Bone health in breast cancer survivors

The objective of this paper is to carry out a systemic review of the literature investigating issues related to bone health in survivors of breast cancer. Given the fact that only a fraction of women with breast cancer receive appropriate assessment of their bone health, it is hoped that this review will help raise awareness of bone health concerns in this patient population. Articles published in the English language addressing issues related to bone health in breast cancer were accessed using Pubmed database. Studies were searched using keywords like: "Osteoporosis", "osteopenia", "bone health", "breast cancer", "denosumab" and "bisphosphonates". Current evidence suggests that women who survive their breast cancer are at high risk for significant bone loss. Recent clinical guidelines recommend assessment of bone mineral density (BMD) in high-risk patients. Nonpharmacologic interventions including lifestyle changes, vitamin D and calcium supplements are extremely important. Bisphosphonates, in both oral and parenteral formulations, are increasingly used while new agents, like denosumab, have recently been approved. Due to the widespread use of screening mammography and early detection programs leading to breast cancer diagnosis at a much earlier stage and the recent introduction of more effective anticancer therapy, more women are surviving their breast cancer, which highlights the need for survivorship programs that address issues like bone health. Many recent professional societies are addressing these issues and updating their recommendations and guidelines.     

Second malignancies among elderly survivors of cancer

The U.S. population is aging, life expectancy is increasing, and cancer is a disease associated with aging. Advances in screening and therapeutics have led to a growing number of cancer survivors who are at risk for the development of secondary malignancies. Although the risks for the development of second malignancies following a first diagnosis of cancer are well described for survivors of childhood malignancies, there are fewer data for malignancies common in older adults. With the aging of the U.S. population, and with improving survival statistics in many adult malignancies, there is an increasing need to identify those second malignancies that might develop in the older adult survivor of cancer. In this paper, we describe the types and rates of second malignancies following cancers commonly seen in older adults and review the literature on these malignancies. Comparisons are made between older and younger adults with regard to the risks for developing treatment-related cancers with different modalities. Recommendations for early detection of second malignancies are summarized, though there remains an unmet need for evidence-based guidelines for screening for second malignancies in the older adult in particular.     

Favorable cardiac risk among elderly breast carcinoma survivors

BACKGROUND: There are two reasons why women who survive breast carcinoma may be at a lower risk of developing coronary heart disease (CHD) compared with women without a history of breast carcinoma. First, estrogens may be etiologic in the development of breast carcinoma and protective of CHD. Second, a common therapy for breast carcinoma (tamoxifen) may be associated with cardiac protection. METHODS: In this population-level cohort study, the authors analyzed data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare program to study the cardiac risk of elderly female Medicare beneficiaries with and without a history of breast carcinoma. Using the SEER file, the authors identified elderly women survivors of Stage 0, I, or II breast carcinoma (n = 5980) diagnosed between the ages of 55 and 64. Using the Medicare 5% noncancer file, the authors also identified elderly women without a history of cancer (n = 23,165). They followed women from age 67 for up to 5 years for hospitalization for acute myocardial infarction (AMI) through a review of Medicare claims. The authors controlled the analyses for race, socioeconomic status, geographic location, cohort entry year, and medical comorbidity. RESULTS: The hazard of hospitalization for AMI for breast carcinoma survivors relative to comparison patients was 0.66 (95% confidence interval, 0.49-0.88). This apparent cardioprotective effect of breast carcinoma survivorship was stronger in breast carcinoma survivors with documented cardiac risk factors. CONCLUSIONS: Survivors of early-stage postmenopausal breast carcinoma are at a significantly lower risk of hospitalization for AMI than women who do not have a history of breast carcinoma. That survivors' risk varies with previous cardiac risk factors may be consistent with effects of selective estrogen receptor modulators. This phenomenon should be evaluated further with individual-level data containing information on patient cardiac risk factors and tamoxifen use to help clarify the mechanism behind the risk reduction.     

Quality of life among long-term breast cancer survivors: a systematic review

The aim of this study was to review the literature on quality of life among long-term survivors of breast cancer and identify the specific aspects of quality of life that were affected in these survivors. We also describe predictors of quality of life. Published research reports were included if they described the quality of life of breast cancer survivors diagnosed at least five years earlier. The methodological quality of the 10 selected studies, conducted between 1997 and 2004, was high according to a list of predefined criteria. Most studies reported that long-term survivors of breast cancer experienced good overall quality of life. However, almost all studies reported that breast cancer survivors experienced some specific problems (e.g., a thick and painful arm and problems with sexual functioning). The current medical condition, amount of social support and current income level were strong positive predictors of quality of life, and the use of adjuvant chemotherapy emerged as a negative predictor. More research on the specific medical and psychosocial needs of survivors is needed in order to be able to design appropriate intervention studies. If anything, this review shows that focusing on the long-term effects of breast cancer is important when evaluating the full extent of cancer treatment.     

Sexual health in long-term breast cancer survivors

Purpose

Next-generation sequencing (NGS) has identified recurrent genomic alterations in metastatic breast cancer (MBC); however, the clinical utility of incorporating routine sequencing to guide treatment decisions in this setting is unclear. We examine the frequency of genomic alterations in MBC patients from academic and community hospitals and correlate with clinical outcomes.

Methods

MBC patients with good performance status were prospectively recruited at the Princess Margaret Cancer Centre (PM) in Canada. Molecular profiling on DNA extracted from FFPE archival tissues was performed on the Sequenom MassArray platform or the TruSeq Amplicon Cancer Panel (TSACP) on the MiSeq platform. Clinical trial outcomes by RECIST 1.1 and time on treatment were reviewed retrospectively.

Results

From January 2012 to November 2015, 483 MBC patients were enrolled and 440 were genotyped. At least one somatic mutation was identified in 46% of patients, most commonly in PIK3CA (28%) or TP53 (13%). Of 203 patients with ≥ 1 mutation(s), 15% were treated on genotype-matched and 9% on non-matched trials. There was no significant difference for median time on treatment for patients treated on matched vs. non-matched therapies (3.6 vs. 3.8 months; p = 0.89).

Conclusions

This study provides real-world outcomes on hotspot genotyping and small targeted panel sequencing of MBC patients from academic and community settings. Few patients were matched to clinical trials with targeted therapies. More comprehensive profiling and improved access to clinical trials may increase therapeutic options for patients with actionable mutations. Further studies are needed to evaluate if this approach leads to improved clinical outcomes.

     

Post-treatment regret among young breast cancer survivors

Objective: The study addresses: (1) what women regret about their breast cancer treatment 5 years later, and (2) what characteristics of disease and treatment predict post‐treatment regret. Method: Interviews were conducted with breast cancer survivors in the San Francisco Bay Area. Participants were interviewed following diagnosis. Five years later, women were asked whether they had any regrets about their cancer treatment (N=449). Qualitative analysis was used to identify regret content, and logistic regression was used to determine what characteristics of treatment predicted regret. Results: Forty two point five percent women in the sample regretted some aspect of the treatment. The most common regrets were primary surgery (24.1%), chemotherapy and/or radiation (21.5%), reconstruction (17.8%), and problems with providers (13.1%). In addition, women regretted inactions (59.2%) (actions that they did not take) more than actions that they did take (30.4%). This represents a novel finding in the study of post‐treatment regret, which has largely focused on regrets over actions. Quantitative analysis revealed that women who were anxious about the future (OR=1.32; p=0.03) or had problems communicating with physicians (OR=1.26; p=0.02) during treatment were more likely to express regret 5 years later. In addition, women with new or recurrent cancers 5 years later were significantly more likely to regret some aspect of their primary treatment (OR=5.81; p<0.001). Conclusion: This research supports addressing the psychosocial aspects of cancer care and improving physician‐patient communication. Evidence is also provided for addressing the unique emotional needs of women with recurrent cancers, who may experience an undue burden of regret. Copyright © 2010 John Wiley & Sons, Ltd.     

Risk of treatment-related esophageal cancer among breast cancer survivors

BackgroundRadiotherapy for breast cancer may expose the esophagus to ionizing radiation, but no study has evaluated esophageal cancer risk after breast cancer associated with radiation dose or systemic therapy use.DesignNested case–control study of esophageal cancer among 289 748 ≥5-year survivors of female breast cancer from five population-based cancer registries (252 cases, 488 individually matched controls), with individualized radiation dosimetry and information abstracted from medical records.ResultsThe largest contributors to esophageal radiation exposure were supraclavicular and internal mammary chain treatments. Esophageal cancer risk increased with increasing radiation dose to the esophageal tumor location (P_trend < 0.001), with doses of ≥35 Gy associated with an odds ratio (OR) of 8.3 [95% confidence interval (CI) 2.7–28]. Patients with hormonal therapy ≤5 years preceding esophageal cancer diagnosis had lower risk (OR = 0.4, 95% CI 0.2–0.8). Based on few cases, alkylating agent chemotherapy did not appear to affect risk. Our data were consistent with a multiplicative effect of radiation and other esophageal cancer risk factors (e.g. smoking).ConclusionsEsophageal cancer is a radiation dose-related complication of radiotherapy for breast cancer, but absolute risk is low. At higher esophageal doses, the risk warrants consideration in radiotherapy risk assessment and long-term follow-up.     

Quality of life among disease-free survivors of rectal cancer.

PURPOSE: To identify factors affecting the quality of life (QoL) of disease-free survivors of rectal cancer. PATIENTS AND METHODS: One hundred twenty-one patients in complete remission more than 2 years after diagnosis were asked to complete three QoL questionnaires: the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30; its colorectal module, QLQ-CR38; and the Duke generic instrument. RESULTS: Patients reported less pain (P =.002) than did controls drawn from the general population. EORTC QLQ-C30 physical scores were also higher among rectal cancer survivors than in the general Norwegian or German population (P =.0005 and P =.002, respectively). Unexpectedly, stoma patients reported better social functioning than did nonstoma patients (P =.005), with less anxiety (P =.008) and higher self-esteem (P =.0002). In the present authors' experience, the QLQ-CR38 does not discriminate between these groups. Residual abdominal or pelvic pain and constipation had the most negative influence on QoL. CONCLUSION: QoL is high among rectal cancer survivors, including stoma patients. Simultaneous use of several QoL questionnaires appears to have value in follow-up and in monitoring the effects of therapy. The impact of residual pain and constipation on long-term QoL should be considered when establishing a treatment regimen.     

Predictors of vasomotor symptoms among breast cancer survivors

Purpose

Vasomotor symptoms (VMS) are a common side effect of breast cancer treatment, yet modifiable factors that may predict VMS among breast cancer survivors are unknown.

Methods

We estimated multivariable-adjusted odds ratios and 95% confidence intervals (aOR, 95% CI) for predictors of VMS among 3595 breast cancer survivors enrolled in the Life and Longevity after Cancer (LILAC) study, an ancillary study of the Women’s Health Initiative (WHI).

Results

VMS post-diagnosis were reported by 790 (22.0%) participants. Risk of VMS after diagnosis was positively associated with prior chemotherapy (aOR 1.80, 95% CI 1.21–2.68) and adjuvant hormone therapy (aOR 2.73, 95% CI 2.08–3.58), postmenopausal hormone therapy use (aOR 1.67, 95% CI 1.30–2.13), prior VMS (aOR 2.20, 95% CI 1.73–2.80), bilateral oophorectomy (aOR 1.77, 95% CI 1.37–2.27), and baseline antidepressant use (aOR 1.49, 1.06–2.09). VMS post-diagnosis were less likely among younger women (aOR 0.94, 95% CI 0.93–0.96), women younger at menopause (aOR 0.98, 95% CI 0.97–1.00), women with more time since diagnosis (aOR 0.92, 95% CI 0.90–0.94), and diabetics (aOR 0.45, 95% CI 0.21–0.95). Metabolic syndrome was not associated with post-diagnosis VMS (aOR 0.76, 95% CI 0.45–1.28).

Conclusions

VMS following breast cancer diagnosis was related to a number of modifiable factors, but was unrelated to metabolic syndrome.

Implications for Cancer Survivors

Identification of factors that predispose women to VMS following a breast cancer diagnosis may allow clinicians to recognize and address VMS in the subset of women who are most likely to experience such symptoms.

     

Increased risks of third primary cancers of non-breast origin among women with bilateral breast cancer

Background:

This study examined the risk of third cancer of non-breast origin (TNBC) among women with bilateral breast cancer (BBC; either synchronous or metachronous), focussing on the relation with breast cancer treatment.

Methods:

Risk was assessed, among 8752 Dutch women diagnosed with BBC between 1989 and 2008, using standardised incidence ratios (SIR) and Cox regression analyses to estimate the hazard ratio (HR) of TNBC for different treatment modalities.

Results:

Significant increased SIRs were observed for all TNBCs combined, haematological malignancies, stomach, colorectal, non-melanoma skin, lung, head and neck, endometrial, and ovarian cancer. A 10-fold increased risk was found for ovarian cancer among women younger than 50 years (SIR=10.0, 95% confidence interval (CI)=5.3–17.4). Radiotherapy was associated with increased risks of all TNBCs combined (HR=1.3; 95%CI=1.1–1.6, respectively). Endocrine therapy was associated with increased risks of all TNBCs combined (HR=1.2; 95%CI=1.0–1.5), haematological malignancies (HR=2.0; 95%CI=1.1–3.9), and head and neck cancer (HR=3.3; 95%CI=1.1–10.4). After chemotherapy decreased risks were found for all TNBCs combined (HR=0.63; 95%CI=0.5–0.87).

Conclusion:

Increased risk of TNBC could be influenced by genetic factors (ovarian cancer) or an effect of treatment (radiotherapy and endocrine therapy). More insight in the TNBC risk should further optimise and individualise treatment and surveillance protocols in (young) women with BBC.     

Spiritual health locus of control and life satisfaction among African American breast cancer survivors

Abstract

Purpose: To examine the relationships between spiritual health locus of control (SHLOC) and satisfaction with life in African American (AA) breast cancer survivors (BCS).

Methods: A total of 118 AABCS completed a mailed survey. Logistic regression models were used to examine relationships among variables of interest.

Results: Annual income and SHLOC were significantly associated with life satisfaction. In unadjusted analyses, high overall SHLOC increased the odds (odds ratio [OR]?=?2.8) of being satisfied with life. The adjusted relationships between SHLOC and life satisfaction differed by income level. Among survivors with lower incomes, high spiritual life/faith and God’s grace subscale scores increased the odds of life satisfaction, when compared to those with higher incomes.

Conclusions: Our data indicated that high overall SHLOC was significantly related to higher odds of life satisfaction. Further, SHLOC may serve as a resource to bolster life satisfaction, especially in low-income AA BCS.     

Use of cancer support groups among Latina breast cancer survivors

Introduction Although Latina women diagnosed with breast cancer may be at greater risk of psychosocial morbidity compared to white women, few utilize support services such as support groups. Reasons for this under-use among Latinas are unknown. Methods A cross-sectional telephone survey examined the association of predisposing, enabling, and need factors with use of cancer support groups among 330 Latina breast cancer survivors recruited from a population-based tumor registry in counties with Spanish language support groups. Results Thirty-two percent had ever used a support group. Among the 225 (68%) women who had never used one, major reasons for not using a support group included receiving enough support from other sources (20%), not needing one (18%), and being unaware of groups in their local area (17%). Women receiving quite a bit or a lot of encouragement from family members to attend a cancer support group were seven times more likely to have ever attended one than women receiving little or no encouragement (OR = 7.04, 95% CI 3.72, 13.30). Spiritual well-being was inversely associated with ever having attended a support group (OR = 0.93, 95% CI 0.89, 0.98). Discussion Results suggest that families play an important role in promoting use of support groups among Latina breast cancer survivors, and that spirituality may offer an alternative source of support. Implications for Cancer Survivors More effort should be directed toward providing culturally and linguistically appropriate support services to breast cancer survivors, and increasing awareness of these services among oncologists, patients and family members.     

Male breast cancer incidence among atomic bomb survivors

To learn more about the role of ionizing radiation in the development of male breast cancer, we evaluated male breast cancer incidence among 45 880 male members of the Life Span Study cohort of Japanese atomic bomb survivors. Male breast cancers, diagnosed between January 1, 1958, and December 31, 1998, were identified through the Hiroshima and Nagasaki Tumor Registries. Nine male breast cancers were diagnosed among exposed Life Span Study members (crude rate = 1.8 per 100,000 person-years), and three were diagnosed among nonexposed cohort members (crude rate = 0.5 per 100,000 person-years). A statistically significant dose-response relation was observed (excess relative risk per sievert = 8, 95% confidence interval = 0.8 to 48; P = .01). Our finding of a statistically significant association between ionizing radiation and male breast cancer incidence adds to the very limited information that shows an association between radiation exposure and an increased risk of male breast cancer.