Does obesity compromise survival in women with breast cancer?

Obesity, measured by high body mass index (BMI >30 kg/m2) is associated with an increased risk of postmenopausal breast cancer but the effect of obesity on prognosis is not clear. A prospectively accrued and regularly validated database of 1579 patients with breast cancer treated in a district general hospital between 1963 and 1999 was analysed for clinical and pathological tumour characteristics including the family history, grade, tumour type, treatment and outcome. The risk factors and outcome of obese and non-obese patients were compared. Breast cancer in obese women was associated with significantly larger tumour size and worse Nottingham prognostic index. There was no statistically significant difference in overall and disease-free survival between obese and non-obese group. Hazard ratios (95% Cl) were 0.81 (0.62-1.06) and 0.80 (0.63-1.01), respectively. In the present study, obesity is not an indicator of worst prognosis of breast cancer.     

Is surgery always indicated in older women with breast cancer?

Although surgery has long been considered the main form of curative treatment for breast cancer, its use in older women may not always be indicated. Whilst surgery has been shown to provide superior local control for breast cancer, there is conflicting evidence on whether surgery offers a significant improvement on overall survival in these patients. The more indolent tumour biology commonly seen in older women with breast cancer, coupled with competing causes of death may alter the goals of treatment. The differing needs of older patients should be thoroughly assessed to consider their comorbidities, functional status and quality of life. A comprehensive geriatric assessment and quality of life assessment could identify pretreatment risk factors and guide clinical decision making, improving morbidity and prognosis. Alternatives to surgery include primary endocrine therapy and primary radiotherapy. Further research is required to identify different patient or tumour factors which can be used to individualize treatment for breast cancer in older women and to develop holistic assessment tools which take into account their individual quality of life, geriatric syndromes and functional needs. A dedicated multidisciplinary-led clinic may provide a suitable platform for the assessment, review and management of this distinctive set of patients.     

Are microinvasion and micrometastasis in breast cancer mountains or molehills?

BACKGROUND: The increased rate of early detection of breast cancer due to widespread mammographic screening has led to an increased incidence of in situ as well as microinvasive carcinoma. The enhanced pathological examination to which sentinel lymph nodes are subjected has led to an increased rate of detection of micrometastatic carcinoma. Despite the augmented rate of diagnoses of both diseases, the pathological diagnoses as well as clinical management of these entities continue to be controversial. DATA SOURCES: A computerized literature search was performed on the Medline and PubMed database from 1990 to date. Relevant earlier publications were also perused. The database of the Department of Pathology at New York Presbyterian Hospital-Well Medical College of Cornell University were also accessed. CONCLUSIONS: Based on cumulative data, patients diagnosed with either microinvasive or micrometastatic carcinoma of breast have a relatively favorable, albeit guarded, prognosis. Treatment recommendations for both of these disease entities continue to be controversial, and may remain so until additional refined clinicopathological data becomes available.     

Are traditional risk factors valid for assessing cardiovascular risk in end-stage renal failure patients?

Aim: Cardiovascular diseases (CVD) are the major cause of morbidity and mortality in end-stage renal failure (ESRF). Establishing whether traditional risk factors are valid predictors of CVD in ESRF is important in order to devise preventive and interventional strategies for the ESRF populations. Methods: In this retrospective cohort study, a cohort of patients on dialysis were examined between September 2000 and February 2001. Only those without previous CVD events at baseline were included. For each individual, 5 year CVD risk was calculated using the New Zealand 5 year CVD risk prediction charts based on the Framingham Heart Study prognostic algorithm. The subsequent 5 year CVD outcome for each patient was determined and the observed rate of first CVD events was compared to the predicted risk. Relation of individual risk factors with the CVD outcome was also assessed. Results: Of the patients, 274 were without previous CVD events at baseline and 27% experienced CVD events during the subsequent 5 years. Observed CVD risk was more than twofold that of predicted risk although there was a linear correlation between the two. Among individual risk factors, increasing age, diabetes and smoking were significantly related to the incidence of the CVD events but, unlike in the general population, systolic blood pressure, total cholesterol/high-density lipoprotein ratio and body mass index were not significantly related to CVD events. Conclusion: The very high incidence of CVD in ESRF patients suggest that non-traditional risk factors present in the uraemic state are independent risk factors for CVD in ESRF patients. Nevertheless, the application of traditional cardiovascular risk profiles does allow risk stratification of the ESRF population.     

Is anthracycline-based chemotherapy alone adequate for young women with estrogen receptor-positive breast cancer?

Recent evidence suggests that young women with estrogen receptor (ER)-positive breast cancer (BC) require additional treatment because of the inadequacy of cyclophosphamide, methotrexate fluorouracil (CMF) alone. Herein we report our findings from 368 premenopausal patients given adjuvant anthracycline alone. Overall, patients had a significantly increasing risk of relapse and dying with decreasing age at diagnosis and ER-negative disease. Interestingly, ER expression was not a negative prognostic factor, even among women <35 years, the 5-year disease-free survival (DFS) tending to be higher in patients with ER-positive rather than -negative BC. The potential of combining anthracyclines and endocrine therapies is reviewed and discussed.     

Are dopamine antagonists a risk factor for breast cancer? An answer from Parkinson's disease

Women undergoing chemotherapy for breast cancer are often administered dopamine antagonist adjuvant medications that may increase levels of prolactin potentially increasing the risk of cancer. Using nationwide computerized registers of death data for the years 1991 through 1996 we examined 12,430,473 deaths of persons over 40 years of age and extracted 144,364 cases with Parkinson's disease (PD), a dopamine deficient population. Patients with PD had lower rates of breast and other types of malignancies, even in the presence of depression and suicide.     

Do women newly diagnosed with breast cancer and consulting surgeon assess decision-making equally?

This study assesses the perception of the decision-making process of 25 surgeons and 194 patients (aged 21-81 years) who had newly diagnosed breast cancer and had to undergo mastectomy or breast-conserving surgery (BCS). The majority of women wanted to participate in decision-making. When it was medically possible to give a choice between BCS and mastectomy, only 59% of women received a choice. The main reason that 11% of the women went against surgeon's recommendations was fear of cancer recurrence. The most influential factors for women were the surgeon's recommendation, and fear of cancer recurrence. Medical assessment and the cosmetic result were the most influential factors for the surgeons. Female surgeons were more influenced by their assessment of the women's need for security, than male. In conclusion, not all women who are eligible for BCS receive an option. Women and surgeons emphasize influencing factors differently. The surgeon's gender was found to influence recommendation given.     

Are cell cycle and apoptosis genes associated with prostate cancer risk in North Indian population?

ObjectiveProstate cancer (CaP) is a heterogeneous, multifactorial, and multifocal disease. Therefore, the search for a combination of functional polymorphisms using cell cycle and apoptotic genes as tumor markers is fundamental for a more precise and reliable diagnosis. In the present study, we investigated the diagnostic value of 3 different genes associated with CaP carcinogenesis, encoding for cell cycle (MDM2, CCND1) and apoptotic (Fas) genes that are differentially expressed in CaP.MethodsIn a hospital-based case control study of northern India, blood samples were obtained from 192 CaP patients and 224 cancer-free age matched unrelated healthy controls of similar ethnicity. They were genotyped for MDM2 G309T, CCND1 G870A, Fas A670G, and G1377A polymorphisms using polymerase chain restriction fragment length polymorphism (PCR-RFLP) method.ResultsMDM2 309GG variant was at reduced risk for developing CaP (P = 0.041; OR, 0.59). Whereas CCND1 AA genotype demonstrated increased risk (P = 0.018; OR, 1.86). The diplotype analysis of Fas G670A and G1377A (G-A) was observed to be associated with a significant increase in CaP risk (P = 0.024; OR, 1.63).ConclusionFindings based on current sample size our results suggested a positive association of CCND1AA genotype and diplotype analysis of Fas G670A and G1377A (G-A) to be associated with CaP risk that could influence the pathophysiology, thereby modulating the risk of CaP.     

Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem?

BACKGROUND: We evaluated the risks and benefits of nipple-sparing mastectomy in a multiinstitutional experience in the settings of risk-reducing surgery and breast cancer treatment. STUDY DESIGN: We analyzed data on 123 patients who had undergone nipple-sparing mastectomy with breast reconstruction for prophylaxis (n=55), treatment of breast cancer (n=41), or both (n=27) at four large centers. RESULTS: Median patient age was 45 years (range 22 to 70 years). There were 192 procedures (69 bilateral, 54 unilateral). Forty-four patients had invasive cancer; 20 had ductal carcinoma in situ (DCIS); 4 had phyllodes tumor. In all of these patients, the nipple tissue was cancer free on pathologic review. Median followup was 24.6 months (range 2.0 to 570.4 months). Local recurrence developed in two patients: one had DCIS in the upper-outer quadrant, with 71.8 months of followup; the other's cancer was invasive, in the upper-outer quadrant, with 6 months of followup. Distant metastasis developed in a third patient, who died 50 months after the procedure. Breast cancer developed in two patients after prophylactic mastectomy: one in the upper-outer quadrant at 61.8 months; one in the axillary tail at 24.4 months. No patients had recurrences in the nipple-areolar complex. Necrosis of the nipple was reported in 22 of 192 patients (11%) and it was judged minimal (less than one-third total skin of nipple) in 13 of 22 patients (59%). Overall cosmesis was judged by the patient and surgeon as good to excellent in the majority of patients. Level of satisfaction with cosmetic results was similar between prophylactic and treatment patients. CONCLUSIONS: The risk of local relapse was very low in our series of nipple-sparing mastectomies performed for DCIS or invasive cancer. Nipple-sparing mastectomy in the risk-reducing and breast cancer-treatment settings may be feasible in selected patients and should be the subject of additional prospective clinical trials.     

Are tobacco use and urine pH indicated as risk factors for bladder carcinoma?

BACKGROUND: Many case-control and cohort studies have shown a positive relationship between bladder carcinoma and tobacco use. Recently, urine pH has been reported to influence aromatic amine carcinogenesis, which have been implicated as potent carcinogens in bladder carcinoma patients. Herein the correlation between bladder carcinoma, tobacco use and urine pH is reported. METHOD: One hundred and forty-one patients with bladder carcinoma and 128 patients with benign prostatic hyperplasia or urolithiasis as controls were selected. All patients were admitted to Osaka City University Hospital for the purpose of surgical treatment. Urine pH was checked by a test tape. RESULTS: Of the patients with bladder carcinoma, 106 were smokers and 35 were non-smokers. In contrast, the number of smokers in the control group was 76 and that of non-smokers was 52. The odds ratio in the bladder carcinoma group calculated for the smoker patients was 2.07, showing a significant correlation between bladder carcinoma and tobacco use. Regarding urine pH, acidic urine was found in 126 patients in the bladder carcinoma group and in 116 patients in the control group. The odds ratio in the bladder carcinoma group for acidic urine was 0.87, showing no significant relationship between bladder carcinoma and urine pH. CONCLUSION: The study found a positive relationship between bladder carcinoma and tobacco use; however, it could not establish a clear relationship between bladder carcinoma and urine pH, even in the smoker group.     

Are chronic dialysis patients at increased risk for cancer?

This review summarizes the plausible mechanisms of carcinogenesis, critically analyzes the literature on cancer risk and discusses issues of cancer screening in chronic dialysis patients. Despite conflicting results among various studies, there is sufficient evidence to conclude that there is a heightened incidence of at least some cancers in dialysis patients. The data most convincingly support an increased risk of genitourinary malignancies. Screening for the common solid organ cancers (prostate, colon, breast and cervix) should be individualized, and is appropriate only for the minority of patients with a life expectancy on dialysis of 10 years or longer. Further research is needed before routine screening for bladder or renal cell cancers can be recommended.     

Is chronic kidney disease an independent risk factor for mortality in breast cancer?

Background

Chronic kidney disease (CKD) is an independent risk factor for morbidity and mortality in multiple disease processes. However, not much is known about the relationship between breast cancer and CKD. CKD is associated with increased difficulty in breast cancer screening or surveillance due to increased calcifications on mammography. In addition, there is concern regarding the optimization of serum levels of chemotherapeutics in patients with CKD or on hemodialysis. We hypothesized that CKD is an independent risk factor for mortality in patients with breast cancer.

Methods

A case-matched, retrospective review of a prospectively maintained database was conducted on patients treated for breast cancer at an academic medical center between 1998 and 2011. Glomerular filtration rates (GFRs) were calculated for each patient at the time of diagnosis, and patients with CKD (GFR <60 mL/min) were matched in a 1:2 ratio with patients with GFR >60 mL/min, controlling for age, stage at diagnosis, and race. Primary end points measured were disease-free survival and overall survival. Statistical analysis was performed using Student t-test and Kaplan–Meier.

Results

Of the 1223 total patients, 54 (4%) had CKD. One hundred five patients without CKD were matched for age, stage at diagnosis, and race. Mean GFR among patients with and without CKD were 47.6 and 83.2 mL/min, respectively (P < 0.001). The 5-y overall survival was 77% for patients with CKD and 86% for patients without CKD (P = 0.47). Disease-free survival was 64% and 81%, respectively (P = 0.45).

Conclusion

Based on our data, CKD does not appear to have a significant impact on outcomes in patients with breast cancer.     

Which bisphosphonates do oncologists prescribe for women with metastatic breast cancer and why? Results of a UK survey

In breast cancer, many bisphosphonates are approved for use in metastatic bone disease which significantly delay and reduce the risk and rate of skeletal complications. There is a paucity of evidence about the relative efficacy of different drugs, routes of administration or optimal doses. Oral and IV administration have various advantages and disadvantages. A total of 112/144 (78%) UK oncologists completed a postal survey about their bisphosphonate prescribing practices and reasons for them. Fifty three percent gave both oral and IV drugs, 40% only IV and 7% only oral. In the absence of scientific evidence, financial constraints often dictated choice and route of administration or local guidelines which were extremely varied. The primary advantages perceived for oral drugs were patient convenience (48%) and for IV to ensure compliance or bioavailability (37%). Adherence to oral bisphosphonates is often poor, but 44% oncologists expected good adherence in >71% patients. More clinical trial data are needed to inform practice.     

Does reoperation predispose to postoperative wound infection in women undergoing operation for breast cancer?

Reoperations for breast cancer predispose to a higher risk of postoperative wound infections than primary procedures. We accomplished a retrospective chart review of 320 women who underwent multiple breast cancer procedures between 10/97 and 8/02. The mean number of procedures was 2.4 (range, 2-5). The overall incidence of wound infection was 6.1 per cent. Wound infections developed, on average, 12 days after surgery (range, 2-30). There was a statistically significant difference in the incidence of wound infection comparing the initial procedure versus the subsequent operation (1.6% vs. 9.4%, P < 0.001). This was also seen with reoperation after an operative biopsy compared to operation after a core biopsy (11.1% vs. 9.7%, P < 0.01). The incidence was increased to 22.0 per cent when the initial operation involved lymph node dissection (sentinel lymph node biopsy or complete axillary lymph node dissection). Wire localization did not increase the incidence of postoperative wound infections, and prophylactic antibiotics were associated with a decreased incidence of wound infection in the reoperative setting. The incidence of wound infection is increased with reoperation after operative biopsy compared to operation after core biopsy and is further increased when the initial biopsy involved lymph node dissection.