High body mass index (BMI) has been associated with worse outcomes and lower overall survival (OS) in patients (pts) with breast cancer (BC). However, this relationship is not clearly defined for those receiving neoadjuvant chemotherapy (NAC). The purpose of this study was to identify whether changes in BMI affected OS and recurrence in pts who received NAC, surgery, and radiation therapy (RT) for advanced BC. We reviewed the medical records of 112 pts with node-positive BC who received NAC at a single institution. Patients who did not receive adjuvant RT were excluded, and 83 pts were analyzed. BMI was recorded at diagnosis and 1-year after RT. Dates of local, regional, and distant failure (LF, RF, DF) were recorded. Breast cancer subtypes were defined as: luminal A (ER/PR-positive and HER2-negative, Ki-67 <16%; n=21), luminal B-like (ER/PR-positive and HER2-negative, Ki-67 > 16%; n=24), HER2-positive (ER/PR-positive or negative, HER2-positive; n=17), and triple-negative (TNBC; ER/PR-negative and HER2-negative; n=21). Time to event outcomes were evaluated using Kaplan-Meier analysis. Patients were dichotomized as losing weight (BMIΔ <0) or gaining weight/constant weight (BMIΔ ≥0). Absolute lymphocyte count (abs lymph) was recorded at the 1-year follow-up. Median follow-up was 48 months (range 12-143 months). There were 31 DF and 22 deaths. Median OS was 45 months. BMI at diagnosis was not predictive of OS or recurrence when categorized into underweight/normal (BMI <25), overweight (BMI 25-29.9), and obese (BMI ≥30). Changes in BMI did not predict for OS (p=0.12) for the general cohort, however, when analyzed by BC subtype, pts with TNBC and BMIΔ <0 showed significantly lower OS than those with BMIΔ ≥0 (p=0.03). Cumulative incidence of DF in pts with TNBC at 12 months was 33% for those with BMIΔ <0 (95% confidence interval [Cl]: 0.07-0.64), and 9% for those with BMIΔ ≥0 (Cl: 0.02-0.46). Distant failure was significantly higher in pts who lost weight across all subtypes (p=0.02); this trend was driven by pts with luminal A and TNBC (p=0.096 and p=0.07, respectively). Local and regional failures were not significantly affected by changes in BMI. When compared to pts with normal lymphocyte count, pts with lymphopenia (abs lymph <1 K/mg) had significantly worse OS and higher RF, independent of changes in BMI (p=0.003 and p=0.02, respectively). Weight loss in pts treated with NAC, surgery, and RT predicted for higher DF and worse OS, particularly in pts with TNBC. This has implications for the importance of maintaining nutrition and body weight during treatment in specific subtypes of high-risk breast cancer. The relationship between BMI and lymphopenia warrants further investigation.

Radiation is an area of medicine often accompanied by numerous patient concerns. Our purpose was to study the impact of a breast radiation patient education video addressing the rationale for radiation, the patient care pathway, and common side effects. The objective was to evaluate patient reported knowledge of radiation, satisfaction with initial consult, and fear/anxiety of treatment after viewing the video. Patients at a single institution presenting for breast radiation were randomized to watch a patient education video or not prior to consultation. A total of 40 patients were enrolled (n=20 randomized to video; n=20 to no video). Patients received a pre and post-consult survey addressing knowledge of radiation, potential side effects, anxiety and fear surrounding radiation, and satisfaction with the consult. Questions were answered on a 5-point Likert scale. The breast radiation patient video achieved its main objective of enhancing patient education on radiation therapy. Patients who viewed the video reported increased knowledge, with 75% being somewhat to extremely confident about the treatment process after viewing the video (3-5 on Likert scale), compared to 35% who did not watch the video. Those who watched the video also reported increased knowledge of radiation side effects (55% reporting a 3-5, compared to 20% who did not watch the video). 100% of those who viewed the video found it to be helpful (3-5 on scale), and 40% found it to be extremely helpful (5 on scale). Additionally, 60% of patients stated they would view the video again. Watching the video translated to improved satisfaction with the consult overall, with 85% reporting extreme satisfaction versus 60% of those who did not watch the video. Finally, the video assisted with patient fear and anxiety. While 45-50% of patients in both the video and non-video group reported at least some anxiety/fear prior to their consult, 65% felt viewing the video decreased their anxiety by a little or a lot (4-5 on scale), and 75% reported being either a little more or much more comfortable with coming for consult after the video (4-5 on scale). In our randomized study of a breast radiation education video, the video achieved goals across all measures by increasing patient knowledge, decreasing anxiety, and increasing comfort. Importantly, the patient video translated to enhanced patient satisfaction overall with 85% extremely satisfied with their consult after viewing the videos. This is important from a department standpoint where something as simple as a pre-consult video can improve the patient experience on a broad level. Further statistical analysis would require increased patient enrollment. Additional work should involve incorporating patient feedback; those who received the video desired additional information on radiation studies and side effects.

An individual's attitude towards whether intellectual change and personal development are possible (growth mindset) or indelible (fixed mindset) can greatly influence performance in challenging situations, whether it be in academic, athletic, professional, or social contexts. In the health setting however, the impact of mindset on one's response to health issues is less established. We developed and validated a survey to assess patients' Health Mindset with the goal of quantifying this relationship, and compared it with previously validated measures of anxiety, depression, insomnia. Between 2012-2018, 110 women undergoing radiotherapy were enrolled on an Institutional Review Board-approved pilot survey study; 9 patients withdrew and were excluded from analysis. Patients with breast cancer and a life expectancy >6 months were included. Participants were asked to complete a questionnaire on their first and last day of radiotherapy. The questionnaire contained 3 validated surveys: Hospital Anxiety and Depression Scale (HADS: 14 items), Insomnia Severity Index (ISI: 7 items), and 'Kind of Person' Implicit theory scale (7 items), as well as an experimental survey (Health Mindset) which was graded on a 6-point Likert scale. The Health Mindset survey contained 9 questions that aimed to quantify the extent to which a person identified with their cancer; patients with low scores identified cancer as a self-defining feature (concrete attitude), while those with high scores felt their identity was independent of their diagnosis (fluid attitude). Scores for each set of questions were averaged for a summary score. Principal component factor (PCF) analysis validated the internal structure of the Health Mindset survey. The relationship between survey scores were analyzed in a linear hierarchical model to account for within-patient correlation. Hierarchical linear regression revealed that Health Mindset correlated to anxiety and depression scores at both time points (p < .0001). In other words, patients who identified as having a concrete attitude indicated higher depression and anxiety, while those who identified as having a fluid attitude indicated lower depression and anxiety. Patients with a concrete attitude indicated scores trending towards higher insomnia (p = .0925). The Health Mindset survey captures attitudes and beliefs patients hold that may indicate risk for anxiety and depression. Further validation is necessary, however our findings demonstrate the importance of considering the impact of cancer diagnosis on mental health. Interventions that teach patients how to adopt a fluid mindset may reduce risk of depression and anxiety.

Language discrepancies create barriers to healthcare that may impact a patient’s course of care including delays in diagnosis, biopsy, resection, and radiation treatment. The aim of this study was to determine if non-English speakers (NES) experience treatment delays within their path to radiation treatment compared to English-speaking patients. NES patients diagnosed with breast cancer and treated with radiation between 2016 and 2017 (n=67) were matched with English-speaking patients based on sex, age, cancer stage, and chemotherapy (neoadjuvant or adjuvant). A total of 27 NES were matched to 40 English speakers; 13 NES were matched to 2 English-speakers and 14 NES were matched to one English speaker. Conditional logistic regression on matched data was used to compare time between diagnostic mammogram and biopsy, resection, Radiation Oncology consult, and start of radiation treatment. We also evaluated the time from resection to Radiation Oncology consult, resection to start of radiation treatment, and Radiation Oncology consult to start of radiation treatment. The time from diagnostic mammogram to diagnostic biopsy was significantly longer for NES compared to English-speaking patients (p= 0.0322), with an average difference of 25 days and an odds ratio of 1.043, 95%CI [1.003, 1.102]. A one-week increase in time to biopsy increased the odds of a patient being NES by 34% (p=0.0322). Although not statistically significant, similar time delay trends were observed between NES and English-speaking patients for time from diagnostic mammogram to resection (p=0.0703), diagnostic mammogram to Radiation Oncology Consult (p=0.0702), and diagnostic mammogram to start of radiation treatment (p=0.0848). We did not observe a difference in time from resection to new visit (p=0.2197) or resection to start of treatment (p=.2004). Independent of sex, age, race/ethnicity, and receipt of chemotherapy, language predicted delays in care for patients undergoing treatment for breast cancer. The most pronounced delay in care for NES was the time from diagnostic mammogram to diagnostic biopsy. However, notable trends were observed as NES patients progressed to resection, Radiation Oncology consult, and the start of radiation treatment. Additional analyses are underway for a larger matched cohort to build on these findings. These results provide preliminary data to help guide future interventions for improving healthcare delivery for Non-English speaking patients.

To determine whether Non-English speaking patients who undergo breast cancer radiation present at a more advanced stage than their English-speaking counterparts do. Patients with breast cancer who underwent radiation treatment from 2016-2017 were identified (n=413 patients). Patients were categorized as English (n=342) vs Non-English Speakers (NES) (n=71), based on patients' self-identified primary language. Stage at presentation (0/DCIS, I, II, III, and IV), age, and race/ethnicity (Hispanic, Asian, Non-Hispanic White, and Other) were recorded. A preliminary analysis was run comparing stage at presentation for all English vs NES patients. Additional analysis using Fisher's Exact test controlled for age <50 (n=102) and ≥50 (n=316), to differentiate between pre-menopausal and post-menopausal patients who might have undergone screening. Finally, conditional odds ratios were calculated while adjusting for age and race/ethnicity using a log linear model. There was a significant difference in stage at presentation between English and NES patients who underwent breast radiation treatment (p=0.0053). More NES patients presented at Stage III (21.1%) compared to English speakers (7.2%). Fewer NES presented with Stage I disease (32.2% vs 47.2% of English speakers). When controlling for age <50 and ≥50, there was a significant difference in stage at presentation in the cohort ≥50 (p=0.0169), with NES more likely to present at Stage III than English speakers (14.7% vs 7.9%), and less likely to present at Stage I (33.3% vs 48.4%). There was no significant difference for those <50 (p=0.5676). Finally, the difference in stage at presentation persisted when controlling for race/ethnicity as well as age, with NES having lower odds of presenting with Stage I disease and higher odds of Stage III disease. With Stage I as a reference, NES have estimated odds of presenting at Stage III that are 4.28 times that of English speakers. Non-English speaking patients with breast cancer present with more advanced disease when compared to English-speaking patients. Non-English speakers have lower odds of presenting with Stage I disease and higher odds of presenting with Stage III disease, even while controlling for age and race/ethnicity. This may indicate NES patients have a harder time gaining access to the healthcare system, thus delaying their work-up and diagnosis. This may then lead to more extensive treatment, including chemotherapy and regional nodal irradiation. Additionally, NES patients ≥50 present at more advanced stage, which may in part be due to undergoing less screening; this remains to be explored. Separate from race/ethnicity, language appears to be an independent predictor of advanced stage disease presentation.

To evaluate factors that affect implant-based reconstruction failure after mastectomy with or without radiation (XRT) in patients treated for breast cancer. Ninety-six patients who underwent mastectomy and tissue expander (TE)/implant-based breast reconstruction with or without XRT were retrospectively identified between 2000 and 2014. Patients with prior reconstruction or unknown radiation treatment history were excluded from analysis. Groups were stratified based on the timing of XRT in relation to implant based reconstruction. Patients either received no radiation (Group 1, n=30), radiation to the TE with subsequent implant exchange (Group 2, n=35), implant exchange prior to radiation (Group 3, n=3), or radiation prior to delayed reconstruction (Group 4, n=3). Some patients underwent mastectomy with implant-based reconstruction for a local recurrence 1-36 years after previous lumpectomy and whole breast XRT (Group 5, n=25). Patients were reviewed for reconstruction failure, defined as implant loss, as well as major complications requiring hospitalization (infection, delayed wound healing, implant exposure, hematoma, seroma). Logistic regression modeling was performed for single predictor and multivariable analyses. Reconstruction failure rates were 10%, 23%, 0%, 33%, and 32%, for Groups 1-5, respectively. Single predictor modeling demonstrated radiation timing, infection, delayed wound healing, implant exposure, age, BMI, total number of lymph nodes resected during surgery and hematoma to be significant predictors for reconstruction failure. Tobacco use, laterality, and time from TE to implant exchange were not predictive. On multivariable analysis only infection (p<0.001), total number of lymph nodes resected (p=0.02), and delayed wound healing (p=0.001) were predictive for reconstruction failure. Radiation timing, as well as implant exposure, hematoma, age, and BMI, failed to remain a significant predictor. Moreover, the number of lymph nodes resected significantly influenced the likelihood of implant failure: the odds of implant failure increased by 9.9% for every additional lymph node resected (OR = 1.099; p=0.03, CI=1.010-1.195). Radiation timing was not a significant predictor for implant-based reconstruction failure in post-mastectomy breast cancer patients. However, infection, extent of nodal surgery, and delayed wound healing correlated with implant loss.

When compared to their older counterparts, breast cancer in young women under the age of 40 tends to be more aggressive with worse outcomes. We sought to evaluate whether nodal response was predictive of outcomes in this patient population. A total of 220 patients treated with NAC followed by mastectomy (MTX) or lumpectomy (L) and/or radiation treatment (RT) were retrospectively reviewed at a single academic institution between 1995 and 2015. Patients were excluded if surgical or RT records were not available at the time of data analysis, if they had metastatic disease at diagnosis, or if they received chemotherapy for other diagnoses. Pathologic complete response (pCR) was defined as no evidence of residual tumor in the breast and sampled axillary lymph nodes (LNs) (ypT0/ypN0). All others were considered to have partial response if there was no tumor in the LNs but residual tumor in the breast (ypT+/ypN0) or residual tumor in the LNs (ypT0/ypN+). Those who had residual tumor in both the breast and the LNs were classified as limited response (ypT+/ypN+). Kaplan-Meier and Cox proportional hazards analyses were performed to identify factors predictive for overall survival (OS). A total of 161 patients were included in the final analysis. Median age was 36 years (range = 20-40). All patients received NAC followed by MTX (69%) or L (31%). Of patients with BRCA genetic results available (n=97), 26% (n= 25) carried mutations in BRCA1 and 7.2% (n=7) in BRCA2. Initial clinical stage at diagnosis was stage I in 4.5%, stage II in 45%, and stage III in 48%. A total of 138 (85.7%) patients received adjuvant RT: 43 of 49 after lumpectomy (6 refused), and 99 of 111 after MTX. In total, 35 patients (21.7%) achieved ypT0/ypN0, 56 patients (34.8%) achieved ypT+/ypN0, and 2 patients achieved ypT0/ypN+. Of the 35 ypT0/ypN0 patients, 28 (80%) went on to receive adjuvant RT after L (n=13) or MTX (n=15). There were no local or regional recurrences in ypT0/ypN0 patients regardless of whether they received adjuvant RT. Two patients with pCR developed distant metastases and are both alive with disease. There were no deaths among ypT0/ypN0 patients (p<.001) with median OS not reached. There was no difference in OS between ypT+/ypN0 versus ypT+/ypN+ patients with median OS of 97 versus 86 months, respectively (p=0.25). Cumulative incidence of distant metastasis was 47% in ypT+/ypN0 patients and 53% in ypT+/ypN+ patients (p=0.46). On multivariable analysis of the entire cohort, mastectomy (p=0.0087), adjuvant RT (0.045), triple negative subtype (p<.0001), pCR (p<.0001), and total number of lymph nodes sampled (p=0.011) were all predictive of improved OS. Our analysis demonstrates that women under 40 years who achieve pCR in the breast and axillary lymph nodes following NAC have excellent outcomes. Women who achieve pCR in the LNs do not have improved OS compared to those who remain LN positive after NAC.