Fertility Preservation and Assisted Reproduction in Patients With Breast Cancer Interrupting Adjuvant Endocrine Therapy to Attempt Pregnancy

PURPOSE

We investigated time to pregnancy, efficacy and safety of fertility preservation, and assisted reproductive technologies (ARTs) in women with early hormone receptor-positive breast cancer (BC) desiring future pregnancy.

PATIENTS AND METHODS

POSITIVE is an international, single-arm, prospective trial, in which 518 women temporarily interrupted adjuvant endocrine therapy to attempt pregnancy. We evaluated menstruation recovery and factors associated with time to pregnancy and investigated if ART use was associated with achieving pregnancy. The cumulative incidence of BC-free interval (BCFI) events was estimated according to the use of ovarian stimulation at diagnosis. The median follow-up was 41 months.

RESULTS

Two hundred seventy-three patients (53%) reported amenorrhea at enrollment, of whom 94% resumed menses within 12 months. Among 497 patients evaluable for pregnancy, 368 (74%) reported at least one pregnancy. Young age was the main factor associated with shorter time to pregnancy with cumulative incidences of pregnancy by 1 year of 63.5%, 54.3%, and 37.7% for patients age <35, 35-39, and 40-42 years, respectively. One hundred and seventy-nine patients (36%) had embryo/oocyte cryopreservation at diagnosis, of whom 68 reported embryo transfer after enrollment. Cryopreserved embryo transfer was the only ART associated with higher chance of pregnancy (odds ratio, 2.41 [95% CI, 1.75 to 4.95]). The cumulative incidence of BCFI events at 3 years was similar for women who underwent ovarian stimulation for cryopreservation at diagnosis, 9.7% (95% CI, 6.0 to 15.4), compared with those who did not, 8.7% (95% CI, 6.0 to 12.5).

CONCLUSION

In POSITIVE, fertility preservation using ovarian stimulation was not associated with short-term detrimental impact on cancer prognosis. Pregnancy rates were highest among those who underwent embryo/oocyte cryopreservation followed by embryo transfer.

Primary ovarian insufficiency associated with lenvatinib therapy in a patient with hepatocellular carcinoma: A case report

The therapeutic effects of molecular targeted drugs are, in some cases, more pronounced than those of conventional chemotherapy, and their introduction as a standard treatment is increasing. The present report describes a case of ovarian insufficiency in a young woman caused by tyrosine kinase inhibitor lenvatinib. The 25-year-old woman received lenvatinib (8 mg/day) for 98 days as preoperative chemotherapy for hepatocellular carcinoma. Blood testing the day before starting lenvatinib administration indicated 4.40 mIU/ml luteinizing hormone (LH), 5.2 mIU/ml follicle-stimulating hormone (FSH) and age-equivalent hormone values. Amenorrhea occurred after the start of administration, and 48 days later, the LH level was 41.8 mIU/ml and the FSH level was 44 mIU/ml, indicating a decrease in ovarian function. The patient underwent hepatectomy, and 49 days after the end of lenvatinib administration, the LH level had improved to 4.5 mIU/ml and the FSH level had improved to 2.5 mIU/ml. After the hepatectomy, the patient began to have regular menstrual cycles once again. Ovarian toxicity has not been recognized as a side effect of lenvatinib. However, the present report describes primary ovarian insufficiency considered to be caused by this drug. Potential damage to ovarian function may need to be considered when molecular targeted drugs with the same mechanism of action as lenvatinib are used in young women.

Oncofertility-related psycho-educational therapy for young adult patients with breast cancer and their partners: Randomized controlled trial

BACKGROUND

A couples' psycho-educational program called Oncofertility! Psycho-Education and Couple Enrichment (O!PEACE) therapy was created and its effect when provided before cancer treatment was examined.

METHODS

This multicenter randomized controlled trial with nonmasking, parallel two-group comparison enrolled women aged 20 to 39 years with early-stage breast cancer and their partners. They were randomly assigned to receive O!PEACE (37 couples) or usual care (37 couples). Primary end points were cancer-related posttraumatic stress symptoms, symptoms of depression, and anxiety. Secondary end points were stress-coping strategies, resilience, and marital relationship.

RESULTS

Women receiving psycho-educational therapy had significantly reduced Impact of Event Scale-revised version for Japanese scores (p = .011, ηp 2  =  = .089). For patients with Impact of Event Scale-revised version for Japanese scores at baseline ≥18.27, O!PEACE therapy improved these scores when compared with usual care (U = 172.80, p = .027, r = 0.258). A >5-point reduction was present in 59.3% and 30% of women in the O!PEACE therapy and usual-care groups, respectively. For partners, O!PEACE therapy significantly improved stress-coping strategies (95% CI, -0.60 to -0.05; p = .018, ηp 2  =  = .074) and escape-avoidance marital communication (95% CI, -0.33 to -0.08; p = .001, ηp 2  = .136). O!PEACE therapy significantly improved the partners' support (95% CI, 0.10-0.50; p = .001, ηp 2  = .127), the rate of receiving fertility preservation consultations, and knowledge levels.

CONCLUSIONS

O!PEACE therapy before cancer treatment can improve posttraumatic stress symptoms, stress-coping behavior, and marital relationships. Larger sample sizes and longer term follow-up are required.

PLAIN LANGUAGE SUMMARY

A psycho-educational program, the Oncofertility! Psycho-Education and Couple Enrichment (O!PEACE) therapy program was developed and evaluated for women diagnosed with breast cancer and their partners. A multicenter randomized controlled trial showed that the O!PEACE psycho-educational therapy, with only two precancer treatment sessions, can reduce cancer-related posttraumatic stress symptoms and improve oncofertility knowledge and marital relationships in young adult patients with breast cancer. The therapy could also improve stress-coping strategies in marital communications with their partners. Couples may use O!PEACE psycho-educational therapy to consider fertility preservation and improve their psychosocial aspects.

Interrupting Endocrine Therapy to Attempt Pregnancy after Breast Cancer

BACKGROUND

Prospective data on the risk of recurrence among women with hormone receptor-positive early breast cancer who temporarily discontinue endocrine therapy to attempt pregnancy are lacking.

METHODS

We conducted a single-group trial in which we evaluated the temporary interruption of adjuvant endocrine therapy to attempt pregnancy in young women with previous breast cancer. Eligible women were 42 years of age or younger; had had stage I, II, or III disease; had received adjuvant endocrine therapy for 18 to 30 months; and desired pregnancy. The primary end point was the number of breast cancer events (defined as local, regional, or distant recurrence of invasive breast cancer or new contralateral invasive breast cancer) during follow-up. The primary analysis was planned to be performed after 1600 patient-years of follow-up. The prespecified safety threshold was the occurrence of 46 breast cancer events during this period. Breast cancer outcomes in this treatment-interruption group were compared with those in an external control cohort consisting of women who would have met the entry criteria for the current trial.

RESULTS

Among 516 women, the median age was 37 years, the median time from breast cancer diagnosis to enrollment was 29 months, and 93.4% had stage I or II disease. Among 497 women who were followed for pregnancy status, 368 (74.0%) had at least one pregnancy and 317 (63.8%) had at least one live birth. In total, 365 babies were born. At 1638 patient-years of follow-up (median follow-up, 41 months), 44 patients had a breast cancer event, a result that did not exceed the safety threshold. The 3-year incidence of breast cancer events was 8.9% (95% confidence interval [CI], 6.3 to 11.6) in the treatment-interruption group and 9.2% (95% CI, 7.6 to 10.8) in the control cohort.

CONCLUSIONS

Among select women with previous hormone receptor-positive early breast cancer, temporary interruption of endocrine therapy to attempt pregnancy did not confer a greater short-term risk of breast cancer events, including distant recurrence, than that in the external control cohort. Further follow-up is critical to inform longer-term safety. (Funded by ETOP IBCSG Partners Foundation and others; POSITIVE ClinicalTrials.gov number, NCT02308085.).

Childbirth after perioperative systemic therapy in patients with breast cancer: a retrospective single institutional study in Japan

BACKGROUND

The number of breast cancer patients of childbearing age has been increasing. Therefore, we investigated the characteristics and the childbearing status of the patients who received systemic therapy for breast cancer during their childbearing age to better understand the clinical impact of childbirth.

METHODS

Female patients with breast cancer younger than 40 years old who underwent surgery and received perioperative systemic therapy from 2007 to 2014 were included in this study. We compared the characteristics of patients with and without childbirth after treatment.

RESULT

Of 590 patients, 26 delivered a child, and 355 did not bear a child during the median observation period of 8.1 years, whilst 209 had unknown childbirth data. The childbirth group had a lower mean age at surgery (32.2 vs. 35.1, P < 0.001). The proportion of patients who desired childbirth and used assisted reproductive technology was significantly higher in the childbirth group (65.4 vs. 23.9% and 45.2 vs. 5.1%, respectively, P < 0.001). The patients in the childbirth group had significantly less advanced disease (P = 0.002). In the childbirth group, the age at childbirth was significantly older in patients who received combined endocrine therapy and chemotherapy (40.8 years) than in patients who received either alone (endocrine therapy: 36.9 years, chemotherapy: 36.7 years, P = 0.04). However, survival was not different between those with and without childbirth.

CONCLUSION

It is critical to recognize the desire for childbirth in patients with breast cancer who are receiving systemic therapy and to provide them with necessary fertility information before treatment to support their decision-making.

Abstract GS4-09: Pregnancy Outcome and Safety of Interrupting Therapy for women with endocrine responsIVE breast cancer: Primary Results from the POSITIVE Trial (IBCSG 48-14/BIG 8-13)

Background: Pregnancy after breast cancer (BC) is of substantial importance for many young women at diagnosis and during follow-up. BC treatment including standard endocrine therapy (ET) (5-10 years) may reduce ovarian reserve and the chances of subsequent successful pregnancy, given conception is contraindicated during ET. A temporary interruption of ET to attempt and carry a pregnancy in this population has never been prospectively studied.

Methods: POSITIVE is a single-arm, prospective, investigator-initiated, international trial evaluating the safety and pregnancy outcomes of interrupting ET for young women with early-stage hormone-receptor-positive (HR+) BC who desire pregnancy. The primary objective is to assess the risk of BC relapse associated with ET interruption for ~2 years to achieve pregnancy. Women ≤42 years with stage I-III HR+ BC who received adjuvant ET (SERM alone, GnRH analogue plus SERM or AI) for 18 to 30 months and wished to interrupt ET to attempt pregnancy were eligible. The primary endpoint is breast cancer free interval (BCFI) defined as the time from enrollment to the first BC event (local, regional, distant recurrence or a new invasive contralateral BC). Planned sample size was 500 patients. Three interim analyses of BCFI were reviewed by the Data Safety Monitoring Committee (DSMC) to assure a 95% chance of stopping the trial early if the annual BCFI event rate exceeded 4%; with primary analysis triggered after 1600 patient years of follow-up (pyfu) and no more than 46 BCFI events defined as the safety threshold. The DSMC recommended continuing the study following each interim analysis. We now report the primary results.

Results: From 12/2014 to 12/2019, 518 women were enrolled. At enrollment, the median age of participants was 37 years (27-43 years); 75.0% were nulliparous, 93.4% had stage I/II disease, 66.3% node-negative. Median time from BC diagnosis to enrollment was 29 months (IQR: 25-32). Tamoxifen alone was the most prescribed ET (41.7%), followed by tamoxifen+ovarian function suppression (35.7%). 62.0% of participants had received neo/adjuvant chemotherapy. At a median follow-up of 41 months (1638 pyfu), 44 participants had experienced a BCFI event, not exceeding the pre-specified safety threshold of 46 events. The 3-year BCFI failure percent was 8.9% (95% CI: 6.3 to 11.6%), similar to the 9.2% (95% CI: 7.6 to 10.8%) calculated in the comparative external control cohort from the SOFT/TEXT trials (Sun et al, Breast 2020). Of 497 women followed for pregnancy status, 368 (74.0%) had at least one pregnancy, 317 (63.8%) had at least one live birth, with a total of 365 babies born. Based on competing risk analysis, 76.3% of patients resumed ET (half within 26 months), 8.3% had BCFI event/death before ET resumption, and 15.4% had not resumed ET yet.

Conclusions: The POSITIVE trial demonstrates that for young women with early HR+ BC desiring pregnancy, temporary interruption of ET to attempt pregnancy does not confer a greater short-term risk of recurrence than that observed in a modern historical control group that did not interrupt ET. Most participants have had a live birth. Further follow-up is planned to confirm long-term safety. These results should be considered in counselling BC patients desiring future pregnancy.

Citation Format: Ann Partridge, Olivia Pagani, Samuel M. Niman, Monica Ruggeri, Fedro Alessandro A. Peccatori, Hatem A. Azim, Marco Colleoni, Cristina Saura, Chikako Shimizu, Anna Saetersdal, Judith Kroep, Audrey Mailliez, Ellen Warner, Virginia F. Borges, Frédéric Amant, Andrea Gombos, Akemi Kataoka, Christine Rousset-Jablonski, Simona Borstnar, Junko Takei, Jeong Eon Lee, Janice Walshe, Manuel Ruiz Borrego, Halle Moore, Christobel Saunders, Vesna Bjelic-Radisic, Snezana Susnjar, Fatima Cardoso, Karen L. Smith, Teresa Ferreiro Vilarino, Karin Ribi, Kathryn Ruddy, Sarra El-Abed, Martine Piccart, Larissa A. Korde, Aron Goldhirsch, Richard D. Gelber. Pregnancy Outcome and Safety of Interrupting Therapy for women with endocrine responsIVE breast cancer: Primary Results from the POSITIVE Trial (IBCSG 48-14/BIG 8-13) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr GS4-09.

The impact of obesity and endocrine therapy on the prognosis of premenopausal women with hormone receptor-positive breast cancer: A single-institute retrospective study

BACKGROUND

Higher body mass index (BMI) is associated with worse prognosis in pre- and postmenopausal patients with breast cancer (BC). However, there is insufficient evidence regarding the optimal adjuvant endocrine therapy for obese premenopausal women with hormone receptor (HR)-positive BC.

AIM

To evaluate the impact of obesity and adjuvant endocrine therapy on prognosis in premenopausal patients with BC.

METHODS AND RESULTS

We retrospectively reviewed the medical record of premenopausal women who received curative surgery for clinical stage I-III HR-positive BC from 2007 to 2017. Patients were classified into five groups according to BMI: underweight (UW), normal weight (NW), obese 1 degree (OB1), obese 2 degree (OB2), and obese 3 degree (OB3) categories. The primary analysis was a comparison of BC-specific survival (BCSS) according to BMI (UW/NW vs. OB1-3) and adjuvant endocrine therapy (with or without ovarian function suppression [OFS]). Of 13 021 patients, the data of 3380 patients were analyzed. BCSS in OB1-3 patients was significantly worse than that in patients with UW/NW (hazard ratio [HR] 2.37; 95% confidence interval [CI], 1.40-4.02: p = .0009). In OB1-3 patients who received tamoxifen (TAM), BCSS was significantly worse than that in UW/NW patients (p = .0086); however, a significant difference was not shown in patients who received TAM and OFS (p = .0921).

CONCLUSION

High BMI was associated with worse prognosis in premenopausal patients with HR-positive BC who received adjuvant TAM. The role of OFS as adjuvant endocrine therapy remains unclear, and further studies are required to explore the adequate management of obese premenopausal patients.

Abstract P4-11-06: Effect of suppressed ovarian function on prognosis of premenopausal obese women with hormone receptor-positive breast cancer: A single-institute retrospective study

Background: Obesity is related to poor prognosis in pre- and postmenopausal patients with breast cancer. However, there is insufficient evidence regarding the optimal adjuvant hormone therapy for obese premenopausal women with hormone receptor-positive breast cancer. We examined the impact of ovarian function suppression (OFS) on the prognosis of obese women with primary hormone receptor-positive breast cancer. Methods: We retrospectively reviewed premenopausal women who received curative surgery for clinical stage I-III hormone receptor (HR)-positive breast cancer at the Cancer Institute Hospital of the Japanese Foundation for Cancer Research from January 2007 to December 2017. All patients were classified into five groups according to body mass index (BMI): underweight (UW), BMI &lt;18.5 kg/m2; normal weight (NW), 18.5-24.9 kg/m2; obese 1 degree (OB1), 25.0-29.9 kg/m2; obese 2 degree (OB2), 30.0-34.9 kg/m2; and obese 3 degree (OB3), ≥35 kg/m2. The primary analysis was a comparison of breast cancer-specific survival (BCSS) according to BMI (UW/NW vs. OB1-3) and adjuvant hormonal therapy (with or without OFS). Secondary endpoints included overall survival (OS). Results: Overall, the total number of patients was 13,021 and the data of 3,380 patients were analyzed, which included patients who received adjuvant tamoxifen (TAM) without OFS (n = 1,836) or with OFS (n = 670). The median follow-up duration was 5.9 years (range, 0.2-12.9). The numbers of patients with UW, NW, OB1, OB2, and OB3 were 404 (12%), 2,482 (73%), 399 (12%), 78 (2%), and 17 (1%), respectively. Obesity was significantly associated with higher stage of breast cancer (p &lt;0.0001). Nuclear grade of breast cancer in OB1-3 patients was significantly higher than that in UW/NW patients (p = 0.0323). BCSS in OB1-3 patients was significantly worse than that in patients with UW/NW (hazard ratio [HR] 2.37; 95% confidence interval [CI], 1.40-4.02: p = 0.0009). In OB1-3 patients who received TAM as adjuvant hormone therapy, BCSS was significantly worse than that in UW/NW patients (p = 0.0086); however, a significant difference was not shown in patients who received TAM and OFS (p = 0.0921). Multivariate analysis revealed that OB3 was an independent prognostic factor compared with NW in patients with stage II/III breast cancer (p = 0.0162).Conclusion: High BMI was associated with worse prognosis in premenopausal patients with HR-positive breast cancer. The negative impact of obesity might be canceled by adding OFS to TAM as adjuvant hormone therapy. Further studies are required to explore the adequate management of obese premenopausal patients.

Citation Format: Yukinori Ozaki, Jun Masuda, Akemi Kataoka, Takahiro Kogawa, Tomomi Abe, Hidetomo Morizono, Lina Inagaki, Fumikata Hara, Toshimi Takano, Takayuki Ueno, Shinji Ohno. Effect of suppressed ovarian function on prognosis of premenopausal obese women with hormone receptor-positive breast cancer: A single-institute retrospective study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-06.

Who are the women who enrolled in the POSITIVE trial: A global study to support young hormone receptor positive breast cancer survivors desiring pregnancy

Background

Premenopausal women with early hormone-receptor positive (HR+) breast cancer receive 5–10 years of adjuvant endocrine therapy (ET) during which pregnancy is contraindicated and fertility may wane. The POSITIVE study investigates the impact of temporary ET interruption to allow pregnancy.

Methods

POSITIVE enrolled women with stage I-III HR + early breast cancer, ≤42 years, who had received 18–30 months of adjuvant ET and wished to interrupt ET for pregnancy. Treatment interruption for up to 2 years was permitted to allow pregnancy, delivery and breastfeeding, followed by ET resumption to complete the planned duration.

Findings

From 12/2014 to 12/2019, 518 women were enrolled at 116 institutions/20 countries/4 continents. At enrolment, the median age was 37 years and 74.9 % were nulliparous. Fertility preservation was used by 51.5 % of women. 93.2 % of patients had stage I/II disease, 66.0 % were node-negative, 54.7 % had breast conserving surgery, 61.9 % had received neo/adjuvant chemotherapy. Tamoxifen alone was the most prescribed ET (41.8 %), followed by tamoxifen + ovarian function suppression (OFS) (35.4 %). A greater proportion of North American women were <35 years at enrolment (42.7 %), had mastectomy (59.0 %) and received tamoxifen alone (59.8 %). More Asian women were nulliparous (81.0 %), had node-negative disease (76.2%) and received tamoxifen + OFS (56.0 %). More European women had received chemotherapy (69.3 %).

Interpretation

The characteristics of participants in the POSITIVE study provide insights to which patients and doctors considered it acceptable to interrupt ET to pursue pregnancy. Similarities and variations from a regional, sociodemographic, disease and treatment standpoint suggest specific sociocultural attitudes across the world.

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Fertility and pregnancy are priority concerns for young breast cancer survivors.

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POSITIVE explores a transient interruption of endocrine therapy to allow conception.

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Patients' characteristics highlight features considered suitable to study enrolment.

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Overall, patients enrolled had a relatively high median age and low-risk disease.

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Variations emerged across continents suggesting specific sociocultural attitudes.

Impact of body mass index on the prognosis of Japanese women with operable hormone receptor-positive breast cancer: A single institutional retrospective study

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Background: Higher body mass index (BMI) has been associated with an increased risk of developing hormone receptor (HR)-positive breast cancer (BC) in postmenopausal women, but its relationship with prognosis in patients with HR-positive BC remains unclear. In particular, there is limited data on BMI and prognosis in Asian patients with BC, whose BMI distribution differs from that of Westerners. Methods: We retrospectively reviewed data from Japanese women who underwent curative surgery for clinical stage I-III HR-positive BC in our institution between January 2007 and December 2017. The patients were classified into five groups based on BMI: underweight (UW), BMI < 18.5 kg/m2; normal weight (NW), 18.5 to 24.9 kg/m2; obese 1 degree (OB1), 25.0 to 29.9 kg/m2; obese 2 degree (OB2), 30.0 to 34.9 kg/m2; obese 3 degree (OB3), ≥ 35 kg/m2. We compared the clinicopathological features between patients with OB1-3 and those with UW and NW. The prognostic analysis of breast cancer-specific survival (BCSS) and overall survival (OS) was performed using the log-rank test and Cox proportional hazards model between the two groups. Subgroup analysis of BCSS and OS was performed in premenopausal and postmenopausal patients. Results: Overall, 6,421 patients were included in the study. The median follow-up duration was 5.9 years (range, 0.2-12.9). The number of patients with UW, NW, OB1, OB2, or OB3 was 599 (9%), 4477 (70%), 1085 (17%), 224 (3%), and 36 (1%), respectively. Of these, 3380 (53%) were premenopausal and 2968 (46%) were postmenopausal. Patients with OB1-3 had a significantly higher stage of BC, a higher number of lymph node metastases, and were associated with higher Ki67 index and nuclear grade compared to those with UW and NW. A total of 521 all-cause and 307 breast cancer-specific deaths as well as 824 recurrences were observed. Both BCSS and OS in patients with OB1-3 were significantly worse than those in the UW and NW patients (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.14-2.42; HR, 1.64; 95%CI, 1.25-2.18, respectively) by univariate analysis. In addition, the Kaplan-Meier curve for each BMI group showed that the prognosis of BCSS and OS was gradually worse in the order of NW, OB1, OB2, and OB3. Subgroup analysis revealed that BCSS and OS were significantly worse in patients with OB1-3 than in those with UW and NW for premenopausal patients (HR, 2.37; 95%CI, 1.40-4.02; HR, 1.91; 95%CI, 1.17-3.11, respectively), but not for postmenopausal patients (HR, 1.26; 95%CI, 0.74-2.16; HR, 1.29; 95%CI, 0.92-1.82, respectively). Multivariate analysis showed that tumor stage and nuclear grade were independent prognostic factors, but OB1-3 was not. Conclusions: Obesity was associated with a worse prognosis as it correlated with advanced stage and high nuclear grade in Japanese patients with HR-positive BC, especially in premenopausal patients.

Abstract PS2-32: Incidental malignant findings on pre-admission chest computed tomography scan for coronavirus disease screening in patients with breast cancer or other cancers

Background: Amidst the coronavirus disease (COVID-19) pandemic, pre-admission chest computed tomography (CT) screening has been performed for all patients (pts) scheduled for cancer surgery to prevent the nosocomial spread of COVID-19 at our cancer center in Tokyo. This strategy was employed owing to a shortage of polymerase chain reaction assay opportunities and the relatively abundant availability of CT scanning in Japan. Notably, a screening CT may reveal incidental findings that are different from the original purpose of the examination. Thus far, there are no reports of incidental malignant findings on CT scans for COVID-19 screening. Methods: This single-institutional retrospective study included pts scheduled for surgery and who underwent pre-admission CT scans for COVID-19 screening between April 26, 2020, and June 12, 2020. Clinical and radiological data of pts were extracted from medical records. Clinical data included age, sex, medical history, and treatment. All CT scans for COVID-19 screening were examined one or two days before surgery and interpreted by two trained radiologists. This study aimed to reveal the ratio of incidental findings related to malignancy. Results: Between April 26, 2020, and June 12, 2020, 863 pts underwent pre-admission CT scans for COVID-19 screening. Median patient age was 58 years (range, 11-91 years), and 511 (59%) of the pts were female. The most common disease was breast cancer (n = 165, 19%), followed by colorectal cancer (n = 108, 13%), gynecological cancer (n = 107, 12%), and other cancers (n = 483, 56%). CT scan revealed radiological findings of pneumonia in 23 pts (2.7%); therefore, surgery was postponed for these pts. Incidental findings were detected in 28 pts (3.2%), including one pneumothorax and 27 findings related to malignancies. The present study included 165 pts (19%) with breast cancer and who were scheduled for curative surgery. Among them, incidental findings related to malignancies were detected in nine pts (5.5%), including small ground-glass pulmonary nodules (GGN) (n=5), pancreatic duct dilatation (n=1), suspected vertebral metastasis (n=2) and suspected liver tumor (n=1). All pts did not undergo breast surgery but underwent additional examinations after surgery. Five pts (2.5%) with GGN needed follow-up. One patient’s pancreatic duct dilatation was diagnosed as benign using ultrasound. One patient with suspected vertebral metastasis was diagnosed with degenerative changes. The other patient was diagnosed with multiple bone metastases by bone scintigraphy, and further treatment was planned. Pre-admission screening CT scan for pts with other cancers was performed in 698 pts (81%). Among them, findings related to malignancies were detected in 18 pts (2.6%), including breast nodules (n=3), lung nodules (n=5), liver metastasis (n=1), progression of metastasis (n=3), mediastinum tumor (n=1), and GGN (n=5). Two of the three pts with breast nodules were diagnosed with invasive breast cancer and planned for breast surgery after the current cancer treatment. Two pts developed new lung metastasis, and the surgical strategy was changed. The progression of known liver or lung metastasis was detected in three pts, which led to the addition of systemic chemotherapy without modification of surgical treatment. One patient had a mediastinum tumor, and an MRI evaluation after surgery revealed an athymic cyst. Five pts were determined to have GGN, and follow-up was required. Conclusion: The proportion of pts for whom pre-admission CT for COVID-19 revealed incidental findings was 3.2%. Incidental breast cancer was found in 0.4% of female pts. GGNs needed follow-up examination in 2.5% of operable breast cancer pts. Physicians and surgeons should be aware of incidental malignant findings in the COVID-19 screening CT scan.

Citation Format: Jun Masuda, Akemi Kataoka, Katsunori Oikado, Natsue Uehiro, Yukinori Ozaki, Lina Inagaki, Chieko Kato, Hidemoto Morizono, Toshimi Takano, Takayuki Ueno, Shinji Ohno. Incidental malignant findings on pre-admission chest computed tomography scan for coronavirus disease screening in patients with breast cancer or other cancers [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-32.

Abstract PS12-17: Baseline characteristics of women enrolled in the POSITIVE trial (pregnancy outcome and safety of interrupting therapy for women with endocrine responsIVE breast cancer)

Background: Pregnancy is a major concern for young breast cancer (BC) survivors. Conception after BC in women with hormone receptor positive (HR+) disease is affected by the standard 5-10 years of adjuvant endocrine therapy (ET) during which pregnancy is contraindicated and fertility may be waning. The POSITIVE Trial (IBCSG 48-14/BIG 8-13/Alliance A221405/NCT02308085) investigates the impact of temporary ET interruption to allow pregnancy.

Methods: POSITIVE enrolled premenopausal women with stage I-III HR+ early BC, ≤42 years of age, who had received adjuvant ET (SERM alone, ovarian function suppression (OFS) plus SERM or AI) for 18 to 30 months, and wished to interrupt ET to attempt pregnancy. An interruption of ET for up to 2 years was foreseen to allow pregnancy (after a 3-month ET washout period), delivery, and breastfeeding if desired/feasible. Resumption of ET to complete 5-10 years of treatment was planned as soon as pregnancy/breastfeeding was completed or after it was ensured conception was not possible. We report baseline characteristics of participants enrolled in POSITIVE by region of enrollment.

Results: From 12/2014 to 12/2019, 518 participants were enrolled at 116 centers in 20 countries across 4 continents. The table shows the baseline characteristics of the enrolled women.

Several differences were seen across regions: A higher proportion of participants &lt;35 yrs (43%) enrolled in North America than in Europe (33%) or Asia (26%). Eighty-one percent of Asian women had no children at enrollment compared to 75% and 68% of European and North American women, respectively. Consistently, a greater percent of women in Asia (56%) had used fertility preservation measures, compared to Europe (53%) and North America (43%). Stage distribution was also different across continents: a greater percent of Asian participants had stage I, grade 1 and node-negative disease (51%, 29% and 76 %, respectively) compared to European (46%, 14% and 67%) and North American (43%, 16% and 55%) women. Only 19% of Asian women had either 1-3 positive nodes and grade 3 tumors, the proportion increased to 28% and 35% in Europe and to 41% and 38% in North America, respectively. North American women were more likely to have had mastectomy (60% vs. Asian (44%) and European (41%)); European women were more likely to have had chemotherapy (69% vs. North American (56%) and Asian (42%)). ET administration prior to enrollment differed substantially by region: Most North American women had SERM (T) alone (58%), and when OFS was added to oral ET, it was combined with AI in 19% and with T in 8% of participants, respectively. In Asia most women received T + OFS (55%), followed by T alone (36%), and AI + OFS (6%). In Europe, T + OFS was the most frequent treatment (40%), followed by T alone (37%) and AI + OFS (17%). Median duration of ET before enrollment was similar across regions (22-24 months).

Conclusion: Regional variation of baseline characteristics of women enrolled in the POSITIVE trial may provide important insights into different medical and sociocultural attributes and attitudes of the study participants and investigators from those regions.

Affiliation: POSITIVE Investigators, International Breast Cancer Study Group, Alliance for Clinical Trials in Oncology, Breast International Group, North American Breast Cancer Group

CharacteristicRegion: Europe / North America / Asia-Pacific61% / 23% / 16%Median age at enrollment, yrs (IQR)37 (33-39)Caucasian race77%No children prior to enrollment74%Prior fertility preservation measures taken51%Stage I / II46% / 45%0 / 1 positive nodes65% / 21%Grade 2 / 348% / 33%HER2-negative74%Mastectomy46%Chemotherapy61%ET: SERM alone / SERM+OFS / AI+OFS41% / 35% / 16%Median duration of prior ET, mos (IQR)23 (20-27)

Citation Format: Ann H Partridge, Samuel M Niman, Monica Ruggeri, Fedro A Peccatori, Hatem A Azim, Jr, Marco Colleoni, Cristina Saura, Chikako Shimizu, Anna Barbro Sætersdal, Judith Kroep, Ellen Warner, Virginia F Borges, Andrea Gombos, Akemi Kataoka, Christine Rousset-Jablonski, Simona Borstnar, Hideko Yamauchi, Jeong Eon Lee, Janice M Walshe, Manuel Ruíz Borrego, Halle CF Moore, Christobel Saunders, Fatima Cardoso, Snezana Susnjar, Vesna Bjelic-Radisic, Karen L Smith, Martine Piccart, Larissa A Korde, Aron Goldhirsch, Richard D Gelber, Olivia Pagani. Baseline characteristics of women enrolled in the POSITIVE trial (pregnancy outcome and safety of interrupting therapy for women with endocrine responsIVE breast cancer) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS12-17.

Short-term effects of low-dose tolvaptan in acute decompensated heart failure patients with severe aortic stenosis: the LOHAS registry

Background

Tolvaptan exerts potent diuretic effects in heart failure patients without hemodynamic instability. Nonetheless, its clinical efficacy for acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) remains unclear. This study aimed to evaluate the short-term effects of tolvaptan in ADHF patients with severe AS.

Methods

The LOw-Dose Tolvaptan (7.5 mg) in Decompensated Heart Failure Patients with Severe Aortic Stenosis (LOHAS) registry is a multicenter (7 centers) prospective registry that assessed the short-term effects of tolvaptan in subjects hospitalized for ADHF with severe AS. A total of 59 subjects were enrolled between September 2014 and December 2017. The primary endpoints were changes in body weight and fluid balance measured daily from baseline up to 4 days.

Results

The median [interquartile range] patient age and aortic valve area were 85.0 [81.0–89.0] years and 0.58 [0.42–0.74] cm2, respectively. Body weight continuously decreased, and fluid balance was maintained from baseline to day 4 (p&lt;0.001, p=0.194, respectively). Median serum B-type natriuretic peptide concentration significantly decreased from 910.5 to 740.0 pg/mL by day 4 (p=0.002). However, systolic blood pressure and heart rate were non-significantly changed (p=0.250, p=0.656, respectively). Hypernatremia (&gt;150 mEq/L) and worsening renal function occurred in 2 (3.4%) and 4 (6.8%) patients, respectively.

Conclusions

Short-term treatment with low-dose tolvaptan is safe and effective, providing stable hemodynamic parameters in patients with ADHF and severe AS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This research was supported by Otsuka Pharmaceutical Co., Ltd.

Blood coagulation status after transcatheter aortic valve implantation between the patients with vitamin k antagonist and direct oral anticoagulants

Background

Ischemic stroke after transchatheter aortic valve implantation (TAVI) was recognized. Previous study showed that the median time of a stroke was 2.0 days (IQR, 1.0–5.0) after TAVI. One of the main mechanisms for ischemic stroke after TAVI was hyper-coagulation activity associated with TAVI procedure. However, the change of coagulation status in patients with oral anticoagulant (OAC) therapy was not investigated fully.

Purpose

We investigated the difference of blood coagulation parameters between the patients with vitamin K antagonist (VKA) and those with direct oral anticoagulants (DOAC).

Methods

We enrolled 253 patients underwent transfemoral TAVI between February 2017 and March 2019 in our hospital. Of 253 patients, 71 patients (age: 85, male: 20%) took OAC therapy (VKA: 21 patients, DOAC: 50 patients). Patients who took apixaban was 32 patients, rivaroxaban was 7, edoxaban was 11. Prothrombin activation fragment 1+2 (F1+2) as a molecular marker of thrombin generation, thrombin-anti-thrombin complex (TAT) as a marker of thrombin neutralization, soluble fibrin monomer complex (SFMC) as a marker of thrombophilia and fibrin/fibrinogen degradation product (FDP) as a marker of fibrinolysis were measured before and immediately after TAVI, and on 1 and 2 day postoperatively. We also assessed ischemic stroke after TAVI between 2 groups according to BARC-2 criteria.

Results

In patients with VKA, the value of PT-INR the day before TVAI was 1.2 (1.1–1.4). The level of F1+2 in patients with VKA was significantly greater on day 0 postoperatively than those with DOAC [855 pmol/l (595–1135) vs 614 pmol/l (452–774) P=0.003]. The level of SFMC in patients with VKA was significantly greater on day 0 postoperatively than those with DOAC [37.4 μg/ml (17.3–64.5) vs. 15.7 μg/ml (8.8–27.3) P=0.002]. The level of FDP in patients with VKA was significantly greater on day 0 postoperatively than those with DOAC [VKA: 5.8 μg/ml (3.8–7.9), DOAC: 4.0 μg/ml (3.1–5.3) P=0.023]. There were no patients with ischemic stroke among 2 groups.

Conclusion

This study revealed that coagulation activity was increased after TAVI. Furthermore, the coagulation activity in patients with VKA was significantly higher than that with DOAC at especially immediately after TAVI. Careful attention should be paid to hyper-coagulation status after TAVI in patients with VKA.

Funding Acknowledgement

Type of funding source: None

Physician's knowledge, attitudes and practice pattern for breast cancer diagnosed during pregnancy: a survey among breast care specialists in Japan

BACKGROUND

Breast cancer diagnosed during pregnancy (BCP) is uncommon, and thus there is limited evidence on its treatment. However, the incidence of BCP is increasing probably due to women having children at an older age. We aimed to clarify the practice patterns and limitations in treatment for BCP in Japan.

METHODS

A cross-sectional survey was developed for board-certified Japanese breast cancer specialists (n = 1583) to evaluate their knowledge, attitude, experience, and practice patterns regarding BCP. Survey items also included questions regarding potential barriers of practice toward patients diagnosed during pregnancy and respondents' background.

RESULTS

In March 2018, 492 (31.1%) breast oncologists responded to the survey. Among them, 234 (48%) respondents had the experience of treating at least one case of BCP. The accuracy of knowledge about BCP was evaluated by three items regarding BCP treatment from the latest Japanese Breast Cancer Society treatment guideline, and 265 (54%) were categorized to have "appropriate knowledge". Majority of the physicians (89%) have responded that patients should be treated in a center where both a cancer-treating team and obstetrician exist, and 48% responded that treating patients by the collaboration of cancer-treating team and obstetric team in different institutes is an alternative reasonable option.

CONCLUSIONS

Interest, knowledge, and awareness of the guidelines appear to influence physician attitude, and thus it is urgently important to lay out educational materials and learning opportunities regarding BCP for breast specialists. A regional network of oncologists, obstetricians, and pediatricians to support the BCP patients should be developed.

An intervention RCT-study aimed at improving mental health and increasing understanding of fertility preservation with Oncofertility! Psycho-Education And Couple Enrichment (O!PEACE) therapy

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Background: Although ASCO revised Guidelines (2013) recommends referring to psychological professionals if cancer patients show concerns or anxiety about fertility, there is no evidence regarding the efficacy of psychotherapy. The aim of this study is to examine whether the Psycho-Education And Couple Enrichment (O!PEACE) therapy can reduce psychiatric symptoms and improve stress coping and marital relationship in breast cancer patients. Methods: Trial design: multicenter randomized controlled trial, pre-post design. Subjects were women aged 20–39 years with breast cancer before cancer treatment and their husbands. Couples were randomly assigned to receive O!PEACE therapy (n = 37) or not (usual care: n = 37). Assessments of PTSD symptoms, depression and anxiety were made as the primary end points at baseline and at the end of therapy before cancer treatment. Stress coping strategies, resilience, marital relationships, and marital communication were examined as secondary end points. Results: Four participants in O!PEACE therapy and one participant in the usual care withdrew from the trial. Intention-to-treat analyses were conducted using analysis of covariance after multiple imputation by R and SPSS. Series of ANCOVAs were integrated according to Rubin’s rule. A significant decrease was observed in the primary outcome of PTSD symptoms, from baseline to post-intervention, in women who participated in O!PEACE therapy (p = .011, ηp2 = .089). According to post-hoc analyses, for patients with a higher baseline IES-R-J score, O!PEACE therapy resulted in a significantly higher reduction in follow-up assessment IES-R-J score when compared with usual care (U = 172.80, p = .027, r = .258): 59.3% of the women in O!PEACE therapy showed a 5-point or greater reduction, whereas in usual care, 30.0% showed a 5-point or greater reduction. For husbands, the O!PEACE therapy also showed a significant improvement of giving up and blaming others as the stress coping strategy and escape-avoidance coping strategy in their marital communication. For breast cancer patients, the O!PEACE therapy significantly improved support from husbands and the patients’ knowledge level of oncofertility compared with those receiving usual care. Conclusions: Only two counseling sessions of O!PEACE therapy can reduce patients’ distress, improve their husbands’ coping style, and may build a better cooperative relationship for couples in terms of fertility preservation and cancer treatment. Clinical trial information: UMIN000017754 .

P2621Clinical safety and efficacy of tolvaptan for acute phase therapy in patients with low-flow severe aortic stenosis

Background

Conventional diuretic therapy for low-flow (LF) severe aortic stenosis (SAS) often has an inadequate effect or causes hemodynamic instability. Tolvaptan is used for acute heart failure in addition to conventional diuretics in Japan, and it does not cause intravascular dehydration.

Purpose

This study aimed to retrospectively investigate the safety and efficacy of tolvaptan in the acute phase patients with SAS and compared LF-SAS with normal-flow (NF) SAS.

Methods

56 consecutive SAS patients are analyzed. The primary endpoints were adverse clinical events (death, worsening heart failure, worsening renal failure, fatal arrhythmia, cardiogenic or hypovolemic shock, and use of inotropic agents) and the volume of urine and fluid balance within 48 hours of tolvaptan administration (Figure).

Results

Among 56 patients, 16 had LF-SAS (29%), and 40 had NF-SAS (71%). Severe adverse clinical events were not observed 48 hours after tolvaptan administration. In both groups, the urine volume significantly increased after tolvaptan administration in comparison to 24 hours before tolvaptan administration (both, p<0.01). There were no changes in the urine volume during the initial 24 and 48 hours. In the LF-SAS group, tolvaptan resulted in a significant decrease in fluid balance during the initial 24 and 48 hours compared to 24 hours before tolvaptan administration (p<0.05).

Treatment and data collection protocols

Conclusion

Adding tolvaptan to conventional treatment leads to an increase in urine output and a decreased fluid balance without hemodynamic instability in patients with LF-SAS.

Acknowledgement/Funding

None