Anees B. Chagpar

PURPOSE: Successful completion of chemotherapy is critical to improve breast cancer outcomes. Relative dose intensity (RDI), defined as the ratio of chemotherapy delivered to prescribed, is a measure of chemotherapy completion and is associated with cancer mortality. The effect of exercise and eating a healthy diet on RDI is unknown. We conducted a randomized trial of an exercise and nutrition intervention on RDI and pathologic complete response (pCR) in women diagnosed with breast cancer initiating chemotherapy. METHODS: One hundred seventy-three women with stage I-III breast cancer were randomly assigned to usual care (UC; n = 86) or a home-based exercise and nutrition intervention with counseling sessions delivered by oncology-certified registered dietitians (n = 87). Chemotherapy dose adjustments and delays and pCR were abstracted from electronic medical records. T-tests and chi-square tests were used to examine the effect of the intervention versus UC on RDI and pCR. RESULTS: Participants randomly assigned to intervention had greater improvements in exercise and diet quality compared with UC ( P < .05). RDI was 92.9% ± 12.1% and 93.6% ± 11.1% for intervention and UC, respectively ( P = .69); the proportion of patients in the intervention versus UC who achieved ≥85% RDI was 81% and 85%, respectively ( P = .44). The proportion of patients who had at least one dose reduction and/or delay was 38% intervention and 36% UC ( P = .80). Among 72 women who received neoadjuvant chemotherapy, women randomly assigned to intervention were more likely to have a pCR than those randomly assigned to UC (53% v 28%; P = .037). CONCLUSION: Although a diet and exercise intervention did not affect RDI, the intervention was associated with a higher pCR in patients with hormone receptor–positive/human epidermal growth factor receptor 2–negative and triple-negative breast cancer undergoing neoadjuvant chemotherapy.

Purpose We developed a virtual interactive course for female faculty/practicing physicians and trainees to hone their skills in negotiation and sought to evaluate the impact of this on their knowledge, comfort, and skill in negotiation. Methods We surveyed participants as to their comfort and experience with negotiation before and after the course, as well as three months later. Results Of the 102 participants in the faculty course, 55 (53.9%) were academic ladder faculty, and 47 (46.1%) were in surgery or a surgical subspecialty. Participants were significantly more comfortable with negotiation initiation, strategy, and post-settlement settlement after the course (p < 0.001 for each). 91.1% found the course valuable, 92.9% felt their knowledge about negotiation increased, and 85.7% wished they would have taken this course earlier. 98.2% stated they were likely to use some of the things they learned in this course in future. Three months later, 40.7% of respondents stated they had used what they had learned: 57.7, 41.7, and 32.0% had negotiated for pay, promotion, or job-related perks, respectively. These negotiations went “better than expected” in 26.6, 30, and 37.5%, respectively. Prior to the course, only 3 (2.9%) felt that their last negotiation went “very well” or better; three months after the course, 28% felt their last negotiation after the course went “very well” or “extremely well” (p = 0.002). Conclusion Negotiation training can have a significant impact on female physicians’ comfort in initiating negotiation, negotiation strategy and post-settlement discussions. Such training significantly increases “better than expected” negotiations.

Approximately one-quarter of annual global cervical cancer deaths occur in India, possibly due to cultural norms promoting vaccine hesitancy. We sought to determine whether people of Indian ancestry (POIA) in the USA exhibit disproportionately lower human papilloma virus (HPV) vaccination rates than the rest of the US population. We utilised the 2018 National Health Interview Survey to compare HPV vaccine initiation and completion rates between POIA and the general US population and determined factors correlating with HPV vaccine uptake among POIA. Compared to other racial groups, POIA had a significantly lower rate of HPV vaccination (8.18% vs. 12.16%, 14.70%, 16.07% and 12.41%, in White, Black, Other Asian and those of other/mixed ancestry, respectively, P = 0.003), but no statistically significant difference in vaccine series completion among those who received at least one injection (3.17% vs. 4.27%, 3.51%, 4.31% and 5.04%, P = 0.465). Among POIA, younger individuals (vs. older), single individuals (vs. married), those with high English proficiency (vs. low English proficiency), those with health insurance and those born in the USA (vs. those born outside the USA) were more likely to obtain HPV vaccination (P = 0.018, P = 0.006, P = 0.029, P = 0.020 and P = 0.019, respectively). Public health measures promoting HPV vaccination among POIA immigrants may substantially improve vaccination rates among this population.

Preventing in-breast recurrence is a primary goal for breast-conserving surgery (BCS), as local recurrence can lead to additional surgery, further systemic therapy, and poorer cosmetic outcomes. Prevention of local recurrence may also lead to improved overall survival, as suggested by a meta-analysis¹ of randomized clinical trials that showed 1 excess death for every 4 ipsilateral breast tumor recurrences. The strongest current predictor of local recurrence is the presence of tumor at the lumpectomy margins.^2-6 The site of local recurrence is often close to the original tumor site with histological characteristics similar to the primary tumor, suggesting that local recurrences can arise from residual tumor left at the time of lumpectomy.^7-9 Rates of residual carcinoma in reexcisions or mastectomies following initially negative lumpectomy margins have been shown to exceed 40% in some cohorts.^10-13

Introduction Breast cancer survivors are often prescribed medications for at least 5 years to reduce recurrence risk, yet some forego this treatment due to cost. We sought to elucidate the prevalence of this and the factors contributing to it. Methods The National Health Interview Survey (NHIS) is a population-based survey, representative of the civilian non-institutionalized US population, administered annually by the CDC. People diagnosed with breast cancer within the past 5 years surveyed in the 2018 NHIS formed the cohort of interest. Results Of the 24,858 breast cancer survivors surveyed, representing 244,607,304 in the population, 6.32% stated that they needed a prescription medicine within the past 12 months, but didn’t get it filled because they couldn’t afford it. Of those who had gotten a prescription within the past 12 months, 5.71, 5.94 and 7.48% had either skipped doses, taken less medication than prescribed, or delayed filling a prescription, respectively, to save money. 11.99% of people had done at least one of these, thereby foregoing treatment. On bivariate analyses, factors associated with foregoing treatment included age, race, education, family income, and insurance status (p < 0.001 for all). On multivariable analysis, age, race, family income, and insurance status were all independent predictors of foregoing treatment (p < 0.001 for all); education status was not significant in the model (p = 0.211). Conclusion Roughly 12% of breast cancer survivors who are prescribed medications within the first 5 years of their diagnosis will forego treatment due to cost. Family income and insurance status are key modifiable drivers of this.

Breast cancer survivors may experience sleep disturbances that can affect their physical and mental well-being. We sought to determine the association, if any, between yoga and sleep among breast cancer survivors in a population-based cohort. The National Health Interview Survey is designed to be representative of the US civilian non-institutionalized population. We evaluated breast cancer survivors in the 2017 cohort to determine the association between yoga and self-reported quality of sleep. Of the 25,905 people surveyed, representing 238,738,039 in the population, 1.59% reported a previous history of breast cancer. Breast cancer survivors were less likely to report having practiced yoga in the preceding 12 months, compared to those without a history of breast cancer (9.98% vs 13.78%, P = .011). In addition, they were more likely to report having had trouble falling asleep (44.64% vs 36.32%, P = .002), staying asleep (53.72% vs 39.43%, P < .001), and using sleep medication on at least 1 day within the previous week (23.80% vs 13.49%, P < .001) than those without breast cancer. Among breast cancer survivors, there were no significant differences in difficulty falling asleep (39.16% vs 44.98%, P = .482), difficulty staying asleep (61.17% vs 52.70%, P = .305), and needing sleep medication (19.03% vs 24.53%, P = .395) between those who practiced yoga and those who did not. Controlling for sociodemographic factors, there remained no association between yoga and difficulty falling or staying asleep among breast cancer survivors. There is no direct association between yoga and sleep quality in breast cancer survivors.