly low, with no more than a third of any racial/ethnic group of women reporting discrimination on any item. As a result, responses were dichotomized into never vs. ever experiencing discrimination. A CCFA of all 9 items suggested improved model fit could be achieved by adding a correlated error term between two items with similar wording. After removing the item with the smallest factor loading from this item pair, a final CCFA produced adequate model fit (RMSEA=0.06, CFI=0.99, TLI=0.99). Standardized factor loadings ranged from 0.71-0.91. DIF analyses of the remaining 8 items indicated uniform DIF with an appreciable effect size for one item: “had to wait longer than other people to be seen by your health care team” (p&amp;lt;0.001, effect size=0.03). The final medical discrimination scale comprised 7 items and demonstrated good reliability (α=0.84). The mean summed score was 1.24 (SD=1.90; range=0.0-7.0 in total sample). Preliminary evidence of convergent validity was observed: medical discrimination scores were significantly positively correlated with mistreatment while receiving breast cancer care due to race/ethnicity (r=0.39, p&amp;lt;0.0001), and significantly negatively correlated with satisfaction with care (r=-0.42, p&amp;lt;0.0001). Conclusion: A 7-item medical discrimination scale demonstrated unidimensionality, internal reliability, convergent validity, and uniformity of responses by race for women diagnosed with breast cancer. This is the first medical discrimination scale developed for a diverse group of breast cancer patients and may be of interest to researchers and clinicians interested in how perceptions of discrimination in the medical context contribute to disparities in breast cancer care and outcomes. Citation Format: Felisa A. Gonzales, Salma Shariff-Marco, Michelle M. Langer, Bryce B. Reeve, Amani M. Nuru-Jeter, Laura A. Dwyer, Scarlett Lin Gomez. Validation of a new medical discrimination scale among a diverse population of breast cancer survivors. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C16.

Clinical characteristics of metachronous contralateral breast cancer following diagnosis interval

Purpose: As the population of breast cancer survivors increasing, concerns for second primary cancer has been grown. The most frequent second primary tumor after breast cancer diagnosis is contralateral breast cancer (CBC). CBC developed less than five years showed poor prognosis. However, in Korea, little is known about the clinical characteristics of CBC regarding diagnosis interval. Methods: We retrospectively reviewed medical records of the patients who diagnosed stage I-III breast cancer from three tertiary medical centers and identified CBC patients. We divided those patients into early-onset CBC (ECBC), which diagnosed within five years, and late-onset CBC (LCBC) which developed after five years since primary cancer. We also searched available published original articles regarding bilateral breast cancer in Korean population for comparison. Results: Between January 2003 and December 2013, a total of 3,695 patients were included. During follow up, 22 patients diagnosed as CBC. Mean age of ECBC (n=10) was 50.9±15.4 and that of LCBC (n=12) was 45.5±14.3. There were no significant difference between ECBC and LCBC in menopausal status, menarcheal age, family history of breast cancer, clinical stage, and pathologic characteristics. ECBC was related worse disease-free survival than LCBC (P=0.017). With meta-analysis of published reports in Korean population, the incident rate calculated from person-month was 0.06. Conclusion: ECBC showed poor prognosis than LCBC with cut-off at five years since diagnosis of primary breast cancer, and it was consistent with Western reports. Intensive treatment might be needed in those patients with ECBC.

Obesity, ethnicity, and quality of life among breast cancer survivors and women without breast cancer: the long-term quality of life follow-up study.

The purpose of this study was to examine the relationship between obesity and quality of life (QOL) among Hispanic and non-Hispanic white breast cancer survivors and population-based controls from the 'Long-Term Quality of Life Study'--a 12- to 15-year follow-up study of breast cancer cases/survivors and controls from New Mexico (n = 451). Using multiple linear regressions, obesity measures [body mass index (BMI) ≥ 30 kg/m(2)] at baseline and follow-up interview were modeled with composite scores for physical and mental health from the SF-36 Quality of Life Survey. Interaction between ethnicity and BMI and change in BMI were evaluated. All models were adjusted for age, ethnicity, Charlson Index, depression, fatigue, and physical activity. Baseline obesity (β = -6.58, p = 0.04) was significantly associated with decreased mental health among survivors, but not among controls. Obesity at baseline and follow-up were significantly associated with decreased physical health among survivors (baseline β = -10.51, p = 0.004; follow-up β = -7.16, p = 0.02) and controls (baseline β = -11.07, p < 0.001; follow-up β = -5.18, p = 0.04). No significant interactions between ethnicity and BMI were observed. Our findings provide unique information about a diverse population of breast cancer survivors and controls and the impact of obesity on the mental and physical aspects of QOL.

Abstract A61: Perspectives on transitioning from cancer treatment to breast cancer survivorship

Abstract Introduction: The population of breast cancer survivors continues to grow due to improved medical treatments and education. Yet there is a lack of comprehensive survivorship care planning to manage overall health following cancer treatment. The Institute of Medicine (IOM) recommends psychosocial components be included in survivorship care plans to address long-term psychological distress. African Americans in particular experience disproportionate levels of psychosocial distress in breast cancer survivorship. Thus the goal of this study was to understand the psychosocial needs, resources, and cultural influences during the transition from treatment to survivorship from the perspectives of both the oncology professionals and survivors themselves. Methods: Twenty-nine, semi-structured one-on-one interviews were conducted in Washington State by African-American community advocates as part of a larger on-going study. Twelve oncology professionals (OPs) and 17 female African-American breast cancer survivors (BCSs) were interviewed. Open-ended interview guides were tailored for BCSs and OPs respectively. Interviews were transcribed, coded, and analyzed using principles of constant comparison grounded theory, in which concepts were identified and themes derived from interview data. Interviews were approximately 45 minutes in duration and participants received $40 compensation for their time. Results: Similar to previous literature, psychosocial needs identified by both BCSs and OPs included fear of recurrence, emotional and financial distress, and support issues. However, the role of daily stressors and microaggressions described by many BCSs were not widely identified by OPs. BCSs also indicated a need for more empathetic interactions from OPs during medical visits. A major gap identified between the BCSs and OPs was found in the source of psychosocial information provided to BCSs. Nearly half of the BCSs indicated psychosocial support was received from community-based programs (spiritual and secular) whereas many OPs believed support was provided as part of clinical services at their institution. However, several OPs did state that there are numerous community resources available to survivors. Many professionals stated that a structured protocol is not in place to help survivors identify available services and some specifically identified the need to include psychosocial factors in the survivorship care plan. A few OPs suggested that follow-up appointments with survivors 3-, 6- and 12-months after cancer treatment may reduce feelings of isolation and lack of support. With regard to cultural factors that may impact the transition to survivorship, many of the BCSs noted they did not openly share their cancer experience with others, family/friends or professionals, which they indicated is an African-American cultural trait; specifically, the desire to appear as a “strong” woman. Some OPs also mentioned this aspect of the African-American culture as a possible barrier to communication about psychosocial well-being during medical visits. Some survivors conveyed interest in mentoring future BCSs stating a need for African Americans to support each other, but did not specifically describe how this support would differ from other sources of support. OPs discussed historical injustices as a potential source of mistrust within African American breast cancer survivors. Conclusion: While there are many areas of overlap between BCSs and OPs regarding psychosocial needs of African-American BCSs, there remain gaps of primarily social and institutional systemic barriers to care. Study limitations and some recommendations to meet the psychosocial needs of African American breast cancer survivors have emerged from the interviews and are discussed. Citation Format: Swati Somuri, Rachel M. Ceballos, Sarah H. Hohl, Rachel M. Malen, Bridgette Hempstead, Jacci Thompson-Dodd. Perspectives on transitioning from cancer treatment to breast cancer survivorship. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A61.

Breast magnetic resonance imaging (MRI) surveillance in breast cancer survivors.

PurposeAs the breast cancer survivor population increases, the topic of screening these women for recurrences is increasingly relevant. In our institution, we use both breast MRI and mammography in the surveillance of breast cancer survivors, although little data exists on the use of MRI in this setting. We present a retrospective analysis of our experience and compare the sensitivity and specificity of MRI vs. mammography in this setting.MethodsWe identified women under 65 with a history of breast cancer and at least one follow-up MRI performed along with a mammogram done within 6 months of the MRI. We compared the outcomes of MRI and mammography in terms of biopsies performed as well as in detection of new cancers.ResultsOf 617 charts reviewed, 249 patients met inclusion criteria, with 571 paired MRI/mammogram results. There were 27 biopsies performed due to MRI findings alone, 10 done due to mammographic findings alone, and 15 done based on abnormalities seen on both imaging modalities. There were 8 malignancies identified based on an abnormal MRI, 3 detected on both MRI and mammography, and none identified via mammography alone. Overall, MRI had a sensitivity of 84.6% (the 95% CI 54.6–98.1) and a specificity of 95.3% (the 95% CI 93.3–96.9); mammography a sensitivity of 23.1% (the 95% CI 5.0–53.8), and a specificity of 96.4% (the 95% CI 94.5–97.8).ConclusionsBreast MRI is a useful surveillance modality in breast cancer survivors and may be more sensitive at detecting recurrences than mammography alone in this population.

Validation of the French translation-adaptation of the impact of cancer questionnaire version 2 (IOCv2) in a breast cancer survivor population.

BackgroundThe Impact of Cancer version 2 (IOCv2) was designed to assess the physical and psychosocial health experience of cancer survivors through its positive and negative impacts. Although the IOCv2 is available in English and Dutch, it has not yet been validated for use in French-speaking populations. The current study was undertaken to provide a comprehensive assessment of the reliability and validity of the French language version of the IOCv2 in a sample of breast cancer survivors.MethodsAn adapted French version of the IOCv2 as well as demographic and medical information were completed by 243 women to validate the factor structure divergent/divergent validities and reliability. Concurrent validity was assessed by correlating the IOCv2 scales with measures from the SF-12, PostTraumatic Growth Inventory and Fear of Cancer Recurrence Inventory.ResultsThe French version of the IOCv2 supports the structure of the original version, with four positive impact dimensions and four negative impact dimensions. This result was suggested by the good fit of the confirmatory factor analysis and the adequate reliability revealed by Cronbach's alpha coefficients and other psychometric indices. The concurrent validity analysis revealed patterns of association between IOCv2 scale scores and other measures.Unlike the original version, a structure with a Positive Impact domain consisting in the IOCv2 positive dimensions and a Negative Impact domain consisting in the negative ones has not been clearly evidenced in this study. The limited practical use of the conditional dimensions Employment Concerns and Relationship Concerns, whether the patient is partnered or not, did not make possible to provide evidence of validity and reliability of these dimensions as the subsets of sample to work with were not large enough. The scores of these conditional dimensions have to be used with full knowledge of the facts of this limitation of the study.ConclusionsIntegrating IOCv2 into studies will contribute to evaluate the psychosocial health experience of the growing population of cancer survivors, enabling better understanding of the multi-dimensional impact of cancer.

Associations between diabetes medication use and risk of second breast cancer events and mortality

Diabetes and certain diabetes medications have been shown to influence breast cancer (BC) risk. Less is known about their relation to BC outcomes. Our objective was to evaluate the effects of diabetes and diabetes medications on risk of second breast cancer events (SBCE) and mortality. This population-based cohort study was conducted among women diagnosed with early-stage (I-II) BC and enrolled in an integrated health plan. Exposures of interest were diabetes and medication classes including insulin, metformin, and sulfonylureas. Outcomes of interest were SBCE defined as recurrence or second primary BC, BC-specific mortality, and all-cause mortality. We used multivariable Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for diabetes and medication use while accounting for potential confounders and competing risks. Among 4,216 women, 13% developed SBCE during a median follow-up of 6.3years. 610 women had diabetes of which 76% used oral diabetes medication and/or insulin. Findings suggested that diabetes increased the risk of recurrence (HR=1.57; 95% CI 1.09-2.25) but not overall SBCE (HR=1.29; 95% CI 0.94-1.76) or second primary BC (HR=0.74; 95% CI 0.39-1.41). Among women with diabetes, insulin use was associated with increased risks of recurrence (HR=1.94; 95% CI 1.08-3.48) and all-cause mortality (HR=2.33; 95% CI 1.70-3.20). Metformin use was associated with lower all-cause mortality (HR=0.55; 95% CI 0.38-0.79). Our findings show an association between diabetes and increased recurrence risk, and risk may be greater among insulin users. Metformin may reduce all-cause mortality among BC survivors. Given the growing breast cancer survivor population, further research in larger, more diverse populations is warranted.

Effectiveness of an Internet Delivered Behavioral Weight Loss Intervention Provided to Breast Cancer Survivors

Purpose: Excess weight is associated with negative outcomes among breast cancer survivors. Our primary objective was to pilot test the value of an internet delivered behavioral weight loss (BWL) intervention for breast cancer survivors. Methods: Stage 0-III breast cancer survivors with excess weight who did (CHEMO) and did not receive chemotherapy (NO CHEMO) were recruited to participate. The 6 month BWL intervention included behavior modification strategies, calorie reduction and an increase in moderate exercise. The primary outcome was change in anthropometrics. Secondary outcomes were change in food intake and physical activity. Results: Fifty women were recruited (25 who received chemotherapy; 25 who did not receive chemotherapy) and 34 completed post testing. The results from both an intent-to-treat analysis and analyzing including only subjects who completed the intervention identified that both the CHEMO and NO CHEMO groups lost significant weight. Participants in the CHEMO and NO CHEMO groups who completed the intervention lost 4.5% and 7.5% of baseline body weight respectively. The NO CHEMO group lost a significant percent of their baseline body fat while the CHEMO group did not. The intervention resulted in a significant fat free mass loss for the CHEMO group, while fat free mass was preserved in the NO CHEMO group. The calorie deficit for the NO CHEMO group was significant while the CHEMO group did not achieve a significant reduction in calories consumed. No exercise parameter changed in either group. Conclusion: Individuals with breast cancer experience significant weight loss with an internet delivered intervention. Women who received chemotherapy lost less weight, less body fat and more fat free mass than survivors who did not receive chemotherapy. Despite variable success between groups, an internet based BWL program results in weight loss in a breast cancer survivor population.

Abstract P2-14-02: Complications of breast reconstruction in a provincial population of breast cancer survivors

Abstract Background: Breast cancer is the most prevalent cancer in women in Canada. There are varying reports of the use of breast reconstruction in various populations and very few prospective trials or population reports of complications related to breast reconstruction in breast cancer patients. The goal of this study is to describe the use of breast reconstruction in breast cancer survivors in British Columbia, the risk of complications after breast reconstruction, and factors associated with a higher risk of complications. Methods: Electronic Records from the BC Cancer Agency were used to identify women diagnosed with invasive breast cancer between 2001-2008 in British Columbia. Administrative hospital records used with permission of the British Columbia Ministry of Health, obtained through PopulationData BC, were used to obtain details about all surgeries,hospital admissions and associated complications for the cohort. Analyses of reconstruction for those treated with breast-conserving surgery (BCS) versus mastectomy were done separately. For those who underwent mastectomy following BCS, complications after BCS before mastectomy were attributed to the BCS, and those that occurred after mastectomy were attributed to the mastectomy. These analyses included a description of the type of reconstruction procedures used in this era, and the frequency and types of complications after the reconstruction procedures. Logistic regression was used to identify risk factors for complications post reconstruction. Results: The cohort consisted of 18,642 women; 4868 had mastectomy alone, 8633 had BCS alone, 2894 had both, and 2247 had neither surgery. Of those undergoing BCS (11527), 746 had reconstructive procedures. Most of these were separate procedures; 55% were ≤50 years of age. The most common complication was "miscellaneous complication of internal prosthetic devices, implants or grafts". One hundred eight (14%) of those with reconstruction after BCS had complications within 30 days of the reconstruction procedure, 134 (18%) had complications within one year of the procedure. Of those undergoing mastectomy (7762), 7497 had their mastectomies within 1 year of diagnosis. Ninety-six had bilateral mastectomies. 1766 underwent reconstructive procedures; 74% were immediate procedures, 57% were ≤ 50 years of age. The most common complication was "miscellaneous complication of internal prosthetic devices, implants or grafts". One hundred sixty-seven (9%) of those with reconstruction after (or with) mastectomy had complications within 30 days of the reconstruction procedure, 227 (13%) had complications within one year of the procedure. Regression analysis showed that no radiotherapy (OR=0.65) and premenopausal status (OR=0.70) were significantly associated with a lower risk of complication post reconstruction. Conclusion: Complications related to reconstructive procedures for breast cancer happened in the minority of breast cancer survivors. They were more common in those with BCS, and were more likely for those who underwent adjuvant radiotherapy or were postmenopausal. Citation Format: Elaine S Wai, Ling Hong Lu, Cheryl Alexander, Mary L Lesperance, Mary L McBride, Scott Tyldesley, Chris Taylor. Complications of breast reconstruction in a provincial population of breast cancer survivors [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-14-02.

Abstract P6-10-10: History of chemoprevention in patients with newly diagnosed breast cancers

Abstract Background: Chemoprevention (including tamoxifen, raloxifene and exemestane) is a strategy to reduce breast cancer incidence in high risk women. Studies have shown at least a 50% decrease in the incidence of breast cancer in users of these drugs. The benefit is limited to a reduction in the incidence of ER/PR positive breast cancer. However, there is a growing population of women who have used these agents for primary breast cancer prevention, and a larger population of breast cancer survivors who have used these drugs as part of their systemic treatment. The purpose of this study was to identify a contemporary cohort of women with newly diagnosed breast cancers who had utilized chemoprevention strategies and describe their patterns of disease. Methods: The Breast Cancer Database at our institution was queried for patients who reported use of chemopreventive drugs and developed breast cancer between 1/2010-4/2014. Patients were divided into primary and secondary chemoprevention groups (no previous history of breast cancer and previous history of breast cancer, respectively). Descriptive statistics were utilized. Results: Out of a total of 1782 patients with newly diagnosed breast cancer, there were 106 (6%) patients who had used a chemopreventive agent. Out of these 106 patients, 91 (86%), had used the drug as part of their systemic therapy for prior breast cancer, with a median of 11 years from the initial diagnosis to the diagnosis of a second breast cancer. The primary chemoprevention group included women with risk based on family history and atypical hyperplasias. The majority of patients (81%) were diagnosed with early stage disease (stage 0, 1). In both groups, the majority of cancers were ductal in origin (84%). Eight of the 15 patients (53%) in the primary chemoprevention group were on treatment at the time of their cancer diagnosis; while 29% of patients in the secondary group were on treatment at the time of diagnosis. In the secondary group, 49% were contralateral second primary breast cancers and 44% were ipsilateral recurrences. Interestingly, the majority of cancers in both groups were ER/PR positive. Conclusions: Our cohort of women who used chemoprevention drugs were overwhelmingly diagnosed with early stage breast cancer, likely reflecting their commitment to screening. The majority of cancers were ER/PR positive. In this group, the choice of cancer treatment will need to be modified in light of prior hormonal treatment. Many of the patients in the secondary group were past users of prevention agents and further work is needed to clarify the duration of benefit of these drugs. In a similar vein, we look forward to research efforts to define the optimal age to initiate primary chemoprevention in high risk women. Citation Format: Jennifer Chun, Freya Schnabel, Shira Schwartz, Karen Hiotis, Amber Guth, Deborah Axelrod. History of chemoprevention in patients with newly diagnosed breast cancers [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-10-10.

Cancer and cardiovascular disease: the use of novel echocardiography measures to predict subsequent cardiotoxicity in breast cancer treated with anthracyclines and trastuzumab.

As the population of breast cancer survivors grows, it has become evident that chemotherapy has significant cardiotoxic side effects. Echocardiography is a noninvasive, cost-effective, and widely available imaging tool that is well positioned to serve as a primary modality for monitoring chemotherapy-induced cardiotoxicity. Although left ventricular ejection fraction is a standard measurement by which to monitor chemotherapy-induced cardiotoxicity, its predictive value in identifying subsequent cardiotoxicity is limited. More sophisticated echocardiography modalities may offer improved sensitivity and specificity for detecting chemotherapy-induced cardiotoxicity. These include tissue Doppler imaging measures, newer techniques based upon two- and three-dimensional strain and torsion analysis, and three-dimensional measures of cardiac size. While these modalities are not all currently part of clinical practice, a body of data supporting their use is steadily building. More research remains to be performed, and noninvasively detecting cancer therapy-induced cardiac dysfunction at the earliest stages is of increasing interest.

Long-term follow-up for cardiovascular disease after chemotherapy and/or radiotherapy for breast cancer in an unselected population

Whereas earlier research focused on specific patient groups, this study assessed the risk of cardiovascular disease (CVD) in an unselected population curatively treated for breast cancer (BC), compared with an age-matched random sample of controls. Risks were determined in BC survivors and controls. CVD was divided into three categories: congestive heart failure, vascular cardiac diseases, and "other" cardiac diseases. Hazard ratios (HRs) and 95% confidence intervals (95% CI) adjusted for age, CVD, and CVD risk factors at baseline were determined by Cox regression analyses. All 561 survivors of BC experienced surgery of whom 229 received (neo)adjuvant radiotherapy, 145 received chemotherapy (with or without radiotherapy), and 187 received no adjuvant therapy. During follow-up (median 9; range 5-57 years), CVD occurred in 176/561 (31%) survivors and in 398/1,635 (24%) controls. After radiotherapy, no increased risks of congestive heart failure (HR 0.5; 95% CI 0.2-1.8), vascular cardiac diseases (HR 1.1; 95% CI 0.7-1.7), or other cardiac diseases (HR 1.3; 95% CI 0.8-2.3) were found compared with controls. Similar results were found after chemotherapy for congestive heart failure (HR 1.8; 95% CI 0.6-5.8), vascular cardiac diseases (HR 1.1; 95% CI 0.5-2.3), and other cardiac diseases (HR 1.2; 95% CI 0.3-5.5). In an unselected population of BC survivors, no significant increased risk of CVD after radiotherapy and/or chemotherapy was found compared with controls. However, the HRs after chemotherapy were in-line with previous studies. Future studies should include more detailed information on treatment and more specific outcome measures.