Pretreatment health measures and complications after surgical management of elderly women with breast cancer.

BACKGROUND: Elderly patients with breast cancer are less likely to be offered surgery, partly owing to co-morbidities and reduced functional ability. However, there is little consensus on how best to assess surgical risk in this patient group. METHODS: The ability of pretreatment health measures to predict complications was investigated in a prospective cohort study of a consecutive series of women aged at least 70 years undergoing surgery for operable (stage I-IIIa) breast cancer at 22 English breast units between 2010 and 2013. Data on treatment, surgical complications, health measures and tumour characteristics were collected by case-note review and/or patient interview. Outcome measures were all complications and serious complications within 30 days of surgery. RESULTS: The study included 664 women. One or more complications were experienced by 41·0 per cent of the patients, predominantly seroma or primary/minor infections. Complications were serious in 6·5 per cent. More extensive surgery predicted a higher number of complications, but not serious complications. Older age did not predict complications. Several health measures were associated with complications in univariable analysis, and were included in multivariable analyses, adjusting for type/extent of surgery and tumour characteristics. In the final models, pain predicted a higher count of complications (incidence rate ratio 1·01, 95 per cent c.i. 1·00 to 1·01; P = 0·004). Fatigue (odds ratio (OR) 1·02, 95 per cent c.i. 1·01 to 1·03; P = 0·004), low platelet count (OR 4·19, 1·03 to 17·12: P = 0·046) and pulse rate (OR 0·96, 0·93 to 0·99; P = 0·010) predicted serious complications. CONCLUSION: The risk of serious complications from breast surgery is low for older patients. Surgical decisions should be based on patient fitness rather than age. Health measures that predict surgical risk were identified in multivariable models, but the effects were weak, with 95 per cent c.i. close to unity.

Is lack of surgery for older breast cancer patients in the UK explained by patient choice or poor health? A prospective cohort study.

BACKGROUND: Older women have lower breast cancer surgery rates than younger women. UK policy states that differences in cancer treatment by age can only be justified by patient choice or poor health. METHODS: We investigate whether lack of surgery for older patients is explained by patient choice/poor health in a prospective cohort study of 800 women aged ≥70 years diagnosed with operable (stage 1-3a) breast cancer at 22 English breast cancer units in 2010-2013. DATA COLLECTION: interviews and case note review. OUTCOME MEASURE: surgery for operable (stage 1-3a) breast cancer <90 days of diagnosis. Logistic regression adjusts for age, health measures, tumour characteristics, socio-demographics and patient's/surgeon's perceived responsibility for treatment decisions. RESULTS: In the univariable analyses, increasing age predicts not undergoing surgery from the age of 75 years, compared with 70-74-year-olds. Adjusting for health measures and choice, only women aged ≥85 years have reduced odds of surgery (OR 0.18, 95% CI: 0.07-0.44). Each point increase in Activities of Daily Living score (worsening functional status) reduced the odds of surgery by over a fifth (OR 0.23, 95% CI: 0.15-0.35). Patient's role in the treatment decisions made no difference to whether they received surgery or not; those who were active/collaborative were as likely to get surgery as those who were passive, that is, left the decision up to the surgeon. CONCLUSION: Lower surgery rates, among older women with breast cancer, are unlikely to be due to patients actively opting out of having this treatment. However, poorer health explains the difference in surgery between 75-84-year-olds and younger women. Lack of surgery for women aged ≥85 years persists even when health and patient choice are adjusted for.

Are lower rates of surgery amongst older women with breast cancer in the UK explained by co-morbidity?

BACKGROUND: Around 60% of women ≥ 80 years old, in the UK do not have surgery for their breast cancer (vs<10% of younger age groups). The extent to which this difference can be accounted for by co-morbidity has not been established. METHODS: A Cancer Registry/Hospital Episode Statistics-linked data set identified women aged ≥ 65 years diagnosed with invasive breast cancer (between 1 April 1997 and 31 March 2005) in two regions of the UK (n=23038). Receipt of surgery by age was investigated using logistic regression, adjusting for co-morbidity and other patient, tumour and treatment factors. RESULTS: Overall, 72% of older women received surgery, varying from 86% of 65-69-year olds to 34% of women aged ≥ 85 years. The proportion receiving surgery fell with increasing co-morbidity (Charlson score 0=73%, score 1=66%, score 2+=49%). However, after adjustment for co-morbidity, older age still predicts lack of surgery. Compared with 65-69-year olds, the odds of surgery decreased from 0.74 (95% CI: 0.66-0.83) for 70-74-year olds to 0.13 (95% CI: 0.11-0.14) for women aged ≥ 85 years. CONCLUSION: Although co-morbidity is associated with a reduced likelihood of surgery, it does not explain the shortfall in surgery amongst older women in the UK. Routine data on co-morbidity enables fairer comparison of treatment across population groups but needs to be more complete.

Older women with operable breast cancer are less likely to have surgery.

BACKGROUND: Older women are less likely to receive standard management for breast cancer than younger postmenopausal women. Whether differences in general health explain variations in the rates of surgery is not known. METHODS: In this prospective cohort study, 76 women aged 65 years or more attending breast units in Greater Manchester completed a survey measuring functional status (Elderly Population Health Status Survey's Activity of Daily Living), generic health status (Short Form 12) and health-related quality of life (European Organization for Research on Treatment of Cancer Quality of Life Questionnaire C30). Case-note review assessed co-morbidity (Charlson Index) and management. Primary surgery for operable breast cancer was investigated using logistic regression. RESULTS: A Charlson Index of 1 or more did not predict the use of surgery (P = 0.363). However, for each point increase on the 1-4 scale indicating worsening functional status, the odds of having surgery decreased by 16 times (odds ratio 0.063). The odds of a woman of 80 years or more having surgery decreased by a factor of 44 (odds ratio 0.023) compared with women aged 65-79 years, accounting for co-morbidity, functional status, pretreatment stage, social deprivation and type of hospital. CONCLUSION: Older women were less likely to have surgery for operable breast cancer than younger women, even after accounting for differences in general health and co-morbidity.

Non-standard management of breast cancer increases with age in the UK: a population based cohort of women > or =65 years.

Evidence suggests that compared to younger women, older women are less likely to receive standard management for breast cancer. Whether this disparity persists once differences in tumour characteristics have been adjusted for has not been investigated in the UK. A retrospective cohort study involving case note review was undertaken, based on the North Western Cancer Registry database of women aged > or =65 years, resident in Greater Manchester with invasive breast cancer registered over a 1-year period (n=480). Adjusting for tumour characteristics associated with age by logistic regression analyses, older women were less likely to receive standard management than younger women for all indicators investigated. Compared to women aged 65-69 years, women aged > or =80 years with operable (stage 1-3a) breast cancer have increased odds of not receiving triple assessment (OR=5.5, 95% confidence interval (CI): 2.1-14.5), not receiving primary surgery (OR=43.0, 95% CI: 9.7-191.3), not undergoing axillary node surgery (OR=27.6, 95% CI: 5.6-135.9) and not undergoing tests for steroid receptors (OR=3.0, 95% CI: 1.7-5.5). Women aged 75-79 years have increased odds of not receiving radiotherapy following breast-conserving surgery compared to women aged 65-69 years (OR=11.0, 95% CI: 2.0-61.6). These results demonstrate that older women in the UK are less likely to receive standard management for breast cancer, compared to younger women and this disparity cannot be explained by differences in tumour characteristics.

Exposure to a community-level HIV prevention intervention: who gets the message.

As part of the evaluation of a community-level HIV prevention program for women, this study examined predictors of exposure to print media and community outreach and assessed the relationship between exposure to the intervention and condom use behavior. Data from interviews with 479 women randomly selected from the intervention community in 1995 and 1996 were examined. Analysis of demographic and risk characteristics were conducted to identify predictors of exposure to the project's HIV prevention messages. Additionally, logistic regression analyses were conducted to examine the effects of intervention exposure on condom use, controlling for factors related to exposure. The results revealed that the print media campaign reached the largest number of women. However, women at highest risk did not have high rates of exposure to print media, but had greater exposure to outreach. Exposure to print media had an effect on increased communication with a main partner about condom use, but was not significantly related to condom use last time had sex. There were no significant main effects for exposure to outreach on condom use behavior. An important finding of this analysis was that each intervention strategy was successful in reaching a different portion of the target population and that exposure had differential effects on the condom use behavior of particular segments of the target population.

PIP: The five-city Prevention of HIV in Women and Infants Demonstration Projects (WIDP) evaluated a community-level intervention aimed at promoting condom use by young urban women at risk for HIV infection through print media and community outreach. This article analyzes data from interviews with 479 women 15-34 years of age randomly selected from the Philadelphia, Pennsylvania (US), intervention community in 1995 and 1996. By the time of the 1995 and 1996 surveys, 51% of women in the intervention community had been exposed. Exposure to print media peaked in 1995 at 46% and levelled off at 44% in 1996, while exposure to community outreach decreased from 23% in 1995 to 14% in 1996. Logistic regression analysis indicated that exposure to print media was highest among women currently in drug or alcohol treatment and those who reported binge drinking in the preceding month; exposure to outreach activities was greatest among women who had a sexually transmitted disease (STD) history and exchanged sex for money. For women over 21 years old who had ever had an STD and were employed, exposure to print media was strongly predictive of condom use at last intercourse. Women who exchanged sex for money and were exposed to community outreach were unlikely to use condoms, but prone to discuss condoms with their main partner, which may be a pathway to future condom use. Program planners must identify the specific population groups they want to reach and plan intervention strategies accordingly. Several different strategies may be required to ensure messages reach those at greatest risk of HIV.

An analysis of vacancy rates, turnover, and wages among nursing occupations in New York state hospitals, nursing homes, and diagnostic and treatment facilities.

This study investigates the balance between the supply and demand for nurses and nurse assistive personnel in New York state. Data collected in 1992 and 1993 from three surveys of hospitals, nursing homes, and diagnostic and treatment facilities are combined, reported, and analyzed. Although there were regional differences, the mean non-New York City vacancy rate was 4% for registered nurses and 5% for licensed practical nurses. The 6-month mean turnover rate for registered nurses was 8%; however, licensed practical nurses, nurse technicians, and nurse attendants had mean turnover rates of 16% and over. Turnover rates were lowest in hospitals. Nurse anesthetists earned the highest salary, a mean of about $61,000 per year. Salaries for nurse anesthetists and other nurses varied substantially by region.

Effect of indomethacin and benoxaprofen on immune complex interaction with cultured glomerular cells.

Prostaglandins of the E series (PGE) increased immune complex (IC) interaction with cultured glomerular cells in a previous study. The present study examines the effect of indomethacin (IND) and benoxaprofen (BEN) on interaction of IC with cultured cells and their effect on PGE enhanced cell-IC interaction. IC were formed with antigen modified to produce a cationic (CAT) charge or left unmodified (UM). IND increased cell interaction with IC formed with CAT antigen (CAT IC). BEN had no effect on the interaction of IC formed with either antigen. The combined use of IND and PGE increased CAT IC interaction to the same degree as when each was used alone. BEN prevented the increased CAT IC interaction produced by IND or PGE when used in combination. Protamine sulfate prevented the enhanced CAT IC interaction produced by IND or PGE while sodium heparin had no effect. The results indicate IND and PGE increase cell IC interaction, the increase is not additive when they are combined, the effects of both are blocked by BEN, and protamine sulfate inhibits the effects of both compounds.

Effect of prostaglandins on immune complex interaction with glomerular cells in vitro.

Previous studies demonstrated that prostaglandins of the E1 (PGE1) series reduced immune complex (IC) accumulation and inflammation in murine glomeruli in IC glomerulonephritis (GN). This study examines the effect of PGE1 on IC interaction with cultured rabbit glomerular cells and heparan sulfate synthesis by the cells. IC were formed with antigen chemically modified to produce a cationic (CAT) charge or left unmodified (UM). CAT IC binding to cells was greater than UM IC in the absence of PGE1. CAT IC binding to cells was increased by PGE1 while UM IC interaction was not affected. Prolonged exposure of cells to PGE1 enhanced CAT IC binding. Heparan sulfate synthesis by the cells was not affected by the concentrations of PGE1 employed. The findings suggest the benefit provided by PGE1 in murine IC GN may not be due to a direct effect on glomerular cells which reduces glomerular IC accumulation.

Effect of antigen charge on immune complex interaction with glomerular cells in culture.

The effect of antigen charge on immune complex (IC) interaction with glomerular cells was evaluated using cultured rabbit glomerular cells. Rat albumin (Alb) was modified to produce a cationic charge; isoelectric point (pI) 7.4-8.0; anionic charge, pI 4.0-4.2; or left unmodified, pI 6.2-6.4. I125-IC (100 micrograms Alb in complex) was incubated with cells for 44 hr. Cationic Alb IC (CAT IC) interaction was 7 and 10 times greater than unmodified (UM) and anionic (AN) IC, 7596 +/- 613 vs 1016 +/- 176 and 746 +/- 106 pg I125-Alb/micrograms cell protein, mean +/- SE (P less than 0.01). A 10-fold excess of unlabeled CAT Alb decreased CAT IC interaction (6342 +/- 432 vs 1246 +/- 296 pg I125-Alb/micrograms cell protein, P less than 0.01) increased UM IC (981 +/- 186 vs 3994 +/- 394 pg I125-Alb/micrograms cell protein, P less than 0.01), and had no effect on AN IC. A 10-fold excess unlabeled CAT IC increased interaction of both CAT IC (7067 +/- 514 vs 37,416 +/- 3026 pg I125-Alb/micrograms cell protein) and UM IC (994 +/- 123 vs 12,922 +/- 566 pg I125-Alb/micrograms cell protein) but not of AN IC. Incubation of cells with CAT, UM, or AN Alb followed by specific antibody demonstrated increased antibody interaction with cells exposed to CAT Alb (15,212 +/- 676 vs 3866 +/- 406 and 1785 +/- 206 pg I125-IgG/microgram cell protein for UM and AN Alb, respectively).

Interaction of immune complexes with cultured rabbit glomerular cells.

Rabbit glomerular cell cultures were established from adolescent and mature rabbits in the absence of antibiotics. Fibroblast growth factor was added to half the cultures. Immune complexes (IC) formed with 125I bovine albumin and rabbit antibody were incubated with 10-day-old cultures for 44 h. Cell-IC interaction was observed in all samples but was increased in cultures without growth factor: the effect was not age dependent. Cells cultured without growth factor had increased surface accumulation of fibronectin. Addition of antifibronectin antibody to cell cultures did not inhibit cell complex interaction. The presence of unlabeled IC reduced labeled IC binding in cultures without growth factor. Binding of IC made with F(ab')2 fragments exceeded that of IC made with intact IgG. The results suggest IC bind with cultured glomerular cells and the degree of interaction is influenced by the presence of growth factors which alter cell membrane composition.

Nephrotoxicity of radiocontrast media in ischemic renal failure in rabbits.

Ischemic renal failure was produced in rabbits by occluding the renal arteries for 90 min. Group 1 (n = 8) received radiocontrast media at the time of occlusion, group 2 (n = 8) 24 h after occlusion, and group 3 (n = 8) 3 days after occlusion. Group 4 (n = 12) was subjected to ischemic injury alone, group 5 (n = 4) served as sham-operated controls and group 6 (n = 4) did not undergo surgery but received radiocontrast media. Serum creatinine concentration in group 1 increased to a greater degree (p less than 0.001) than all other groups and did not return to normal during the 8-day observation period. Creatinine concentration in groups 2, 3, 4, and 6 were comparable and significantly increased compared to sham-operated group (p less than 0.05). Urinary excretion of alanine aminopeptidase and N-acetyl-beta-glucosaminidase in group 1 was significantly greater than all other groups (p less than 0.05). Microscopic analysis indicated tubular necrosis was more prominent in group 1. Radiocontrast media is nephrotoxic and in the setting of ischemic injury may prevent recovery of renal function. Toxicity was dependent on the time of administration since functional impairment was not increased if dye was given 1 or 3 days after ischemic injury.