Susan Hong

Hormone Replacement Therapy and Breast Cancer: Heterogeneous Risks by Race, Weight, and Breast Density

BACKGROUND Although studies have demonstrated a positive association between hormone replacement therapy (HRT) and breast cancer risk, this association may vary by patient factors. METHODS We analyzed 1642824 screening mammograms with 9300 breast cancer cases in postmenopausal women aged 45 years or older derived from the Breast Cancer Surveillance Consortium, a longitudinal registry of mammography screening in the United States. Multiple imputation methods were used to accommodate missing data for HRT use (14%) and other covariables. We performed logistic regression to estimate odds ratios (ORs) for breast cancer associated with HRT use within strata of race/ethnicity, age, body mass index (BMI), and breast density, with two-way interaction terms between HRT use and each key covariable of interest. P values for assessing possible interactions were computed from Wald z statistics. All statistical tests were two-sided. RESULTS HRT use was associated with greater than 20% increased risk in white (OR = 1.21; 95% CI = 1.14 to 1.28), Asian (OR = 1.58; 95% CI = 1.18 to 2.11), and Hispanic women (OR = 1.35; 95% CI = 1.09 to 1.67) but not black women (OR = 0.91; 95% CI = 0.72 to 1.14; P interaction = .04). In women with low/normal BMI and extremely dense breasts, HRT use was associated with the highest breast cancer risk (OR = 1.49; 95% CI = 1.21 to 1.83), compared with nonusers. In overweight/obese women with less-dense breasts, no excess risk was associated with HRT use (adjusted ORs = 0.96 to 1.03). CONCLUSIONS The impact of HRT use on breast cancer risk varies according to race/ethnicity, BMI, and breast density. This risk stratification could help in advising HRT use for the relief of menopausal symptoms.

Cancer survivorship care: Exploring the role of the general internist

According to the National Cancer Institute (NCI), cancer survivorship encompasses the “physical, psychosocial, and economic issues of cancer from diagnosis until the end of life.” Today, one in 30 Americans are cancer survivors. Almost two-thirds have at least one chronic health condition. As the numbers of cancer survivors increase, cancer itself can be viewed as a chronic medical condition. This paper illustrates some of the challenges faced by cancer survivors. We discuss the limitations of current models of survivorship care, including shared care. In addition, we explore how the American Board of Internal Medicine’s previously proposed credential of Comprehensive Care Internist could serve to define and integrate the complex needs of adult cancer survivors with the skills and talents of general internists.

The Breast–Thyroid Cancer Link: A Systematic Review and Meta-analysis

Rates of thyroid cancer in women with a history of breast cancer are higher than expected. Similarly, rates of breast cancer in those with a history of thyroid cancer are increased. Explanations for these associations include detection bias, shared hormonal risk factors, treatment effect, and genetic susceptibility. With increasing numbers of breast and thyroid cancer survivors, clinicians should be particularly cognizant of this association. Here, we perform a systematic review and meta-analysis of the literature utilizing PubMed and Scopus search engines to identify all publications studying the incidence of breast cancer as a secondary malignancy following a diagnosis of thyroid cancer or thyroid cancer following a diagnosis of breast cancer. This demonstrated an increased risk of thyroid cancer as a secondary malignancy following breast cancer [OR = 1.55; 95% confidence interval (CI), 1.44–1.67] and an increased risk of breast cancer as a secondary malignancy following thyroid cancer (OR = 1.18; 95% CI, 1.09–1.26). There is a clear increase in the odds of developing either thyroid or breast cancer as a secondary malignancy after diagnosis with the other. Here, we review this association and current hypothesis as to the cause of this correlation. Cancer Epidemiol Biomarkers Prev; 25(2); 231–8. ©2016 AACR.

The Expanding Use of Third-Generation Aromatase Inhibitors: What the General Internist Needs to Know

ABSTRACTBACKGROUNDBreast cancer patients represent the largest group of adult cancer survivors in the US. Most breast cancers in women 50 years of age and older are hormone receptor positive. Third generation aromatase inhibitors (AIs) are the newest class of drugs used in treating hormone responsive breast cancer. It is often during start of adjuvant hormone therapy that the breast cancer patient establishes (or reestablishes) close follow-up with their general internist.OBJECTIVEGiven the large numbers of breast cancer patients in the US and the increasing use of third generation AI’s, general internists will need to have a clear understanding of these drugs including their benefits and potential harms. Currently there are three third generation aromatase inhibitors FDA approved for use in the US. All have been shown to be superior to tamoxifen in disease free survival (DFS) in the treatment of both metastatic and early breast cancers.RESULTSWhile the data on side effects is limited, AI (compared to tamoxifen) may result in higher rates of osteoporosis and fractures, more arthralgias, and increased vaginal dryness and dysparuenia. Limited information on their effects on the cardiovascular system and neuro-cognitive function are also available. Patient’s receiving adjuvant hormone therapy are generally considered disease free or disease stable and require less intensive monitoring by their breast cancer specialist.CONCLUSIONSIn situations where patients experience significant negative side effects from AI therapy, discussions to discontinue treatment (and switch to an alternative endocrine therapy) should involve the cancer specialist and take into consideration the patient’s risk for breast cancer recurrence and the impact of therapy on their quality of life. In some cases, patients may choose to never initiate AI treatment. In other cases, patients may choose to prematurely discontinue therapy even if therapy is well tolerated. In both settings increased knowledge by the general internists will likely facilitate discussions of risks versus benefits of therapy and possibly improve compliance to adjuvant hormone therapy.

Factors associated with compliance to adjuvant hormone therapy in Black and White women with breast cancer

BackgroundStudies have demonstrated lower rates of breast cancer survival for Black versus White women. Factors implicated include later stages at diagnosis, differences in tumor biology, and lower compliance rates to adjuvant hormone therapy (AHT) among Black women with hormone sensitive breast cancer. We examined factors associated with compliance to AHT among Black and White women with invasive breast cancer.MethodsWomen with estrogen receptor positive (ER+), non-metastatic breast cancer were identified by the cancer registry at the University of Chicago Hospital and asked to complete a mail-in survey. Compliance was defined by self-reported adherence to AHT ≥80% at the time of the survey plus medical record verification of persistence (completion of 5 years of AHT). Logistic regression was used to determine factors associated with compliance to AHT.Results197 (135 White and 62 Black) women were included in the analysis. 97.4% of patients reported adherence to therapy. 87.4% were found to be persistent to therapy. Overall compliance was 87.7% with no statistically significant racial difference seen (87.9% in White and 87.0% in Black, P = 0.87). For both Black and White women, compliance was strongly associated with both perceived importance of AHT (OR =2.1, 95% CI:1.21-3.68, P = 0.009) and the value placed on their doctor’s opinion about the importance of AHT (OR = 4.80, 95% CI: 2.03-11.4, P < 0.001).ConclusionsIn our cohort of Black and White women, perceived importance of AHT and the degree to which they valued their doctor’s opinion correlated with overall compliance. This suggests that Black and White women consider similar factors in their decision to take AHT.

Abstract A31: Factors associated with compliance to adjuvant hormone therapy for African American and Caucasian women.

Background: Studies have documented lower rates of breast cancer survival for African American versus Caucasian women. Differences in compliance to adjuvant hormone therapy (AHT) may partially explain the survival disparity. The purpose of our study is to examine whether or not a difference in self-reported compliance to AHT exists between African American and Caucasian women and to describe which factors may impact this compliance. Methods: Women who were 2-10 years from diagnosis of estrogen receptor positive, non-metastatic breast cancer at the University of Chicago Hospital were asked to complete a voluntary mail-in survey. All information was self-reported. Compliance to AHT was defined as not missing more than 2 doses of therapy a month and completing 5 years of therapy (or still taking therapy if less than 5 years had passed between initiation of therapy and date of survey completion). Chi square tests and logistic regressions were performed to compare compliance rates by sociodemographic factors, reported perception of AHT importance, and self-perceived risk for breast cancer recurrence. Results: Among the 381 eligible patients, 217 (56.9%) completed the survey. Overall self-reported compliance rate to AHT was 78.5%. African American women (n = 66, 30.8%) reported lower compliance rates compared to Caucasian women (70.0% vs. 82.3%, P = 0.055). For both African American and Caucasian women, perceived importance of AHT (from not important to very important) was correlated with higher rates of reported compliance (OR = 10.65; 95% CI: 3.55-31.94). Patients who weighted their cancer doctors opinion more when considering taking or stopping AHT were also more likely to report being compliant (OR = 1.99; 95% CI: 0.75-5.25), whereas patients who reported being very worried about side effects were less likely to report being compliant (OR = 0.34; 95% CI: 0.10-1.13). Perceived risk of breast cancer recurrence, however, was not associated with reported compliance. Conclusions: For both African American and Caucasian women, compliance to adjuvant hormone therapy was associated with greater perceived importance of therapy. This study suggests that educating our patients on the importance of hormone therapy may significantly impact their compliance. Citation Format: Christina H. Suh, Sumita Bhatta, Ningqi Hou, Zakiya N. Factors associated with compliance to adjuvant hormone therapy for African American and Caucasian women. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A31.

The Effect of Preoperative MRI on Mastectomy Rates in Breast Cancer Patients.

Background: Currently, there are two primary surgical options for the treatment of early stage breast cancer: modified radical mastectomy and breast conserving surgery (BCS) with post-surgical radiation. Numerous studies have shown that there is no survival difference between the two surgical treatments, however, in recent years, there is data to suggest that mastectomy rates have been on the rise. While many factors undoubtedly influence surgical management decisions in breast cancer patients, the effect of routine use of preoperative breast MRI may be a contributor to the rise in mastectomy rates. Methods: Breast cancer patients who were treated surgically and received a preoperative MRI were identified using a database from the University of Chicago Department of Radiology, which contains information on over 4200 patients who have received breast MRI since 2002. These patients were cross-referenced with data from the University of Chicago Cancer Registry, which contains information regarding type of surgical treatment, surgeon, stage of cancer at time of diagnosis and surgical stage for all breast cancer patients treated at the University of Chicago Hospitals from 2000-2007. Annual mastectomy rates from 2000-2007 were calculated and compared using Pearson9s Chi Square test. Annual mastectomy rates were stratified by mean age at diagnosis and stage of disease. Mastectomy rates prior to routine use of preoperative MRI (2000-2002) and after routine use of preoperative MRI (2005-2007) were calculated for breast cancer patients under 45 and over 45 years of age and rates were compared using Fisher9s exact test. Results: A total of 1,404 patients received surgical treatment for a new diagnosis of breast cancer between 2000 and 2007 at the University of Chicago Hospitals. Results to date indicate that mastectomy rates across all years are not significantly different (p = 0.315). Results also indicate that the mean age at diagnosis of patients who receive mastectomy as the initial surgical treatment for their breast cancer is higher than those who receive BCS from 2000-2002, but is lower than those who receive BCS from 2003-2007. In addition, breast cancer patients under the age of 45 have higher rates of mastectomy since the routine use of preoperative MRI which trends toward statistical significance (p = 0.0598). Conclusion: These preliminary results indicate that overall mastectomy rates at the University of Chicago Hospitals are not increasing in concordance with the increased use of preoperative MRI testing, but that younger breast cancer patients may have higher rates of mastectomy in the MRI era. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4019.