Impact of RxPONDER on breast cancer treatment in an academic-community hospital

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Background: The introduction of Oncotype Dx set the stage for targeting chemotherapy treatment to only patients who would derive a benefit. RxPONDER trial then demonstrated that postmenopausal women with 1-3 positive lymph nodes, could forego chemotherapy if the recurrence score (RS) was ≤25. The most common chemotherapy regimens for breast cancer are taxotere and cytoxan or dose dense adriamycin/cytoxan followed by taxol. Chemotherapy can have many side effects and can increase risk of hospitalization due to complications. In addition, the financial cost can be considerable. Four cycles of TC will approximately cost $59,000, and most patients likely receive doses of growth factor support (neulasta is $12,565 per dose), totaling at minimum to $100,000 per patient. The purpose of this study was to look at the impact of RxPONDER on our patients. We reviewed patients who had RS at our institution in the last 5 years to see if we were appropriately treating patients with chemotherapy and hormonal therapy, or if a large group could be treated with hormonal therapy alone. Methods: This was an IRB approved retrospective chart review of patients at an academic-community hospital from 2015-2019. We identified patients ≥50 years old diagnosed with ER+/HER2- node positive breast cancer. Exclusion criteria included: M1, pN2, pN3. Univariate analysis used to compare patients that had RS vs those that did not. Student’s t-test was used to analyze whether there was a difference in rate of patients getting chemotherapy based on RS. Results: 216 patients were identified with ER+/Her2- breast cancer and 1-3 positive lymph nodes. 142 had RS (65.7%). Of those with RS, 140 were T1-T2 (98.6%), 131 had 1-2 positive LNs (92.3%), 115 had RS≤25 (80.9%), and 56 received chemotherapy (39.4%). Of the 74 patients without RS, 60 were T1-T2 (94.6%), 69 had 1-2 positive LNs (93.2%), and 51 received chemotherapy (68.9%). 30 patients who met the RxPONDER criteria (postmenopausal, 1-3 positive lymph nodes, and RS ≤25) still received chemotherapy. Conclusions: If we apply the RxPONDER trial recommendations, 30 patients would have been spared chemotherapy. In addition, 54.2% RxPONDER patients had RS ≤25. Extrapolated by percentage, 40 of the 74 patients who did not get RS in our study may have also been spared the side effects and cost of chemotherapy. This would be a savings of at least $3-7 million dollars to the health care system. RxPONDER makes a significant impact, not only in appropriately deescalating breast cancer treatment, but also to counter the increasing cost of medical care.[Table: see text]

Five-year longitudinal mammographic follow-up after breast cancer

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Background: Breast Cancer recurrences following radiation are seen in the first three to five years after treatment. As part of our Survivorship Program, annual screening mammography is a guideline following treatment with the exception of those patients who undergo bilateral mastectomy. To evaluate compliance with this guideline, we followed patients treated in 2012 for breast cancer at our institution, over the five-year period through 2017. Methods: A retrospective chart review of patients diagnosed with breast cancer in 2012 was conducted and annual mammography was assessed for compliance for a period of five-years. Compliance was defined as having annual mammography screening for five years, until recurrence or until death. Results: 252 patients were treated for Breast Cancer in 2012. Of these, 15 patients had follow-up elsewhere. 4 patients had metastatic disease at the time of diagnosis and were not included. 3 patients with male breast cancer had no mammographic follow-up. 5 patients had bilateral mastectomies and were excluded leaving 225 patients followed for compliance. Of the 225 evaluable patients, 134 (59.5%) were compliant with mammography. 126 (56.0%) had a full five years of follow-up and had no recurrent breast cancer. 158 (70.2%) had four years of follow-up. 168 patients (74.7%) had three years of follow-up. 178 (79.1%) had two years of follow-up. 190 (84.4%) had at least one year of follow-up. 14 (6.2%) died before the five year follow-up of causes not related to breast cancer. 7 (3.1%) developed metastatic disease during follow-up and no additional mammography was carried out. 7 had ipsilateral recurrence, 3 had contralateral recurrence (4.4%). Conclusions: In an upper-middle class population that is well insured and should be compliant, only 59.5% of eligible patients were compliant with mammography for five-years, until recurrence or death. Since almost 5% of patients in this cohort recurred in the breast, follow-up with annual mammography is critical. The Survivorship Care Plan (SCP) discussion with the patient is a strategy to address compliance with annual follow-up. Future studies are planned to re-evaluate compliance with annual mammography.

Diagnostic accuracy of the Videssa protein-based liquid biopsy for breast cancer in suspicious mammography

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Background: The Videssa protein-based blood test (Provista Diagnostics) is a combined proteomic biomarker assay that aims to detect established breast cancer – rendering it useful in patients with abnormal or difficult-to-interpret mammograms. Since the incidence of malignancy for BI-RADS 4 biopsies is approximately 20%, a significant percentage of patients undergo needle biopsy unnecessarily. The Videssa assay provides an alternative diagnostic method by way of a non-invasive liquid biopsy. Methods: Our goal was to assess whether this liquid biopsy combined with 3D tomographraphic mammography could accurately predict disease status to reduce the amount of unnecessary tissue biopsies. An IRB-approved, prospective, single-arm study had patients with BI-RADS4 lesions with calcifications requiring tissue biopsy undergo the blood test prior to stereotactic core biopsy. Subsequent results and biopsy pathology were correlated. Results: 46 patients were initially entered with BI-RADS4 calcifications. 9 patients had DCIS (19.6%) and 37 patients had benign calcifications (80.4%). No patient had invasive cancer. Liquid biopsy results were elevated in 2 patients with DCIS (22% sensitivity) and in 5 patients with benign biopsies (10.8%). At interim analysis, the liquid biopsy demonstrated a 28.5% positive predictive value (PPV) and 82% negative predictive value (NPV). Tumor grade did not affect results. We subsequently discontinued using the blood test for BI-RADS4 calcifications and enrolled 13 patients with non-palpable solid lesions to determine the correlation. The liquid biopsy was elevated in 1 of 4 patients with invasive cancer (25% sensitivity) and was not elevated in all 9 patients with benign biopsies (100% NPV). At one-year follow-up, 3 of the 5 patients with an elevated blood assay and negative biopsy have had no incidence of cancer on subsequent imaging. The remaining 2 patients are scheduled for follow-up. Conclusions: In our study, the NPV of the Videssa liquid biopsy is not robust enough to defer tissue biopsy in any patient with indeterminate calcifications on imaging, nor is it specific enough to help predict results in high risk solid lesions. We do not see this liquid biopsy changing our current practice.

A comparison of genomic assays in determining risk of late recurrence and benefit of extended endocrine therapy (EET)

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Background: Breast cancer patients who are ER positive, lymph node negative have the best overall prognosis. However 50% of recurrences occur after 5 years. The Breast Cancer Index (BCI) is a gene expression-based biomarker that provides an individual risk of distant recurrence and benefit of EET based on a continuous risk model. (1) The BCI may help with clinical decisions regarding EET since prolonged therapy may have an increase in side effects including uterine cancer, DVT, myalgias and bone loss. The OncotypeDX is a 21 gene assay that predicts recurrence with a recurrence score. A recent study by Wolmark et al. evaluated the use of quantitative Estrogen Receptor Index (ESRI) combined with RS and found that RS was prognostic in patients with higher quantitative ESRI, suggesting EET be used for patients with intermediate and high RS with ESR1 expression > 9.1. (2) Methods: 20 patients, ER positive, node negative who had the BCI and ONC-DX performed were evaluated in this retrospective IRB approved review. Results: Using ESRI alone 85% of patients would be recommended to continue an additional 5 years of EET. Using BCI this number was reduced to 35%. Conclusions: Comparing both the risk of recurrence and benefit of ETT, ESRI and BCI were concordant only 37.5% of the time. The cost of extended adjuvant therapy with Anastrazole ($190/mos x 60 mos = $11,400) or Tamoxifen ($50/mos x 60 mos = $ 3,000) would have resulted in a cost savings of $79,800 (Anastrazole) or $21,000 (Tamoxifen) for this small group of patients. Utilization of the BCI (cost $ 3416.00) may be a cost effective and accurate genomic approach in determining the use of EET and avoiding concomitant side effects.

Abstract P3-13-10: A comparison of the micro-impulse radar SAVI SCOUT to the radioactive I125 seed in localization of non-palpable breast cancer for breast conserving therapy

Breast conservation and primary radiation (BCT) is a widely used treatment for early stage breast cancer patients. Studies report a 20-40 percent re-excision rate to obtain clear margins. Current localization practices include needle, radioactive seed and intraoperative U/S. Seed localization has been found to decrease tissue volume excision and improve patient satisfaction. However, radioactive seed programs are difficult to implement due to cumbersome regulations by the Nuclear Regulatory Commission (NRC). SAVI SCOUT® is a new technology cleared by the FDA for tumor localization. This device utilizes non-radioactive, micro-impulse radar (radar) to provide surgical guidance. The aim of this study was to evaluate the SCOUT® and determine its equivalence to seed localization by comparing re-excision rates and specimen volume.

70 patients with clinical stage 0, I, or II breast cancer who were treated with BCT were included in this IRB approved review. 35 patients were compared using the SCOUT radar localization technique with 35 patients using the radioactive iodine 125 seed localization technique. All patients received a wide segmental resection. The tissue was oriented and assessed clinically (visualization and palpation) and radiographically (Kubtec's XPERT 40 Digital Specimen Radiography System) in the operating room. Additional margins were excised if deemed to be suspicious by the surgeon (unless the anterior margin was skin or the posterior margin was the pectoral muscle fascia). Final margin status for both groups was compared. A positive margin was any margin with tumor on ink. The total volume of the excised specimen plus additional margins was recorded by the pathologist.

In all 70 patients, the targeted lesions, seed and/or reflectors were successfully removed. There were 420 margins assessed (6 for each specimen), using the additional margins excised as the final margin for evaluation of tumor on ink. Of the 210 final margins in the specimens excised using the seed, 5 margins (2.38%) in 4 patients were positive. 5 margins (2.38%) were also positive in 4 patients using the SCOUT. Nine patients in total returned to the operating room for re-excision. [One re-excision was performed as physician preference for close (<2mm) margins for DCIS.] 5/9 patients requiring re-excision were found to have residual disease. A total of 119 additional margins were excised from 51 patients at the initial operation. 68 margins from 26 patients (SCOUT) and 51 margins from 25 patients (seed). Of the 119, 5 margins were found to be positive. 3 margins 4.41% (3/68) in the SCOUT group and 2 margins 3.92% (2/51) in the seed group. The average volume resected from the SCOUT averaged 81.28 cm3 while the volume of the seed averaged 100.39 cm3 (p-value 0.209).

The use of SCOUT for non-palpable tumor localization was equivalent to seed localization when comparing margin re-excision rate and tissue volumes. We conclude that SCOUT is an excellent alternative in breast cancer localization and can be easily implemented in most hospitals for breast conservation therapy.

Citation Format: Nolano SE, Thalhiemer LO, Yu E, Grujic E, Carter WB, Frazier TG. A comparison of the micro-impulse radar SAVI SCOUT to the radioactive I125 seed in localization of non-palpable breast cancer for breast conserving therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-10.

Concordance of Van-Nuys Prognostic Index, Memorial Sloan Kettering Breast Cancer nomogram and Oncotype Dx DCIS scores in prediction of ductal carcinoma in situ(DCIS) recurrence risk

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Background: Ductal Carcinoma in situ (DCIS) has a wide spectrum of bioagressiveness. Three models used to assess recurrence risk (RR) of DCIS include: the Van-Nuys Prognostic Index (VN), Memorial Sloan Kettering Breast Cancer Nomogram (MN) and Oncotype Dx DCIS Score (OD; Genomic Health, Redwood City, CA). The aim of our study was to evaluate the concordance between these RR models. Methods: An IRB-approved retrospective chart review was performed on 37 consecutive patients at our institution with DCIS from 12/2011-4/2015 who underwent breast conservation surgery and in whom an OD was obtained. The OD and ‘any recurrent event at 10-years’ scores were used to stratify patients into low risk (LR; OD DCIS score <39/<17%), intermediate risk (IR; 39-54/17-24%) and high risk (HR; >54/>24%), as outlined in the original OD study. The ‘10-year RR’ scores from MN were stratified using the same percentile breakdown as OD. The VN were stratified into LR (4-6), IR (7-9) and HR (>9) groups based on the updated VN study’s guideline. Pathologic slides were re-reviewed by one pathologist blinded to OD score to determine size and margin width based on the protocol outlined in the original VN paper. The three scores for each patient were compared. Results: Eleven patients (29.7%) had concordance between all three scores and all were LR. In 10.8% of patients, there was no concordance between the three scores. The concordance between the OD and VN, OD and MN, and VN and MN was 64.9%, 48.6% and 35.1%, respectively. Conclusions: In evaluating RR, determining LR may have the greatest implication since this group may be the least likely to benefit from adjuvant radiotherapy. Concordance between all three models was seen only in LR patients. All patients who were LR by VN were also LR by OD and MN. Determining a VN initially may help guide additional testing. The added value of OD may be primarily in patients who are not LR by VN. The MN seems to be of limited value in this study. Larger studies assessing these relationships and their outcomes in predicting potential RR in DCIS are warranted.

Randomized trial using gonadotropin-releasing hormone agonist triptorelin for the preservation of ovarian function during (neo)adjuvant chemotherapy for breast cancer

PURPOSE

Chemotherapy-induced amenorrhea is a serious concern for women undergoing cancer therapy. This prospective randomized trial evaluated the use of gonadotropin-releasing hormone (GnRH) analog triptorelin to preserve ovarian function in women treated with chemotherapy for early-stage breast cancer.

PATIENTS AND METHODS

Premenopausal women age 44 years or younger were randomly assigned to receive either triptorelin or no triptorelin during (neo)adjuvant chemotherapy and were further stratified by age (< 35, 35 to 39, > 39 years), estrogen receptor status, and chemotherapy regimen. Objectives included the resumption of menses and serial monitoring of follicle-stimulating hormone (FSH) and inhibin A and B levels.

RESULTS

Targeted for 124 patients with a planned 5-year follow-up, the trial was stopped for futility after 49 patients were enrolled (median age, 39 years; range, 21 to 43 years); 47 patients were treated according to assigned groups with four cycles of adriamycin plus cyclophosphamide alone or followed by four cycles of paclitaxel or six cycles of fluorouracil, epirubicin, and cyclophosphamide. Menstruation resumed in 19 (90%) of 21 patients in the control group and in 23 (88%) of 26 in the triptorelin group (P= .36). Menses returned after a median of 5.8 months (range, 1 to 19 months) after completion of chemotherapy in the triptorelin versus 5.0 months (range, 0 to 28 months) in the control arm (P= .58). Two patients (age 26 and 35 years at random assignment) in the control group had spontaneous pregnancies with term deliveries. FSH and inhibin B levels correlated with menstrual status.

CONCLUSION

When stratified for age, estrogen receptor status, and treatment regimen, amenorrhea rates on triptorelin were comparable to those seen in the control group.

HER2-positive male breast cancer with thyroid cancer: an institutional report and review of literature

We report a rare finding of two male breast cancer patients with HER2-positive breast cancer who also developed thyroid cancer. We reviewed 45 male breast cancer patients treated in our institution from 2003 to 2008. Only five male breast cancer patients were HER2-positive. In reviewing the published data, we found no cases of thyroid cancer and concurrent breast cancer in men. However, breast cancer and thyroid cancer have shown close association in women. This finding therefore provokes speculation as to whether we should investigate whether women with HER2-positive breast cancer are at a higher risk for thyroid cancer. Although this observation seems to be clinically prevalent, publications are sparse in clinical research areas linking thyroid cancer to breast cancer.

Ultralight metallic microlattices

Ultralight (<10 milligrams per cubic centimeter) cellular materials are desirable for thermal insulation; battery electrodes; catalyst supports; and acoustic, vibration, or shock energy damping. We present ultralight materials based on periodic hollow-tube microlattices. These materials are fabricated by starting with a template formed by self-propagating photopolymer waveguide prototyping, coating the template by electroless nickel plating, and subsequently etching away the template. The resulting metallic microlattices exhibit densities ρ ≥ 0.9 milligram per cubic centimeter, complete recovery after compression exceeding 50% strain, and energy absorption similar to elastomers. Young's modulus E scales with density as E ~ ρ(2), in contrast to the E ~ ρ(3) scaling observed for ultralight aerogels and carbon nanotube foams with stochastic architecture. We attribute these properties to structural hierarchy at the nanometer, micrometer, and millimeter scales.

Institutional variation in the surgical treatment of breast cancer: a study of the NCCN

OBJECTIVE

To investigate the relationship between supply of subspecialty care and type of procedure preferentially performed for early stage breast cancer.

BACKGROUND

Three surgical options exist for early stage breast cancer: (1) breast conserving surgery (BCS), (2) mastectomy with reconstruction (RECON), and (3) mastectomy alone. Current guidelines recommend that surgical treatment decisions should be based on patient preference if a patient is eligible for all 3. However, studies demonstrate persistent variation in the use of BCS and RECON.

METHODS

Patients undergoing an operation for DCIS or stage I or II breast cancer at NCCN institutions between 2000 and 2006 were identified. Institutional procedure rates were determined. Spearman correlations measured the association between procedure types. Patient-level logistic regression models investigated predictors of procedure type and association with institutional supply of subspecialty care.

RESULTS

Among 10,607 patients, 19% had mastectomy alone, 60% BCS, and 21% RECON. The institutional rate of BCS and RECON were strongly correlated (r = -0.80, P = 0.02). Institution was more important than all patient factors except age in predicting receipt of RECON or BCS. RECON was more likely for patients treated at an institution with a greater supply of reconstructive surgeons or where patients live further from radiation facilities. RECON was less likely at institutions with longer waiting times for surgery with reconstruction.

CONCLUSIONS

Even within the NCCN, a consortium of multidisciplinary cancer centers, the use of BCS and mastectomy with reconstruction substantially varies by institution and correlates with the supply of subspecialty care.

Role of axillary staging in women diagnosed with ductal carcinoma in situ with microinvasion

BACKGROUND

Axillary staging via sentinel node biopsy (SLNB) in patients with ductal carcinoma in situ with microinvasion (DCISM) is routinely performed but remains controversial with regard to the risk-benefit ratio.

METHODS

Retrospective single-institution review of patients with diagnosis of DCISM (invasive tumor ≤ 0.1 cm). Age, clinicopathologic data, and follow-up were recorded.

RESULTS

Of 90 patients, 33% were diagnosed by core needle biopsy (CNB), 37% by excisional biopsy, and 29% were upstaged from DCIS on CNB to DCISM at final operation. Three (10%) of 30 patients with DCISM on CNB were upstaged to invasive cancer on final pathology. Median age at diagnosis was 58.9 years (range: 30-89). Lumpectomy was performed in 45% of patients and mastectomy in 55%. Mean number of sentinel nodes was 2.59 (SE 0.17). Six (6.9%) of 87 patients with DCISM as final diagnosis had a positive SLNB (four lumpectomies, two mastectomies). There was no correlation with any clinicopathologic features, including palpable DCIS, DCIS grade/necrosis, or age at diagnosis. All six SLNB-positive patients had a complete axillary dissection; two had additional disease. Median follow-up time was 74.2 months (range: 2-169). In-breast recurrence was seen in three patients (5%), regardless of SLN status, DCIS grade, or necrosis. Two patients developed distant metastasis. Overall survival was 94.19% at 5 years for DCISM and 100% for DCISM with nodal disease.

CONCLUSION

DCISM comprises 0.6% of breast cancer diagnoses at our institution. There is a low likelihood of nodal spread; however, a lack of identifiable clinicopathologic features associated with a positive SLNB limits selective SLNB use.

A mammaglobin-A targeting agent for noninvasive detection of breast cancer metastasis in lymph nodes

Pathologic axillary lymph node (ALN) status is an important prognostic factor for staging breast cancer. Currently, status is determined by histopathology following surgical excision of sentinel lymph node(s), which is an invasive, time consuming, and costly procedure with potential morbidity to the patient. Here, we describe an imaging platform for noninvasive assessment of ALN status, eliminating the need for surgical examination of patients to rule out nodal involvement. A targeted imaging probe (MamAb-680) was developed by conjugation of a mammaglobin-A-specific monoclonal antibody to a near-infrared fluorescent dye. Using DNA and tissue microarray, mammaglobin-A was validated as a cell-surface target that is expressed in ALN-positive patient samples but is not expressed in normal lymph nodes. In vivo selectivity was determined by i.v. injection of MamAb-680 into mice with mammaglobin-A-positive and -negative mammary fat pad (MFP) tumors; and by peritumoral MFP injection of the targeted imaging probe in mice with spontaneous ALN metastases. Fluorescence imaging showed that probe was only retained in positive tumors and metastases. As few as 1,000 cells that endogenously express mammaglobin-A were detected in ALN, indicating high sensitivity of this method. Translation of this approach offers considerable potential as a noninvasive clinical strategy to stage breast cancer.

Consequences of axillary ultrasound in patients with T2 or greater invasive breast cancers

BACKGROUND

Axillary ultrasound (AUS) with needle biopsy is used to detect metastasis in patients with invasive breast cancers. Our hypothesis is that preoperative AUS significantly reduces sentinel node biopsy (SLNB) use in patients with invasive breast tumors >2 cm upon clinical examination.

METHODS

A single-institution database of patients with breast cancer and AUS was reviewed. Patients with incomplete records, clinical tumor <2 cm, or postoperative AUS were excluded. A control cohort of non-AUS patients with clinical T2 (cT2) or greater disease was identified. Clinicopathologic data were collected. Simple Kappa coefficient and chi-square statistical analyses were performed.

RESULTS

AUS was performed in 153 patients vs. 370 controls. Of AUS patients, 112 (73.2%) had cT2 disease vs. 272 (73.5%) controls. Median AUS patient age was 53.7 (range, 22.8-85.8) years vs. 53.8 (range, 26.7-91.6) years; median pathologic tumor was 3.8 (range, 1.0-20.0) cm in AUS patients vs. 2.5 (range, 0.1-11.0) cm. Among AUS patients, 78% had needle biopsy; 85 of 120 (70.8%) were positive. Sixty-eight patients had SLNB: 33 after negative AUS and 35 after negative needle biopsy. Twenty-three SLNB (37.3%) were positive; 15 of 33 after negative AUS and 8 of 35 after a negative needle biopsy. Axillary dissection was performed in 102 of 153 vs. 225 of 370 controls. Sensitivity and specificity of AUS was 86.2% and 40.5%. Sensitivity of AUS plus needle biopsy was 89.3% with 100% specificity. Neoadjuvant chemotherapy was given to 49.7% of AUS patients. AUS reduced costs by more than $4,000 per patient.

CONCLUSIONS

AUS reduces SLNB use and affects treatment in patients with cT2 or greater breast cancer. Routine AUS should be considered in this population.

Indications for sentinel lymph node biopsy in the setting of prophylactic mastectomy

BACKGROUND

Bilateral/contralateral prophylactic mastectomy (PM) is offered to high-risk women to decrease their actual or perceived breast cancer risk. When an invasive occult cancer is identified, prevailing wisdom suggests that an axillary dissection be performed. This single-institution study aims to identify patients who may benefit from sentinel node biopsy (SLNB) at the time of prophylactic mastectomy.

STUDY DESIGN

We performed a retrospective review of a prospective database of patients treated at our institution with bilateral/contralateral PM between 1995 and 2006. We examined patients' clinicopathologic characteristics in comparison with their incidence of occult cancer in the contralateral breast or axilla.

RESULTS

There were 449 patients who underwent PM and SLNB. Twenty-eight underwent bilateral PM. Of the 28, no occult cancers were identified. Occult cancers were identified in 18 of 420 (4.3%) contralateral prophylactic specimens; they were invasive in 6 (1.4%). In cases of occult carcinoma, the primary established tumor was more likely to be of invasive lobular histology. Eight of 420 (2%) patients had a positive contralateral sentinel node, and within this subset of 8 patients the majority had locally advanced disease on the known tumor side. Other features associated with a positive contralateral sentinel node included the presence of lymphovascular involvement or skin or nipple involvement and grade 2 to 3 invasive primary established tumors.

CONCLUSIONS

Overall, SLNB in patients undergoing bilateral PM or contralateral PM associated with early-stage disease is not indicated. But patients with locally advanced primary breast cancers have a significantly increased risk of occult cancer in the contralateral axilla, likely due to crossover metastasis; this select group of patients may benefit from SLNB at the time of surgery.

Tumor-induced upregulation of Twist, Snail, and Slug represses the activity of the human VE-cadherin promoter

Endothelial integrity is dependent on intracellular adherens junctions formed by complexes of vascular endothelial (VE)-cadherin and catenins. We have previously demonstrated that exposing endothelial cells (EC) to breast cancer cell-conditioned media (CM) for 24h results in a reduction in VE-cadherin protein and mRNA levels. Herein, we examined the mechanism(s) involved in the downregulation of VE-cadherin by CM. Human dermal microvascular EC exposed to CM showed a downregulation in VE-cadherin promoter activity and upregulation of Twist, Slug, and Snail expression. Reporter gene analysis demonstrated a direct repression of the VE-cadherin promoter by Slug, Snail, and Twist expression plasmids. At least two E-box motifs appear to be involved in this regulatory process as shown by electrophoretic mobility shift assays. These results suggest that factors released by breast cancer cells are able to upregulate Twist, Slug, and Snail expression in EC, which in turn downregulate the activity of the VE-cadherin promoter.

Chemotherapy use for hormone receptor-positive, lymph node-negative breast cancer

PURPOSE

To describe the frequency of chemotherapy use for hormone receptor (HR)-positive, lymph node (LN)-negative breast cancer from 1997 to 2004 at eight National Comprehensive Cancer Network institutions, to explore whether chemotherapy use varied over time and between institutions, and to identify factors associated with the decision to forego chemotherapy.

PATIENTS AND METHODS

Among women younger than age 70 years with HR-positive, LN-negative breast cancer measuring more than 1 cm, we analyzed the frequency of chemotherapy use on a yearly basis. A multivariable logistic regression model assessed the relationship between receipt of chemotherapy and year of diagnosis, institution, tumor features, and patient characteristics. Interaction terms were added to the model, and stratified analyses were conducted to further explore the determinants of chemotherapy use.

RESULTS

Fifty-five percent of 3,190 women received chemotherapy. Chemotherapy use was less common for patients with 1.1- to 2-cm tumors than for patients tumors greater 2 cm (47% v 87%, respectively; P < .01) and for women age 60 to 69 years versus women younger than age 50 years (24% v 76%, respectively; P < .01). On multivariable analysis, predictors independently associated with receiving chemotherapy included larger tumor size, higher grade, human epidermal growth factor receptor 2 overexpression, younger age, and institution (P < .01 for all). Institutions exhibited dramatically different rates of chemotherapy use (from 46% to 65%) and patterns of change in chemotherapy use over time (from a 79% relative increase to a 22% relative decrease).

CONCLUSION

Although institutions seemed to agree that not all women with HR-positive, LN-negative breast cancer need chemotherapy, there did not seem to be consensus regarding which women should get chemotherapy. Only prospective randomized controlled trials will conclusively establish which subtypes of HR-positive, LN-negative breast cancer benefit from chemotherapy.

Purified human chorionic gonadotropin induces apoptosis in breast cancer

Agents that induce apoptosis in breast cancer cells have great potential to facilitate chemotherapeutic intervention and improve patient outcomes. In this study, the effects of injecting purified human chorionic gonadotropin (hCG) directly into human breast cancer xenografts grown in nude mice were examined. It was shown that intratumoral injection of purified hCG increased the apoptotic index in breast cancer xenografts. These results were supported by the findings that exposure of breast cancer cells to purified hCG decreased cell viability in five different breast cancer cell lines. In some of these cell lines, the effects of hCG in cell viability appear to correlate with activation/expression of the hCG/luteinizing hormone receptor. Preoperative apoptotic induction by factors such as purified hCG may improve local control or work synergistically with neoadjuvant chemotherapy to improve complete pathologic response of locally advanced breast cancer.