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Background: Breast cancer (BC) is the most common malignancy among women of reproductive age. Given limited data describing the conception and pregnancy experience of young BC survivors, we sought to explore these outcomes to inform counseling of women interested in future childbearing. Methods: Participants with stage 0-III BC in the Young Women’s Breast Cancer Study (NCT01468246), a multi-center, prospective cohort of women diagnosed at age ≤ 40 from 2006-2016 who reported ≥ 1 live birth from a pregnancy after diagnosis were sent a survey with investigator-developed questions focused on their first post-diagnosis live birth. Women who had been diagnosed with BC during pregnancy were excluded from this analysis. The survey assessed conception, use of assisted reproductive technology (ART), pre-implantation genetic testing (PGT), endocrine therapy (ET), and peripartum complications. Summary statistics are presented. Results: 92/119 eligible women completed the survey (response rate: 77%). Median age at diagnosis was 32 (range:17-40) years and at delivery was 37 (range: 29-47) years. Median time from diagnosis to delivery was 58 months (range: 11-154). Most women had stage 2 BC (43%, 40/92); 68% received chemotherapy (63/92); about half (51%, 47/92) were nulligravida at diagnosis. Overall, 61% of pregnancies were conceived naturally (56/92) and 39% with ART (36/92): 32% by in-vitro fertilization (IVF, 29/92), 7% with fertility medications only (6/92), and 1 with intrauterine insemination. 38% of IVF pregnancies were conceived using products from fertility preservation prior to BC treatment (11/29). Among women who used ART, 74% attempted to conceive naturally (25/36) for a median of 9 (range: 2-48) months prior to pursuing ART. The most common reasons for pursuing ART include infertility following BC treatment (33%, 12/36) and expediting conception to resume treatment (17%, 6/36). 11% of those with known inherited pathologic variant mutations underwent PGT (2/19). Reasons for not pursuing PGT included belief in more effective cancer risk reduction in the future (29%, 5/17), not being offered PGT (24%, 4/17), high cost (12%, 2/17), no interest in IVF (12%, 2/17), acceptable odds for inheriting the mutation (24%, 4/17), and belief in other risk reduction strategies (18%, 3/17); 1 woman reported ethical concerns. Of 57 women who took ET pre-pregnancy (63%), nearly all (96%, 55/57) discontinued ET > 3 months prior to attempting to conceive; 1 discontinued after awareness of pregnancy. Of those who had received prior ET, 60% resumed ET (34/57) a median of 3 (range: 1-50) months after pregnancy. Among 23 women who did not resume, 13 (23%) had completed the recommended duration; the remaining 10 reported one or more of the following reasons: felt better while off (28%, 6/23), desire for another child (22%, 5/23), and desire to breastfeed (17%, 4/23). Median time to delivery was 39 (range: 28-42) weeks with 12% delivering preterm < 37 weeks (11/92). 47% had a Caesarean section (43/92), with prolonged labor the most common indication (33%, 14/43). Hypertensive disorders of pregnancy (HDP, 20%, 18/92), gestational diabetes (7%, 6/92), small for gestational age (7%, 6/92), and postpartum hemorrhage (5%, 5/92) were the most common obstetrical complications. 9% of women had newborns requiring NICU admission (8/92) and 9% had low birth weight (8/92). Conclusion: Among young BC survivors with a live birth following diagnosis, most conceived naturally, with the majority who used ART first attempting natural conception. There was limited use of PGT among mutation carriers with ¼ not having been offered testing. Patient reported peripartum complications appear consistent with population norms, though the relatively higher rate of HDP bears further research. Among those yet to complete their ET, a notable proportion did not resume following delivery. This novel data may help to inform the care of young breast cancer survivors pursuing pregnancy. Citation Format: Kimia Sorouri, Tal Sella, Shoshana Rosenberg, Margaret Loucks, Kathryn Ruddy, Shari I. Gelber, Rulla M. Tamimi, Jeffrey M. Peppercorn, Lidia Schapira, Virginia F. Borges, Steven E. Come, Ellen Warner, Ann Partridge. Conception and Pregnancy Among Young Breast Cancer Survivors [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-08-05.

Background: Breast cancer (BC) is the most common malignancy in women of reproductive age, and the incidence of the disease is rising in this population. Many of these women are interested in childbearing after their BC treatment and a substantial minority will go on to have a live birth. Some will also want to breastfeed. However, there is only limited information available regarding the experience of young BC survivors breastfeeding following treatment. Methods: Participants in the Young Women’s Breast Cancer Study (YWS), a multi-center, prospective cohort study of women diagnosed with BC at age ≤ 40 years between 2006-2016, who reported at least one live birth following their diagnosis with stage 0-III BC were sent an additional survey including investigator-developed questions focused on breastfeeding after breast cancer treatment. Women who had been diagnosed with BC during pregnancy were excluded from this analysis. The survey assessed whether they breastfed, reasons for attempting and stopping breastfeeding, breastfeeding with the treated breast and untreated breast, and supports. Summary statistics, including medians and proportions, are presented. Results: Of 118 eligible women sent a survey, 92 completed the survey (78% response rate). Median age at diagnosis of BC was 32 (range: 17-40) years and at delivery was 37 (range: 29-47) years. 54% of women had attempted to breastfeed (50/92). Among those who had not, 93% noted a history of bilateral mastectomies (39/42). Additional reasons for not attempting to breastfeed included no interest regardless of BC history (5%, 2/42) and 1 woman underwent a unilateral mastectomy and did not think her supply would be sufficient. Among the women who did attempt breastfeeding, 68% had undergone lumpectomy and radiotherapy (34/50) with 85% of those women reporting that the treated breast did not produce milk (29/34). The 5 women who produced milk from the treated breast noted that the supply was substantially less than the untreated breast. To assist with breastfeeding, 76% used a pump only on the untreated breast (38/50) and 14% on both breasts (7/50). Women breastfed for a median of 5.5 (range:< 1-60) months and 64% were “somewhat”/“very much” satisfied with their ability to breastfeed (32/50). The most common reasons cited for stopping breastfeeding included having completed the planned duration (36%, 18/50), to start/resume endocrine therapy (22%, 11/50), and to resume breast imaging (8%, 4/50). Among patients who had not undergone a double mastectomy, 47% recalled receiving specific information about breastfeeding after a history of breast cancer (25/53), most commonly from the oncology team (56%, 14/25), lactation consultant (48%, 12/25), or online resources (44%, 11/25). Conclusion: In the largest series to date detailing the breastfeeding experiences of young BC survivors, approximately half of young BC survivors with a successful pregnancy attempted to breastfeed. Among those who had undergone prior lumpectomy and radiotherapy, women reported no milk production or only limited supply from the treated breast. Despite these limitations, most women who attempted to breastfeed were satisfied with their ability to do so. Specific resources to support the experience of breastfeeding in BC survivors are needed. Citation Format: Tal Sella, Kimia Sorouri, Shoshana Rosenberg, Margaret Loucks, Kathryn Ruddy, Shari I. Gelber, Rulla M. Tamimi, Jeffrey M. Peppercorn, Lidia Schapira, Virginia F. Borges, Steven E. Come, Ellen Warner, Ann Partridge. Breastfeeding in Survivors of Early Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-08-06.

The NCCN Guidelines for Survivorship are intended to help healthcare professionals who work with survivors to ensure that the survivors’ complex and varied needs are addressed. The NCCN Guidelines provide screening, evaluation, and treatment recommendations for the consequences of adult-onset cancer and its treatment; recommendations to help promote physical activity, weight management, and immunizations in survivors; and a framework for care coordination. This article summarizes updates to the NCCN Guidelines pertaining to preventive health for cancer survivors, including recommendations about alcohol consumption and vaccinations.

We examined emotional distress in cancer survivors diagnosed as adolescents or young adults (AYAs) versus cancer survivors diagnosed as middle/older adults and versus the general population without a history of cancer.Using the 2014-2017 National Health Interview Surveys, 2500 AYA survivors (initial cancer diagnosed between aged 15-39 years) were matched with 2500 middle/older adult survivors (initial cancer diagnosed at aged ≥40 years) as well as with 1609 from the general population without a history of cancer. Multinomial logistic regression models estimated the risk of emotional distress (measured using the validated Kessler distress (K6) scale) in the study population (AYA vs. middle/older adult cancer survivors and vs. general population without cancer), adjusting for known covariates.Emotional distress was more prevalent among AYAs (average age 52.8 ± 19.1 years) than middle/older adult (average age 67.4 ± 14.0 years) cancer survivors (moderate: 25.5% vs. 19.4%; and severe: 6.4% vs. 4.4% [P.0001]); however, there was no difference in emotional distress between AYA cancer survivors (moderate: 26.8% and severe: 7.5%) versus general population without cancer (moderate: 23.7% and severe: 6.2%). In the multivariable multinomial analyses, AYA cancer survivors had higher risk of reporting emotional distress (adjusted relative risk = 1.45; 95% confidence interval = 1.13-1.86) than middle/older adult cancer survivors.Psychosocial support may be especially needed for cancer survivors diagnosed as adolescents or young adults to mitigate adverse psychosocial outcomes.

Weight gain after a breast cancer diagnosis is common and is associated with inferior outcomes. Young survivors may be especially susceptible to weight changes given the impact of treatment on menopausal status.The authors identified women who were diagnosed with stage 0 to III breast cancer at age 40 years or younger between 2006 and 2016 from a multicenter prospective cohort. Self-reported weight was collected at diagnosis and at 1 year and 3 years postdiagnosis. Tumor and treatment data were obtained from medical records and patient surveys. Multinomial logistic regression was used to identify the factors associated with weight gain (≥5%) or weight loss (≥5%) versus stable weight at 1 year and 3 years postdiagnosis.The cohort included 956 women with a median age of 37 years at diagnosis. Mean weight significantly increased over time from 66.54 ± 14.85 kg at baseline to 67.33 ± 15.53 and 67.77 ± 14.65 kg at 1 year and 3 years, respectively (p ≤ .001 for both comparisons). The proportion of women experiencing ≥5% weight gain increased from 24.8% at 1 year to 33.9% at 3 years. At 1 year, less self-perceived financial comfort, Black race, and stage III disease were significantly associated with weight gain; at 3 years, only less self-perceived financial comfort remained significant. Baseline overweight or obesity was significantly associated with weight loss at both time points. Chemotherapy, endocrine therapy, and treatment-related menopause were not associated with weight change.One third of young breast cancer survivors experienced clinically significant weight gain 3 years after diagnosis; however, treatment-related associations were not observed. Age-appropriate lifestyle interventions, including the reduction of financial barriers, are needed to prevent weight gain in this high-risk population.

Purpose:Young age at breast cancer diagnosis correlates with unfavorable clinicopathologic features and worse outcomes compared with older women. Understanding biological differences between breast tumors in young versus older women may lead to better therapeutic approaches for younger patients.Experimental Design:We identified 100 patients ≤35 years old at nonmetastatic breast cancer diagnosis who participated in the prospective Young Women's Breast Cancer Study cohort. Tumors were assigned a surrogate intrinsic subtype based on receptor status and grade. Whole-exome sequencing of tumor and germline samples was performed. Genomic alterations were compared with older women (≥45 years old) in The Cancer Genome Atlas, according to intrinsic subtype.Results:Ninety-three tumors from 92 patients were successfully sequenced. Median age was 32.5 years; 52.7% of tumors were hormone receptor-positive/HER2-negative, 28.0% HER2-positive, and 16.1% triple-negative. Comparison of young to older women (median age 61 years) with luminal A tumors (N = 28 young women) revealed three significant differences: PIK3CA alterations were more common in older patients, whereas GATA3 and ARID1A alterations were more common in young patients. No significant genomic differences were found comparing age groups in other intrinsic subtypes. Twenty-two patients (23.9%) in the Young Women's Study cohort carried a pathogenic germline variant, most commonly (13 patients, 14.1%) in BRCA1/2.Conclusions:Somatic alterations in three genes (PIK3CA, GATA3, and ARID1A) occur at different frequencies in young versus older women with luminal A breast cancer. Additional investigation of these genes and associated pathways could delineate biological susceptibilities and improve treatment options for young patients with breast cancer.See related commentary by Yehia and Eng, p. 2209

This study aimed to examine the association between mindsets-established, but mutable beliefs that a person holds-and health-related quality of life in survivors of breast and gynecologic cancer.A cross-sectional survey study was conducted with breast and gynecologic cancer survivors. Measures included the Illness Mindset Questionnaire and Functional Assessment of Cancer Therapy-General (FACT-G).Two hundred seventy-three survivors (74% breast/26% gynecologic) who were on average 3.9 years post-diagnosis (SD = 4.2), Mage 55 (SD = 12) completed the survey (response rate 80%). Of the survivors, 20.1% (N = 55) endorsed ("agree" or "strongly agree") that Cancer is a Catastrophe, 52.4% (N = 143) endorsed that Cancer is Manageable, and 65.9% (N = 180) endorsed that Cancer can be an Opportunity (not mutually exclusive). Those who endorsed a maladaptive mindset (Cancer is a Catastrophe) reported lower health-related quality of life (HRQOL) compared with those who did not hold this belief (p.001). Alternatively, those who endorsed more adaptive mindsets (Cancer is Manageable or Cancer can be an Opportunity) reported better HRQOL compared with those who disagreed (all p-values.05). All three mindsets were independent correlates of HRQOL, explaining 6-15% unique variance in HRQOL, even after accounting for demographic and medical factors.Mindsets about illness are significantly associated with HRQOL in cancer survivors. Our data come from a one-time evaluation of cancer survivors at a single clinic and provide a foundation for future longitudinal studies and RCTs on the relationship between mindsets and psychosocial outcomes in cancer survivors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Among 2,186 U.S. adults with invasive cancer and laboratory-confirmed SARS-CoV-2 infection, we examined the association of COVID-19 treatments with 30-day all-cause mortality and factors associated with treatment. Logistic regression with multiple adjustments (e.g., comorbidities, cancer status, baseline COVID-19 severity) was performed. Hydroxychloroquine with any other drug was associated with increased mortality versus treatment with any COVID-19 treatment other than hydroxychloroquine or untreated controls; this association was not present with hydroxychloroquine alone. Remdesivir had numerically reduced mortality versus untreated controls that did not reach statistical significance. Baseline COVID-19 severity was strongly associated with receipt of any treatment. Black patients were approximately half as likely to receive remdesivir as white patients. Although observational studies can be limited by potential unmeasured confounding, our findings add to the emerging understanding of patterns of care for patients with cancer and COVID-19 and support evaluation of emerging treatments through inclusive prospective controlled trials.Significance:Evaluating the potential role of COVID-19 treatments in patients with cancer in a large observational study, there was no statistically significant 30-day all-cause mortality benefit with hydroxychloroquine or high-dose corticosteroids alone or in combination; remdesivir showed potential benefit. Treatment receipt reflects clinical decision-making and suggests disparities in medication access.This article is highlighted in the In This Issue feature, p. 1426

Supplemental tables, figures, and list of participants

Supplementary Table from Somatic and Germline Genomic Alterations in Very Young Women with Breast Cancer

Purpose:Young age at breast cancer diagnosis correlates with unfavorable clinicopathologic features and worse outcomes compared with older women. Understanding biological differences between breast tumors in young versus older women may lead to better therapeutic approaches for younger patients.Experimental Design:We identified 100 patients ≤35 years old at nonmetastatic breast cancer diagnosis who participated in the prospective Young Women's Breast Cancer Study cohort. Tumors were assigned a surrogate intrinsic subtype based on receptor status and grade. Whole-exome sequencing of tumor and germline samples was performed. Genomic alterations were compared with older women (≥45 years old) in The Cancer Genome Atlas, according to intrinsic subtype.Results:Ninety-three tumors from 92 patients were successfully sequenced. Median age was 32.5 years; 52.7% of tumors were hormone receptor-positive/HER2-negative, 28.0% HER2-positive, and 16.1% triple-negative. Comparison of young to older women (median age 61 years) with luminal A tumors (N = 28 young women) revealed three significant differences: PIK3CA alterations were more common in older patients, whereas GATA3 and ARID1A alterations were more common in young patients. No significant genomic differences were found comparing age groups in other intrinsic subtypes. Twenty-two patients (23.9%) in the Young Women's Study cohort carried a pathogenic germline variant, most commonly (13 patients, 14.1%) in BRCA1/2.Conclusions:Somatic alterations in three genes (PIK3CA, GATA3, and ARID1A) occur at different frequencies in young versus older women with luminal A breast cancer. Additional investigation of these genes and associated pathways could delineate biological susceptibilities and improve treatment options for young patients with breast cancer.See related commentary by Yehia and Eng, p. 2209

Supplementary Figure from Somatic and Germline Genomic Alterations in Very Young Women with Breast Cancer

Chronic myeloid leukemia (CML) is effectively treated with long-term tyrosine kinase inhibitor (TKI) therapy, yet little is known about risks of prolonged TKI exposure in young patients, and long-term effect monitoring is not standardized. We surveyed North American pediatric oncologists (n = 119) to evaluate perceived risk of and surveillance practices for potential toxicities associated with prolonged TKI exposure in children and adolescents/young adults (AYAs) with CML. Survey domains included general and specific risk perceptions and surveillance practices for asymptomatic patients on chronic TKI therapy. We analyzed data descriptively and explored relationships between risk perceptions and surveillance. Risk perceptions varied among oncologists but were similar across six categories (thyroid, cardiac, vascular, metabolic, fertility, psychologic), with less than one-third rating each risk as moderate or high in pediatric and AYA patients. More oncologists perceived moderate or high risk of growth abnormalities in children (62% pediatric, 14% AYA) and financial toxicity in all patients (60% pediatric, 64% AYA). A greater proportion of oncologists with moderate or high perceived risk of thyroid abnormalities reported testing thyroid function compared to those with lower perceived risk; patterns for metabolic risk/lipid tests and cardiac risk/tests were similar. In summary, we found that pediatric oncologists had variable risk perceptions and surveillance practices for potential toxicities associated with prolonged TKI exposure. Standardizing surveillance would help quantify risks and refine recommendations. Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2021.2017085 .

PURPOSE: Race and ethnicity have been shown to affect quality of cancer care, and patients with low English proficiency (LEP) have increased risk for serious adverse events. We sought to assess the impact of primary language on health care engagement as indicated by clinical trial screening and engagement, use of genetic counseling, and communication via an electronic patient portal. METHODS: Clinical and demographic data on patients with breast cancer diagnosed and treated from 2013 to 2018 within the Stanford University Health Care system were compiled via linkage of electronic health records, an internal clinical trial database, and the California Cancer Registry. Logistic and linear regression models were used to evaluate for association of clinical trial engagement and patient portal message rates with primary language group. RESULTS: Patients with LEP had significantly lower rates of clinical trial engagement compared with their English-speaking counterparts (adjusted odds ratio [OR], 0.29; 95% CI, 0.16 to 0.51). Use of genetic counseling was similar between language groups. Rates of patient portal messaging did not differ between English-speaking and LEP groups on multivariable analysis; however, patients with LEP were less likely to have a portal account (adjusted OR, 0.89; 95% CI, 0.83 to 0.96). Among LEP subgroups, Spanish speakers were significantly less likely to engage with the patient portal compared with English speakers (estimated difference in monthly rate: OR, 0.43; 95% CI, 0.24 to 0.77). CONCLUSION: We found that patients with LEP had lower rates of clinical trial engagement and odds of electronic patient portal enrollment. Interventions designed to overcome language and cultural barriers are essential to optimize the experience of patients with LEP.

The NCCN Guidelines for Survivorship are intended to help healthcare professionals who work with survivors to ensure that the survivors' complex and varied needs are addressed. The NCCN Guidelines provide screening, evaluation, and treatment recommendations for the consequences of adult-onset cancer and its treatment; recommendations to help promote physical activity, weight management, and immunizations in survivors; and a framework for care coordination. This article summarizes updates to the NCCN Guidelines pertaining to preventive health for cancer survivors, including recommendations about alcohol consumption and vaccinations.

Clonal hematopoiesis of indeterminate potential (CHIP), an emerging biomarker for personalized risk-directed interventions, is increased in cancer survivors. However, little is known about patient preferences for CHIP testing. We surveyed participants in a prospective cohort study of young women with breast cancer (BC). The emailed survey included an introduction to CHIP and a vignette eliciting participants’ preferences for CHIP testing, considering sequentially: population-based 10-year risk of BC recurrence, hematologic malignancy, and heart disease; increased CHIP-associated risks; current CHIP management; dedicated CHIP clinic; and hypothetical CHIP treatment. Preference changes were evaluated using the McNemar test. The survey response rate was 82.2% (528/642). Median age at time of survey was 46 years and median time from diagnosis was 108 months. Only 5.9% had prior knowledge of CHIP. After vignette presentation, most survivors (87.1%) recommended CHIP testing for the vignette patient. Presented next with CHIP-independent, population-based risks, 11.1% shifted their preference from testing to not testing. After receiving information about CHIP-associated risks, an additional 10.1% shifted their preference to testing. Preference for testing increased if vignette patient was offered a CHIP clinic or hypothetical CHIP treatment, with 7.2% and 14.1% switching preferences toward testing, respectively. Finally, 75.8% of participants desired CHIP testing for themselves. Among participants, 28.2% reported that learning about CHIP caused at least moderate anxiety. Most young survivors favored CHIP testing, with preferences influenced by risk presentation and potential management strategies. Our findings highlight the importance of risk communication and psychosocial support when considering biomarkers for future risk in cancer survivors. This trial has been registered at www.clinicaltrials.gov as #NCT01468246.

BACKGROUND Financial toxicity includes distress and burden from cancer-related costs. Women are more likely to experience worse cancer-related financial outcomes than men. This study evaluated breast and gynecologic cancer patients' subjective experiences of financial toxicity and associations with distress and quality of life (QOL). METHODS A cross-sectional survey study included measures of financial toxicity (Comprehensive Score for Financial Toxicity [COST] Version 2), distress (Patient Health Questionnaire), and QOL (Functional Assessment of Cancer Therapy). Chi-square, t-tests, and ANOVAs examined bivariate relationships. Two regression models tested associations between financial toxicity and distress and QOL, controlling for covariates. Financial toxicity subgroups were compared based on a validated grading system. RESULTS Participants (N = 273; 74% breast cancer) averaged 54.65 years (SD = 12.08), were 3.42 years (SD = 4.20) post-diagnosis, and 33% reported cancer-related change in employment status. Financial toxicity was "mild" overall (COST M = 26.11, SD = 11.14); 32% worried about cancer-related financial problems (quite a bit/very much; item-level analysis). Worse financial toxicity related to younger age (p

Background Although Medicaid expansion is associated with decreased uninsured rates and earlier cancer diagnoses, no study has demonstrated an association between Medicaid expansion and cancer mortality. Our primary objective was to quantify the relationship between early Medicaid expansion and changes in cancer mortality rates. Methods We obtained county-level data from the National Center for Health Statistics for adults aged 20-64 years who died from cancer from 2007 to 2009 (preexpansion) and 2012 to 2016 (postexpansion). We compared changes in cancer mortality rates in early Medicaid expansion states (CA, CT, DC, MN, NJ, and WA) vs nonexpansion states through a difference-in-differences analysis using hierarchical Bayesian regression. An exploratory analysis of cancer mortality changes associated with the larger-scale 2014 Medicaid expansions was also performed. Results In adjusted difference-in-differences analyses, we observed a statistically significant decrease of 3.07 (95% credible interval = 2.19 to 3.95) cancer deaths per 100 000 in early expansion vs nonexpansion states, which translates to an estimated decrease of 5276 cancer deaths in the early expansion states during the study period. Expansion-associated decreases in cancer mortality were observed for pancreatic cancer. Exploratory analyses of the 2014 Medicaid expansions showed a decrease in pancreatic cancer mortality (−0.18 deaths per 100 000, 95% confidence interval = −0.32 to −0.05) in states that expanded Medicaid by 2014 compared with nonexpansion states. Conclusions Early Medicaid expansion was associated with reduced cancer mortality rates, especially for pancreatic cancer, a cancer with short median survival where changes in prognosis would be most visible with limited follow-up.

The NCCN Guidelines for Survivorship are intended to help healthcare professionals working with cancer survivors to ensure that each survivor’s complex and varied needs are addressed. The Guidelines provide screening, evaluation, and treatment recommendations for consequences of adult-onset cancer and its treatment; recommendations to help promote healthful lifestyle behaviors, weight management, and immunizations in survivors; and a framework for care coordination. This article summarizes the recommendations regarding employment and return to work for cancer survivors that were added in the 2021 version of the NCCN Guidelines.

Dr. Schapira, a medical oncologist, offers a candid account of the intersection of personal and professional experiences of loss. In this chapter the author explores the basic question of what a patient wants and needs from their doctor when confronted with a life-threatening illness. She takes the reader on a quick tour of medical training and reflects on how she handled personal and professional losses at various moments during her career. The interwoven threads of the narrator’s growth and professional development are presented against the backdrop of the prevailing culture of medicine. The author reflects that stoicism as a personal attribute was highly valued during her training and describes how it affected her emotional response to suffering and loss.

OBJECTIVE: Scan-related anxiety ("scanxiety") refers to the fear, stress, and anxiety in anticipation of tests and scans in follow-up cancer care. This study assessed the feasibility of Ecological Momentary Assessment (EMA) for real-world, real-time capture of scanxiety using patients' personal smartphone. METHODS: Adolescent and Young Adult survivors of childhood cancer were prompted to complete EMA surveys on a smartphone app three times per day for 11 days (33 surveys total) around their routine surveillance scans. Participants provided structured feedback on the EMA protocol. RESULTS: Thirty out of 46 contacted survivors (65%) enrolled, exceeding the preregistered feasibility cutoff of 55%. The survey completion rate (83%) greatly exceeded the preregistered feasibility cutoff of 65%. Participants generally found the smartphone app easy and enjoyable to use and reported low levels of distress from answering surveys. Participants reported significantly more daily fear of cancer recurrence (FCR) and negative affect in the days before compared to the days after surveillance scans, aligning with the expected trajectory of scanxiety. Participants who reported greater FCR and scanxiety using comprehensive measures at baseline also reported significantly more daily FCR around their surveillance scans, indicating validity of EMA items. Bodily threat monitoring was prospectively and concurrently associated with daily FCR, thus warranting further investigation as a risk factor for scanxiety. CONCLUSIONS: Findings indicate the feasibility, acceptability, and validity of EMA as a research tool to capture the dynamics and potential risk factors for scanxiety. ispartof: PSYCHO-ONCOLOGY vol:31 issue:8 pages:1322-1330 ispartof: location:England status: published

As survival with early-stage, hormone receptor (HR)-positive breast has improved, it is essential to understand the long-term risks of incident comorbidities with different adjuvant endocrine therapy (ET) options.Women treated with tamoxifen and/or an aromatase inhibitor (AI) for stages 1-3, HR-positive/HER2-negative breast cancer from 2000 to 2016 in either of two healthcare systems in the San Francisco Bay Area were included. We considered the following comorbidities: cerebrovascular accidents, congestive heart failure, dementia, depression/anxiety, diabetes mellitus, hyperlipidemia, myocardial infarction, non-alcoholic steatohepatitis, osteoporosis/fracture, peripheral vascular disease, and venous thromboembolism. Cause-specific Cox proportional hazards models were fit to time-to-new-diagnosis for each comorbidity, accounting for death as a competing risk. Hazard ratios (HR) and 95% confidence intervals (CI) for tamoxifen versus AI were reported.Among 2,902 analyzed patients, the median age at diagnosis was 58.3 years; 67.6% were non-Hispanic white, 22.3% Asian, 7.5% Hispanic, and 1.7% non-Hispanic Black. Half (54.7%) used AIs only, 27.6% used tamoxifen only and 17.7% used both tamoxifen and AIs sequentially. Tamoxifen was associated with a lower risk of osteoporosis than AI (multivariable HR 0.45, 95% CI 0.32-0.62). No other incident comorbidity risk varied between users of tamoxifen versus AIs.In a diverse, multi-institutional, contemporary breast cancer cohort, the only incident comorbidity that differed between ET options was osteoporosis, a known side effect of AIs. These results may inform clinical decision-making about ET, and reassure patients who have bothersome symptoms on AIs that they are unlikely to develop worse comorbidities if they switch to tamoxifen.

The impact of patient demographics and local therapy choice on arm morbidity in young breast cancer patients is understudied despite its importance given the long survivorship period. This study assessed patient-reported arm morbidity in the Young Women’s Breast Cancer Study (YWS), a prospective cohort study. From 2006 to 2016, 1302 women with breast cancer diagnosed at the age of 40 years or younger enrolled in the YWS. The participants regularly complete surveys. The response rates are higher than 86%. Using the Breast Cancer Prevention Trial Checklist, this study examined the prevalence of patient-reported postoperative arm swelling and decreased range of motion (ROM) 1 year after diagnosis, stratified by local therapy strategy, in patients who had surgery for stages 1 to 3 disease. Logistic regression analysis was used to identify risk factors for arm morbidity. Among 888 eligible participants (median age, 37 years), 14% reported arm swelling and 34% reported decreased ROM at 1 year. Arm swelling was reported by 23.6% of the patients who had axillary lymph node dissection (ALND) and 24.6% of the patients who received ALND and post-mastectomy radiation therapy (PMRT). In the multivariable analysis, the patients who reported being financially uncomfortable or who had ALND were at higher risk of arm swelling at 1 year. Being overweight, receiving ALND after sentinel lymph node biopsy, and receiving PMRT were associated with decreased ROM at 1 year. High rates of self-reported arm morbidity in young breast cancer survivors were reported, particularly in patients receiving ALND and PMRT. Attention to the risks and benefits of differing local therapy strategies for ALND and PMRT patients is warranted.

ImportanceSexual orientation and gender identity data are not collected by most hospitals or cancer registries; thus, little is known about the quality of breast cancer treatment for patients from sex and gender minority (SGM) groups.ObjectiveTo evaluate the quality of breast cancer treatment and recurrence outcomes for patients from SGM groups compared with cisgender heterosexual patients.Design, Setting, and ParticipantsExposure-matched retrospective case-control study of 92 patients from SGM groups treated at an academic medical center from January 1, 2008, to January 1, 2022, matched to cisgender heterosexual patients with breast cancer by year of diagnosis, age, tumor stage, estrogen receptor status, and ERBB2 (HER2) status.Main Outcomes and MeasuresPatient demographic and clinical characteristics, as well as treatment quality, as measured by missed guideline-based breast cancer screening, appropriate referral for genetic counseling and testing, mastectomy vs lumpectomy, receipt of chest reconstruction, adjuvant radiation therapy after lumpectomy, neoadjuvant chemotherapy for stage III disease, antiestrogen therapy for at least 5 years for estrogen receptor–positive disease, ERBB2-directed therapy for ERBB2-positive disease, patient refusal of an oncologist-recommended treatment, time from symptom onset to tissue diagnosis, time from diagnosis to first treatment, and time from breast cancer diagnosis to first recurrence. Results were adjusted for multiple hypothesis testing. Compared with cisgender heterosexual patients, those from SGM groups were hypothesized to have disparities in 1 or more of these quality metrics.ResultsNinety-two patients from SGM groups were matched to 92 cisgender heterosexual patients (n = 184). The median age at diagnosis for all patients was 49 years (IQR, 43-56 years); 74 were lesbian (80%), 12 were bisexual (13%), and 6 were transgender (6%). Compared with cisgender heterosexual patients, those from SGM groups experienced a delay in time from symptom onset to diagnosis (median time to diagnosis, 34 vs 64 days; multivariable adjusted hazard ratio, 0.65; 95% CI, 0.42-0.99; P = .04), were more likely to decline an oncologist-recommended treatment modality (35 [38%] vs 18 [20%]; multivariable adjusted odds ratio, 2.27; 95% CI, 1.09-4.74; P = .03), and were more likely to experience a breast cancer recurrence (multivariable adjusted hazard ratio, 3.07; 95% CI, 1.56-6.03; P = .001).Conclusions and RelevanceThis study found that among patients with breast cancer, those from SGM groups experienced delayed diagnosis, with faster recurrence at a 3-fold higher rate compared with cisgender heterosexual patients. These results suggest disparities in the care of patients from SGM groups and warrant further study to inform interventions.

Background: The prognosis of early-stage, hormone receptor-positive breast cancer is excellent with 5-year overall survival rates greater than 90%. In the context of excellent survival, it is important to quantify the long-term comorbidities associated with endocrine therapy. Methods: Eligible patients were women diagnosed with stages 1-3, hormone receptor-positive and Her2-negative breast cancer from January 1999 to December 2016 and treated at one or more of two healthcare systems in the San Francisco Bay Area (Stanford University or the community-based Palo Alto Medical Foundation, N=3,044). Duration of therapy with aromatase inhibitors and/or tamoxifen was ascertained. Long-term comorbidities analyzed were congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), cerebrovascular accidents (CVA), dementia, depression/anxiety, diabetes mellitus (DM), peptic ulcer disease (PUD), hyperlipidemia (HLD), myocardial infarction (MI), non-alcoholic steatohepatitis (NASH), osteonecrosis of the jaw, osteoporosis, peripheral vascular disease (PVD), and venous thrombotic events (VTE). Pre-existing comorbidities were defined as those diagnosed any time up to 1 year after breast cancer diagnosis. Incident comorbidities that developed on or after endocrine therapy were defined as those diagnosed any time after 1 year following breast cancer diagnosis. Results: The median patient age was 58.1 years. Patients were 67.8% non-Hispanic white, 22.1% Asian, 7.6% Hispanic, 1.7% non-Hispanic Black, and 0.8% other. Most (69.6%) had private insurance. For endocrine therapy, almost half (48.3%) used aromatase inhibitors only (median duration 35.1 months), 20.6% used tamoxifen only (median duration 29.4 months), and the remainder used both aromatase inhibitors (AI) and tamoxifen (median duration of any endocrine therapy: 47.8 months). Comorbidity results are in the Table. Notable unadjusted hazard ratios for the association of incident comorbidities with tamoxifen (versus AI) use include: HLD 0.45 [95% confidence interval, CI 0.25-0.8]; MI 0.66 [CI 0.04-9.88]; CHF 1.23 [CI 0.29-5.1]; CVA 0.46 [CI 0.14-1.54]; depression/anxiety 0.89 [CI 0.45-1.76]; osteoporosis 0.37 [CI 0.23-0.59]; and DM 1.34 [CI 0.44-4.07]. Results of multivariable analysis will be presented, adjusting for comorbidities present before cancer diagnosis, age, race and insurance status. Conclusions: In a diverse, real-world cohort of breast cancer patients treated in two healthcare systems, incident HLD and osteoporosis were significantly less common with tamoxifen versus AI use, while other comorbidities did not vary with type of endocrine therapy. These results may inform clinical decision-making about endocrine therapy for early-stage, hormone receptor-positive breast cancer. Table. Comorbidities relative to timing of breast cancer diagnosisComorbidityPrevalence before cancer diagnosisIncidence after cancer diagnosisCongestive heart failure65 (2.1)70 (2.3)Chronic obstructive pulmonary disease348 (11.4)127 (4.2)Cerebrovascular accident83 (2.7)77 (2.5)Dementia15 (0.5)25 (0.8)Depression/Anxiety599 (19.7)245 (8)Diabetes239 (7.9)101 (3.3)Peptic ulcer disease36 (1.2)19 (0.6)Hyperlipidemia870 (28.6)363 (11.9)Myocardial infarction12 (0.4)18 (0.6)Non-alcoholic steatohepatitis40 (1.3)62 (2)Osteonecrosis of jawNA (NA)2 (0.1)Osteoporosis/Fracture791 (26)608 (20)Peripheral vascular disease22 (0.7)31 (1)Venous thrombotic event65 (2.1)74 (2.4) Citation Format: Tanya Gupta, Natasha Purington, Mina Liu, Summer Han, George Sledge, Lidia Schapira, Allison Kurian. Incident comorbidities in a diverse cohort of women treated for early-stage, hormone receptor-positive breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-24.

Background: Young age at diagnosis is an independent risk factor for recurrence and death from breast cancer (BC), with the greatest impact of young age demonstrated in hormone receptor positive (HR+) disease. Younger women are less likely to be adherent to endocrine therapy (ET), which may contribute to disparate outcomes. Methods: As part of a prospective cohort that enrolled women with BC diagnosed at age ≤40 between 2006-2016, we identified women with HR+, Stage I-III BC. Serial surveys with items assessing socio-demographic and treatment information including medication use are administered 1-2 times per year. Medical record review was used to ascertain stage and HR status and to confirm recurrent disease (locoregional, distant, or new primary breast cancer). Women who initiated ET but discontinued it Citation Format: Shoshana M Rosenberg, Yue Zheng, Philip Poorvu, Kathryn Ruddy, Rachel Gaither, Rulla Tamimi, Lidia Schapira, Jeffrey Peppercorn, Steven Come, Virginia Borges, Ann Partridge. Endocrine therapy non-persistence and recurrence in young women with early stage breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD2-08.

OBJECTIVE We aimed to investigate eligibility for breast-conserving surgery (BCS) pre- and post-neoadjuvant systemic therapy (NST), and trends in the surgical treatment of young breast cancer patients. BACKGROUND Young women with breast cancer are more likely to present with larger tumors and aggressive phenotypes, and may benefit from NST. Little is known about how response to NAC influences surgical decisions in young women. METHODS The Young Women's Breast Cancer Study (YWS), a multicenter prospective cohort of women diagnosed with breast cancer at age ≤40, enrolled 1302 patients from 2006 to 2016. Disease characteristics, surgical recommendations, and reasons for choosing mastectomy among BCS-eligible patients were obtained through the medical record. Trends in use of NST, rate of clinical and pathologic complete response (cCR and pCR), and surgery were also assessed. RESULTS Of 1117 women with unilateral stage I-III breast cancer, 315 (28%) received NST. Pre-NST, 26% were BCS eligible, 17% were borderline eligible, and 55% were ineligible. After NST, BCS eligibility increased from 26% to 42% (p < 0.0001). Among BCS-eligible patients after NST (n = 133), 41% chose mastectomy with reasons being patient preference (53%), BRCA or TP53 mutation (35%) and family history (5%). From 2006 to 2016, the rates of NST (p = 0.0012), cCR (p < 0.0001) and bilateral mastectomy (p < 0.0001) increased, but the rate of BCS did not increase (p = 0.34). CONCLUSION While the proportion of young women eligible for BCS increased after NST, many patients choose mastectomy, suggesting that surgical decisions are often driven by factors beyond extent of disease and treatment response.

Breast cancer rates are increasing among individuals with a South Asian heritage, i.e., from India, Pakistan, Nepal, Bhutan, Sri Lanka, Maldives, and Bangladesh. Informal caregiving is vastly understudied among this population, despite being influenced by cultural mores such as collectivism, cancer-related stigma, and gender roles. The South Asian Family Approaches to Disease (SAFAD) study took a mixed-methods, observational approach to describe the care networks of informal caregivers via an adapted version of Atlas CareMaps. Thirteen caregivers (43.9+/-14.8y, 30.8% female) were interviewed and included 6 husbands, 1 wife, 2 daughters, 1 son, 1 brother, and 1 friend of the breast cancer survivors. Semi-structured interviews were designed to develop an adapted Atlas CareMap, a visual representation of the caregivers’ care network at the time of the interview. Atlas CareMaps depicted the number of people supported by caregivers, and who provide support; their relationship; the frequency, intensity, and type of care; and modes of communication used. Immediate or extended family members were the most common people included. Results indicated that: 1) caregivers reported 8.8□3.5 individuals in their care network, provided care to 3.5+/-1.8 individuals and received care from 7.3+/-3.5 individuals; 2) caregivers primarily received emotional support from others; 3) their survivors’ care teams were often included as a source of support and medical knowledge for survivors, but only three noted that the care teams supported them directly. Describing these networks is a key step to developing culturally-concordant programs that can support South Asian caregivers, even as they care for breast cancer survivors.

PURPOSE: Patient-reported outcome measurements (PROMs) are increasingly used for cancer patients receiving active treatment, but little is known about the implementation and usefulness of PROMs in cancer survivorship care. This systematic review evaluates how cancer survivors and healthcare providers (HCPs) perceive PROM implementation in survivorship care, and how PROM implementation impacts cancer survivors' health outcomes.METHODS: We systematically searched PubMed/MEDLINE, Embase, CINAHL, Web of Science, and Cochrane Database of Systematic Reviews from database inception to February 2022 to identify randomized and nonrandomized studies of PROM implementation in cancer survivors.RESULTS: Based on prespecified eligibility criteria, we included 29 studies that reported on 26 unique PROMs. The studies were heterogeneous in study design, PROM instrument, patient demographics, and outcomes. Several studies found that cancer survivors and HCPs had favorable impressions of the utility of PROMs, and a few studies demonstrated that PROM implementation led to improvements in patient quality of life (QoL), with small to moderate effect sizes.CONCLUSIONS: We found implementation of PROMs in cancer survivorship care improved health outcomes for select patient populations. Future research is needed to assess the real-world utility of PROM integration into clinical workflows and the impact of PROMs on measurable health outcomes.IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivors accepted PROMs. When successfully implemented, PROMs can improve health outcomes after completion of active treatment. We identify multiple avenues to strengthen PROM implementation to support cancer survivors.

Synchronous bilateral breast cancer is uncommon, and its pattern and incidence among younger women is unknown. Here we report the incidence, phenotypes, and long-term oncologic outcomes of bilateral breast cancer in women enrolled in the Young Women’s Breast Cancer Study (YWS). The YWS is a multi-center, prospective cohort study of women with breast cancer diagnosed at age ≤ 40 years. Those with synchronous bilateral breast cancer formed our study cohort. Tumor phenotypes were categorized as luminal A (hormone receptor (HR)+/HER2−/grade 1/2), luminal B (HR+ /HER2+ or HER2− and grade 3), HER2-enriched (HR−/HER2+), or basal-like (HR−/HER2−). Descriptive statistics were used to evaluate tumor phenotypes of bilateral cancers for concordance. Among 1302 patients enrolled in the YWS, 21 (1.6%) patients had synchronous bilateral disease. The median age of diagnosis was 38 years (range 18–40 years). Seventeen (81.0%) underwent genetic testing with 6 found to have pathogenic germline mutations in BRCA1, BRCA2, or TP53. The majority of patients (76.2%) underwent bilateral mastectomy. On pathology, 2 patients had bilateral in-situ disease, 6 had unilateral invasive and contralateral in-situ disease, and 13 had bilateral invasive disease. Of those with bilateral invasive disease, 10 (76.9%) had bilateral luminal tumors and, when fully characterized, 6 were of the same luminal subtype. Only 1 patient had bilateral basal-like breast cancer. At median follow-up of 8.2 years, 14 patients are alive with no recurrent disease. Bilateral breast cancer is uncommon among young women diagnosed with breast cancer at age ≤ 40. In our cohort, the majority of invasive tumors were of the luminal phenotype, though some differed by grade or HER2 status. These findings support the need for thorough pathologic workup of bilateral disease when it is found in young women with breast cancer to determine risk and tailor treatment.

PURPOSE: We sought to characterize the use of Social Media (SM) among breast and gynecologic cancer survivors, as well as associations between patterns of SM use and psychosocial outcomes. METHODS: Two hundred seventy-three breast and gynecologic cancer survivors recruited at the Stanford Women’s Cancer Center completed the study. Participants completed questionnaires to measure quality of life (FACT-G), functional social support (Duke-UNC FSSQ), distress (PHQ-4), decision regret (DRS), and SM use. RESULTS: In total, 75.8% of the sample reported using SM. There was no difference in quality of life (QOL), functional social support (FSS), distress, or decision regret between SM users and non-users. SM users indicated using SM for social support (34.3%) and loneliness (24.6%) more than for information-seeking (15.9%), coping (18.8%), or self-disclosure (14%). SM use for coping was associated with lower QOL (p < .001), lower FSS (p < .001), and higher decision regret (p = .029). Use for social support was associated with lower FSS (p = .029). Use for information seeking was associated with lower QOL (p = .012). Use of SM when lonely was associated with lower QOL (p

The 21-gene Breast Recurrence Score test predicts benefit from adjuvant chemotherapy in estrogen receptor-positive, HER2-negative (ER+/HER2−) breast cancer (BC). We examined whether the 21-gene assay predicts response to neoadjuvant chemotherapy (NCT). We identified patients with stage I–III ER+/HER2− BC treated with NCT from the Young Women’s Breast Cancer Study, a prospective cohort of women diagnosed with BC at age ≤40 years. The 21-gene assay was performed on tumor specimens removed prior to NCT either as part of clinical care or retrospectively for research. Pathological complete response (pCR) was defined as ypT0/is ypN0. The relationship between Recurrence Score result and pCR was evaluated using logistic regression modeling. 76 women received NCT for ER+/HER2− BC and were eligible for this analysis. Median age at diagnosis was 37 years (range 24–40). Scores ranged between 5 and 77 with 50% >25 and 5% 25 was 21% (8/38) vs. 5% in patients with scores