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Introduction: Economic hardship (EH) can negatively influence cancer outcomes. Little is known about the factors that are associated with higher levels of EH among patients with breast cancer (BC). This paper describes EH in women with early-stage BC prior to or at their first chemotherapy treatment (baseline) and explores whether there are differences by race, area deprivation, stress, symptom distress, and social support., Patients and Methods: A descriptive comparative/correlational design was employed using baseline data of a multisite, longitudinal, multimethod study comparing the symptom experience and management prior to prescribed chemotherapy for women with early-stage BC. Participants completed measures for EH, perceived stress, symptom distress, and social support. Race was measured by self-report. Area deprivation indices (ADI) measuring neighborhood economic factors were calculated from publicly available websites., Results: Participants (N = 248; age = 52.9 ± 12.3 years) were 62% White and 38% Black, 54% partnered, and 98% insured. Compared to White patients, Black patients reported higher (worse) EH (1.2 ± 3.0 vs. -0.7 ± 2.4), lived in areas of greater deprivation (80.1 ± 2.1 vs. 50.5 ± 23.5),and were more likely to report inadequate household income (Black: 30.5%; White: 11.1%). Adjusting for race and age, being Black (P< .001), living in an area of greater deprivation (P = .049), higher perceived stress (P = .008), lower perceived appraisal (P = .040), and less tangible support (P < .001) contributed to greater EH. Worse symptom distress trended toward greater EH (P = .07)., Conclusions: This study emphasizes the importance of incorporating baseline holistic assessment to identify patients most likely to experience EH during early-stage BC treatment., Competing Interests: Disclosure All authors have no conflicts of interest to disclose., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Cancer clinicians and systems aim to provide patient-centered care, but not all patients have the self-advocacy skills necessary to ensure their care reflects their needs and priorities. This study examines the feasibility, acceptability, and preliminary efficacy of a self-advocacy serious game (an educational video game) intervention in women with advanced breast or gynecologic cancer., Methods: Women with recently diagnosed (<3 months) metastatic breast or advanced gynecologic cancer were randomized 2:1 to receive a tablet-based serious game (Strong Together) (n = 52) or enhanced care as usual (n = 26). Feasibility was based on recruitment, retention, data completion, and intervention engagement. Acceptability was assessed via a postintervention questionnaire and exit interview. Preliminary efficacy was assessed on the basis of change scores from baseline to 3 and 6 months in self-advocacy (Female Self-Advocacy in Cancer Survivorship Scale) using intention-to-treat analysis., Results: Seventy-eight women (55.1% with breast cancer; 44.9% with gynecologic cancer) were enrolled. Feasibility was demonstrated by satisfactory recruitment (69% approach-to-consent rate; 93% enroll-to-randomize rate), retention (90% and 86% at 3 and 6 months, respectively; 85% data completion), and intervention engagement (84% completed ≥75% of the game). Participants endorsed the intervention's (75%) and trial's (87%) acceptability. Participants in the intervention group experienced significant improvements in self-advocacy at 3 and 6 months compared to participants in the control group., Conclusions: Strong Together is feasible and acceptable among women with advanced breast or gynecologic cancer. This intervention demonstrates promising evidence of clinical efficacy. A future confirmatory trial is warranted to test the efficacy of the intervention for patient and health system outcomes., (© 2023 American Cancer Society.)

Purpose: Patients with advanced cancer experience many complicated situations that can make self-advocacy (defined as the ability speak up for yourself in the face of a challenge) difficult. Few self-advocacy interventions exist, and most are atheoretical with minimal patient engagement. The purpose of this study is to describe participant perspectives of a novel, self-advocacy serious game intervention called Strong Together., Methods: This was a qualitative cross-sectional descriptive study among women receiving cancer care at an academic cancer center within 3 months of an advanced gynecologic or breast cancer diagnosis. Participants randomized to receive the intervention completed one-on-one semi-structured interviews 3-months post Strong Together and had the option to share voice journals about their experiences. Inductive qualitative approaches were used to descriptively analyze transcripts and voice journals. Descriptive content analysis approaches were used to group similar codes together into themes summarizing participants' experiences engaging with the Strong Together intervention., Results: Participants (N = 40) reported that the Strong Together intervention was acceptable, noting that it was realistic and reflective of their personal experiences. Overarching themes included seeing myself in most scenarios and wanting more content; giving me the go ahead to expect more; offering ideas for how to stand up for myself; reinforcing what I am already doing; and reminding me of what I have. Participants suggested adding additional content including diverse characters., Conclusion: This study demonstrated that women with advanced cancer were receptive to a self-advocacy skills-building intervention. Future research should explore the mechanisms linking serious games to learning and health outcomes., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Women with advanced cancer experience significant barriers to achieving high-quality care and maximizing their physical and emotional health. Our novel serious game, Strong Together, aims to teach women with advanced cancer self-advocacy skills needed to improve their symptom burden, quality of life, and patient-centered care., Methods: This is a single-center, multi-site randomized clinical trial of the Strong Together intervention among 336 women within three months of an advanced breast or gynecologic cancer diagnosis. Randomization occurs to the 3-month Strong Together serious game or enhanced care as usual group. The aims are to: (1) evaluate the effects of the intervention on patient self-advocacy (primary outcome); (2) evaluate the effects of the intervention on quality of life, symptom burden, and patient-centered care (secondary outcomes); and (3) evaluate the behavioral and game mechanisms that influence the efficacy of the intervention., Eligibility Criteria: female, age ≥ 18 years; diagnosis of advanced breast or gynecologic cancer within the past 3 months; Eastern Cooperative Oncology Group score of 0-2; English literacy; and ≥ 6-month life expectancy. Patient-reported outcome measures are collected at baseline, 3-months, and 6-months., Conclusion: This protocol is the first large-scale intervention aimed at promoting self-advocacy in women with advanced cancer. Understanding the ability of serious games to impact patient outcomes provides critical information for researchers, clinicians, and stakeholders aiming to improve patient-centered care., Trial Registration: NCT04813276., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To examine (a) the impact of the COVID-19 pandemic on anxiety and post-traumatic stress disorder (PTSD) symptoms and (b) the impact of socioeconomic factors on COVID-19-related anxiety and PTSD symptoms., Sample & Setting: Women with early-stage invasive breast cancer who were receiving chemotherapy in western Pennsylvania and eastern Ohio., Methods & Variables: Baseline study variables included economic hardship, interpersonal relationships, and perceived stress. PTSD and anxiety symptoms were collected in June 2020 (T1) and February 2021 (T2). Group comparisons were made using paired-sample t tests, analysis of variance, and Pearson correlations., Results: There were 88 women at T1 and 64 women at T2. At T1, PTSD symptom scores were significantly associated with less interpersonal support, greater economic hardship, and greater perceived stress. Anxiety scores were associated with perceived stress. At T2, anxiety scores were still associated with perceived stress. However, PTSD symptom scores were no longer associated with interpersonal support, economic hardship, or perceived stress., Implications for Nursing: Anxiety and PTSD symptom measurement during a global pandemic is needed to identify vulnerable patients with breast cancer who need targeted support and emergency guidance in nursing practice.

Estrogen receptor alpha (ER/ESR1) is frequently mutated in endocrine resistant ER-positive (ER+) breast cancer and linked to ligand-independent growth and metastasis. Despite the distinct clinical features of ESR1 mutations, their role in intrinsic subtype switching remains largely unknown. Here we find that ESR1 mutant cells and clinical samples show a significant enrichment of basal subtype markers, and six basal cytokeratins (BCKs) are the most enriched genes. Induction of BCKs is independent of ER binding and instead associated with chromatin reprogramming centered around a progesterone receptor-orchestrated insulated neighborhood. BCK-high ER+ primary breast tumors exhibit a number of enriched immune pathways, shared with ESR1 mutant tumors. S100A8 and S100A9 are among the most induced immune mediators and involve in tumor-stroma paracrine crosstalk inferred by single-cell RNA-seq from metastatic tumors. Collectively, these observations demonstrate that ESR1 mutant tumors gain basal features associated with increased immune activation, encouraging additional studies of immune therapeutic vulnerabilities., (© 2022. The Author(s).)

Background: In metastatic breast cancer (MBC), positive estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status allow for more long-term, sequential treatment options compared to ER-negative and HER2-negative diseases. It is unclear if end-of-life care (timely integration of palliative care, discontinuation of chemotherapy, and enrollment into hospice) in MBC is now tailored to the ER and HER2 status., Objectives: This article explores the association between ER and HER2 status and the quality of end-of-life care received among patients with MBC., Methods: A 20-year MBC clinical database captured demographics, tumor characteristics, and treatment histories of deceased patients with MBC (N = 1,258) at a tertiary hospital located in Pittsburgh, Pennsylvania. Descriptive and inferential statistics were used., Findings: Patients with ER-positive MBC had greater odds of receiving quality end-of-life care than those with ER-negative MBC. HER2 status was not associated with differences in the quality of end-of-life care.

There is growing interest in tissue procurement for cancer research through autopsy. Establishing an autopsy/tissue donation programme for breast cancer research within an academic medical centre in the United States requires consideration, planning, multi-departmental collaboration and labour-intensive maintenance. It is the purpose of this paper to outline the necessary considerations in implementing and maintaining a tissue donation and autopsy programme within a breast cancer centre at a comprehensive cancer centre. Considerations of programme planning include: patient engagement, the recruitment of patients and families into the programme, the role and scope of work of the clinical coordinator, regulatory issues and the coordination with both pathology and the research team at time of death and autopsy/tissue donation. All aspects of the tissue donation/rapid autopsy programme development and implementation are discussed and illustrated through case study. An Autopsy/ Tissue Donation for breast cancer research can be successfully developed and implemented.

Metastatic breast cancer (MBC) carries unique disease burdens with potential for poor-quality end-of-life (EOL) care. It is the purpose of this article to explore the association of poor-quality EOL care indicators according to key tumor, demographic, social, and clinical factors. End-of-life quality indicators were based on Emanuel and Emanuel's good death model in conjunction with Earle et al (2003). A single-institution retrospective chart review of women deceased from MBC between November 2016 and November 2019 with double-verification chart review was completed. Data were analyzed with descriptive, correlative, and comparative statistics. Total sample was N = 167 women, with 14.4% (n = 24) Black and 85.6% (n = 143) White. Mean (SD) age was 55.3 (11.73) years. Overall, MBC survival was 3.12 years (SD, 3.31): White women, 41.2 months (3.4 years), and Black women, 19 months (1.6 years). A total of 64.1% (n = 107) experienced 1 or more indicators of poor-quality EOL care. Patients more likely to experience poor-quality EOL care were older (P = .03), estrogen negative (P = .08), human epidermal growth factor receptor 2 negative (P = .07), from more deprived neighborhoods (P = .02), married (P = .05), and with physical (P = .001) and mental (P = .002) comorbidities. Understanding sociodemographic and clinical factors associated with poor EOL MBC care may be useful for proactive patient navigation., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 by The Hospice and Palliative Nurses Association. All rights reserved.)

Background: Breast cancer is the most common malignancy to spread to the orbit and periorbit, and the invasive lobular carcinoma (ILC) histologic subtype of breast cancer has been reported to form these ophthalmic metastases (OM) more frequently than invasive ductal carcinomas (IDC). We herein report our single academic institution experience with breast cancer OM with respect to anatomical presentation, histology (lobular vs. ductal), treatment, and survival., Methods: We employed the natural language processing platform, TIES (Text Information Extraction System), to search 2.3 million de-identified patient pathology and radiology records at our institution in order to identify patients with OM secondary to breast cancer. We then compared the resultant cohort, the "OM cohort," to two other representative metastatic breast cancer patient (MBC) databases from our institution. Histological analysis of selected patients was performed., Results: Our TIES search and manual refinement ultimately identified 28 patients who were diagnosed with breast cancer between 1995 and 2016 that subsequently developed OM. Median age at diagnosis was 54 (range 28-77) years of age. ER, PR, and HER2 status from the 28 patients with OM did not differ from other patients with MBC from our institution. The relative proportion of patients with ILC was significantly higher in the OM cohort (32.1%) than in other MBC patients in our institution (11.3%, p = 0.007). Median time to first OM in the OM cohort was 46.7 months, and OM were the second most frequent first metastases after bony metastases. After diagnosis of the first distant metastasis of any kind, median survival of patients with ILC (21.4 months) was significantly shorter than that of patients with IDC (55.3 months, p = 0.03). Nine patients developed bilateral OM. We observed a significant co-occurrence of OM and central nervous system metastases (p = 0.0053). The histological analysis revealed an interesting case in which the primary tumor was of a mixed ILC/IDC subtype, while only ILC was present in the OM., Conclusions: OM from breast cancer are illustrative of the difference in metastatic behavior of ILC versus IDC and should be considered when treating patients with ILC, especially in those with complaints of visual acuity changes.

Background: Women with metastatic breast cancer (MBC) experience unique symptom management and psychosocial needs due to aggressive, yet palliative treatment with a progressive, chronic illness., Objective: This article describes the effect of a quality improvement project for coordination of supportive care in MBC. Program evaluations included referral rates for supportive services, patient-reported outcomes of symptom distress, generalized anxiety, and overall well-being., Design: An interdisciplinary Support, Education and Advocacy Program (MBC-SEA) was developed. The 1-hour, weekly, patient review included collaborative assessments to determine needs for social service, psychological counseling, and palliative care. A prospective pre- and postexperimental cohort design with convenience sampling was used. Analysis was conducted with paired t test analysis of pre- and postimplementation outcomes., Setting/participants: Program outcomes of 118 women with MBC visiting an urban outpatient breast cancer clinic during September 2016 to November 2016 (pre) and January 2017 to March 2017 (post) were evaluated., Measurements: Referral rates to social work and palliative care, symptom, anxiety, and overall well-being scores., Results: Following program implementation, referrals to palliative care and social work supportive services increased significantly including patient-reported outcomes symptom distress scores mean difference 1.4 (95% confidence interval [CI]: 0.4306-2.6428), P = .004; generalized anxiety scores mean difference 1.5 (95% CI: 0.5406-2.5781), P = .003; and overall well-being mean difference of -0.7 (95% CI: -1.3498 to -0.0570), P = .03., Conclusions: Purposeful nurse-led assessment for social service and palliative care needs increases referrals with improvement in patient-reported outcomes.

Background: Black women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with White women. Adding further risk, older patients with breast cancer are most at risk for treatment modifications; however, it is unclear if this remains true for Black patients. Furthermore, the clinical implications of treatment modifications and delays on survival is uncertain, particularly in Black patients., Patients and Methods: The purpose was to investigate whether age was a moderator for the association between treatment modifications (dose held, dose delayed, and early cessation) and overall survival and disease-free survival (DFS) in Black women with breast cancer using a retrospective cohort study of patients with early stage breast cancer treated with adjuvant chemotherapy., Results: Across the entire sample (n = 115), 37.4% (n = 43) of patients experienced a treatment modification. There was a significant interaction between age group and held dose for DFS (P = .026). Specifically, those diagnosed at 55 years of age and older, who had doses of chemotherapy held, experienced worse DFS compared with those who did not (hazard ratio, 4.185; 95% confidence interval, 1.187-14.75). In contrast, there was no difference in DFS between those who did and did not have doses held in patients diagnosed below 55 years of age (hazard ratio, 0.626; 95% confidence interval, 0.177-2.218)., Conclusion: In this study, Black women receiving adjuvant chemotherapy for treatment of early stage breast cancer had roughly equal treatment modifications across age groups. However, held doses of chemotherapy in older Black patients were associated with worse DFS. Age may impact clinical outcomes seen with adjuvant chemotherapy treatment modifications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Of women diagnosed with metastatic breast cancer (MBC), 20% to 30% survive ≥5 years. We evaluated data from a large breast cancer program to identify features associated with MBC survival., Patients and Methods: Women diagnosed with MBC in or after 1999 were included. Long-term MBC survival was defined as ≥5 years from date of MBC diagnosis (n = 122), short-term MBC survival as ≤2 years (n = 191). Differences were assessed using t tests, Wilcoxon-Mann-Whitney tests, χ 2 , and Fisher exact tests. Odds ratios (ORs) were calculated using multivariate logistic regression models., Results: Long-term survivors were significantly (P < .05) younger, premenopausal, partnered, had estrogen receptor (ER)-positive, progesterone receptor-positive, and HER2-positive disease, lower Charlson Comorbidity Index, lower rates of visceral metastases, and higher household income. After adjustment for potential confounders, de novo MBC, premenopausal status, ER-positive status, and HER2-positive status remained significantly positively associated with long-term survival (respectively: OR, 2.68 [95% confidence interval (CI), 1.48-4.88]; OR, 1.96 [95% CI, 1.02-3.79]; OR, 3.74 [95% CI, 1.72-8.14]; OR, 2.88 [95% CI, 1.61-5.14]). Triple-negative status, visceral with bone metastases, and brain metastases remained negatively associated with long-term survival (respectively: OR, 0.12 [95% CI, 0.05-0.29]; OR, 0.18 [95% CI, 0.07-0.47]; OR, 0.16 [95% CI, 0.04-0.60]). Partner status and household income were significant in univariate but not multivariate analyses., Conclusion: Diagnosis of de novo MBC, premenopausal status, ER-positive status, and HER2-positive status were positively associated whereas triple-negative status, brain metastases, and visceral with bone metastases were inversely associated with long-term survival. These findings can be applied to better prognosticate survival for MBC patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To determine the incidence of financial toxicity among women with metastatic breast cancer, as well as the relationships among financial toxicity, quality of life, and overall cancer-related distress in members of this patient population., Sample & Setting: 145 women with metastatic breast cancer receiving care at an urban outpatient breast cancer clinic., Methods & Variables: A cross-sectional analysis of women with metastatic breast cancer was performed. Data were collected on patient characteristics, quality of life, cancer-related distress, and financial toxicity using self-administered questionnaires., Results: Financial toxicity is common among women with metastatic breast cancer and more common among low-income women with the disease. In addition, financial toxicity is correlated with worse quality of life and overall cancer-related distress., Implications for Nursing: Nurses should consider financial toxicity for all patients receiving treatment for cancer. Understanding the concerns of specific patient populations and patients with different stages of cancer is necessary to tailor assessment and mitigation strategies.

Background: Estrogen receptor-positive (ER-positive) metastatic breast cancer is often intractable due to endocrine therapy resistance. Although ESR1 promoter switching events have been associated with endocrine-therapy resistance, recurrent ESR1 fusion proteins have yet to be identified in advanced breast cancer., Patients and Methods: To identify genomic structural rearrangements (REs) including gene fusions in acquired resistance, we undertook a multimodal sequencing effort in three breast cancer patient cohorts: (i) mate-pair and/or RNAseq in 6 patient-matched primary-metastatic tumors and 51 metastases, (ii) high coverage (>500×) comprehensive genomic profiling of 287-395 cancer-related genes across 9542 solid tumors (5216 from metastatic disease), and (iii) ultra-high coverage (>5000×) genomic profiling of 62 cancer-related genes in 254 ctDNA samples. In addition to traditional gene fusion detection methods (i.e. discordant reads, split reads), ESR1 REs were detected from targeted sequencing data by applying a novel algorithm (copyshift) that identifies major copy number shifts at rearrangement hotspots., Results: We identify 88 ESR1 REs across 83 unique patients with direct confirmation of 9 ESR1 fusion proteins (including 2 via immunoblot). ESR1 REs are highly enriched in ER-positive, metastatic disease and co-occur with known ESR1 missense alterations, suggestive of polyclonal resistance. Importantly, all fusions result from a breakpoint in or near ESR1 intron 6 and therefore lack an intact ligand binding domain (LBD). In vitro characterization of three fusions reveals ligand-independence and hyperactivity dependent upon the 3' partner gene. Our lower-bound estimate of ESR1 fusions is at least 1% of metastatic solid breast cancers, the prevalence in ctDNA is at least 10× enriched. We postulate this enrichment may represent secondary resistance to more aggressive endocrine therapies applied to patients with ESR1 LBD missense alterations., Conclusions: Collectively, these data indicate that N-terminal ESR1 fusions involving exons 6-7 are a recurrent driver of endocrine therapy resistance and are impervious to ER-targeted therapies.

Purpose: Previous research has explored occupational activity of breast cancer survivors but has not examined the influence of occupational level on symptoms prospectively. The purpose of this study was to examine the relationship between occupational classification and changes in mood and symptom burden for postmenopausal breast cancer survivors during the first year of anastrozole therapy., Methods: This was an exploratory secondary analysis in 49 postmenopausal women receiving anastrozole therapy for early-stage breast cancer. Participants reported their occupation at baseline and completed self-report questionnaires measuring mood and symptom burden at baseline, 6 months, and 12 months. Occupation was classified according to four major skill levels delineated by the International Standard Classification of Occupations (ISCO)., Results: Breast cancer survivors employed at occupational skill levels 1 through 3 reported significantly higher depressive symptoms, fatigue, and total symptoms on average than those employed at ISCO skill level 4. After adjusting for multiple comparisons, this pattern remained for the musculoskeletal, vasomotor, and gastrointestinal symptom subscales., Conclusions: Breast cancer survivors employed at lower skill levels (i.e., ISCO 1-3) reported poorer mood and greater symptom burden than breast cancer survivors employed at a higher skill level (i.e., ISCO 4). Assessing baseline occupation of occupationally active breast cancer survivors may improve understanding of the association between types of occupations and mood and symptom trajectories and may inform development of interventions to mitigate symptom severity in order to help breast cancer survivors maintain optimal occupational function and adherence to therapy.

Rapid autopsy (RA) offers a unique opportunity to obtain a large amount of metastatic tissue at death in order to deepen existing understanding of cancer evolution and heterogeneity. In breast cancer, understanding metastasis is particularly valuable given that treatment regimens are based on the traditional hormone and HER2 receptor status as well as evolving genomic data of the primary tumor. We aimed to elucidate the attitudes and interests of patients with metastatic breast cancer (MBC) toward RA, and to identify associated demographic or disease characteristics that may influence patient attitudes and interest. Ninety-seven patients with MBC were surveyed over the course of 12 months at a large, urban comprehensive cancer center's breast cancer outpatient clinic. 93/97 patients completed the survey sufficiently to be included in the analysis. Fisher's exact test was employed for categorical variables, and t test and rank-sum tests for continuous variables. p values ≤0.05 were considered statistically significant. Of the 93 patients with MBC analyzed, 87 % were willing to donate tissue at death. Marital status and younger age were associated with willingness to donate (p = 0.000, p = 0.025, respectively). Race, employment status, religion/spirituality, and cancer subtype were not associated with likelihood of donating. Forty-five percent of patients felt that doctors should ask about RA at diagnosis of early-stage breast cancer rather than during late-stage disease. These data provide evidence that an RA program would be welcomed by patients and requires initiative by providers.

Bisphosphonates are important therapies used to reduce the risk of skeletal-related events in patients with bone metastases from breast cancer (BC). This retrospective cohort study evaluated the incidence of osteonecrosis of the jaw (ONJ) and renal impairment in women (n = 221) with bone metastases from BC treated with intravenous bisphosphonates from January 1999 to June 2008. In the long-term cohort, 159 patients received pamidronate (n = 9), zoledronic acid (n = 110), or both (n = 40) for ≥24 months. The comparator group consisted of patients treated with intravenous bisphosphonates for 12-23 months (n = 62). After 39 months' median follow-up, six of 159 patients developed ONJ (3.8%; median 38.5 treatment cycles and 44 months' exposure) in the long-term cohort. Of patients who developed ONJ, 50% resumed intravenous bisphosphonates after a 12-month treatment holiday. Renal impairment developed in 19 patients in the long-term cohort (11.9%; median 26 treatment cycles and 26 months' exposure). Of these 19 patients, 11 (57.9%) recovered baseline renal function and seven (36.7%) showed partial recovery. After modification of the intravenous bisphosphonate regimen, 17 of 19 patients (89.4%) resumed therapy. Of the 62 patients in the comparator cohort, one patient developed ONJ (1.6%) and six developed renal impairment (9.7%). Similar incidence rates of ONJ and renal impairment were observed for the long-term and comparator cohorts. Times to ONJ or renal impairment also were similar across intravenous bisphosphonate type. Long-term (≥24 months) intravenous bisphosphonate use in metastatic BC is well tolerated, with low incidences of ONJ and renal impairment., (© 2013 Wiley Periodicals, Inc.)

The presence of comorbidity becomes increasingly important for its prognostic effect on survival in breast cancer patients with advancing age. This study aimed to evaluate the role of comorbidities including hypertension as a mediator of disparity in survival after metastasis diagnosis between younger (≤51 years) and older (>51 years) patients. A total of 553 patients 26-88 years of age with breast cancer metastasis diagnosis from 1 large urban practice were followed between January 1, 1999, and June 30, 2008. Comorbidity variables and survival were analyzed using Cox regression model. To assess comorbidity variables as a mediator of age-survival relationship, 2 approaches have been applied: (1) Baron Kenny approach and (2) alternative assessment to compute the percentage change in the hazard ratios (HRs). The median survival was 40 months, with 265 (47.9%) alive and 288 (52.1%) dead. Older patients had worse survival than younger patients (HR, 1.43; 95% confidence interval [CI], 1.11-1.84). Hypertension was related to survival (HR, 1.45; 95% CI, 1.12-1.89) when age and other covariates were controlled. The effect of age on survival was no longer significant after adjustment for hypertension (HR, 1.26; 95%, CI 0.97-1.65) or hypertension-augmented Charlson comorbidity score (HR, 1.24; 95% CI, 0.95-1.63). Hypertension-augmented Charlson comorbidity score or hypertension was a strong mediator of age-survival relationship among metastatic breast cancer patients, explaining survival disparity between younger and older patients by 44% and 40%, respectively. The study findings suggest that hypertension should be included in the comorbidity information for decision-making support programs.

Background: It is generally accepted that patients with breast cancer metastases have very poor survival. Metastatic breast cancer patients can be considered a heterogeneous population with a varied clinical course, which underscores the need for accurate prediction of survival based on prognostic factors. The purpose of the present study was to identify factors related to survival in breast cancer patients after diagnosis with metastatic disease., Populations and Methods: A total of 557 patients with breast cancer metastasis diagnosis seen at one large urban practice have been followed up between 1 January, 1999 and 30 June, 2010. Demographic, tumor characteristics, clinical factors as predictors of survival were analyzed using log-rank test and Cox regression model., Results: The median survival length was 39 months (range 1-138 months) with 154 (27.7%) alive and 403 (72.3%) dead at the end of follow-up period. This study demonstrated that a history of hypertension, ER/PR status, HER2 status, metastasis-free interval, metastatic location (including brain, bone and liver), and BMI at diagnosis with metastatic breast cancer were the most relevant prognostic factors for survival after metastatic disease diagnosis., Conclusion: Findings of this study may form a foundation for the growing corpus of knowledge explaining the outcome differences in treatment of patients with metastatic breast cancer, potentially helping to create tailored counseling and personalized treatment approaches for this vulnerable group.

It is generally accepted that delay in receiving treatment for breast cancer results in adverse outcomes. The purpose of this study was to evaluate the impact of delay in treatment after the diagnosis of metastatic disease on survival measured from metastatic breast cancer diagnosis and from first treatment while controlling for immortal time effect among patients with metastatic breast cancer. A total of 553 patients with breast cancer metastasis diagnosis from one large urban practice have been followed between January 1, 1999 and June 30, 2008. Prognostic factors and outcomes of these patients were analyzed using log-rank test and Cox regression model. Backward stepwise selection of covariates was conducted to assess the association of treatment delay with survival. The median survival was 40 months (range 1-114 months), with 265 (47.9%) women alive and 288 (52.1%) having died at the end of the follow-up period. Treatment delays of more than 12 weeks had impact on poor survival from first treatment than the delays of 4-12 weeks with borderline significance level (HR 1.76, 95% CI 0.99-3.13, P = 0.056) in multivariate analysis, adjusted by BMI, history of hypertension, ER/PR status, HER2 status, number of metastatic sites, and liver metastasis. Moreover, the interval of 12-24 weeks, compared to the interval of 4-12 weeks was associated with greater risk of death from first treatment (HR 2.39, 95% CI 1.19-4.77, P = 0.014). The treatment delay interval of >12 weeks was not related with survival since metastatic breast cancer diagnosis, compared to the 4-12 weeks of treatment delays. This study demonstrated that delays of over 12 weeks in receiving treatment for metastatic breast cancer were related to adverse survival outcomes measured from initiation of first treatment. The findings of this study support targeted efforts to ensure prompt treatment initiation in patients diagnosed with metastatic breast cancer.

Purpose/objectives: to test the effect of a supportive, one-time psychoeducational intervention on treatment adherence among African American women receiving first adjuvant therapy for breast cancer., Design: a pilot, randomized, controlled clinical trial, two-group design, with one-time intervention and four data collection points., Setting: two University of Pittsburgh Cancer Institute clinics., Sample: 24 African American women., Methods: the Attitudes, Communication, Treatment, and Support (ACTS) intervention is a 45-minute one-on-one session with an African American woman recommended to have chemotherapy for breast cancer. The interventionist is an African American breast cancer survivor. The intervention consists of a discussion about chemotherapy and the importance of communicating knowledge needs and distress, an explanation of the specific treatment plan according to pathology, and support through the survivor testimonial and video clips from the African American community., Main Research Variables: dose of chemotherapy received and dose of chemotherapy prescribed., Findings: Twenty patients completed chemotherapy, and four chose not to begin or discontinued recommended chemotherapy. The groups were equal in key sociodemographic variables. Compared to usual care, the ACTS intervention participants demonstrated trends toward initiation of chemotherapy (100% versus 82%), overall adherence to chemotherapy (92% versus 73%), and percentage of total dose of chemotherapy received or prescribed (94% versus 74%). Compared to usual care, the ACTS intervention participants demonstrated more rapid initiation of chemotherapy and better overall adherence to chemotherapy., Conclusions: the pilot ACTS intervention shows promise as a psychoeducational intervention to assist with chemotherapy decision making among African American women., Implications for Nursing: African American women are at high risk of not receiving the full dose of prescribed chemotherapy for breast cancer for multiple reasons. Nurses must be sensitive to the unique fears and concerns of this population regarding chemotherapy decisions. An intervention addressing these fears and concerns may help to increase adherence.

Preparatory information at the time of metastatic breast cancer diagnosis can be used to enhance patients' coping ability. Women with metastatic breast cancer evaluated a multimedia educational intervention designed to provide sensory and coping information regarding illness. Twenty women with metastatic breast cancer evaluated the materials. The intervention was evaluated very favorably and women identified the materials as needed information. However, they expressed dislike of content outlining possible concerns suggesting future iterations include only positive content. Findings confirm the acceptability and usability of these materials for further testing and ultimately for integration into cancer care practice.

Background: The role of the patient navigator in cancer care and specifically in breast cancer care has grown to incorporate many titles and functions., Objective: To better evaluate the outcomes of patient navigation in breast cancer care, a comprehensive review of empiric literature detailing the efficacy of breast cancer navigation on breast cancer outcomes (screening, diagnosis, treatment, and participation in clinical research) was performed., Methods: Published articles were reviewed if published in the scientific literature between January 1990 and April 2009. Searches were conducted using PubMed and Ovid databases. Search terms included MeSH (Medical Subject Headings) terms, "patient navigator," "navigation," "breast cancer," and "adherence.", Results: Data-based literature indicates that the role of patient navigation is diverse with multiple roles and targeted populations. Navigation across many aspects of the breast cancer disease trajectory improves adherence to breast cancer care. The empiric review found that navigation interventions have been more commonly applied in breast cancer screening and early diagnosis than for adherence to treatment., Conclusion: There is evidence supporting the role of patient navigation in breast cancer to improve many aspects of breast cancer care., Implications for Practice: Data describing the role of patient navigation in breast cancer will assist in better defining future direction for the breast navigation role. Ongoing research will better inform issues related to role definition, integration into clinical breast cancer care, impact on quality of life, cost-effectiveness, and sustainability.

Although much work has been done to quantify the direct and indirect costs of cancer treatment, little is known regarding how these costs impact the daily lives of persons undergoing active treatment of cancer. Content analysis performed on open-ended interviews with 22 women in 3 income categories undergoing chemotherapy for a diagnosis of breast or ovarian cancer revealed 7 themes. Most participants stated that they felt "lucky" or "thankful" that most of the treatment costs were being covered by insurance or personal income. Women also described receiving financial assistance from friends, family, and support organizations and stated that they often made trade-offs between paying for regular family expenses and paying for treatment-related expenses. Worry about future financial expenses and frustrations dealing with regulatory agencies were also pervasive in the interviews. Finally, participants described having to access retirement/savings accounts and voiced concerns regarding the impact of cancer treatment on their work income. Data from the study illuminate the personal impact of cancer costs and suggest that interventions to assist women with cancer in financial planning and negotiating with insurance companies may offset some of the financial burden of cancer treatment.

Fulvestrant, the first drug of the pure estrogen antagonists to be approved for clinical use, is a new therapeutic option for metastatic breast cancer. Fulvestrant offers a unique metastatic breast cancer treatment option because its mechanism of action is the destruction, rather than the blockade, of estrogen receptors. No known agonistic activity exists, limiting potential side effects and receptor exhaustion. The side effect profile of fulvestrant is related to its antiestrogen effect and includes gastrointestinal disturbance, urinary tract infection, and vaginitis. Suggestions for managing the side effects of fulvestrant are described, and a case study is provided as an illustrative aid in understanding the role of this new hormonal agent.

The Oncology Nursing Society's (ONS's) position on quality cancer care states that "quality cancer care incorporates the individual with cancer (and the family) as fully informed partners and decision makers" (ONS, 1997). Patients diagnosed with breast cancer are inundated with information, and oncology nurses help these patients receive quality cancer care by providing and explaining information related to their diagnosis and treatment. This information allows patients to participate in meaningful collaborative decision making. Prognostic tumor markers have provided information that can determine the natural history of breast cancer, identify women with high-risk or aggressive tumors, and help to establish a disease prognosis.