Lori L. Wilson

Strong association of fascin expression with triple negative breast cancer and basal-like phenotype in African-American women

Background Fascin, an actin bundling protein, plays a critical role in cell motility due to formation of actin rich protrusions called filopodia, important in cell migration, invasion and metastatic spread. Fascin overexpression has been associated with epithelial to mesenchymal transition and correlates with progression and unfavourable prognosis in breast carcinoma. Objective To evaluate fascin expression by immunohistochemistry and correlate the expression pattern with clinicopathological parameters in breast cancer in African-American (AA) women, in whom triple negative breast cancer (TNBC), an aggressive subtype, is more prevalent. Methods Tissue microarrays were constructed from formalin-fixed, paraffin-embedded blocks of tumour tissue from primary breast carcinomas in 202 AA women. Immunohistochemical detection of fascin was correlated with four major subtypes of breast carcinoma (luminal A, luminal B, human epidermal growth factor receptor 2 and triple negative (TN)) and other clinicopathological factors, including age, grade, tumour size, stage, regional lymph node status and survival. Results We observed a significant association between fascin expression and TN subtype, oestrogen receptor (ER) negativity, progesterone receptor (PR) negativity, Elston–Nottingham (EN) grade 3 and decreased overall survival. There was also a significant association between expression of CK 5/6, a marker of basal-like phenotype, and fascin expression. Conclusion These results suggest that fascin is a marker for TN subtype having a basal-like phenotype and decreased overall survival. Fascin may represent a target for therapy in TNBC in AA women.

Comparison of Rates and Outcomes of Readmission to Index vs Nonindex Hospitals After Major Cancer Surgery

Importance Increasing regionalization of cancer surgery has the inadvertent potential to lead to fragmentation of care if readmissions occur at a facility other than the index hospital. The magnitude and adverse effects of readmission to a facility other than the one where the surgery was performed are unclear. Objectives To assess rates of readmission to nonindex hospitals after major cancer surgery and to compare outcomes between index and nonindex hospital readmissions. Design, Setting, and Participants In this multicenter, population-based, nationally representative study of adult patients undergoing a major cancer operation (defined as esophagectomies or gastrectomies, hepaticobiliary resections, pancreatectomies, colorectal resections, or cystectomies), retrospective analyses were performed using the Nationwide Readmissions Database (admissions from January 1 through September 30, 2013). Descriptive analyses were performed to determine 90-day readmission characteristics, including timing, cost, and outcomes. Adjusting for clustering by facility, the study used multivariate logistic regression to identify factors associated with nonindex vs index readmissions. The study also used regression models to identify differences in mortality, major complications, and subsequent readmissions between the 2 groups. Data analysis was performed from January 1 through December 31, 2013. Exposures Readmission to index vs nonindex hospitals (defined as any hospital other than the hospital where the major cancer operation was performed). Main Outcomes and Measures Proportion of 90-day readmissions and nonindex readmissions after major cancer surgery, factors associated with nonindex readmissions, and difference between in-hospital mortality, hospital costs, and subsequent readmissions for patients admitted to index vs nonindex hospitals. Results A total of 60 970 patients were included in the study (mean [SD] age, 67 [13] years; 7619 [55.6%] male and 6075 [44.4%] female). The 90-day readmission rate was 23.0%. Of the 13 695 first readmissions, 20.1% were to a nonindex hospital. Independent factors associated with readmission to a nonindex hospital included type of procedure, comorbidities (OR, 1.40; 95% CI, 1.15-1.70), elective admission (OR, 1.21; 95% CI, 1.06-1.37), discharge to a nursing facility (OR, 1.20; 95% CI, 1.07-1.36), and surgery at a teaching hospital (OR, 1.16; 95% CI, 1.00-1.34) (all P < .05). After risk adjustment, patients readmitted to nonindex hospitals had 31.2% higher odds of mortality (odds ratio, 1.31; 95% CI, 1.05-1.64) and 27.3% higher odds of having a major complication (odds ratio, 1.27; 95% CI, 1.14-1.42). Subsequent readmissions and hospital costs were not different between the 2 groups. Conclusions and Relevance Approximately one-fifth of readmissions were to a nonindex hospital and were associated with higher mortality and morbidity than readmission to index hospitals. Factors that influence nonindex readmissions have been identified to target interventions.

How does a concurrent diagnosis of cancer influence outcomes in emergency general surgery patients

BACKGROUND A significant proportion of hospital admissions in the US are secondary to emergency general surgery (EGS). The aim of this study is to quantify outcomes for EGS patients with cancer. METHODS The Nationwide Inpatient Sample (2007 to 2011) was queried for patients with a diagnosis of an EGS condition as determined by the American Association for the Surgery of Trauma. Of these, patients with a diagnosis of malignant cancers (ICD-9-CM diagnosis codes; 140-208.9, 238.4, 289.8) were identified. Patients with and without cancer were matched across baseline characteristics using propensity-scores. Outcome measures included all-cause mortality, complications, failure-to-rescue, length of stay, and cost. Multivariable logistic regression analyses further adjusted for hospital characteristics and volume. RESULTS Analysis of 3,625,906 EGS patients revealed an 8.9% prevalence of concurrent malignancies. The most common EGS conditions in cancer patients included gastro-intestinal bleeding (24.8%), intestinal obstruction (13.5%), and peritonitis (10.7%). EGS patients with cancer universally had higher odds of complications (odds ratio [OR] 95% confidence interval [CI]: 1.20 [1.19 to 1.21]), mortality (OR [95% CI]: 2.00 [1.96 to 2.04]), failure-to-rescue (OR [95% CI]: 1.52 [1.48 to 1.56]), and prolonged hospital stay (OR [95% CI]: 1.69 [1.67 to 1.70]). CONCLUSIONS EGS patients with concurrent cancer have worse outcomes compared with patients without cancer after risk-adjustment.

Readmissions After Complex Cancer Surgery: Analysis of the Nationwide Readmissions Database

PURPOSE Hospital readmissions after surgery are a focus of quality improvement efforts. Although some reflect appropriate care, others are potentially preventable readmissions (PPRs). We aim to describe the burden, timing, and factors associated with readmissions after complex cancer surgery. METHODS The Nationwide Readmissions Database (2013) was used to select patients undergoing a complex oncologic resection, which was defined as esophagectomy/gastrectomy, hepatectomy, pancreatectomy, colorectal resection, lung resection, or cystectomy. Readmissions within 30 days from discharge were analyzed. International Classification of Diseases (9th revision) primary diagnosis codes were reviewed to identify PPRs. Multivariable logistic regression analyses identified demographic, clinical, and hospital factors associated with readmissions. RESULTS Of the 59,493 eligible patients, 14% experienced a 30-day readmission, and 82% of these were deemed PPRs. Half of the readmissions occurred within the first 8 days of discharge. Infections (26%), GI complications (17%), and respiratory conditions (10%) accounted for most readmissions. Factors independently associated with an increased likelihood of readmission included Medicaid versus private insurance (odds ratio [OR], 1.32; 95% CI, 1.17 to 1.48), higher comorbidity score (OR, 1.5; 95% CI, 1.33 to 1.63), discharge to a facility (OR, 1.39; 95% CI, 1.29 to 1.51), prolonged length of stay (OR, 1.42; 95% CI, 1.32 to 1.52), and occurrence of a major in-hospital complication (OR, 1.24; 95% CI, 1.16 to 1.34). CONCLUSION One in seven patients undergoing complex cancer surgery suffered a readmission within 30 days. We identified common causes of these and identified patients at high risk for such an event. These data can be used by physicians, administrators, and policymakers to develop strategies to decrease readmissions.

Abstract P5-12-05: Racial and gender disparity in breast cancer: A review on African American men

Background: Secondary to their comparable racial and socio-demographic background, African American (AA) men and women with breast cancer are expected to have similar outcomes. However, there is a paucity of data demonstrating gender-specific differences in breast cancer across racial/ethnic groups. Our objective is to investigate potential differences between AA men, AA women and White men with breast cancer by evaluating risk factors using a population-based tumor registry. Methods: A retrospective review of the Surveillance Epidemiology and End Results (SEER) database from 1988 to 2008 was conducted. We identified AA men and AA women aged 20 years or older with a primary breast cancer diagnosis or in whom the index breast cancer is the first cancer. A similar group of White men were included to serve for comparison. All available treatment modalities were reviewed. Bivariate analysis of patient characteristics, tumor grade, stage, hormonal assay, and treatment modality was performed using Chi squared test. Survival was estimated and Cox proportional model was used to investigate survival differences comparing AA men, AA women and White men (with AA men as reference), adjusting for age, year of diagnosis, tumor characteristics, as well as treatment received. Subset analyses were done within stage strata. Results: We reviewed 62 758 patient records comprising 506 (0.81%) AA male, 59 234 (94.38%) AA female and 3 018 (4.81%) White males. Most were 50 years or older (57.5%), married (39.4%), had invasive ductal carcinoma (61.9%) and localized disease (42.5%). Mean age at diagnosis was 59 (±11), 55 (±12) and 63 (±11) years for AA males, AA females and White males, respectively. Men were more likely to have moderately differentiated tumors (37.6% and 40.4% for AA males and White males, respectively) compared to AA women who were more likely to have poorly differentiated tumors (39.2%) (p Conclusion: Using a large population-based database, our study demonstrates absence of gender specific difference in breast cancer survival among African Americans. However, AA men were found to have larger tumors, worse stage, and despite presenting with similar grade and receiving similar treatment as White males, had worse outcome. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-12-05.

Abstract 170: Racial differences in stage at diagnosis and survival for premenopausal breast cancer patients.

BACKGROUND: There are racial/ ethnic disparities in breast cancer survival rates in the US. Tumor stage at diagnosis has long been a prognostic factor in breast cancer. Our objective was to determine whether there are racial disparities in tumor stage at diagnosis of breast cancer in pre-menopausal women, using a large national cancer registry. METHODS: We conducted a retrospective analysis using data from the Surveillance Epidemiology and End Results database for 1996-2006. Premenopausal (≤50 years) women with primary diagnosis of breast cancer were identified using appropriate ICD-O-3 codes (C500-C509). Comparing racial/ethnic groups, with white race as the reference, multivariate logistic regression was used to assess the odds of late stage (stage III or IV) versus early stage (stage I or II) diagnosis at presentation, adjusting for prognostic factors, tumor characteristics, and year differences. All statistical tests were two-sided. RESULTS: A total of 86,570 women met our inclusion criteria. Of those, 56,811 (65.62%) were White, 10,789 (12.46%) were Hispanic, 9,896 (11.43%) were Black, 8,115 (9.37%) were Asian or Pacific Islanders, 544 (0.63%) were Native American and for 415 (0.48%) women the race was unknown. A majority of patients were 46-50 years old (43%) and married (65%) at the time of diagnosis. Most were diagnosed with stage II (46%), invasive ductal (93%) histology, 1.1-2cm (36%) in size, poorly differentiated (45%), and without distant metastasis (96%). On multivariate analysis, compared to white women, Black women had 58% higher adjusted odds (OR: 1.58; 95% CI: 1.49-1.68) and Hispanic women had 37% higher odds (OR: 1.37; 95%CI: 1.29-1.46) of having late stage versus early stage breast cancer at time of diagnosis. Figure 1 shows the race specific percent of women diagnosed with late stage cancer across the years. Cancer-specific mortality rates were 10.1% for whites, 21.1% for blacks, 13.4% for Hispanics, 17.6% for Native Americans, and 9.6 % for Asians (p value CONCLUSIONS: Utilizing a large cohort of premenopausal women diagnosed with breast cancer our study showed African-American and Hispanic women have higher incidence of diagnosis of late stage breast cancer as compared to their white counterparts. They as well as Native Americans also have higher cancer specific mortality rates as compared to their white and Asian counterparts. This study provides evidence that premenopausal African-American and Hispanic women represent a high-risk group that will benefit from identification of factors that contribute to late stage at presentation. Figure 1: Percent of women in each race diagnosed with late stage breast cancer over time. Citation Format: Namita Akolkar, Augustine Obirieze, Wayne Frederick, Lori Wilson. Racial differences in stage at diagnosis and survival for premenopausal breast cancer patients. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 170. doi:10.1158/1538-7445.AM2013-170