Citations

Abstract Background: Breast cancers in recently postpartum women may have worse outcomes, but studies examining tumor molecular features by pregnancy recency have shown conflicting results. Methods: This analysis used Carolina Breast Cancer Study data to examine clinical and molecular tumor features among women less than 50 years of age who were recently (≤10 years prior) or remotely (>10 years prior) postpartum, or nulliparous. Prevalence odds ratios (POR) and 95% confidence intervals (CI) were estimated using multivariable models. Results: Recently postpartum women (N = 618) were more frequently lymph node–positive [POR (95% CI): 1.66 (1.26–2.19)], estrogen receptor (ER)-negative [1.37 (1.02–1.83)], and IHC-based triple negative [1.57 (1.00–2.47)] compared with nulliparous (N = 360) women. Some differences were identified between recent versus remotely postpartum; smaller tumor size [0.67 (0.52–0.86)], p53 wildtype [0.53 (0.36–0.77)], and non–basal-like phenotype [0.53 (0.33–0.84)] were more common among recently postpartum. Recently postpartum (vs. nulliparous) had significant enrichment for adaptive immunity, T cells, B cells, CD8 T cells, activated CD8 T cells/natural killer (NK) cells, and T follicular helper (Tfh) cells and higher overall immune cell scores. These differences were attenuated in remotely (compared with recently) postpartum women. Conclusions: These results suggest a dominant effect of parity (vs. nulliparity) and a lesser effect of pregnancy recency on tumor molecular features, although tumor immune microenvironments were altered in association with pregnancy recency. Impact: Our study is unique in examining tumor immune microenvironment and RNA-based markers according to time since last childbirth. Future studies should examine the interplay between tumor features, postdiagnostic treatment, and outcomes among recently postpartum women. See related commentary by McDonald et al., p. 518

Abstract The American Thoracic Society Sleep Core Curriculum updates clinicians on important sleep topics, presented during the annual meeting, and appearing in summary here. This year’s sleep core theme is sleep-disordered breathing and its management. Topics range from pathophysiological mechanisms for the association of obstructive sleep apnea (OSA) and metabolic syndrome, surgical modalities of OSA treatment, comorbid insomnia and OSA, central sleep apnea, and sleep practices during a pandemic. OSA has been associated with metabolic syndrome, independent of the role of obesity, and the pathophysiology suggests a role for sleep fragmentation and intermittent hypoxia in observed metabolic outcomes. In specific patient populations, surgical treatment modalities for OSA have demonstrated large reductions in objective disease severity compared with no treatment and may facilitate adherence to positive airway pressure treatment. Patient-centered approaches to comorbid insomnia and sleep apnea include evaluating for both OSA and insomnia simultaneously and using shared-decision making to determine the order and timing of positive airway pressure therapy and cognitive behavioral therapy for insomnia. The pathophysiology of central sleep apnea is complex and may be due to the loss of drive to breathe or instability in the regulatory pathways that control ventilation. Pandemic-era sleep practices have evolved rapidly to balance safety and sustainability of care for patients with sleep-disordered breathing.

PURPOSE This guideline updates recommendations of the ASCO guideline on chemotherapy and targeted therapy for patients with human epidermal growth factor receptor 2–negative metastatic breast cancer (MBC) that is either endocrine-pretreated or hormone receptor (HR)–negative. METHODS An Expert Panel conducted a targeted systematic literature review guided by a signals approach to identify new, potentially practice-changing data that might translate into revised guideline recommendations. RESULTS The Expert Panel reviewed abstracts from the literature review and retained 14 articles. RECOMMENDATIONS Patients with triple-negative, programmed cell death ligand-1–positive MBC may be offered the addition of immune checkpoint inhibitor to chemotherapy as first-line therapy. Patients with triple-negative, programmed cell death ligand-1–negative MBC should be offered single-agent chemotherapy rather than combination chemotherapy as first-line treatment, although combination regimens may be offered for life-threatening disease. Patients with triple-negative MBC who have received at least two prior therapies for MBC should be offered treatment with sacituzumab govitecan. Patients with triple-negative MBC with germline BRCA mutations previously treated with chemotherapy may be offered a poly (ADP-ribose) polymerase inhibitor rather than chemotherapy. Patients with HR-positive human epidermal growth factor receptor 2–negative MBC for whom chemotherapy is being considered should be offered single–agent chemotherapy rather than combination chemotherapy, although combination regimens may be offered for highly symptomatic or life-threatening disease. Patients with HR-positive MBC with disease progression on an endocrine agent may be offered treatment with either endocrine therapy with or without targeted therapy or single-agent chemotherapy. Patients with HR-positive MBC with germline BRCA mutations no longer benefiting from endocrine therapy may be offered a poly (ADP-ribose) polymerase inhibitor rather than chemotherapy. No recommendation regarding when a patient's care should be transitioned to hospice or best supportive care alone is possible. Additional information is available at www.asco.org/breast-cancer-guidelines .

Background: Randomized controlled trials and meta-analyses have demonstrated the benefits of cardiac rehabilitation (CR) in patients with acute myocardial infarction (AMI). Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of AMI. However, the benefit of CR has not been well studied in patients with SCAD. Purpose: Our objective was to compare the psychosocial and physiological characteristics and outcomes of CR in SCAD patients who participated in CR compared to those who did not. Methods: We performed a retrospective descriptive analysis of patients with angiographically confirmed SCAD enrolled in the Mayo Clinic SCAD Registry from January 2010 through December 2014 who had completed questionnaires (n=354). Demographics, clinical characteristics, Generalized Anxiety Disorder 7-Item Scale (GAD-7), Patient Health Questionnaire-9 (depression measure; PHQ-9), and details about participants’ CR participation and experience were collected via medical record review and questionnaires. Univariate analyses were performed to determine the differences between baseline characteristics and outcomes according to CR participation status. Results: Mean age of participants at time of SCAD was 46 ± 10 years; 95% were female. Seventy-six percent of participants participated in at least one CR session, and those users averaged 18 ± 12 sessions. A majority of CR participants reported physical and emotional benefits (82% and 75%, respectively). Of those who did not participate in CR, the primary reason was because their healthcare provider did not recommend CR (67%). Other reasons included inadequate transportation (12%), no insurance coverage (8%), cost (2%), no energy (2%), and being too ill (2%). On comparative analyses, CR participants had higher mean GAD-7 scores (4.9 vs. 3.9; p=0.03) and were more likely to increase their amount of exercise (p<0.01). Conclusions: Despite the well-known benefits of CR, in this international registry, only 76% of SCAD patients participated. Lack of recommendation for CR by a health care provider was the primary reason patients did not participate. The majority of patients reported benefits from CR. Higher GAD-7 scores were associated with CR participation, an interesting result requiring further evaluation in a larger or prospective cohort.

Background: The recent increase in the public’s interest in health matters has been accompanied by greater attention to the development of Web-based programs by many health-related professional and educational services. Wikiheart is a Web-based program that has been designed to narrow the gaps between care and secondary prevention by directly delivering knowledge to patients in their homes and communities. Purpose: To develop a Web-based program aimed at educating patients and targeted to the specific learning needs of patients with heart disease and associated risk factors. Methods and results: This pilot program is relatively easy to use, web-based educational model. It consists of a collaborative feature, the content of which can be easily edited by users, thus enabling powerful information sharing, interactive chat and article discussions. Participants are categorized into two principal groups: (1) invited or volunteer medical professionals; and (2) patients with their own experiences. This program can be used as an information resource for patients and method of real-time communication between healthcare professionals and patients. This virtual program allows patients to engage with each other, share experiences and become part of an online community. As an online interactive medical reference, this program is also intended to help patients with heart disease learn more about their specific conditions and be educated about preventive measures. For patient confidentiality, password protection would be employed and all clinical images and videos would be required to be de-identified. Material that violates patient privacy will be easily removed. Conclusions: Wikiheart aims to enable the sharing of knowledge relevant to secondary prevention and thus improve the quality of care for patients with heart disease or cardiovascular risk factors. If successfully implemented, the program is likely to enhance researchers’, healthcare providers’ and patients’ learning experiences, and communication within digital world, leading to the improvement of clinic outcome and adherence for patients. Further research is needed in order to identify the best approaches to apply these tools and ultimately boost research productivity, learning experience and patient education.

Introduction: Cardiac rehabilitation (CR) is an effective but highly underutilized therapy for heart disease. Efforts are underway to increase CR referral and enrollment, but little is known about the potential capacity for growth in CR utilization in the United States. To address this concern, we estimated the current national capacity of CR programs across the United States and assessed obstacles to potential growth. Methods: We surveyed all CR Program Directors listed in the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) database in November of 2012. Respondents reported current enrollment levels, current program capacity, program capacity given reasonable expansion, and obstacles to growth. Results: Of 812 Program Directors in the AACVPR database, 290 (36%) completed the full survey. Respondents represented somewhat larger programs compared to non-respondents (4.0 vs. 4.6 full time employees, p = 0.01), but were otherwise similar. Current enrollment levels demonstrated a median [IQ range] of 140 [75,232] patients per year and a current estimated capacity of 192 [100,300] patient per year. Respondents estimated that programs could expand services by 25% to 240 [141,380] patients annually, assuming a significant increase in patient demand and a feasible increase in resources. We estimate that if programs filled to their current capacity, national CR utilization rates would increase from 34.7% to 46.4% (95% CI, 43.9 to 48.9) of eligible US patients each year. Given feasible program expansion, utilization could increase to a maximum of 58.4% (95% CI, 55.2 to 61.6) of qualifying patients. Capacity projections based upon absolute patient numbers and national statistics revealed concordant results. The most commonly cited obstacles to increasing patient participation are shown in the figure. As seen, the majority (88%) are controllable system-related factors unrelated to patient behavior. Conclusions: Even with substantial expansion of all existing CR programs, there is currently insufficient capacity in current CR programs to meet national service needs. Solutions to this problem will likely include the creation of new CR programs, and new policies that improve reimbursement for CR and also embrace new models of CR delivery.