Seul Ki Choi

Body Composition as a Predictor of Toxicity in Patients Receiving Anthracycline and Taxane Based Chemotherapy for Early Stage Breast Cancer.

Purpose: Poor body composition metrics (BCM) are associated with inferior cancer outcomes; however, in early breast cancer (EBC), there is a paucity of evidence regarding the impact of BCM on toxicities. This study investigates associations between BCM and treatment-related toxicity in patients with EBC receiving anthracyclines and taxane–based chemotherapy. Experimental Design: Pretreatment computerized tomographic (CT) images were evaluated for skeletal muscle area (SMA), skeletal muscle density (SMD), and fat tissue at the third lumbar vertebrae. Skeletal muscle index (SMI = SMA/height2) and skeletal muscle gauge (SMG = SMI × SMD) were also calculated. Relative risks (RR) are reported for associations between body composition measures and toxicity outcomes, after adjustment for age and body surface area (BSA). Results: BCM were calculated for 151 patients with EBC (median age, 49 years; range, 23–75 years). Fifty patients (33%) developed grade 3/4 toxicity, which was significantly higher in those with low SMI (RR, 1.29; P = 0.002), low SMG (RR, 1.09; P = 0.01), and low lean body mass (RR, 1.48; P = 0.002). Receiver operating characteristic analysis showed the SMG measure to be the best predictor of grade 3/4 toxicity. Dividing SMG into tertiles showed toxicity rates of 46% and 22% for lowest versus highest tertile, respectively (P = 0.005). After adjusting for age and BSA, low SMG (<1,475 units) was significantly associated with hematologic (RR, 2.12; P = 0.02), gastrointestinal grade 3/4 toxicities (RR, 6.49; P = 0.02), and hospitalizations (RR, 1.91; P = 0.05). Conclusions: Poor BCMs are significantly associated with increased treatment-related toxicities. Further studies are needed to investigate how these metrics can be used to more precisely dose chemotherapy to reduce treatment-related toxicity while maintaining efficacy. Clin Cancer Res; 23(14); 3537–43. ©2017 AACR.

Exploring the HIV continuum of care among young black MSM

Background HIV disproportionately impacts young, black men who have sex with men (YBMSM) who experience disparities across the HIV care continuum. A more nuanced understanding of facilitators and barriers to engagement in care, missed visits, antiretroviral uptake, adherence and viral suppression could improve care and intervention design. Methods A randomized controlled trial of an online intervention, healthMpowerment, enrolled 465 YBMSM (18–30 years); 193 identified as HIV-positive. Bivariable and multivariable analyses of baseline data explored predictors of: engagement in care, missed visits, antiretroviral uptake, self-reported adherence, and viral suppression. Results Mean age was 24.9 years; most identified as gay (71.0%) and were receiving HIV care (89.1%). Among those in care, 52.1% reported no missed visits in the past 12 months, 41 (24.6%) reported one missed visit, and 39 (23.4%) reported two or more. Having insurance (prevalence odds ratio [POR] 4.5; 95% CI: 1.3, 15.8) and provider self-efficacy (POR 20.1; 95% CI: 6.1, 64.1) were associated with being in care. Those with a college degree (POR 9.1; 95% CI: 1.9, 45.2) and no recent marijuana (POR 2.6; 95% CI: 1.2, 5.6) or methamphetamine use (POR 5.4; 95% CI: 1.0, 28.5) were less likely to miss visits. Most (n = 153, 84.1%) had been prescribed antiretroviral therapy. A majority of participants (70.8%) reported ≥90% adherence; those with depressive symptoms had 4.7 times the odds of reporting adherence <90% (95% CI: 1.65, 13.37). Of participants who reported viral load testing in the past six months, 65% (n = 102) reported an undetectable viral load. Disclosure to sex partners was associated with viral suppression (POR 6.0; 95% CI: 1.6, 22.4). Conclusions Multi-level facilitators and barriers to engagement across the continuum of care were identified in this sample of YBMSM. Understanding the distinct needs of YBMSM at each stage of the continuum and addressing them through tailored approaches is critical for long term success in care.

The impact of skeletal muscle on the pharmacokinetics and toxicity of 5-fluorouracil in colorectal cancer

PurposeGreat heterogeneity exists in the ability of adults with cancer to tolerate chemotherapy. Variability in body composition may affect rates of metabolism of cytotoxic agents and contribute to the variable chemotherapy toxicity observed. The objective of this exploratory study was to examine the association of low skeletal muscle, commonly known as sarcopenia, on the pharmacokinetics (PKs) of 5-fluorouracil (5FU) in patients receiving FOLFOX for colorectal cancer.MethodsWe performed a secondary analysis of a completed multicenter trial that investigated PK-guided 5FU dosing in patients receiving mFOLFOX6 +/− bevacizumab for colorectal cancer. Cycle 1 PK samples were obtained 2–44xa0h after the start of the 5FU infusion (steady state).ResultsNo significant differences in first cycle 5FU area-under-the-concentration-time-curve (AUC) were found between sarcopenic and non-sarcopenic patients (17.3 vs. 19.3 AUC, pu2009=u20090.43). Patients with grade 3/4 toxicity had a higher dose of 5FU per kg lean body mass (LBM) (105 vs. 93xa0mg/kg, pu2009=u20090.06), most notably for hematological toxicities (110 vs. 94xa0mg/kg, pu2009=u20090.002); however, no correlation between the dose/LBM and 5FU AUC was found.ConclusionsAlthough our results did not confirm the impact of low skeletal muscle on PKs of 5FU, further research exploring the impact of body composition on chemotherapy PKs and related toxicities is warranted with the potential for alternative dosing strategies in sarcopenic patients to reduce unnecessary toxicities while maintaining efficacy.

Weight changes in postmenopausal breast cancer survivors over 2 years of endocrine therapy: a retrospective chart review

PurposeObesity and weight gain after breast cancer (BC) diagnosis can affect cancer outcomes. This study explores the question of weight change during the first 2xa0years of endocrine treatment (ET) to identify the independent effects of BC diagnosis and treatment on post-diagnosis weight trajectories in early-stage postmenopausal BC survivors.MethodsThe study design is a retrospective chart review. Chi square tests and ANOVA were used to compare patients who gained >2xa0kg, lost >2xa0kg, or had stable weight. Log-binomial regression models were used to evaluate associations between patient characteristics and weight trajectories.ResultsThe final sample is Nxa0=xa0300, with mean age at BC diagnosis of 65xa0years and 76% white. After 2xa0years of ET, 39% of study participants had gained >2xa0kg, 27% had lost >2xa0kg, and 34% had stable weight. Relative risks (RR) for weight gain were as follows: age at diagnosisxa0=xa00.98 (0.96, 0.99), being marriedxa0=xa01.48 (1.04, 2.12), weight change between BC diagnosis and start of ETxa0=xa00.98 (0.97, 0.99), Stage IIxa0=xa01.42 (1.01, 2.01) or Stage IIIxa0=xa01.99 (1.41, 2.82), PR negativexa0=xa00.70 (0.51, 0.96), HER2 positivexa0=xa01.51 (1.07, 2.13), mastectomyxa0=xa01.49 (1.12, 1.98), axillary node dissectionxa0=xa01.67 (1.27, 2.20), adjuvant chemotherapyxa0=xa01.49 (1.02, 2.19), and neoadjuvant chemotherapyxa0=xa02.29 (1.67, 3.14). Type of ET (tamoxifen or aromatase inhibitor) was not significant.ConclusionsIn our sample of postmenopausal early-stage BC survivors, a majority had stable or lost weight during the first 2xa0years of ET. Higher disease complexity and associated treatment posed higher RR for weight gain.

Measuring and understanding adherence in a home-based exercise intervention during chemotherapy for early breast cancer

PurposeEnsuring and measuring adherence to prescribed exercise regimens are fundamental challenges in intervention studies to promote exercise in adults with cancer. This study reports exercise adherence in women who were asked to walk 150xa0min/week throughout chemotherapy treatment for early breast cancer. Participants were asked to wear a FitbitTM throughout their waking hours, and Fitbit steps were uploaded directly into study computers.MethodsDescriptive statistics are reported, and both unadjusted and multivariable linear regression models were used to assess associations between participant characteristics, breast cancer diagnosis, treatment, chemotherapy toxicities, and patient-reported symptoms with average Fitbit steps/week.ResultsOf 127 women consented to the study, 100 had analyzable Fitbit data (79%); mean age was 48 and 31% were non-white. Mean walking steps were 3956 per day. Nineteen percent were fully adherent with the target of 6686 steps/day and an additional 24% were moderately adherent. In unadjusted analysis, baseline variables associated with fewer Fitbit steps were: non-white race (pxa0=xa00.012), high school education or less (pxa0=xa00.0005), higher body mass index (pxa0=xa00.0024), and never/almost never drinking alcohol (pxa0=xa00.0048). Physical activity variables associated with greater Fitbit steps were: pre-chemotherapy history of vigorous physical activity (pxa0=xa00.0091) and higher self-reported walking minutes/week (pxa0<xa00.001), and higher outcome expectations from exercise (pxa0=xa00.014). Higher baseline anxiety (pxa0=xa00.03) and higher number of chemotherapy-related symptoms rates “severe/very severe” (pxa0=xa00.012) were associated with fewer steps. In multivariable analysis, white race was associated with 12,146 greater Fitbit steps per week (pxa0=xa00.004), as was self-reported walking minutes prior to start of chemotherapy (pxa0<xa00.0001).ConclusionsInexpensive commercial-grade activity trackers, with data uploaded directly into research computers, enable objective monitoring of home-based exercise interventions in adults diagnosed with cancer. Analysis of the association of walking steps with participant characteristics at baseline and toxicities during chemotherapy can identify reasons for low/non-adherence with prescribed exercise regimens.

Financial Toxicity among Patients with Bladder Cancer: Reasons for Delay in Care and Effect on Quality of Life

Purpose: Costly surveillance and treatment of bladder cancer can lead to financial toxicity, a treatment related financial burden. Our objective was to define the prevalence of financial toxicity among patients with bladder cancer and identify delays in care and its effect on health related quality of life. Materials and Methods: We identified patients with bladder cancer in the University of North Carolina Health Registry/Cancer Survivorship Cohort. Financial toxicity was defined as agreement with having “to pay more for medical care than you can afford.” Health related quality of life was measured using general and cancer specific validated questionnaires. Statistical analyses were performed using the Fisher exact test and the Student t‐test. Results: A total of 138 patients with bladder cancer were evaluated. Median age was 66.9 years, 75% of the patients were male and 89% were white. Of the participants 33 (24%) endorsed financial toxicity. Participants who were younger (p = 0.02), black (p = 0.01), reported less than a college degree (p = 0.01) and had noninvasive disease (p = 0.04) were more likely to report financial toxicity. On multivariable analysis only age was a significant predictor of financial toxicity. Patients who endorsed financial toxicity were more likely to report delaying care (39% vs 23%, p = 0.07) due to the inability to take time off work or afford general expenses. On general health related quality of life questionnaires patients with financial toxicity reported worse physical and mental health (p = 0.03 and <0.01, respectively), and lower cancer specific health related quality of life (p = 0.01), physical well‐being (p = 0.01) and functional well‐being (p = 0.05). Conclusions: Financial toxicity is a major concern among patients with bladder cancer. Younger patients were more likely to experience financial toxicity. Those who endorsed financial toxicity experienced delays in care and poorer health related quality of life, suggesting that treatment costs should have an important role in medical decision making.

Correlates of Self-Reported Viral Suppression among HIV-Positive, Young, Black Men Who Have Sex with Men Participating in a Randomized Controlled Trial of An Internet-Based HIV Prevention Intervention

BackgroundYoung, black men who have sex with men are disproportionately impacted by the US HIV epidemic, and HIV-positive, young, black men who have sex with men face stark disparities in HIV clinical outcomes. MethodsWe performed an observational analysis of the 199 HIV-positive black men aged 18 to 30 years followed up for 12 months in healthMpowerment, a randomized controlled trial of an Internet-based HIV prevention intervention, to identify time-varying correlates of self-reported viral suppression using relative risk (RR) regression. ResultsRetention at the 12-month visit was 84%. One hundred five (65%) of 162 participants reported being undetectable at baseline. At 3, 6, and 12 months, 83 (72%) of 115, 84 (82%) of 103, and 101 (86%) of 117 reported an undetectable viral load, respectively. In a multivariable model, participants who reported homelessness (RR, 0.85; 95% confidence interval [CI], 0.72–0.99), who had clinically significant depressive symptoms (RR, 0.88; 95% CI, 0.79–0.98), and who used methamphetamine or crack (RR, 0.61; 95% CI, 0.38–0.96) were less likely to report an undetectable viral load. Young men who engaged in condomless insertive anal intercourse were more likely to report viral suppression (RR, 1.14; 95% CI, 1.04–1.24). ConclusionHIV care for young, black men who have sex with men must be multidimensional to address medical needs in the context of mental health, substance use, and housing insecurity.

Associations of functional, psychosocial, medical, and socio-demographic factors with cognitive screening in chemotherapy naïve patients with breast cancer

To describe associations of functional, psychosocial, medical, and socio‐demographic factors with performance on a cognitive screening test in chemotherapy naïve patients with breast cancer.

Financial Toxicity in Adults With Cancer: Adverse Outcomes and Noncompliance

PURPOSE:nBecause of the escalating cost of cancer care coupled with high insurance deductibles, premiums, and uninsured populations, patients with cancer are affected by treatment-related financial harm, known as financial toxicity. The purpose of this study was to describe individuals reporting financial toxicity and to identify rates of and reasons for affordability-related treatment noncompliance.nnnMETHODS:nFrom May 2010 to November 2015, adult patients (age ≥ 18 years) with cancer were identified from a Health Registry/Cancer Survivorship Cohort. Financial toxicity was defined as agreement with the phrase You have to pay for more medical care than you can afford from the Patient Satisfaction Questionnaire-18. Logistic regression and Fisher exact tests were used to compare groups.nnnRESULTS:nOf 1,988 participants, 524 (26%) reported financial toxicity. Patients reporting financial toxicity were more likely age 65 years or younger, female, nonwhite, non-English speaking, not married, less educated, and to have received a diagnosis more recently (all P < .001). Participants with financial toxicity were more likely to report noncompliance with medication, owing to inability to afford prescription drugs (relative risk [RR], 3.55; 95% CI, 2.53 to 4.98), and reported forgoing mental health care (RR, 3.89; 95% CI, 2.04 to 7.45), doctors visits (RR, 2.98; 95% CI, 1.97 to 4.51), and medical tests (RR, 2.54; 95% CI, 1.49 to 4.34). The most endorsed reasons for delayed care were not having insurance coverage and being unable to afford household expenses.nnnCONCLUSION:nMore than 25% of adults with cancer reported financial toxicity that was associated with an increased risk for medical noncompliance. Financial toxicity remains a major issue in cancer care, and efforts are needed to ensure patients experiencing high levels of financial toxicity are able to access recommended care.

Weight gain in hormone receptor-positive (HR+) early-stage breast cancer: is it menopausal status or something else?

PurposeThis study investigates weight trajectories in pre- versus postmenopausal breast cancer (BC) survivors diagnosed with hormone receptor-positive tumors, with a specific focus on discerning menopausal status and type of endocrine treatment (ET) as risk factors for weight gain during ET.MethodsWe conducted a retrospective review of electronic medical records. Descriptive statistics and Chi-squared and t tests were used to compare pre- and postmenopausal women. Chi-squared tests and ANOVA were used for within-group associations between patient characteristics and weight trajectories. Log-binomial regression models were used to estimate relative risk for weight gain.ResultsThe final sample was 32% premenopausal (nxa0=xa0140) and 68% postmenopausal (nxa0=xa0298). Relative risk (RR) for weight gain during ET was highest in women who were premenopausal (RRxa0=xa01.29, 1.03–1.52) and had Stage 3 BC (RRxa0=xa02.12, 1.59–2.82), mastectomy (RRxa0=xa01.49, 1.19–1.88), axillary node dissection (RRxa0=xa01.39, 1.11–1.73), and chemotherapy (RRxa0=xa01.80, 1.37–2.36). For each kg of weight gained between BC diagnosis and start of ET, and for each additional year of age, RR of gaining weight during ET decreased (RRxa0=xa00.98, 0.97–0.99, and RRxa0=xa00.99, 0.98–0.99, respectively). Menopausal status and type of ET were not significant predictors of weight gain. In multivariable analysis, only weight loss between BC diagnosis and start of ET was significant.ConclusionThe association of weight loss prior to ET and subsequent substantial weight gain during ET warrants further investigation.