86.16 The relationship between ANXA1 expression and breast cancer outcome is different in each subtype.

Posted on January 31, 2019

M. Okano1, E. Katsuta1, M. Oshi1, X. Peng2, L. Yan2, K. Takabe1  1Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA 2Roswell Park Cancer Institute,Biostatistics & Bioinformatics,Buffalo, NY, USA

Introduction: Annexin A1 (ANXA1) is a phospholipid-linked protein, is known to have multiple functions related to inflammatory pathways, cell proliferation and the regulation of cell death signaling. ANXA1 was reported to have some association with cancer development, but the role of ANXA1 seems different depends on cancer types. Recently, we reported that ANXA1 is associated with triple-negative breast cancer (TNBC) and its poor prognosis in 211 Japanese breast cancer cases. Some reports similarly that ANXA1 high expressed breast cancer has poor survival. On the other hand, there are some studies demonstrating opposite results with high ANXA1 expression being associated with better outcome. It is speculated that the breast cancer subtypes may be one of the reasons for these controversial results. In this study, we investigated the association of ANXA1 mRNA/protein expression and patient survival in each subtype using gene and protein expression data of the publically available large cohort.

Methods: Clinical, RNA-seq and Reverse Phase Protein Array (RPPA) data were obtained from the Cancer Genome Atlas (TCGA). Overall survival (OS) and Gene set enrichment analysis (GSEA) were conducted comparing high and low expression group. 

Results:Among ER positive and HER2 positive patients, low mRNA expression of ANXA1 group has significantly worse OS (p=0.004, p=0.005, respectively). On the other hand, high mRNA expression of ANXA1 group showed significantly worse OS (p=0.028) in TNBC patients. In analysis using RPPA data, OS was significantly shorter in patients with high ANXA1 tumors among ER positive patients and HER2 positive patients (p<0.001, p=0.016, respectively) but high ANXA1 group has worse OS in TNBC patient (p=0.0095), which were in agreement with transcriptome analysis. To explore the mechanism of these results, GSEA was conducted. In TNBC patients, high ANXA1 expression tumors were enriched EMT related genes (NES=1.916, p=0.004), IL2/STAT5 (NES=2.04, p=0.003) and TNF-α signaling related genes (NES=2.02, p=0.011). On the other hand, in ER positive and HER2 positive patients, high ANXA1 expression tumors were enriched apoptosis related genes (NES=2.30, p<0.01) and p53 pathway related genes (NES=2.08, p<0.01).

Conclusion:We demonstrate high expression of ANXA1 enriched EMT signaling related gene expression in TNBC patients that associated with worse OS. On the other hand, in ER positive patients and HER2 positive patients, high ANXA1 expression is associated with better progression and the possible reason of this outcome is the apoptosis and p53 pathway. This discrepancy between ER positive breast cancer and TNBC on the effect of ANXA1 expression on patient survival might exemplify the fact that these subtypes possess significantly deferent molecular/genetic backgrounds.

 

86.06 Development of Malignancy-Risk Gene Signature Assay for Predicting Breast Cancer Risk

Posted on January 31, 2019

J. Sun1, W. Sun1, D. Chen2, J. Li2, R. Roetzheim1, C. Laronga1, M. C. Lee1  1Moffitt Cancer Center And Research Institute,Breast Oncology,Tampa, FL, USA 2Moffitt Cancer Center And Research Institute,Biostatistics And Bioinformatics,Tampa, FL, USA

Introduction:
The Gail Model estimates 5-year risk of developing breast cancer (BC) in unaffected women using health information. Our objective was to develop a clinical assay to quantify risk of BC occurrence in women receiving benign breast biopsy using a unique gene expression signature to estimate risk of subsequent BC.

Methods:
A 56-gene malignancy risk (MR) gene signature assay was validated for formalin-fixed paraffin-embedded (FFPE) tissue. Women who developed BC <2 years from a benign breast biopsy were identified and matched by age and biopsy date to unaffected controls with 2+ years of follow-up; biopsies were obtained at a single institution from 2007-2011. The MR was applied to benign breast and available BC specimens. Receiver operating characteristic curves were generated to determine diagnostic accuracy of the MR score and the Gail Model. BC risk was calculated by MR score only, Gail score only, and combined MR and Gail scores, then analyzed using leave-one-out-cross validation.

Results:

663 women with benign breast biopsies were identified. 100 women had concurrent BC biopsies and were excluded, leaving 563 women with benign results; 48 women developed BC (cases) within 2 years of biopsy. Follow-up data was collected at 2- and 5-year follow-up; 2 control patients developed BC between years 2-5 and were reclassified. 30 BC cases were matched to 60 unaffected controls, but analyzable tissue-based assays were only obtained for 17 benign “pre-cancer” case biopsies and 35 unaffected benign control biopsies due to poor cellularity of FFPE. 28 malignant tissue case assays were also obtained for comparison (Figure 1). Kruskal-Wallis rank sum test confirmed a difference between the three groups (Figure 1). MR assay signatures were higher in the case group than control group (p=0.09).

When comparing the MR and Gail scores, the MR score did not reach statistical significance when calculated for control and pre-case groups in two separate cohorts (n=52, p=0.246; n=43, p=0.75), while the Gail score suggested difference between the two groups (n=43, p=0.107, AUC=0.683). The MR score demonstrated poor predictive value when applied alone (AUC=0.538-0.613). However, the two tests demonstrated the best predictive value when combined (AUC=0.710).

Conclusion:
Due to small sample size, we were not able to demonstrate predictive capability of the MR signature alone; however, we demonstrated the feasibility of using FFPE gene expression assays to develop a predictive test for BC. Our current technique was limited by poor cellularity of benign breast samples. We intend to further investigate the combination of MR signature and Gail Model score as a more accurate risk assessment for women undergoing benign breast biopsy.

86.02 Different impacts of Bone Morphogenetic Protein expressions in Breast Cancer Patients’ Prognosis

Posted on January 31, 2019

K. Takabe1, E. Katsuta1, A. A. Maawy1, L. Yan2  1Roswell Park Cancer Institute,Breast Surgery, Department Of Surgical Oncology,Buffalo, NY, USA 2Roswell Park Cancer Institute,Department Of Biostatistics And Bioinformatics,Buffalo, NY, USA

Introduction:  Bone morphogenetic proteins (BMPs) are members of the TGFβ family of signaling pathways and are known to be essential in fetal development, tissue differentiation and a multitude of cellular functions. In breast cancer, differential expressions are noted among different subtypes. BMPs are also known to regulate the epithelial to mesenchymal transition, tissue invasion and metastasis. Low expression of BMP7 is known to be associated with a more metastatic phenotype, especially bone metastases. However, the impact of comprehensive BMPs gene expressions on breast cancer patients’ survival is still understudied. This study aimed to investigate the association of BMPs gene expression with breast cancer patients’ survival using a ‘big data’ approach employing RNA sequencing from The Cancer Genome Atlas (TCGA).

Methods:  A total of 1093 treatment naïve breast cancers underwent genetic sequencing and the results of their sequencing stored in TCGA dataset. Overall survival (OS) was compared between high and low mRNA expression of indicated BMP related genes; BMP1, BMP2, BMP3, BMP4, BMP5, BMP6, BMP7, BMP10, BMP15 and BMP receptors 1A (BMPR1A) and 1B (BMPR1B), based upon RNA-sequencing data of TCGA.

Results: TCGA cohort was representative of national breast cancer patients with respect to stage, pathology and survival. High expression of BMP1 (p<0.001), BMP3 (p=0.002), BMP5 (p=0.020), BMP7 (p<0.001) and BMPR1A (p<0.001) significantly associated with better OS. On the other hand, high expression of BMP6 (p<0.001) and BMPR1B (p=0.005) significantly associated with worse OS. BMP2, BMP4, BMP10 and BMP15 did not associate with OS. When we analyzed by subtype, in consistent with the whole cohort analysis result, BMP7 high expression significantly associated with better prognosis in both ER positive (p<0.001) and negative tumors (p<0.001). Interestingly high expression of BMP6 associated with better prognosis in ER positive tumor (p=0.004), whereas it associated with worse prognosis in ER negative tumors (p=0.006).   

Conclusion: BMP expression profiles may be of value in prognostication. Intervention in this pathway may serve to improve outcomes, manage metastatic disease and assist in clinical decision making on optimal therapy based on risk of recurrence or metastasis.

 

47.20 Implant Sparing Nipple Sparing Mastectomy

Posted on January 31, 2019

E. E. Burke1, C. Laronga1, W. Sun1, S. J. Hoover1, N. Khakpour1, J. V. Kiluk1, M. C. Lee1  1Moffitt Cancer Center,Breast Oncology,Tampa, FL, USA

Introduction: Nipple sparing mastectomy has become an option for the treatment and prevention of breast cancer in selected women. Our experience with implant sparing mastectomy suggests that this is a safe and effective option for women with previous retropectoral implant augmentation. We aimed to explore outcomes of patients that underwent concurrent implant and nipple sparing mastectomy (ISNSM) at our institution.

Methods:  A retrospective review of patients undergoing ISNSM for either prevention or treatment of breast cancer from 2009 until 2017 was performed at a single institution. Data including patient and tumor characteristics, stage, systemic and radiation therapy use, 90-day complication rates, additional reconstruction, and disease recurrence was collected.

Results: A total of 11 patients were identified after ISNSM; the average BMI was 22.8kg/m2 (range 18.6-30.9). Four (36.4%) had breast cancer in the breast undergoing ISNSM, 3 (27.3%) had a known pre-operative diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS) in the contralateral breast for which the nipple was excised, and 4 (36.4%) had no disease in either breast. The mean age of the cohort was 48 years, with mean of 52.1 years in those with breast cancer and 41 years in those without breast cancer. Average tumor size was 15mm in breasts treated with ISNSM; all had negative margins of resection, negative analysis of nipple base, and none had disease recurrence after average follow up of 34.9 months (range 0.4-80 months). Final pathological stage was stage 0 for 1 patient, Ia for 3 patients, IIa for 1 patient and IIb for 1 patient. In the 4 disease free patients, 2 were BRCA1+, 1 was BRCA2+, and 1 had a PALB2 mutation. There have been no diagnoses of breast cancer in the 7 patients that pursued implant and nipple sparing mastectomy in breasts without cancer after an average of 33.5 months (range 7-63 months). Ninety-day complication rates in this group were low overall. There was no nipple necrosis, 1 patient developed wound dehiscence with skin flap loss requiring operative intervention, 1 patient required takeback to OR for hematoma and 1 patient had a wound infection requiring antibiotics. Of the 11 patients, 9 (81.8%) have undergone delayed reconstruction requiring only implant exchange. One has not required implant exchange and one has not yet undergone implant exchange. Average time to exchange was 12.5 months (range 3-52 months).  None of these patients required delayed flap reconstruction. 

Conclusion: ISNSM was effective and well tolerated in this highly selected group of patients with acceptable oncologic outcomes and low complication rates. Patients undergoing this procedure pursued delayed reconstruction and none required flap reconstruction. Further investigation into this option for the treatment and prevention of breast cancer is warranted.   
 

47.19 Is Excision of Radial Scar Identified on Core Needle Biopsy (CNB) Necessary?

Posted on January 31, 2019

K. Nimtz1, K. Hookim2, A. Sevrukov3, T. Tsangaris1, A. Willis1, A. Berger1, M. Lazar1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2Thomas Jefferson University,Pathology,Philadelphia, PA, USA 3Thomas Jefferson University,Radiology,Philadelphia, PA, USA

Introduction: Quantifying the risk of upgrade to malignancy with radial scars has been an ongoing challenge in the breast cancer research community. Previous reviews show radial scars account for 5-9% of findings on core needle biopsy. The upgrade rate varies from 0-40% making management of radial scars controversial.  Multiple studies have investigated the association of radial scar and malignancy, with recent studies indicating lower rates. The lack of consensus on the optimal management highlights the need for further analysis of radial scar and its risk of upgrade to malignancy. We sought to identify our institutional upgrade rate of radial scar identified on core needle biopsy.

Methods: An IRB approved retrospective review of pathology and radiology databases from 2010 to 2017 was performed to identify radial scar found on core needle biopsy.  We excluded patients with malignancy associated with radial scar and those who did not undergo surgical excision. The initial imaging findings prompting the core needle biopsy as well as the upgrade rate to malignancy (invasive ductal/lobular carcinoma and ductal carcinoma in situ) on surgical excision were assessed. 

Results: We identified 127 patients with radial scar on a core needle biopsy.  Due to malignancy associated with radial scar, no surgical excision or incomplete records, we excluded 75 patients leaving 52 patients for analysis. Of these, 4 of 52 (7.7%) patients had an upgrade to malignancy upon surgical excision of the radial scar—2 with DCIS and 2 with invasive ductal cancer.  All 4 of these patients had findings on both mammography and ultrasound.  Eight patients had atypia associated with radial scar on core needle biopsy, two of which were upgraded to malignancy at the time of surgical excision.  The rate of upgrade for radial scar alone on core needle biopsy was 2 of 44 (4.5%).  Of the 44 patients with radial scar alone on core needle biopsy, 15 (34%) were found to have atypia (6 with flat epithelial atypia, 5 with atypical ductal hyperplasia, 2 with lobular carcinoma in situ, one with atypical lobular hyperplasia and one with both atypical ductal and lobular hyperplasia) on surgical excision.

Conclusion: With the increasing use of digital tomosynthesis, it is possible that more radial scars will be identified on core needle biopsy.  Although  the upgrade rate to malignancy was only 4.5%, there was a substantial upgrade rate of pure radial scar to some type of atypia which could alter subsequent management. Additionally, one-quarter of radial scars with atypia upgraded to malignancy on excision. For these reasons, careful consideration should be given to re-excision of core needle biopsy showing radial scar with and without atypia.

 

47.14 Clinical Significance of Increased Body Mass Index in Breast Cancer Patients

Posted on January 31, 2019

S. R. Kaslow1, C. Cartier1, M. L. Plasilova1  1New York University Langone Health,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Multiple studies have associated increased body mass index (BMI) with more aggressive breast cancer tumor biology and worse clinical outcomes, however, many of these studies were conducted with primarily non-Hispanic white patients. We aimed to compare the clinical outcomes and breast cancer tumor biology of patients with increased BMI (≥25) and normal BMI (18-25) at New York University Langone Health (NYULH), which serves a racially and ethnically diverse patient population. 

Methods:
We extracted data on geography, race/ethnicity, breast cancer recurrence rates, and tumor biology from the NYULH Institutional Breast Cancer Database, which contains sociodemographic and clinical information for breast cancer patients who received first definitive surgery at New York University Langone Medical Centers in Manhattan and Brooklyn.

Results:
Our data included 3,091 patients with invasive breast cancer and ductal carcinoma in situ. Breast cancer patients living in Brooklyn had increased BMI compared to breast cancer patients living in Manhattan (p=0.013). There was no statistically significant difference in breast cancer recurrence in patients with increased BMI relative to those with normal BMI (p>0.5). Our data show a higher proportion of ethnic minorities diagnosed with breast cancer in Brooklyn compared to Manhattan, including African Americans (35.2% vs. 17.6%) and Asian Americans (12.1% vs. 8.5%). We did not find a significant difference in breast cancer recurrence when comparing White and non-White patients with increased BMI.

Conclusion:
Despite differences in ethnic minority status between two study sites and statistically significant differences in BMI based on residence, breast cancer patients treated within NYULH with increased body mass index did not have statistically significant different breast cancer recurrence rate.
 

47.13 Standardization of Oncotype DX Ordering By Surgery at a Safety Net Hospital: Pilot Study

Posted on January 31, 2019

A. Keshinro1, E. Johnson1, E. Horowitz1, E. Warnack1, K. Joseph1  1NYU School of Medicine,Surgery,New York, NEW YORK, USA

Introduction:

Oncotype DX is a useful assay that helps oncologists and patients determine whether patients should undergo adjuvant chemotherapy or hormonal therapy. Testing for Oncotype may lead to delays in chemotherapy that can lead to clinically adverse outcomes. In order to decrease the delays in ordering the test as well as the turn around time, and as a result, initiation of chemotherapy, we implemented a new ordering protocol at Bellevue Hospital involving pathology, breast surgery to standardize the criteria for ordering Oncotype DX.  

Methods:  

As part of a quality improvement process to standardize the ordering process for Oncotype DX post-operatively, pathology and breast surgery met with representatives of Genomic Health to determine new workflows to improve the ordering process for Oncotype DX. In addition, methods for communicating pathology results and insurance status were identified. After new workflows were put in place, any patient that fit the criteria for Oncotype DX testing was ordered by breast surgery as soon as the final pathology was received (May-August 2018). Time from surgery to order, time from surgery to report, number of Oncotype DX orders, method by which oncotype dx is ordered, and type of insurance were examined.

 

Results:

There was a significant decrease in the overall turnaround time from surgery to Oncotype DX result from 64 days to 29 (55% reduction) (p<0.05). Implementation of the new workflow had the largest impact on reducing time from surgery to ordering the test (50 days to 17 days), a 66% reduction (p<0.05). 72% of the orders are now being placed by portal vs 6% before standardization, 14% by paper vs 88% before standardization, 14% by fax vs 6% before standardization. In addition, the payor mix has changed to include 11.3% Medicare vs 0% before standardization. Total number of Oncotype orders for 2017 were 16 (eligible cases 41), and cases YTD 2018-18.

Conclusions:

Implementation of a new ordering process has allowed access to individualized treatment planning to more eligible patients; 12.5% increase over 2017 orders within 7 months into the year (16 orders in 2017 vs. 18 orders by July 2018), ordering by portal helps to improve efficiency of ordering and receiving results.

Less than half of eligible patients were offered Oncotype DX in 2017, before adoption of the new protocol. By implementing this protocol more eligible patients will receive appropriate management.

Given the medically underserved population that our clinic serves (64% are immigrants and 73% have Medicaid or self pay), we can improve the level of care to our patients.

As we continue the protocol we will examine the impact on reduction on chemotherapy wait times.

 

 

 

47.12 Quilting Suture in Closure of Mastectomy Skin Flaps for Locally Advanced Breast Cancer in Myanmar

Posted on January 31, 2019

S. Myint1, T. Lwin1, W. Yee1, H. Thuya1, A. Myat1, Y. Kyaw1, K. Nyunt1, K. Khaing1, T. Lwin1  1University of medicine (1), Yangon,Department Of Surgery,Yangon, YANGON, Myanmar

Introduction: Seroma formation is the most frequent postoperative complication after breast cancer surgery. In 2015 surgery for breast cancer at the Yangon General Hospital amounted to 17.12% (229) of all the elective major operations. In 2016, 244 cases of modified radical mastectomy (MRM) were carried out and 32.38 % of locally advanced breast cancer patients developed seroma post operatively. Seroma cause discomfort, and wound complications.Seroma prolonged hospital stay and delayed adjuvant therapy. It can leads to poor prognosis. We explored whether quilting sutures could reduce seroma occurrence. Quilting sutures aim to prevent shearing between skin flaps and chest wall and to reduce the dead space.

Methods: Twenty five breast cancer patients from 1st July 2017 to 31st December 2017 were included in this descriptive study. All underwent modified radical mastectomy. After MRM  quilting sutures were applied to approximate  skin flaps to underlying pectoral muscle at an interval of 2 to 3 cm. Customized, strategically placed, multiple alternating interrupted quilting sutures are put with 3/0 vicryl at various parts of the flaps. A close drainage tube was usually inserted into the axilla. The skin was closed with two layer techniques. Drainage tube was removed when the 24 hour drain amount was less than 30mls in two consecutive days. Patients were followed up in the outpatient clinic and the clinically significant seroma were detected by clinical examination and ultrasoung examination. 

Results: The average time to insert quilting suture is 12 mins. None of the cases develop permanent skin dimplings one month after operation. Post-operatively,mean amount of drainage tube output is 274.9 ml. Five patients (20%) developed clinically significant seroma in follow-up visits and underwent needle aspiration. The mean number of needle aspiration is 3 times. Mean amount of seroma aspirated is 300 ml. None of the patients develop wound sepsis or wound gaping.   

Conclusion:MRM is frequently performed at the Yangon General Hospital and seroma is a common complication. It can prolong hospital stay and can lead to frequent visits to clinic and delay adjuvant therapy. Quilting suture reduced the incidence of seroma formation from 32% to 20%. This technique is cost effective and can be performed by general surgeons. We feel that this may be an important technique for breast cancer surgery in low resource settings and warrants further investigation.

 

47.08 Breast Cancer Treatment Patterns in Women Age ≥ 80: A Report from the National Cancer Database

Posted on January 31, 2019

J. Frebault1, C. Bergom2, M. Shukla2, Y. Zhang3, C. Huang3, A. Kong1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 3University of Wisconsin-Milwaukee,Zilber School Of Public Health,Milwaukee, WI, USA

Introduction:
Women aged ≥80 are an increasing proportion of patients diagnosed with breast cancer in the US. There are no established guidelines for decision making in this population, particularly due to consideration of performance status and competing comorbidities. This study aims to identify national treatment patterns and survival outcomes in breast cancer patients aged 80 and over.

Methods:
Women aged ≥80 diagnosed with ductal carcinoma in situ (DCIS) or stage I-III invasive breast cancer from 2005-2014 were identified in the National Cancer Database. We excluded cases with incomplete staging and treatment details. Kaplan-Meier curves and Cox proportional hazard models were used to evaluate survival outcomes. Chi-square and logistic regression models were used to identify demographic, disease, and facility factors that influenced receipt of breast surgery.

Results:
We identified 62575 women with invasive cancer and 6070 with DCIS. Of the invasive cases, 94% received breast surgery. Age <85, white race, lower stage, and smaller tumor size were associated with receipt of surgical treatment (p<0.0001 for all). Those who received breast surgery were more likely to be estrogen receptor (ER)+ (p=0.001), HER2- (p<0.0001), and healthier, with a comorbidity score of 0 or 1 (p<0.0001). They were also more likely to have axillary surgery (p<0.0001), chemotherapy (p=0.0009), and radiation (p<0.0001). Among DCIS patients, 98% had breast surgery. White patients (p=0.003) and those <85 years old (p<0.0001) were more likely to receive surgery. Those who had surgery were more likely to receive radiation (p<0.0001). When compared to academic programs, surgical management was more likely to be performed in community cancer centers for both invasive cancer (p<0.0001) and DCIS (p=0.04). On multivariate analysis of invasive cancer patients, those with white race, age <90, lower stage, ER-, or fewer comorbidities were more likely to have surgery (all p<0.0001). On multivariate analysis of DCIS patients, those age <90 were more likely to have surgery (p<0.0001). Black women were half as likely to receive surgery (p=0.02). In both groups, overall survival was higher for those who received surgery compared to those who did not (p<0.0001), with a hazard ratio of 3.3 [95% CI 3.18-3.46] for invasive cancer (Fig. 1) and 2.2 [95% CI 1.72-2.83] for DCIS.

Conclusion:
The vast majority of breast cancer patients age ≥80 in this nationwide dataset received primary surgical management, which was associated with a significant survival advantage for both invasive and non-invasive disease. Surgical intervention should be considered in patients with few comorbidities and favorable tumor characteristics.

47.06 Impact of Geographic Dispersal of National Accreditation Program for Breast Centers on Quality Care

Posted on January 31, 2019

A. C. Alapati1, L. A. Riba1, R. B. Davis2, T. A. James1  1Beth Israel Deaconess Medical Center,Surgery,Boston, MA, USA 2Beth Israel Deaconess Medical Center,Medicine,Boston, MA, USA

Introduction: The National Accreditation Program for Breast Centers (NAPBC) is dedicated to the improvement of quality of care for patients with breast disease. Geographical distribution of healthcare resources is an important dimension of quality. Little has been published about breast center allocation patterns with respect to demand and impact on population health outcomes. The purpose of this study is to analyze incidence and mortality rates of breast cancer in relation to NAPBC distribution in the US.

Methods: The incidence and mortality rates of breast cancer per state in 2014 were retrieved from the Center for Disease Control and Prevention.  We determined the number of NAPBC centers in each state per 1000 cases of breast cancer. Data were analyzed by spearman (non-parametric) correlation.

Results:The total number of NAPBC centers is 570. Across the US there is an average of 2.8 centers/1000 cases of breast cancer; standard deviation 1.9, range from 0 to 8.7.  A positive correlation (r = 0.45) exists between breast cancer incidence and the number of centers (p=0.0009). The correlation between mortality and centers/1000 cases is weakly negative (r=-0.20), (p=0.16).

Conclusion:Our study demonstrates that NAPBC centers are adequately distributed according to breast cancer incidence in the US. However, the presence of NAPBC centers did not impact mortality rates. Additional strategies are warranted to control population mortality rates for breast cancer.

 

47.04 Survival Outcomes of Early-Stage Hormone Receptor Positive Breast Cancer in the Elderly

Posted on January 31, 2019

A. Nayyar1, K. K. Gallagher1, P. D. Strassle1, C. G. Moses1, K. P. McGuire2  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA

Introduction:
Women ≥70 years old form a significant proportion of patients affected by breast cancer (BC). Treatment decisions for this patient population are complicated given presence of comorbidities, reduced tolerability of therapy and limited enrollment in clinical trials. A growing body of evidence suggests equivalent outcomes in elderly patients with hormone receptor positive, early-stage BC patients receiving primary endocrine therapy only or surgery with subsequent endocrine therapy. Whether these results are reproduced in the larger BC population outside of a clinical trial, currently remains unclear.

Methods:
Women ≥70 years old, diagnosed with early-stage invasive BC between January 2008 and December 2013, with tumor size T1 or T2 and minimal nodal involvement (N0 and N1), endocrine and/or progesterone receptor positive, and started endocrine therapy within a year of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked datasets. Endocrine therapy use was identified using outpatient prescription fills for Anastrozole, Exemestane, Fulvestrant, Letrozole, Raloxifene, Tamoxifen, and Toremifene. Surgical intervention included either breast conserving surgery or mastectomy. Trends in the use of primary endocrine therapy only were assessed using Poisson regression. Multivariable Cox proportional hazard regression was used to estimate the association between undergoing surgery within a year of diagnosis and 5-year all-cause mortality, after adjusting for patient demographics, comorbidities, and clinical cancer characteristics. Similar methods were used to assess 5-year cancer-specific mortality, where non-cancer mortality was treated as a competing risk. 

Results:
Overall, 8,968 women were included in the analysis; 8,146 (91%) received surgery with endocrine therapy and 832 (9%) received primary endocrine therapy alone. The proportion of women not receiving surgery remained consistent between 2008 and 2013, p=0.24. The 5-year mortality was 7% (n=660), and 21% of all deaths were due to cancer causes (n=140). After adjustment, 5-year mortality was lower among women undergoing surgery (HR 0.55, 95% CI 0.44, 0.67, p<0.0001) (Figure). Similar results were found when looking at 5-year cancer-specific mortality (HR 0.35, 95% CI 0.22, 0.56, p<0.0001).

Conclusion:
Elderly BC patients with early-stage, hormone receptor positive disease receiving primary surgical intervention plus endocrine therapy had improved survival compared to those receiving primary endocrine therapy alone. This study reflects the importance of surgical intervention for elderly BC patients and warrants further investigation to evaluate whether surgery may be omitted safely in subsets of elderly patients.

47.03 Implant Sparing Mastectomy: A Novel and Safe Surgical Approach for Breast Cancer

Posted on January 31, 2019

E. E. Burke1, C. Laronga1, W. Sun1, B. J. Czerniecki1, S. J. Hoover1, N. Khakpour1, J. V. Kiluk1, M. C. Lee1  1Moffitt Cancer Center,Breast Oncology,Tampa, FL, USA

Introduction:   In women undergoing mastectomy for breast cancer with prior retropectoral implant-based augmentation, implant sparing mastectomy has been reported. In this study, the safety and feasibility of this novel surgical approach was evaluated.

Methods:  A retrospective review of all patients undergoing implant sparing mastectomy from 2006 to 2018 for either breast cancer treatment or prevention at a single institution was performed. Data including patient and tumor characteristics, stage, use of systemic therapy and radiation therapy, 90-day complication rates, type of reconstruction, and recurrence of disease was collected.  

Results: A total of 74 women were identified with implant sparing mastectomy from 2006 to 2018.  Of these, 49 (66.2%) underwent bilateral mastectomy. A total of 66 (89.2%) received mastectomy after diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS) while 8 (10.8%) elected mastectomy for prophylaxis. Among 66 breast cancer patients, resection margins were negative in 53 (80.3%), negative but close (DCIS < 2mm) in 10 (15.2%), and positive in 3 (4.5%). Five (7.6%) of these breast cancer patients had a documented recurrence; 4 at distant sites, and 1 local recurrence in the chest wall despite adjuvant chemotherapy and radiation therapy in the setting of node positive disease for which axillary lymph node dissection was declined. No new breast cancer diagnoses were reported in the 8 patients that underwent implant sparing mastectomy for prophylaxis alone. Ninety-day complication rates for all patients were low; 1 patient (1.4%) had a seroma requiring aspiration, 1 patient (1.4%) had a wound infection requiring antibiotics, and 4 (5.4%) had a hematoma requiring operative intervention. Three patients (4.1%) had wound dehiscence and 8 (10.8%) had flap loss. Of those patients with flap loss, 6 required debridement in the operating room (OR), and 1 of these patients required OR for free flap loss that was performed immediately after implant sparing mastectomy. The only complication rate higher than expected based on the literature was that of hematoma requiring operative intervention.  The vast majority, 64 (86.5%) underwent delayed reconstruction. Of these, only 7 required flap reconstruction, the remainder of patients underwent implant exchange only. 

Conclusion: For patients with previous implant-based augmentation pursuing mastectomy for breast cancer treatment or prevention, implant sparing mastectomy is a novel surgical approach with local recurrence and overall complication rates comparable to skin-sparing mastectomy with the exception of a slightly increased hematoma rate.  Finally, delayed reconstruction for these patients often requires no more than implant exchange with a low rate of need for flap reconstruction. As such this study suggests that implant sparing mastectomy is a safe and reasonable approach for selected patients.

 

47.01 Breast Reconstruction Disparities Remain Despite Affordable Care Act Medicaid Expansion

Posted on January 31, 2019

A. N. Cobb1, E. Eguia1, U. Maduekwe2, C. Godellas1, P. C. Kuo3  1Loyola University Medical Center,General Surgery,Maywood, IL, USA 2Loyola University Medical Center,Plastic Surgery,Maywood, IL, USA 3University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:

Following the implementation of Medicaid expansion via the Affordable Care Act (ACA), more women had access to cancer surgical care. However, the rates of reconstruction following mastectomy remain low. This study aims to evaluate the impact of Medicaid expansion on the utilization of breast reconstruction following mastectomy for breast cancer.

Methods:

We conducted a retrospective review using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for the years pre (2010-2013) and post (2014) Medicaid expansion.  We compare the incidence of breast reconstruction in Medicaid expansion states (MD, NY, WA) vs. non-expansion (FL) states. Reconstruction was defined as the observed procedure rate per 1,000 cancer admissions. A generalized linear model with a Poisson distribution and logistic regression was used with incidence rate ratios (IRR) and difference-in-differences (DID).   

Results:

We identified 65,178 females diagnosed with breast cancer. Of those 13,161 (16%), underwent breast reconstruction.   Patients in non-expansion states were slightly older with a mean age of 49 (8.6) [vs 48 (8.6) p<.001] and had lower Elixhauser comorbidity indices at 2.0 (1.1) [vs. 2.1 (1.2) p<.0001]. Both groups were predominantly white (65%) and had Medicaid insurance, though there were a higher proportion of Medicaid patients in non-expansion states (86.1% vs. 84.5%). The rates of breast reconstruction did not significantly increase in expansion states, even when adjusting for age, comorbid disease and race (IRR=1.04 95% CI [.75,1.44]). Additionally, living in a Medicaid expansion state post-implementation did not increase patients’ odds of getting reconstructive surgery (OR 1.16 95% CI .82-1.65). African-American women were 30% (OR .68 95% CI .64-.72) less likely to get reconstruction than their white counterparts while Hispanic women had increased odds of reconstruction overall (OR 1.16 95% CI 1.08-1.24).

Conclusion:

The rates of breast reconstruction have remained virtually unchanged pre and post Medicaid Expansion in both expansion and non-expansion states. Disparities in breast reconstruction remain after the ACA's expansion of Medicaid and may disproportiontely impact African American women . 

 

29.10 Insurance Coverage Trends for Breast Surgery in Cisgender Women, Cisgender Men, and Transgender Men

Posted on January 31, 2019

A. Almazan2, E. Boskey1, O. Ganor1  1Boston Children’s Hospital,Plastic And Oral Surgery,Boston, MA, USA 2Harvard Medical School,Boston, MA, USA

Introduction:  The criteria used to judge the medical necessity of a surgery can vary substantially between insurance providers and related procedures. Despite procedural similarities, insurance policies enforce different requirements for reimbursement of reduction mammoplasty (RM) in cisgender women, gynecomastia excision (GE) in cisgender men, and gender-affirming mastectomy (GAM) in transgender men. In this study, we examine how analogous procedures may be treated differently for patients of different genders, and we identify differences in coverage policies across insurance providers.

Methods: For each procedure, we examined the medical necessity criteria from the websites of the 9 largest national insurance networks that have national coverage guidelines, the 6 federal plans available through the Federal Employees Health Benefits plan, and 5 state plans for a large national network with state-based coverage policies. Plan policies were reviewed to determine coverage and identify standard medical necessity criteria for each procedure. For each plan, we recorded whether each procedure was covered and whether each medical necessity criterion was adopted.

Results: Coverage was highly variable between procedures. None of the plans excluded RM from coverage. 2 national networks, 2 federal plans, and 2 state plans excluded GE. 2 federal plans excluded GAM. Minimum age was the medical necessity criterion with the most variability between procedures. 5 of the 14 policies that cover GE explicitly required patients to be over the age of majority, compared to 10/20 RM policies and 16/18 GAM policies. GAM was the procedure with the most variable criteria between policies, with 10 different combinations of 5 criteria observed.

Conclusion: Insurance coverage and restrictiveness of medical necessity criteria for breast tissue removal are highly variable. Coverage for GE is fairly limited, and coverage exclusions for GAM exist despite the passage of transgender-specific insurance non-discrimination laws. Medical necessity criteria for RM and GE are somewhat inconsistent across insurers. Criteria for GAM are even more variable, despite the existence of published standards of care for transgender patients. Improving the consistency of insurance coverage for breast tissue removal, and streamlining procedure guidelines, has the potential to streamline the process of care.

29.08 Shared Decision-making for Unilateral Breast Cancer Patients Choosing between CPM and UM

Posted on January 31, 2019

J. Huang1, A. Chagpar1  1Yale University School Of Medicine,New Haven, CT, USA

Introduction:

Choosing between contralateral prophylactic mastectomy (CPM) and unilateral mastectomy (UM) is a personal decision, but the patient’s surgeon may influence this. We sought to determine how different patient-doctor communication strategies play into the decision-making process.

Methods:

Female unilateral breast cancer patients who had a mastectomy at a large academic institution were approached to participate in a survey regarding patient-physician communication and their decision between CPM and UM. Patient satisfaction with decision was measured using the 5-point Satisfaction with Decision (SWD) scale (higher = more satisfied). Non-parametric statistics were performed using SPSS version 24.

Results:

100 (91.7%) of 109 patients approached completed the survey and were included in this cohort; the median age was 49.5 years (range 29-82). 54 patients chose to undergo CPM (54%). 33 patients (33%) reported being recommended UM, 6 patients (6%) reported being recommended CPM, and 61 patients (61%) reported that their doctors employed shared decision-making (SDM), i.e., made no strong recommendation either way. The majority of patients who stated their doctors recommended UM chose UM (78.8%); similarly, 83.3% of those who stated their doctors recommended CPM chose CPM. Of the 39 patients whose doctors recommended a surgery, 8 patients (20.5%) did not follow their doctor’s advice. These patients were equally as satisfied with their decision as those who did follow their doctor’s advice (p=0.441). Compared to patients that followed their doctor’s advice, patients who did not tended to use a 2nd physician’s opinion (38.7% vs. 0%, p=0.042) as well as photos of cosmetic results (37% vs. 6.5%, p=0.049) in their decision-making process. There was no difference in age, race, education, insurance type, or income between patients who followed their doctor’s advice versus those who did not (p>0.05). Patients who reported engaging in SDM tended to choose CPM (68.3% vs. 30.8%, p<0.001). The mean SWD score of the entire cohort was 4.80 out of 5.00 (range 3.17-5.00). Patients who did not engage in SDM were similarly satisfied with their decision as those who did engage in SDM (mean SWD score 4.77 vs. 4.83, p=0.286). In terms of patient reported preferences for patient-physician communication, 12 patients (12%) preferred the doctor to provide a recommendation, 7 (7%) preferred to make the decision on their own, and 81 (81%) preferred to engage in SDM. Race, education, insurance type, income, and age did not differ between types of preferred communication strategies (p>0.05).

Conclusion:

When the physician provides an initial recommendation between UM and CPM, patients tend to follow it, while patients who engaged in SDM tend to choose CPM. While most patients state that they prefer to have physicians engage in SDM, patients were equally as satisfied with their surgical decision whether they engaged in SDM or not.

29.07 Increased APOBEC3C-H Gene Expression is Associated with Improved Outcome in Breast Cancer

Posted on January 31, 2019

M. Asaoka1,2, S. K. Patnaik1, A. L. Butash1, E. Katsuta1, T. Ishikawa2, K. Takabe1,2  1Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA 2Tokyo Medical University,Department Of Breast Surgery And Oncology,Shinjuku, Tokyo, Japan

Introduction:

APOBEC enzymes are known as strong mutagenic factors, particularly in breast cancer. APOBEC3B (A3B) gene expression is significantly increased in breast cancer and associated with tumor mutation load and intra-tumor heterogeneity. The relevance of the other APOBEC3s (A3A, C-H) is not yet clear in breast cancer. Therefore, we analyzed these genes, looking at their association with survival, mutations, and immune activity.

Methods:

We collected gene expression data for primary tumors (1091) and adjacent normal tissues (113) from The Cancer Genome Atlas (TCGA). Patients were divided into 3 equal groups by gene expression to compare high and low expressors. Tumor immune features like cytolytic activity and T cell receptor (TCR) diversity were quantified from gene expression data. Data for some of these features, mutation-related aspects, and survival were obtained from TCGA publications. Gene expression data for 55 breast cancer cell-lines was from Cancer Cell Line Encyclopedia. Cox regression and Spearman methods were used for survival and correlation analyses, resp. Welch t test was used for group comparison, with P <0.05 deemed significant. Hallmark gene-sets were used for enrichment analysis.

Results:

A3B and A3C represented 91% of A3 gene expression in breast cancer cell-lines. In patients, expression of A3B was higher in tumors compared to normal tissue (4.5x), while that of A3C was lower (0.5x). A3B or A3A levels had no effect on overall (OS) or disease-specific survival (DSS). But, higher expression for each of A3C-H was significantly associated with improved OS (HR, 0.45-0.66) or DSS (0.43-0.61). The prognostic value of high A3C-H expression was validated in two gene expression meta-datasets (KMPlot and SurvExpress). A3A and A3B expression levels correlated with both tumor mutation burden and neoantigen load (ρ = 0.28-0.34), which resp. were 2.0-2.9x more in high expressors. There was no association of tumor mutation burden or neoantigen load with A3C-H. A3C-H expression levels correlated positively with both total immune cell and lymphocyte populations in tumor (ρ = 0.29-0.70 & 0.20-0.50, resp.), whereas the correlations were poor for A3B (0.10 & -0.01, resp.). Expression of genes related to immune function like interferon response and complement activation was enriched in high A3C-H expressors, which also had significantly more CD4 and CD8 T cells, and TCR diversity (2.3-4.0x, 2.1-5.4x & 1.3-2.1x, resp.). Concordantly, for each of A3C-H, expression correlated with tumor immune cytolytic activity (ρ = 0.31-0.79), which was increased 3.1-7.9x in high expressors.

Conclusion:

APOBEC3s are DNA mutators. However, unlike A3B, whose expression is associated with poor survival, increased expression of A3C-H confers a survival benefit. Further studies are warranted to explore if the increased A3C-H expression reflects a heightened anti-cancer immune response, and if A3C-H can be used as prognostic biomarkers.

29.04 Radiation Following Autologous Breast Reconstruction – Is It Safe Practice?

Posted on January 31, 2019

L. A. Gamble1, S. Sha2, J. L. Kelly1, L. A. Jarvis4, G. L. Freed3, K. M. Rosenkranz1, C. V. Angeles1  2Stony Brook University,School Of Medicine,Stony Brook, NEW YORK, USA 3Dartmouth-Hitchcock Medical Center,Plastic Surgery,Lebanon, NEW HAMPSHIRE, USA 4Dartmouth-Hitchcock Medical Center,Radiation Oncology,Lebanon, NEW HAMPSHIRE, USA 1Dartmouth-Hitchcock Medical Center,General Surgery,Lebanon, NEW HAMPSHIRE, USA

Introduction:  The incidence of immediate breast reconstruction (IBR) following mastectomy for breast cancer has steadily been on the rise while the indications for post mastectomy radiation therapy (PMRT) have broadened. Current literature demonstrates conflicting data regarding surgical complications and timing of PMRT, while the safety of PMRT following autologous breast reconstruction (ABR) is still considered controversial. We sought to investigate the safety of PMRT in breast cancer patients who undergo ABR.

Methods:  Retrospective chart review was performed on all patients treated with mastectomy between 2000-2006 at a single, academic institution. Data collected included patient demographics, PMRT, and postoperative complications including seroma, infection, fat necrosis, and contracture documented from the time of surgery until one year post surgery. Median follow-up was 6.19 years. Chi-square analysis was performed with significance set at p <0.05.

Results: 592 patients underwent mastectomy for breast cancer treatment or prophylaxis. Only half of these patients (49%; 292/592) underwent reconstruction. The majority (83%; 240/292) received ABR, and 95% (228/240) were done at the time of mastectomy (IBR). The most common flap performed was the transverse rectus abdominis (TRAM) flap at 72.1%, followed by 24.2% latissmus dorsi (LD), and 3.7% other flaps (including superior and inferior gluteal artery perforators, and transverse upper gracilis). Of the immediate ABR patients, 57/228 received PMRT. Of these, 54% (31/57) suffered any surgical complication and 23% (13/57) were classified as Clavien-Dindo grade IIIb (CD IIIb). Comparatively, 171/228 patients did not receive PMRT with almost half (84/171) having complications, but only 26% (45/171) were classified as CD IIIb. There was no statistically significant difference in overall complication rate or CD IIIb complications between ABR patients with or without PMRT (p=0.742 and p=0.357, respectively). Additionally, we found no significant difference in overall complication rate in patients who underwent PMRT when comparing between those who had no reconstruction versus those who had ABR (p=0.0623).

Conclusion: Our data shows no statistically significant difference in the complication rate between breast cancer mastectomy patients who received PMRT after ABR versus no reconstruction.  Additionally, there is no difference in the rate of complications between ABR patients who did or did not receive PMRT. This study supports the idea that it is safe to radiate a reconstructed breast.

 

29.03 Adhering to Surgical and Oncologic Standards Improves Survival in Breast Cancer Cohorts

Posted on January 31, 2019

B. Zhao1, C. Tsai1, K. K. Hunt2, S. L. Blair1  2University Of Texas MD Anderson Cancer Center,Breast Surgical Oncology,Houston, TX, USA 1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:
The American College of Surgeons Clinical Research Program published evidence-based surgical and oncologic standards for breast cancer in the Operative Standards for Cancer Surgery.  Recommended standards include surgical resection with negative margins, removal of all sentinel lymph nodes (SLN) and removal of >10 lymph nodes (LN) for complete axillary dissection (ALND), and the use of adjuvant therapy after surgical resection. However, the rates of adherence to these standards nationwide is unknown. 

Methods:
Using the National Cancer Database from 2004-2015, we selected distinct cohorts of breast cancer patients who underwent surgical resection: clinical T1N0M0 under age 70 (CT1), clinical T2N0M0 or T3N0M0 (CT2/3), and clinical M0, pathologic N2 or N3 (PN2/3). For CT1 and CT2/3 patients, we considered patients with negative margins, any form of adjuvant therapy, and ³2 LNs examined as meeting standards. For PN2/3 patients, we considered those with negative margins, any form of adjuvant therapy, and ³10 LNs examined as meeting standards. We compared outcomes of those who met standards versus those who did not for all cohorts. We performed Kaplan-Meier analysis with log-rank test to compare survival for patients based on achieving standards and Cox proportional hazards model for individual predictors of improved survival while controlling for patient comorbidities. 

Results:
We identified 318,853 (65.0%) CT1 patients, 164,593 (67.3%) CT2/3 patients, and 77,626 (67.7%) PN2/3 patients who met surgical and oncologic standards. Survival data is shown in the table. For PN2/3 patients, the median survival for those who met standards was significantly longer than those who did not meet standards (109.34 months versus 72.97, p<0.001). Patients were significantly more likely to meet standards if they were treated at an academic center (p<0.001 for all cohorts). For CT1 and CT2/3 patients, ³2 LNs examined, endocrine therapy, radiation therapy, and negative margins were predictors of improved survival. For CT1 patients, chemotherapy was a predictor of worse survival, but was a predictor of improved survival in CT2/3 patients. For PN2/3 patients, ³10 LNs examined, endocrine therapy, chemotherapy, radiation therapy, and negative margins were predictors of improved survival. 

Conclusion:
Approximately a third of patients are not receiving evidence-based minimal standards as part of their surgical and oncologic treatment for breast cancer.  Adhering to surgical and oncologic standards improves survival in CT1, CT2/3, and PN2/3 breast cancer patients.  Efforts to improve knowledge of, and adherence to, these surgical and oncologic standards should be emphasized. 
 

29.02 Underinsurance and Healthcare Utilization among Working-Age Breast Cancer Patients

Posted on January 31, 2019

S. Obeng-Gyasi1, L. Timsina1, O. Bhattacharyya3, S. E. Severance1, C. S. Fisher1, D. A. Haggstrom2  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 2VA HSR&D Center for Health Information and Communication,Indianapolis, IN, USA 3Indiana University Purdue University,Department Of Economics,Indianapolis, IN, USA

Introduction: Breast cancer is the most common female cancer in the United States. For working-age patients, a cancer diagnosis can be financially devastating secondary to disease related reduction in work productivity, loss of employment, and subsequent increased economic burden. The objective of this study is to understand out-of-pocket costs (OOP), health care utilization costs (outpatient visits, office-based visits, ambulatory care, prescription medication cost), and the rate of underinsurance among working age breast cancer patients. 

Methods: The study data was obtained using the Medical Expenditure Panel Survey data from 2008-2012.  Self-responding patients ages 18-64 with an age at diagnosis of breast cancer within two years of the survey interviews were included. The data was divided into three groups based on insurance:  private, Medicaid, and other public.  The other public includes patients with Non-Medicaid state or local insurance or other federal programs. Bivariate intergroup analysis was conducted. A multivariable logistic regression model tested variables associated with underinsurance. Underinsurance was defined as spending at least 10% of the household income on breast cancer related OOP.

Results:The study cohort included 14,586 patients. The groups differed significantly by marital status (p=0.004), race/ethnicity (p=0.0002), education (P <0.0001), percent below the poverty level (p<0.0001), family income (P <0.0001) and employment (P<0.0001).   Mean total annual OOP costs were $2006.0 (95% CI 1705.5, 2305.5) for the privately insured, $991.0 (95% CI -160.1, 2142.3) for Medicaid, and $7420.0 (95% CI 1722.8, 13117) for other public insurance. The majority of OOP cost were on prescriptions, $706.0 (95% CI 557.7, 854.6), and office-based visits, $779. 0(95% CI 641.7, 916.3). Patients with other public insurance spent the most OOP costs on prescriptions $3258.0 (95% CI 2047.2, 4467.8) and office-based visits $3258.0 (95% CI 2047.2, 4467,8). Being divorced (OR 5.6, p=0.029), living in the Midwest (OR 18.6, p=0.001) or South (OR 7.49 p=0.015) compared to the Northwest and having other public insurance (OR 12.2, p=0.012) were all associated with an increased rate of underinsurance. Conversely, employment (OR 0.21, p=0.011) and having Medicaid (OR 0.09, p= 0.006) were associated with a reduced rate of underinsurance.

Conclusion:Breast cancer patients spend most of their OOP costs on prescriptions and office-based visits. Since Medicaid was protective against underinsurance and higher OOP costs, future longitudinal studies should monitor whether Medicaid policy changes continue to reduce the economic vulnerability among cancer patients. Fifteen states in the South and Midwest have not expanded Medicaid, and this public policy decision appears to expose breast cancer patients to substantially greater financial burdens. Medicaid expansion should be considered to mitigate financial burden among working age women with breast cancer.

 

29.01 Impact of Global Migration on Asian Breast Cancer: A Comparison between US and Taiwan

Posted on January 31, 2019

J. Wu1,2, Y. Hung2, S. M. Stapleton2, Y. Hsu2, S. T. Oseni2, C. Huang1, D. C. Chang2  1National Taiwan University Hospital,Surgery,Taipei, Taiwan 2Massachusetts General Hospital,Surgery,Boston, MA, USA

Introduction:

More than half of the Asian Americans with breast cancer were born in Asia, however it is unknown whether their disease patterns are different from Asians born in the US. We hypothesize that nativity status may have an impact on the onset and the presentation of breast cancer in the Asian population.

Methods:

A retrospective analysis was performed for Asian females³ 20 years old in the US Surveillance, Epidemiology, and End Results (SEER) Program database, and as a convenience sample from Asia, in the Taiwan Cancer Registry (TCR) for the years 2004-2010. The primary end point was proportion of patients who had early-onset breast cancer, defined as breast cancer age at onset before 50. Secondary outcome was the proportion of advanced breast cancers, defined by American Joint Committee on Cancer staging III to IV. Three groups of patients were compared: Native Asian in Taiwan (TW), Asia-born Asian American (AAA), and US-born Asian American (USAA).

Results:

We identified 13,404 patients (2,743 USAA & 10,661 AAA) in SEER and 49,322 TW in TCR. TW presented at an earlier age than AAA (median age 51vs 56) and USAA (median ­­­­­­61). TW had the highest proportion of early-onset breast cancer (44.3% vs 31.7% AAA and 23.7% USAA, p < 0.001). In addition, both TW and AAA had significantly higher rates of advanced cancer at presentation than USAA (22.8% and 17.2% vs 13.8%, respectively, p < 0.001).

Conclusions:

Recent immigrants to the US may be at increased risk of earlier and more aggressive breast cancers. Future studies should determine whether these differences are due to biomedical factors, access to healthcare, or poor healthcare quality affecting immigrant communities. The impact of immigration on health and disease remains an under-appreciated but important way through which we can further understand the interaction between social and biomedical factors on disease onset and progression.

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