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Original Investigation
December 5, 2019

Body Composition, Adherence to Anthracycline and Taxane-Based Chemotherapy, and Survival After Nonmetastatic Breast Cancer

Author Affiliations
  • 1Division of Research, Kaiser Permanente Northern California, Oakland
  • 2Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 3Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
  • 4Department of Agricultural, Food and Nutritional Science, University of Alberta, 2-06 Agriculture/Forestry Centre, Edmonton, Alberta, Canada
  • 5Covenant Health Palliative Institute, Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alberta, Canada
  • 6Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
  • 7Division of Oncology, Rambam Health Care Campus, Haifa, Israel
JAMA Oncol. 2020;6(2):264-270. doi:10.1001/jamaoncol.2019.4668
Key Points

Question  Is body composition associated with tolerance and adherence to anthracycline and taxane-based chemotherapy and, thus, breast cancer mortality?

Findings  In this cohort study of 1395 patients with nonmetastatic breast cancer, greater adiposity was associated with lower relative dose intensity (ratio of delivered to planned chemotherapy dose). Lower relative dose intensity was associated with increased risk of death after breast cancer and partially mediated the association of greater adiposity with mortality.

Meaning  Although most chemotherapies are dosed according to body surface area, body composition may identify patients at risk for lower relative dose intensity, which could compromise therapeutic efficacy and may be one of multiple pathways through which adiposity is associated with increases in breast cancer mortality.


Importance  Although most chemotherapies are dosed on body surface area or weight, body composition (ie, the amount and distribution of muscle and adipose tissues) is thought to be associated with chemotherapy tolerance and adherence.

Objectives  To evaluate whether body composition is associated with relative dose intensity (RDI) on anthracycline and taxane-based chemotherapy or hematologic toxic effects and whether lower RDI mediates the association of adiposity with mortality.

Design, Setting, and Participants  An observational cohort study with prospectively collected electronic medical record data was conducted at Kaiser Permanente Northern California, a multicenter, community oncology setting within an integrated health care delivery system. Participants included 1395 patients with nonmetastatic breast cancer diagnosed between January 1, 2005, and December 31, 2013, and treated with anthracycline and taxane-based chemotherapy. Data analysis was performed between February 25 and September 4, 2019.

Exposures  Intramuscular, visceral, and subcutaneous adiposity as well as skeletal muscle were evaluated from clinically acquired computed tomographic scans at diagnosis.

Main Outcomes and Measures  The primary outcome was low RDI (<0.85), which is the ratio of delivered to planned chemotherapy dose, derived from infusion records; in addition, hematologic toxic effects were defined based on laboratory test values. To evaluate associations with overall and breast cancer–specific mortality, logistic regression models adjusted for age and body surface area were fit as well as Cox proportional hazards models adjusted for age, race/ethnicity, adiposity, Charlson comorbidity index score, and tumor stage and subtype. The mediation proportion was computed using the difference method.

Results  The mean (SD) age at diagnosis of the 1395 women included in the study was 52.8 (10.2) years. Greater visceral (odds ratio [OR], 1.19; 95% CI, 1.02-1.39 per SD) and intramuscular (OR, 1.16; 95% CI, 1.01-1.34 per SD) adiposity were associated with increased odds of RDI less than 0.85. Greater muscle mass was associated with a decreased odds of hematologic toxic effects (OR, 0.84; 95% CI, 0.71-0.98 per SD). Relative dose intensity less than 0.85 was associated with a 30% increased risk of death (hazard ratio, 1.30; 95% CI, 1.02-1.65). Lower RDI partially explained the association of adiposity with breast cancer–specific mortality (mediation proportion, 0.20; 95% CI, 0.05-0.55).

Conclusions and Relevance  Excess adiposity, presenting as larger visceral or intramuscular adiposity, was associated with lower RDI. Lower RDI partially mediated the association of adiposity with worse breast cancer–specific survival. Body composition may help to identify patients likely to experience toxic effects and subsequent dose delays or reductions, which could compromise chemotherapeutic efficacy.

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