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Breast cancer study finds survival increases when time between diagnosis and concluding treatments is limited

Research found a decrease in patient survival rates when treatment options – surgery, chemotherapy and radiation – are completed more than 38 weeks from the time of diagnosis.

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Research from Cleveland Clinic in the U.S. and Cleveland Clinic Abu Dhabi in the U.A.E. has found a decrease in patient survival rates when treatment options – surgery, chemotherapy and radiation – are completed more than 38 weeks from the time of diagnosis. 

The observational study, which included more than 28,000 breast cancer patients registered in the American National Cancer Database, is the largest of its kind to evaluate breast cancer survival and time to completion for all therapies. It found the treatment duration of less than 38 weeks was associated with a higher five-year survival –  89.9 percent compared to the 83.3 percent in the greater than 38 weeks treatment duration. This builds on previous research that noted poorer outcomes when there was a delay in time to treatment initiation, although time to treatment completion was not assessed in these studies.

The study’s authors point out it is important to identify the reasons for delays in treatment and where in the process they occur, and to design programs to measure and pursue optimization of time to treatment to decrease anxiety for patients and improve their chances of survival.

“The biggest difference in our study from others that have looked at time to treat was that we looked at the time from diagnosis to the completion of the multimodality treatment, not only at one individual part, to identify the 38-week window to improve survival rate for patients with breast cancer,” said Debra Pratt M.D., director of the Breast Center at Cleveland Clinic Fairview Hospital, and the lead author of the study.

“In breast and other cancers, patients don’t only get surgery, but may also require chemotherapy and radiation therapy,” Dr. Pratt said. “This becomes a complicated system to navigate and there are multiple reasons why delays arise in treatment being completed. This analysis helps us identify opportunities for improving care within the delivery systems.”

Other studies evaluating the time to treatment for breast cancer by individual treatment modality have concluded that the optimal time from diagnosis to first surgical treatment was less than 90 days from diagnosis; less than 120 days from diagnosis to adjuvant chemotherapy; and when chemo is administered, the radiation should start less than 365 days from date of diagnosis.  The last two are consistent with Commission on Cancer’s Cancer Central Clinical Participant Registry (C3PR) quality indicators.

“What we found is that the optimal time for treatment completion is 99 days shorter than C3PR quality indicators,” Dr. Pratt said. “We have so much more data now to reassess these quality indicators and determine what those metrics should be.”

The study did not allow researchers to gauge the causes for delays beyond 38 weeks, but Dr. Pratt said from experience, she can divide them into medical, personal and systemic factors.

“If patients have medical issues, they may have to go through other assessments, such as cardiac clearance, which are done as a precaution,” she explained. “These are the hardest to control. Other delays are personal, for example, where the patient does not want to be seen at the first appointment available because of financial reasons or chooses to prioritize a family event over surgery.”

She says medical facilities can, however, control some of the systemic factors to speed up the process. These include adequate staffing and improved systems to increase ease of access, such as making special reservations to schedule urgent assessments like metastatic surveys and breast MRI, as well as a reduction in insurance delays in approving tests required to complete pre-treatment assessments.  

Stephen Grobmyer M.D., chair of the Oncology Institute at Cleveland Clinic Abu Dhabi, an integral part of Mubadala Health, and a co-author on the study, says that care must be consolidated to help patients receive treatment on time.

“What we see happen traditionally in the U.S. and even in the U.A.E. is that the patient has to visit multiple specialists – first a surgeon, then a medical oncologist for chemotherapy followed by a radiation oncologist – all of which are scheduled weeks apart and in different places,” he said. “There is this phenomenon of ‘serial care,’ rather than coordinated and planned care.”

Dr. Grobmyer adds that Cleveland Clinic has tried to avoid this issue with their coordinated multidisciplinary cancer programing. For example, in preparation of the opening of its cancer tower, Cleveland Clinic Abu Dhabi opened its dedicated Breast Health Clinic last year. The facility offers targeted diagnostic testing, genetic counseling, innovative therapies and treatments, as well as reconstruction specialists and disease-specific experts to address all breast health issues, in one location and in the shortest time possible.

“We are trying to anticipate the needs of the patients and plan for all their treatment from the beginning so that it is seamless, efficient and reduces their anxiety,” he said. “We have also started measuring time to treatment as a quality measure.”

Dr. Pratt said further studies to determine which type of treatment has the most delays will aid their efforts in optimizing care.

“One of the data points missing in our study was the last day of chemotherapy for these patients, so we could not determine where the majority of delays occurred,” she said. “One of my hopes is to look at our patients’ data to know where the challenges lie and how we can fix them.”.

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Closeness with dads may play special role in how kids weather adolescence

Additionally, father-youth intimacy was associated with higher self-esteem from early through mid-adolescence for both boys and girls. Mother-youth intimacy was associated with higher self-esteem across most of adolescence for girls, and during early and late adolescence for boys.

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Photo by Daiga Ellaby from Unsplash.com

Adolescence can be an emotionally turbulent time, but new research at Penn State found that close, supportive relationships with parents — especially dads — at key points during adolescence can help stave off certain adjustment problems.

The researchers examined how emotionally close and supportive relationships with parents — referred to in the research as “parental intimacy” — in families with mothers and fathers affected their children’s self-esteem, weight concerns, and depressive symptoms at different points across adolescence.

They found that closeness with fathers had broad, positive effects across adolescence for both daughters and sons. But while close relationships with mothers also had benefits, they were more limited by their children’s age, and weren’t protective against all the adjustment issues measured in the study for both girls and boys.

Anna Hochgraf, doctoral candidate in human development and family studies, said the findings suggest that while close relationships with moms are certainly important, fathers may play an important, distinct role in fostering healthy adjustment in adolescents.

“Adolescents tend to feel emotionally closer to their mothers than to their fathers and mothers tend to have supportive conversations with their children more frequently than fathers do,” Hochgraf said. “This may make emotional closeness with fathers more salient and, in turn, protective against these common adjustment problems experienced during adolescence.”

According to the researchers, adolescence is a period of development that includes many biological, cognitive, emotional and social changes that can lead to certain adjustment issues, with weight concerns, low self-esteem, and symptoms of depression being some of the most common, especially for girls.

But, previous research has also shown that close relationships with parents have the potential to help protect against the development of some of these problems. Hochgraf said she and the other researchers wanted to explore the topic further, breaking the results down by participants’ age, gender, and relationship with each parent.

“We wanted to investigate when during the course of adolescence intimacy with mothers and fathers becomes a protective factor for body image concerns, depressive symptoms, and low self-esteem, and whether intimacy is more strongly associated with positive adjustment at some ages than at others,” Hochgraf said. “We also wanted to see if patterns differed for girls and boys.”

The researchers recruited 388 adolescents from 202 two-parent families with both fathers and mothers for the study. Data was gathered at three checkpoints when the participants were between the ages of 12 and 20, and included information on participants’ weight concerns, symptoms of depression, and self-esteem, as well as measurements of intimacy between parents and their kids.

Intimacy was measured by the participants answering questions such as how much they go to their mother or father for advice or support and how much they share inner feelings or secrets with them, to which the adolescents responded with a score ranging from one to five.

Hochgraf said it was important to gather data at several points in time because problems with adjustment, as well as relationships with parents, can change and develop swiftly throughout adolescence.

“Rather than assume that the associations between parent-adolescent intimacy and adolescent adjustment problems are static across adolescence, we studied changes in these links as a function of age,” Hochgraf said. “This approach enabled us to determine at which ages parent-youth intimacy may be most protective against body image concerns, depressive symptoms and self-esteem.”

After analyzing the data, the researchers found several different effects of parental intimacy on their sons and daughters at different times throughout adolescence. These effects were also different between mothers and fathers.

“For example, while father-adolescent intimacy was associated with fewer depressive symptoms across adolescence, mother-adolescent intimacy was associated with fewer depressive symptoms during mid-adolescence, around age 15,” Hochgraf said.

They also found that father-youth intimacy was associated with fewer weight concerns for both girls and boys throughout most of adolescence, with the greatest effects in mid-adolescence for girls and late adolescence for boys. In contrast, mother-youth intimacy was only associated with fewer weight concerns for boys, and only in early adolescence.

Additionally, father-youth intimacy was associated with higher self-esteem from early through mid-adolescence for both boys and girls. Mother-youth intimacy was associated with higher self-esteem across most of adolescence for girls, and during early and late adolescence for boys.

Hochgraf said the study — recently published in the Journal of Family Psychology — underscores the importance of parents being close, open and supportive with their children.

“Parents can promote their adolescents’ healthy development by fostering emotionally warm, accepting, and supportive relationships with them,” Hochgraf said. “There are a number of evidence-based, family-centered prevention programs that can help parents improve or maintain positive relationship quality and communication with their children throughout adolescence and that have been shown to prevent multiple adolescent adjustment problems.”

Gregory Fosco, associate professor of human development and family studies; Stephanie Lanza, professor of biobehavioral health and human development and family studies; and Susan McHale, distinguished professor of human development and family studies, also participated in this work.

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Heart patients need more help to lose weight

Positive associations were found between lifestyle improvements and weight loss in obese or overweight patients. Compared to those who gained 5% or more of their body weight, those who lost at least 5% of their body weight had more frequently reduced fat and sugar intake, increased consumption of fruit, vegetables, and fish, done regular physical activity, attended a cardiac rehabilitation and prevention program and followed dietary advice from a health professional.

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Weight loss is given insufficient priority in the management of heart patients despite the benefits, according to a study published today in European Heart Journal – Quality of Care and Clinical Outcomes, a journal of the European Society of Cardiology (ESC).

The study of more than 10,000 patients found that less than 20% had a healthy body mass index (BMI) at the time of hospitalisation for a heart event. Some 16 months later, 86% of patients who were obese during hospitalisation were still obese while 14% of overweight patients had become obese. Young women were particularly affected, with nearly half of those under 55 years being obese. Yet more than a third of obese patients said they had not received advice on physical activity or nutrition and nearly one in five said they had not been informed that they were overweight.

“It seems that obesity is not considered by physicians as a serious medical problem, which requires attention, recommendations and obvious advice on personal weight targets,” stated the authors.

Weight loss is strongly recommended in overweight and obese patients with coronary heart disease to improve blood pressure and lipids levels and reduce the risk of type 2 diabetes, thereby lowering the likelihood of another heart event. This study investigated the management of patients who were overweight or obese at the time of hospitalization for a first or recurrent heart event (e.g. heart attack or elective procedure to unblock clogged arteries). The researchers examined lifestyle advice received, actions taken, and the relationship between weight changes and health status.

The researchers pooled data from the EUROASPIRE IV (2012 to 2013) and EUROASPIRE V (2016 to 2017) studies, which were conducted in 29 countries. The analysis included 10,507 patients with coronary heart disease. Patients were visited 6 to 24 months after hospitalisation for their heart event (the average gap was 16 months). The visit consisted of an interview, questionnaires and a clinical examination including weight, height and blood tests.

One in four participants (24.8%) were women and the average age at the time of hospitalisation was 62.5 years. At the time of hospitalisation, 34.9% of patients were obese and another 46.0% were overweight.3 By the time of the study visit (on average 16 months later), an even greater proportion of patients were obese (36.9%). Rates of obesity rates were higher in younger patients with a prevalence of 40.1% in those aged under 55 years (men 38.3%, women 48.4%).

Regarding the link between weight changes and health status, overweight or obese patients who lost 5% or more of their body weight had significantly lower levels of hypertension, dyslipidaemia, and previously unrecognised diabetes compared to those who gained 5% or more of their body weight – despite being equally treated with blood pressure and lipid lowering medications. They also reported higher levels of physical and emotional quality of life.

As for the advice patients received, half of all patients were advised to follow a cardiac prevention and rehabilitation programme, with no difference in advice according to their weight status. For obese patients, less than two-thirds were advised to follow dietary recommendations (63.7%) or to do regular physical activity (64.2%).

Positive associations were found between lifestyle improvements and weight loss in obese or overweight patients. Compared to those who gained 5% or more of their body weight, those who lost at least 5% of their body weight had more frequently reduced fat and sugar intake, increased consumption of fruit, vegetables, and fish, done regular physical activity, attended a cardiac rehabilitation and prevention program and followed dietary advice from a health professional.

The authors noted that weight gain was significantly associated with smoking cessation. In patients who were overweight or obese at hospitalisation, those who quit smoking gained 1.8 kg on average in contrast to the 0.4 kg average weight gain observed in persistent smokers.

Study author Professor Catriona Jennings of the National University of Ireland – Galway said cardiac rehabilitation programs, which typically emphasize exercise, should give equal priority to dietary management. She said: “Weight loss is best achieved by adopting healthy eating patterns and increasing levels of physical activity and exercise. Whilst actively trying to lose weight at the same time as trying to quit smoking is not advised, adopting a cardio-protective diet and becoming more physically active has the potential to mitigate the effects of smoking cessation on weight gain in patients trying to quit. Their aim is to maintain their weight and to avoid gaining even more weight following their quit.”

“Uptake and access to cardiac rehabilitation programs is poor with less than half of patients across Europe reporting that they completed a program,” added Professor Jennings. “Such programs would provide a good opportunity to support patients in addressing overweight and obesity, especially for female patients who were found to have the biggest problem with overweight and obesity in the study. Uptake and access could be improved with the use of digital technology, especially for women, who possibly are less likely to attend a program because they have many other competing priorities, such as caring for others. There are good reasons for people to address their weight after a cardiac event. – but it’s not easy and they do need help.”

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Coffee doesn’t raise your risk for heart rhythm problems

Each additional daily cup of coffee consumed among several hundred thousand individuals was associated with a 3 percent lower risk of any arrhythmia occurring, including atrial fibrillation, premature ventricular contractions, or other common heart conditions.

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Photo by Clay Banks from Unsplash.com

In the largest study of its kind, an investigation by UC San Francisco has found no evidence that moderate coffee consumption can cause cardiac arrhythmia.

In fact, each additional daily cup of coffee consumed among several hundred thousand individuals was associated with a 3 percent lower risk of any arrhythmia occurring, including atrial fibrillation, premature ventricular contractions, or other common heart conditions, the researchers report. The study included a four-year follow up.

The paper is published in JAMA Internal Medicine.

“Coffee is the primary source of caffeine for most people, and it has a reputation for causing or exacerbating arrhythmias,” said senior and corresponding author Gregory Marcus, MD, professor of medicine in the Division of Cardiology at UCSF.

“But we found no evidence that caffeine consumption leads to a greater risk of arrhythmias,” said Marcus, who specializes in the treatment of arrhythmias. “Our population-based study provides reassurance that common prohibitions against caffeine to reduce arrhythmia risk are likely unwarranted.”

While some professional societies suggest avoiding caffeinated products to lower the risk for arrhythmia, this connection has not been consistently demonstrated – indeed, coffee consumption may have anti-inflammatory benefits and is associated with reduced risks of some illnesses including cancer, diabetes, and Parkinson disease.

In the new study, UCSF scientists explored whether habitual coffee intake was associated with a risk of arrhythmia, and whether genetic variants that affect caffeine metabolism could modify that association. Their investigation was conducted via the community-based UK Biobank, a prospective study of participants in England’s National Health Services.

Some 386,258 coffee drinkers took part in the coffee research, with an average mean age of 56 years; slightly more than half were female. It was an unprecedented sample size for this type of inquiry.

In addition to a conventional analysis examining self-reported coffee consumption as a predictor of future arrhythmias, the investigators employed a technique called “Mendelian Randomization,” leveraging genetic data to infer causal relationships. As those with the genetic variants associated with faster caffeine metabolism drank more coffee, this analysis provided a method to test the caffeine-arrhythmia relationship in a way that did not rely on participant self-report and should have been immune to much of the confounding inherent to most observational studies.

With a mean four-year follow up, data were adjusted for demographic characteristics, health and lifestyle habits.

Ultimately, approximately 4 percent of the sample developed an arrhythmia. No evidence of a heightened risk of arrhythmias was observed among those genetically predisposed to metabolize caffeine differently. The researchers said that higher amounts of coffee were actually associated with a 3 percent reduced risk of developing an arrhythmia.

The authors noted limitations including the self-reporting nature of the study, and that detailed information on the type of coffee – such as espresso or not – was unavailable.

“Only a randomized clinical trial can definitively demonstrate clear effects of coffee or caffeine consumption,” said Marcus. “But our study found no evidence that consuming caffeinated beverages increased the risk of arrhythmia. Coffee’s antioxidant and anti-inflammatory properties may play a role, and some properties of caffeine could be protective against some arrhythmias.”

Co-authors are Eun-jeong Kim, MD; Thomas J. Hoffmann, PhD; Gregory Nah, MA; Eric Vittinghoff, PhD; and Francesca Delling, MD, all of UCSF.

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