Employment status and work-related difficulties in family caregivers of terminal cancer patients compared with the general population

9580

Background: This study was aimed to investigate the employment status and work-related difficulties among family caregiver of terminal cancer patients compared with the general population. Methods: A survey was administered to 381 family caregivers of terminal cancer patients at 11hospitals and 994 general populations aged more than 18 years. Results: Family caregivers of terminal cancer patients were female (66.7%) and the patient's spouse (50.9%), with mean age of 46.8years (SD, 13.5). 212(56.1%) were working before cancer diagnosis, however, only 133(36.3%) continued working currently. Compared with the general population, 233(63.7%)family caregivers of terminal cancer patients were more likely to be not working (adjusted odds ratio [aOR] =2.39; 95% confidence interval [95%CI] = 1.73 to 3.29).Those who continued working reported more easy fatigability (40.6% vs 22.4%) and reduced working hours (20.3% vs 2.1%) than general population. For those doing housework, caregiving itself (56.4%) were identified to be the most common difficulties, followed by easy fatigability (32.3%). Major reasons for not working were providing care to the terminal cancer patients (24.0%). Older age (aOR=10.37; 95%CI=2.80 to 38.41), female sex (aOR=4.28; 95%CI=2.25 to 8.13), lower household income (aOR=2.19; 95%CI=1.19 to 4.06), bearing medical cost by other than spouse (aOR=2.10; 95%CI=1.05 to 4.19), and low performance status of the patients (aOR=2.00; 95%CI=1.01 to 3.95) were significantly associated with not working. Conclusions: When compared to the general population, family caregivers of terminal cancer patients were at risk job loss from their caregiving burden, and caregiving and easy fatigability were the major work-related difficulties. Our study might help make a strategy to reduce job loss for family caregivers' caregiving burden.

No significant financial relationships to disclose.

Survival time and its prognostic factors in advanced unresected cholangiocarcinoma without chemoradiation

e15681

Background: To evaluate survival time and its prognostic factors contributing to survival of advanced unresected cholangiocarcinoma. Methods: We reviewed the experience of 330 patients with histologically proven unresected advanced intrahepatic and hilar cholangiocarcinoma and evaluated their survival time and significant prognostic factors. They did not receive any surgery, chemotherapy and radiotherapy and they underwent only palliative nonsurgical biliary drainage if it was needed to relieve biliary obstructive symptom. Results: Survival time of overall cholangiocarcinoma (median±SD) was 3.9±7.8 months; 3±5.3 months for intrahepatic cholangiocarcinoma, 5.9±10.1 months for hilar cholangiocarcinoma. By Kaplan-Meier survival analysis, intrahepatic cholangiocarcinoma patients survived significantly shorter than hilar cholangiocarcinoma patients. By multivariate analysis for intrahepatic cholangiocarcinoma, distant metastasis was independently associated with shorter survival time. Multivariate analysis for hilar cholangiocarcinoma showed initial CEA > 30 ng/dl were independent predictors of shorter survival. Conclusions: Patients with unresectable cholangiocarcinoma who do not undergo surgery, chemotherapy and/or radiotherapy have a dismal prognosis. We hope that the outcome of our study would help clinicians better predict the prognosis of cholangiocarcinoma patients not receiving such aggressive treatments. These data would be used as the comparable data for control groups of future studies to assess the outcome of newly designed or developed treatment method.

No significant financial relationships to disclose.

Pretransplant comorbidity as an outcome predictor in adult patients younger than 60 years of age receiving standard induction chemotherapy for de novo acute myeloid leukemia

7055

Background: Comorbidity has been evaluated as an outcome predictor in elderly patients receiving induction chemotherapy for acute myeloid leukemia (AML) as well as in patients undergoing allogeneic hematopoietic cell transplantation (HCT) for various hematologic disorders. In this single-institute retrospective study, we investigated the prognostic significance of comorbidity in younger AML patients. Methods: A total of 276 patients, aged 14 to 59 years, who received standard induction chemotherapy consisting of cytarabine plus daunorubicin or idarubicin for de novo AML excluding M3 subtype between 2000 and 2007 were included. Pre-treatment comorbidity score, assessed by the HCT specific comorbidity index (HCT-CI), was calculated using clinico- pathologic data, which were retrieved from Asan Medical Center Leukemia Registry Database. The HCT-CI score was 0 in 113 patients (40.9%), 1 in 94 (34.1%), and ≥ 2 in 69 (25.0%). Results: In the univariate analyses, the HCT-CI score was not a significant prognostic factor for induction of complete remission (CR), whereas survival outcomes such as overall survival (OS), relapse-free survival (RFS) and event-free survival (EFS) were significantly different according to the HCT-CI scores (Table). The multivariate models showed that the HCT-CI score was an independent prognostic factor for EFS (P=0.044), but not for OS (P=0.301) and RFS (P=0.119). Other independent prognostic factors were age (P=0.001 for OS, P=0.002 for RFS, P=0.006 for EFS), initial leukocyte counts (P=0.006 for CR, P<0.001 for OS, P=0.039 for RFS), initial uric acid levels (P=0.004 for RFS, P=0.001 for EFS), and cytogenetic risk groups (P=0.012 for CR, P<0.001 for OS, P<0.001 for RFS, P=0.005 for EFS). Conclusions: Pre-treatment comorbidity may provide additional prognostic information over established prognostic factors in patients younger than 60 years of age receiving standard induction chemotherapy for de novo AML.

[Table: see text]

No significant financial relationships to disclose.

Study of anxiety and depression in cervical cancer survivors

e20644

Background: Cervical cancer is the second leading cause of cancer related deaths among women in Korea. However, few studies have been conducted to elucidate the psychological distress of this population. This study aimed to examine the prevalence of anxiety and depression among cervical cancer survivors, and to identify factors associated with such caseness. Methods: A total of 832 cervical cancer survivors recruited from six large hospitals in Korea completed a mailed survey, which included the Hospital Anxiety and Depression Scale (HADS), European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, and QLQ-CX24. Anxiety and depression were defined by a score of ≥ 8 on the HADS subscales. With a framework that included socio-demographic, clinical, and symptom characteristics, multivariate logistic regression models were used to identify factors associated with anxiety and depression. Results: Among cervical cancer survivors, 34.3% reported HADS-defined anxiety and 39.7% reported HADS-defined depression. Anxiety was associated with having a lower income (OR=1.95, p=.021), smoking (OR=2.42, p=.002), poor body image (OR=3.26, p<.001), peripheral neuropathy (OR=2.21, p=.002), menopausal symptoms (OR=2.02, p=.004), and sexual inactivity (OR=2.35, p=.001). Depression was associated with younger age (OR=1.75, p=.006), having a lower income (OR=2.14 p<.001), drinking (OR=1.56, p=.050), poor body image (OR=4.59, p<.001), peripheral neuropathy (OR=2.34, p<.001), and sexual inactivity (OR=2.68, p=.002). Both anxiety and depression were influenced by socio-demographic factors, health behaviors, and cervical cancer-specific symptom characteristics rather than cancer- or treatment-related factors. Conclusions: Anxiety and depression were highly prevalent among cervical cancer survivors in Korea. This examination of risk factors for anxiety and depression will be helpful for the development of clinical management strategies in cervical cancer survivors.

No significant financial relationships to disclose.

Adherence to National Quality Forum (NQF) colorectal cancer indicators among members of the Florida Initiative for Quality Cancer Care (FIQCC) consortium

6563

Background: FIQCC is a consortium of 10 institutions participating in a comprehensive practice-based system of quality self-assessment across a number of cancer types. The NQF has endorsed several performance measures to assess the quality of care for colorectal cancer (CRC) patients. We have sought to identify adherence to NQF CRC indicators among members of FIQCC. Methods: Comprehensive chart reviews were conducted for all patients with CRC first seen in 2006 by a medical oncologist at one of the 10 FIQCC sites (2 academic/8 community). NQF quality measures included: 1) consideration or administration of chemotherapy to patients with stage III colon cancer (CC); 2) completeness of pathology reporting for CRC; 3) >12 regional lymph nodes (LN) examined for resected CC. Statistical comparisons were performed using chi-squared analysis. Results: The population consisted of 475 patients (250 men and 225 women) with a median age of 65 years (range 27–92). Chemotherapy was considered/administered in 96.5% (136/141) of stage III CC patients. With respect to CRC pathologic reporting, there was strong compliance (>90%) for reporting the number of LN examined and involved by tumor, proximal/distal margin status, depth of invasion, and histologic grade. However, only 225 of 295 (76.2%) reports documented lymphovascular invasion status. Radial margin status was included for 45% (27/60) of surgical rectal cancer specimens. Only 73.9% (173/234) of CC cases had >12 LN examined. Of the NQF measures, significant differences across practice sites were noted for the reporting of histologic grade (p = 0.0002), proximal/distal margin status (p = 0.049), and lymphovascular invasion (p < 0.0001). Conclusions: Although there was uniformly strong adherence to the application of adjuvant therapy for stage III CC across FIQCC sites, the adequacy of lymphadenectomy and LN examination for resected CC was lower and varied considerably across sites. There remains room for improvement of pathologic CRC reporting across the whole consortium as well as at individual sites. The FIQCC initiative allows for the identification of targets for global quality improvement as well as of specific measures for individual institutions.

No significant financial relationships to disclose.

Value of preoperative staging of breast cancer patients using computed tomography to detect asymptomatic lung and liver metastasis

1105

Background: Preoperative clinical staging in breast cancer patients is important to determine the most appropriate treatment plans and to predict prognosis for individual patients. Identifying unexpected distant metastases in newly diagnosed breast cancer patients frequently alters initial treatment plans. Routine imaging studies to detect lung or liver metastasis is not indicated in patients with early and operable breast cancer. A recent study showed that routine use of chest radiograph and liver ultrasound does not provide much diagnostic benefit in early breast cancer patients. Methods: We aimed to investigate the value of preoperative computed tomography to detect asymptomatic liver and lung metastasis in breast cancer patients. We performed preoperative CT for 667 breast cancer patients to detect lung and liver metastasis among 1,636 primary breast cancer patients who had been diagnosed and treated between January 2006 and December 2007 at Seoul National University Hospital. Results: CT showed abnormal findings (suspicious of metastasis or indeterminate nodules) in 78 patients (10.5%). Among these, abnormal finding in 13 patients (1.7%) turned out to be true metastatic lesions. There was no CT-detected lung or liver metastasis in patients with T1 tumor and 4 metastases in patients with T2 tumor. There was no CT-detected lung or liver metastasis in patients with negative axillary lymph node metastasis. When patients were classified according to the AJCC staging, CT-detected true metastatic lesions were only present in stage III patients (13 out of 173 patients, 7.5%). The true metastatic lesions in lung or liver were all small sized nodules, ranging from 0.3cm to 1.2cm in largest diameters. In seven patients, the CT-detected metastatic lesions were less than 1cm which is in contrast with the previous studies. Conclusions: Our results demonstrated the lack of usefulness in performing routine CT exams to detect asymptomatic liver and lung metastasis in early breast cancer patients. Staging CT might be useful in stage III patients, since 13 (7.5%) patients were upstaged to stage IV by the use of CT.

No significant financial relationships to disclose.

Detection of human papillomavirus DNA from the breast carcinomas and the cervix: Are they correlated?

1544

Background: The association between human papillomavirus (HPV) and cervical cancer is well known. However, it remains unclear whether there is also a correlation between HPV infection and human breast cancer. The aim of this study is to investigate the hypothetic association between HPV infection and breast carcinoma through the comparison of the type of HPV infection in the breast and cervix. Methods: From April to December 2008, 106 patients who were diagnosed as breast cancer and underwent mastectomy were analyzed. Their breast tissue (tumor, normal parenchyme, and nipple-areolar complex) and cervix smear were analyzed for HPV infection with DNA chip microarray method. Results: 24 patients (23.1%) showed HPV infection in their cervix smear; high-risk type of HPV was found in 12 patients. But only six patients (5.8%) revealed the HPV infection in breast cancer; half of them were high-risk group (HPV-16, 31); the same types of HPV was found at the normal breast tissue in two patients of them. However, there were no patients with HPV infection in both breast and cervix concurrently. Conclusions: There were no positive results for HPV infection of cervix in HPV-infected breast cancer patients. Also, we cannot find that the presence of high-risk HPV in the breast might be related to the breast carcinogenesis. We concluded that HPV infection is not correlated to the carcinogenesis of breast.

No significant financial relationships to disclose.

The relationship between the responses to prior systemic therapies and the efficacy of subsequent pemetrexed (Pem) therapy in patients (pts) with advanced non-small cell lung cancer (NSCLC)

8061

Background: Pem has been used for pts with previously treated advanced NSCLC. We tried to examine whether the response to prior systemic therapy regimen could predict the efficacy of subsequent Pem therapy. Methods: The medical record of clinical stage IIIB or IV NSCLC pts who received Pem as the second-line or further-line treatment were analyzed retrospectively. Prior systemic therapies were divided into 4 types [gemcitabine based (G), paclitaxel based (P), docetaxel based (D), and EGFR tyrosine kinase inhibitors (I)]. Along with that, patients were classified into two response groups, either responders (partial responses or stable disease for 4 months or more) or non-responders to each type of the prior therapy. Response rate (RR) and progression free survival (PFS) for Pem therapy were analyzed according to the response groups for each type of prior therapies. Results: A total of 247 pts received Pem therapy, and their median PFS was 2.3 months. The number of pts who previously received G, P, D and I, was 159, 120, 110, and 139, respectively. The RR for Pem was higher in responders to G therapy than in non-responders to G (15.0% vs 4.3%, p = 0.02). In addition, median PFS after Pem therapy was longer in responders to G therapy than in non-responders (3.0 vs 1.7 months, p = 0.007). However, the responses to prior P, D, I therapies had no impact on the efficacy of subsequent Pem therapy. By univariate analyses, the variables of the responders to G therapy, female, never-smoker, ECOG performance status 0–1 were good predictive factors for Pem therapy in terms of PFS. By multivariate analysis, only the responders to G therapy had a statistical significance (Hazard ratio = 0.55; 95% CI, 0.37–0.82). Conclusions: The response to the prior gemcitabine based therapy was a predictive factor for subsequent pemetrexed therapy for advanced NSCLC.

No significant financial relationships to disclose.

A randomized phase II study of FOLFOX or FOLFIRI.3 as second-line therapy in patients with advanced pancreatic cancer previously treated with gemcitabine-based chemotherapy

4618

Background: Only few clinical trials have been conducted in patients with advanced pancreatic cancer after failure of first-line gemcitabine-based chemotherapy. We conducted a randomized phase II trial of modified FOLFOX vs. modified FOLFIRI.3 as second-line regimen for the patients with gemcitabine refractory pancreatic cancer ( NCT00786006 ). Methods: Patients with advanced pancreatic adenocarcinoma previously treated with gemcitabine were randomly assigned to FOLFOX or FOLFIRI.3 stratifying by age (≤ 65 vs. >65), performance status (0–1 vs. 2) and prior response to gemcitabine (PR/SD vs. PD). FOlFIRI.3 regimen consisted of Irinotecan 70 mg/m2 (over 60 min) D1, leucovorin 400 mg/m2 (over 2h) D1, 5-FU 2000 mg/m2 (over 46 hours) from D1, then irinotecan 70 mg/m2 (over 60 min) at the end of the 5-FU infusion every two week. FOLFOX regimen is composed of oxaliplatin 85 mg/m2 (over 120 min) D1, LV 400 mg/m2 D1, 5-FU 2,000 mg/m2 (over 46 hours) every two week. The primary end-point was 6-month overall survival (P0=20%) and Simon-Wittes-Ellenberg design was used to calculate the sample size (29 evaluable patients for each treatment arm). Results: From January 2007 to December 2008, sixty patients were enrolled and randomized to FOLFOX (N=30) or FOLFIRI.3 (N=30). Baseline characteristics were well balanced between each arm; median age 56 (35–60) vs. 56 yo (37–73); ECOG PS 0/1/2, 5/24/1 vs. 5/25/0; prior response to gemcitabine-based chemotherapy PR/SD/PD 10/13/7 vs. 10/11/9. With a median follow-up period of 6.0 months (95% CI, 4.7–7.3) the median overall survival was 4.0 months in both group (HR=0.95, 95% CI 0.52–1.75) with 6-month survival rates of 25% and 20%, respectively. The median PFS was 1.4 months for FOLFOX and 1.9 months for FOLFIRI.3 (HR=1.11, 95% CI, 0.64–1.92). Disease control (PR+SD) was achieved in 20% (5/25 in FOLFOX) and 28% (7/25 in FOLFIRI.3) of patients with measurable disease. The incidences of grade 3/4 toxicities were similar in both groups. Conclusions: Both FOLFOX and FOLFIRI.3 were tolerated with manageable toxicity, offering modest activity as second-line treatment of patients with advanced or metastatic pancreatic cancer, previously treated with gemcitabine.

No significant financial relationships to disclose.

Impact of patient age on quality of care in the treatment of colorectal cancer: Results from the Florida Initiative for Quality Cancer Care (FIQCC)

6548

Background: The quality of colorectal cancer (CRC) treatment has been suggested to vary by age, with older patients receiving poorer quality care. As part of a state-wide quality improvement effort, the FIQCC developed and implemented methods to assess the quality of care of several cancers among practices across the state of Florida. The current report focuses on the variability of adherence to CRC quality indicators for treatment and surveillance by patient age. Methods: Medical chart reviews were conducted of all patients first seen by a medical oncologist for CRC in 2006 at one of the 10 FIQCC sites (2 academic/8 community). Abstractors were trained and periodically monitored. Abstraction focused on assessing adherence to quality indicators consistent with evidence-, consensus-, and regulatory-based guidelines. Variability in adherence across age quartiles was evaluated using a Fisher's exact test. Of the 475 patients whose charts were reviewed, 53% were male, 80% were diagnosed with colon cancer and the median age was 65 years (range 27 to 92 years). Results: Adherence was consistently (p values>.05) high across all age quartiles for presence of chemotherapy flow sheets (85%-93%), assessment of body-surface area (98%-100%) and performance of complete colon evaluation within 12 months of surgery (87%-89%). Moderate-to-low adherence was consistent by age for performance of CEA test before (74%-84%) or in the 6 months after (75%-82%) surgery/chemotherapy, and documentation of planned chemotherapy dose (51%-59%). Adherence decreased with increasing age for documentation of discussion/referral for chemotherapy in non-metastatic CRC cases (100%, 99%, 93%, and 89%; p = 0.001), but was consistently adhered to for all ages among metastatic cases (100%). The documentation of consent for patients treated with chemotherapy also varied by age-quartile (63%. 57%, 79%, and 73%; p = 0.02). Conclusions: Overall quality of CRC treatment was not consistent across the broad spectrum of patient age. Our data suggest age related disparity in the recommendation for adjuvant chemotherapy. Efforts should be made to understand the reasons for these differences and to improve and standardize the quality of CRC care for patients across all age groups.

No significant financial relationships to disclose.

A multicenter phase II study to evaluate efficacy and safety of gefitinib as the first-line treatment for Korean patients (pts) with advanced pulmonary adenocarcinoma harboring EGFR mutations

8066

Background: This study (D7913L00056) was designed to prospectively evaluate the efficacy and safety of first-line gefitinib treatment in pts with advanced pulmonary adenocarcinoma harboring EGFR mutations and to explore the molecular factors affecting the efficacy of gefitinib. Methods: Chemo-naïve pts with advanced (stage IIIB/IV/recurrent disease) pulmonary adenocarcinoma underwent direct DNA sequencing of tumor EGFR exons 18, 19 and 21. Pts with EGFR mutations received gefitinib 250 mg/d until disease progression or unacceptable toxicity. The primary end-point was objective response rate (ORR). The protocol planned to accrue 45 pts with EGFR mutations in a single stage. Results: Out of 147 screened pts, 45 pts (31%) had EGFR mutations and received gefitinib. The most common EGFR mutations were in-frame exon 19 deletions (del 19, 29 pts, 64%) and L858R point mutations in exon 21 (L858R, 15 pts, 33%). One patient had atypical mutation of L861Q in exon 21. The ORR by RECIST was 53.3% (95% CI, 38.8 to 67.9) and disease control rate (DCR) including stable disease was 86.7%. Progression free survival (PFS) at 12 months (mo) was 74.6% (95% CI, 58.8 to 85.1). Median PFS was not reached after median 10.1 mo follow-up. Treatment was well tolerated. Six pts experienced grade 3 toxicities including rash, pruritis, and anorexia. No grade 4 toxicities were reported. Subgroup analysis according to the EGFR mutation subtypes was carried out. The ORR and DCR were higher in pts with del 19 than those with L858R (62.1% vs 33.3%; P=0.0705 and 96.6% vs 66.7%; P=0.0062, respectively). All 4 pts with progressive disease had an L858R mutation. No secondary resistant mutations such as T790M were found in those pts. In addition, PFS at 12 mo was significantly better in pts with del 19 than those with L858R (63.2% vs 23.8%, P=0.0034). Conclusions: Gefitinib as the first-line treatment for Korean pts with advanced pulmonary adenocarcinoma harboring EGFR mutations was very effective and well tolerated. Subgroup analysis suggests that the benefit from gefitinib treatment was more prominent in pts with the del 19 mutation.

[Table: see text]

Comparison of serum HER-2/neu between trastuzumab-based regimen and anthyracycline-based regimen during neoadjuvant chemotherapy in advanced primary breast cancer

e11582

Background: Serum Her-2/neu has been known as molecular surrogating marker of predicting treatment response in Her-2 positive breast cancer. We compare the change of serum Her-2/neu during neoadjuvant chemotherapy between trastuzumab(H) and anthyracyline(A) based treatment. Methods: All breast cancers were tested by immunohistochemical stain and FISH for Her-2/neu before treatment. Serum Her-2/neu was twice measured by Chemiluminescence immunoassay(ADVIA centaurTMsystem) before neoadjuvant chemotherapy and before operation. The cutoff value was 10.2 mg/ml according to previous study. Pathologic complete response (pCR) was considered as no residual tumor or remnant ductal carcinoma in situ, partial response (PR) was less than 50% decrease in maximal diameter in pathologic tumor size. Results: Serum Her-2/neu of trastuzumab group was more decreased than of anthyracyline group (H; 12.9 ± 14.5 ng/mL vs. A; 2.2 ± 1.2 ng/mL, p=0.024). In trastuzumab group, pCR was relatively correlated with decrease of serum Her-2/neu (PR: 0.8 ± 0.84 ng/ml vs. pCR: 21.1 ± 13.2 ng/ml, p=0.08). Conclusions: A decrease in serum Her-2/neu levels during treatment was associated with pathologic response in patients receiving neoadjuvant chemotherapy, particularly, trastuzumab-based regimen. Serum Her-2/neu levels may serve to monitoring neoadjuvant therapy in Her-2/neu positive breast cancer.

No significant financial relationships to disclose.

Induction chemotherapy followed by concurrent chemoradiotherapy with/without esophagectomy for locally advanced esophageal squamous cell carcinoma

e15526

Background: To assess the feasibility of preoperative induction chemotherapy in addition to concurrent chemoradiotherapy (CCRT) followed by esophagectomy if possible for locally advanced esophageal squamous cell carcinoma (ESCC) with a special emphasis on M1a or nodal M1b disease. Methods: Patients who had histologic proof of T3N1M0, M1a, or nodal M1b ESCC first received up to 3 courses of induction chemotherapy (paclitaxel 70 mg/m2 or docetaxel 40 mg/m2 IV 1-hr D 1, 8; cisplatin 35 mg/m2 IV 2-hr D 1, 8; 5-fluorouracil 2000 and leucovorin 300 mg/m2 IV 24-hr D 1, 8; repeated every 28 days). This was followed by CCRT (paclitaxel 35 mg/m2 1-hr D 1, 4 /wk, cisplatin 15 mg/m2 1-hr D 2, 5/wk, and radiotherapy 2 Gy D 1–5 /wk) (Lin CC et al. Ann Oncol 18:93–8,2007). When the accumulated radiation dose reached 40 Gy, the feasibility of esophagectomy was evaluated in all patients. In patients for whom esophagectomy was not feasible, CCRT was continued to a dose of 60 Gy. Results: Fifty-six patients (M:F = 51:5, median age 58, range 41–78) with locally advanced (T3N1M0:M1a:M1b[nodal] = 30:7:19) ESCC (upper:mid:lower = 15:25:16) were enrolled from June 22, 2006 to December 17, 2008. By December 31, 2008, 10 patients are still under protocol treatment. Eighteen (T3N1:M1a:M1b[nodal] = 14:3:1) (40%) and 20 of 46 patients underwent surgery and continued CCRT up to 60 Gy, respectively. Nine (T3N1:M1a:M1b[nodal] = 7:2:0) (20%) and 5 patients had pathologic complete response and microscopic residual disease, respectively. With a median follow-up of 8.4 months (range 0.5–30.8), 17 (T3N1:M1a:M1b[nodal] = 9:2:6) patients had relapse. Four and 13 patients had local recurrence and distant metastasis, respectively. The median progression-free survival was 20.3 months. The median overall survival had not reached yet with 1- and 2-year overall survival being 76 and 57%, respectively. There was no difference in progression- free or overall survival among patients with T3N1M0, M1a, or nodal M1b disease. Conclusions: Three-step strategy of preoperative taxane-based induction chemotherapy then CCRT followed by esosphagectomy if possible appears quite active in locally advanced ESCC patients with 46% having M1a or nodal M1b disease.

No significant financial relationships to disclose.

Randomized phase II study of gefitinib alone or with simvastatin in previously treated advanced non-small cell lung cancer (NSCLC)

8057

Background: Statins reduce not only serum cholesterol levels but also mevalonate synthesis by inhibiting HMG-CoA reductase. Mevalonate is a precursor of several cellular major products including dolichol, geranylpyrophosphate (GPP) and farnesyl-pyrophosphate (FPP). Dolichol has a stimulatory effect on DNA synthesis and is linked to several tumor cell proteins. GPP and FPP cause isoprenylation of Ras and Rho those regulate signal transduction of several membrane receptors crucial for cell proliferation, differentiation, and apoptosis, which result in resistance to gefitinib. Thus depletion of mevalonate metabolites may enhance gefitinib activity in NSCLC. This study compared gefitinib alone with gefitinib plus simvastatin in patients with recurrent NSCLC after at least one chemotherapy. Methods: Between May 2006 and September 2008, 107 patients (51% male, 74% adenocarcinoma, 50% never-smoker, 54% more than two prior regimens) were randomly assigned to gefitinib alone (250 mg/d orally, n=53) or gefitinib plus simvastatin (250mg/d and 40 mg/d orally, respectively, n=54). A cycle was considered as 4 weeks of treatment. Therapy was continued until disease progression or intolerable toxicities. The primary end point was to assess response rate. Secondary end points included time to progression and survival. Median follow-up was 10.1 months. Results: Efficacy was similar for gefitinib and gefitinib plus simvastatin groups. Objective tumor response rates (RR) were 31.5% (95% CI, 19.1 to 43.9) and 32.1% (95% CI, 19.5 to 44.7); median PFS were 1.9 and 2.0 months; and median OS were 9.5 and 12.7 months, respectively. In subgroup analysis, gefitinib plus simvastatin showed a trend for higher RR than gefitinib alone in non-adenocarcinoma group (38.5% vs. 7.7%, p=0.08). Adverse events at both arms were generally mild (grade 1 or 2) and consisted mainly of skin reactions. Conclusions: Gefitinib combined with simvastatin did not improved efficacy compared to gefitinib alone in this unselected patient population, but showed a trend for higher efficacy in non-adenocarcinoma patients. Although it is preliminary, gefitinib combined with simvastatin showed slightly increased OS. Updated survival data will be presented.

No significant financial relationships to disclose.

Regulatory role of p53 in cancer metabolism through SCO2 and TIGAR in human breast cancer

e22128

Background: Cancer cells showed higher rate of anaerobic respiration than normal cells. The exact mechanisms for this higher rate of glycolysis in cancer cells remain to be elucidated. Recent researches suggest that p53, the most commonly mutated tumor suppressor gene, might play an important roles in the regulation of energy generating metabolic pathways that switch from oxidative phosphorylation to glycolysis through synthesis of cytochrome C oxidase 2 (SCO2) and TP53-induced glycolysis and apoptotic regulator (TIGAR). Methods: We investigated the expression of p53, SCO2, TIGAR and cytochrome C oxidase (COX) in 95 cases of invasive ductal carcinoma using immunohistochemistry. Results: Overexpression of p53, SCO2, TIGAR and COX was observed in 27.4% (26 cases), 82.1% (78 cases), 76.8% (73 cases), and 77.9% (74 cases) respectively. Overexpression of p53 was significantly associated with decreased expression of SCO2 (p=0.009), COX (p=0.001) and TIGAR (p=0.03). Conclusions: These results suggest that p53 can modulate the metabolic pathways via SCO2 and TIGAR in human breast cancer.

No significant financial relationships to disclose.

Genetic and proteomic features associated with survival after treatment with erlotinib in first-line therapy of non-small cell lung cancer

8089

Background: An improved understanding of molecular features of cancers and cancer patients associated with benefit from targeted therapies could allow the rational personalization of therapies to increase the probability of efficacy and decrease toxicity and cost. Multiple biomarkers have been proposed for predicting benefit after therapy with EGF receptor targeted therapies in first line colon and second line lung cancer therapy. Methods: In this study, we analyzed available tumor and serum samples from ECOG 3503, a single arm phase II study of erlotinib in first line lung cancer, for mutations in Kras and EGFR, as well as the previously described serum MALDI proteomic classifier (Veristrat). Out of 137 enrolled patients, there were 93 serum samples and 43 tumor samples available. Results: Molecular analysis of a subset of tumors from patients enrolled in ECOG 3503 shows that 10/43 (23%) contained Kras mutations and 3/43 (7%) harbored EGFR mutations. Classification of the 93 available sera for the pattern of proteins previously published as associated with survival after treatment with gefitinib identified 68/93 (73%) as predicted to be “good” and 25/93 (27%) predicted to have poor survival. Of the 6 responders with available serum, 5 were classified as MALDI good. Correlation with survival demonstrated a highly statistically significant correlation with MALDI status (p < 0.001), and a marginally significant association of EGFR mutation with survival (p = 0.05), but no correlation with ras mutation status. Median survival was 10.8 months in MALDI good patients and 3.9 in MALDI poor patients. MALDI status was independent of both ras and EGFR mutation status. Conclusions: Thus, in distinct contrast to colon cancer, ras gene mutations do not appear to be associated with survival after first line EGFR-targeted therapy in lung cancer. The previously defined MALDI predictor is potent and highly clinically significantly associated with survival after first line treatment with erlotinib, and is independent of mutations in ras and EGFR in this dataset.

[Table: see text]

A phase I/II study of combination therapy of S-1 and irinotecan in patients with previously untreated metastatic or recurrent colorectal cancer

e15023

Background: To investigate S-1 and irinotecan (CPT-11) combination as an alternative to infusional 5- fluorouracil/leucovorin plus CPT-11, we performed a phase I/II trial to determine maximum tolerated dose (MTD), efficacy and toxicity in metastatic or recurrent colorectal cancer. In addition, we evaluated the association between genotypes of candidate genes and phenotypes. Methods: S-1 was administered orally at a dose of 70 mg/m2 (level I-III) or 80 (IV and V) from day 1 to 14. CPT-11 was given i.v. on day 1, stepping up to 175 (level I), 200 (II), 225 (III and IV) or 250 (V) mg/m2 . The treatment was repeated every 3 weeks. The association of the UGT1A1 genotypes (*6, *28, and *60) and CYP2A6 genotypes (*4, *7, and *9) with toxicities or efficacy were analyzed in patients who participated in phase II portion. Results: Twenty-three patients entered the phase I and 30 enrolled in phase II study. The MTD of S-1 and CPT-11 was considered to be 80 mg/m2 and 250 mg/m2, respectively. The dose-limiting toxicities (DLTs) were diarrhea and neutropenia. The recommended dose (RD) was determined at a S-1 dose of 80 mg/m2 and a CPT- 11 dose of 225 mg/m2. The overall response rate was 66.7% (95% CI, 48.7–84.6) at the RD level. Median time to progression was 7.6 months (95 % CI, 5.7–9.5). Median survival time was not reached. Grade3–4 neutropenia was observed in 53.4% of the patients. Grade 3–4 nonhematologic toxicities were diarrhea (16.7%) and asthenia (6.7%). The frequencies of UGT1A1*60, *28, and *6 allele were 25.8%, 10.3%, and 15.5%, respectively. Homozygous for *28 or *6 were not observed. All three double heterozygous for *28 and *6 experienced grade 3–4 neutropenia. The allele frequencies of CYP2A6*4, *7, and *9 were 15.5%, 8.6%, and 29.3%, respectively. There were no association between CYP2A6 genotypes and response rates or toxicities. Conclusions: The combination of S-1 and CPT-11 was effective and had manageable toxicities in patients with metastatic or recurrent colorectal cancer.

[Table: see text]

No significant financial relationships to disclose.

Triple detection method for sentinel lymph node detection

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Background: Sentinel lymph node biopsy is widely accepted method to determine nodal stage of breast cancer. There are several reported method for detecting sentinel lymph node. The aim of this study was to show the new detection method of sentinel lymph node and show the effectiveness of this method. Methods: We did prospective study and enrolled 25 patients who underwent partial mastectomy and sentinel lymph node biopsy. We injected indigocyanine green (green dye) at peritumoral lesion, indigocarmine dye (blue dye) in subareolar area and radioisotope (Tc-99m) injection. Sentinel lymph nodes are identified by color change or radioisotope uptake, and classified by each color (blue or green) and radioisotope uptake. We compared the detection rate from our study with that from the previous studies. Results: Sentinel lymph nodes were detected in all patients (25/25). Green color stained sentinel lymph nodes were identified in 18 patients (18/25), blue color stained sentinel lymph nodes were identified in 15 patients (15/25) and radioactive lymph nodes were identified in 19 patients (19/25). Conclusions: The triple mapping method showed higher detection rate than the previous studies and this method is recommendable to detect sentinel lymph node.

No significant financial relationships to disclose.

A randomized phase II trial of weekly docetaxel plus either cisplatin or oxaliplatin in patients with previously untreated advanced gastric cancer: Preliminary results

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Background: Docetaxel, in combination with cisplatin or oxaliplatin, has demonstrated efficacy against AGC. This randomized phase II trial evaluated two weekly docetaxel-based regimens to see which would be most promising according to objective response rate (ORR) as first-line therapy in AGC. Methods: Chemotherapy-naïve patients with measurable unresectable and/or metastatic gastric adenocarcinoma and a performance status ≤2 were randomly assigned to receive docetaxel (35 mg/m2) weekly on days 1 and 8 of a 21-day cycle plus either cisplatin (60 mg/m2 on day 1) (arm A) or oxaliplatin (120 mg/m2 on day 1) (arm B). Toxicity was assessed on days 1, 8, and 21 of each cycle, and response was evaluated every 2 cycles. Results: Between March 2007 and December 2008, 61 eligible patients entered. In Arm A, 29 patients were evaluable for objective response and 31 for safety. In Arm B, 28 patients were evaluable for objective response and 30 for safety. Median age was 52 years and disease status was comparable for both arms. Ten of 29 (34.5%) patients had a confirmed objective response in the arm A (95% confidence interval [CI] 17.1–51.8%) and 11 of 28 (39.2%) patients had a confirmed objective response in the arm B (95% CI 21.1- 57.2%). No significant difference was noted between the arms both for ORR (p=0.202) or for disease control (58.6% and 82.1%, respectively, p=0.082). Median progression free survival time was 4.4 month in the arm A and 4.3 months in the arm B (Hazard ratio = 0.936; 95% CI, 0.503–1.744; p = 0.836). There was no relevant difference in the occurrence of overall grade ¾ toxicity between the two arms (51.6% vs. 46.6%, respectively; p=0.800). Neutropenia was the most common grade 3/4 toxicity (32.3% vs. 36.6%, respectively). There was one treatment related death in Arm B. Conclusions: The preliminary results showed that both treatment arms have similar clinical efficacy as front-line treatment in AGC. Each regimen has a manageable tolerability profile. The accrual is ongoing.

No significant financial relationships to disclose.

Risk stratification by hormonal receptor (ER, PgR) and HER2 status in small (≤1cm) invasive breast cancer: Who might be a possible candidate for adjuvant treatment?

564

Background: With the increasing use of screening mammography, the proportion of ≤ 1 cm invasive breast cancer is increasing. Identification of breast cancer molecular subtypes has resulted in a better appreciation of the biologic heterogeneity, which is not fully explained by clinicopathologic features including staging system. The aims of this study were: 1) to identify the risk factors of systemic metastases in patients with ≤ 1 cm invasive breast cancer and 2) to investigate the patients group at greatest risk of such failure even in these small tumors. Method: Data were collected retrospectively in the breast cancer registry of our institution for patients with invasive breast cancer from October 1994 to December 2004. Results: Of 4,036 patients who received curative breast cancer surgery, 466 patients who had T1a or T1b breast cancer were identified. 39 patients who received neoadjuvant chemotherapy were excluded in this study. Ipsilateral axillary lymph node involvement was found in 13% (57/427) at the time of surgery. Axillary lymph node involvement was much more common in HER-2 positive group (33% vs 11%, p < 0.0001) and triple negative (TN) group (24% vs 11%, p = 0.002) than in hormone receptor positive group. During median 61 months of follow-up, overall 10 year estimated distant relapse-free survival (DRFS) and overall survival (OS) were 95% and 92%, respectively. Multivariate analysis was conducted in 370 (T1aN0, T1bN0) patients, who had no lymph node involvement. In Cox-regression model, HER-2 positivity and triple negativity were identified as independent prognostic factors to predict DRFS [Hazard ratio (HR) 8.8, p = 0.003 for HER-2 positive group; HR 5.1, p = 0.026 for TN group] and OS (HR 5.0, p = 0.067 for HER-2 positive group; HR 11.1, p = 0.017 for TN group) in T1bN0 tumors. Limiting to T1aN0 tumors, statistical significance was not maintained. Conclusions: Even though T1aN0 and T1bN0 tumors have been known to have a relative low risk of systemic failure, anti-HER-2 directed therapy for HER-2 positive group and new innovative adjuvant systemic treatment for TN group in patients with T1bN0 tumor should be considered. Prospective adjuvant trials should be warranted in these subgroups of patients.

No significant financial relationships to disclose.

Phase I dose-finding study of sorafenib in combination with capecitabine and cisplatin as a first-line treatment in patients with advanced gastric cancer

4559

Background: We conducted a phase I dose-finding study of sorafenib (S) in combination with capecitabine (X) and cisplatin (P) in patients with previously untreated metastatic or inoperable advanced gastric cancer. Methods: Four dose levels of S, X, and P combination were tested. The doses of S (p.o. daily), X (p.o. on days 1–14), and P (i.v. on day 1) were escalated at the following schedule; level 1: S 400 mg/d, X 1,600 mg/m2/d, P 80 mg/m2; level 2: S 800 mg/d, X 1,600 mg/m2/d, P 80 mg/m2; level 3: S 800 mg/d, X 2,000 mg/m2/d, P 80 mg/m2; level 1A: S 800 mg/d, X 1,600 mg/m2/d, P 60 mg/m2. The cycle was repeated every 3 weeks. Dose limiting toxicities (DLTs) were evaluated only in the first cycles and a standard 3+3 dose escalation design was implemented. Results: A total 21 pts were enrolled in the study. No DLTs were observed at dose level 1 (n=3). One DLT (grade 3 diarrhea) was noted at dose level 2 (n=6), and 2 DLTs (two grade 4 neutropenias longer than 5 days in duration) were observed at dose level 3 (n=6), which made the level 3 dose the maximum tolerated dose (MTD). However, at cycle 2 and thereafter at dose level 2, the relative dose intensity (RDI) of S and X could not be maintained (mostly below 80%) due to the frequent dose reductions and cycle delays. So, we explored a new dose level (1A) between dose level 1 and 2. Since no DLTs were found in 6 patients at level 1A with RDI mostly above 80% throughout the treatment period, level 1A was determined as recommended dose (RD). Most frequent grade 3 and 4 hematologic toxicities were neutropenia (25.0% of cycles), and most frequent grade 2 and 3 non-hematologic toxicities were hand-foot syndrome (9.4%), asthenia (7.0%), and anorexia (5.5%). The objective responses were confirmed in 10 out of 16 patients with measurable lesions (62.5%; 95% CI, 38.8–86.2%). With a median follow-up of 8.1 months, estimated median progression-free survival was 10.0 months (95% CI, 1.6–18.4 months) and median overall survival has not been reached. Conclusions: Diarrhea and neutropenia were DLTs in this S, X, and P combination. The dose schedule of sorafenib 400 mg po bid daily with capecitabine 800 mg/m2 po bid on days 1–14, and cisplatin 60 mg/m2 iv on day 1 in every 3 weeks is recommended for further development in AGC.

[Table: see text]

The role of prophylactic antimicrobials during autologous stem cell transplantation: A single center experience

7105

Background: The aim of this retrospective study was to investigate the efficacy of antibiotic prophylaxis during autologous peripheral stem cell transplantation (ASCT) in patients with multiple myeloma (MM) and non-Hodgkin's lymphoma (NHL). Methods: We searched Asan Medical Center Registry for NHL and MM: Total 114 cases received antimicrobial prophylaxis; while 118 cases did not receive antimicrobial prophylaxis during ASCT. Results: In prophylaxis group, 80 of 114 (70.2%) patients had experienced febrile episodes at median day +6 after transplantation with a statistically significant difference (P<0.001). In no-prophylaxis group, 111 of 118 (94.1%) patients had experienced at median day +5. Documented infection occurred in 14 of 114 (12.3%) patients in prophylaxis group, and 16 of 118 (13.6%) patients in no-prophylaxis group (P=0.846). In these patients, the positive blood culture was seen in 12 (10.5%) of 114 patients in prophylaxis group, and 12 (10.7%) of 118 patients in no-prophylaxis group (P=1.000). Documented viral infection or reactivation was not observed in prophylaxis group, but observed in 4 patients of no-prophylaxis group. Both groups showed no invasive fungal infection or serious adverse event during ASCT. The day of infection resolved was a median day +15 (range, 3–29) in prophylaxis group and day +14 (range, 2–70) in no-prophylaxis group (P=0.945). The duration of antimicrobial treatment was median 10 days both in prophylaxis group and in no-prophylaxis group (P=0.565). Conclusions: In our experience, the antimicrobial prophylaxis seems to decrease the incidence of febrile episodes during ASCT, but seems to have no beneficial effect on reducing infectious complications. The antimicrobial prophylaxis of our study did not show the difference in the detection of causative organism as an infective agent, duration of antimicrobial therapy and hospitalization between two groups.

No significant financial relationships to disclose.

Prognostic significance of preoperative serum tumor markers in the patients with curatively resected advanced gastric cancers

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Background: We evaluated the prognostic significance of preoperative tumor markers, carcinoembryonic antigen (CEA), carbohydrate antigen 19–9 (CA19–9), and carbohydrate antigen 72–4 (CA72–4), in the patients with curatively resected advanced gastric cancers (AGC). Methods: Preoperative serum tumor markers were available for 667 patients who had been enrolled in a phase III trial of adjuvant chemotherapy (AMC0201). We compared the relapse free survival (RFS) and overall survival (OS) according to patient's pre-treatment clinical characteristics and serum tumor markers by using log rank test and Cox proportional hazard model. Results: Of total 667 patients, 3 year RFS rate and OS rate were 67.4% and 75.0%, respectively. Postoperative pathologic stage was II in 353 (52.9%), IIIA in 202 (30.3%), IIIB in 61 (9.1%), and IV (M0) in 51 (7.6%). CEA, CA19–9, CA72–4 were elevated pre-operatively in 64 of 665 patients (9.6%), 75 of 664 patients (11.3%), and 121 of 639 patients (18.9%), respectively. After the median follow-up of 38.4 months, 209 patients (31.3%) had recurrence, and 164 patients (24.6%) died. In the univariate analysis, location of tumor, type of surgery, Borrmann type, TNM stage, the elevation of CEA and CA72–4 level were significant prognostic factors for RFS and OS. In the multivariate analysis, serum CA72–4 was independent significant prognostic factor for RFS and OS as well as tumor location, Borrmann type, and stage Conclusions: Pre-operative serum CEA and CA72–4 levels were independent prognostic factors as well as clinical characteristics of pathologic stage, tumor location and Borrmann type in patients with curatively resected AGC.

No significant financial relationships to disclose.

Definitive chemoradiation therapy with capecitabine in locally advanced pancreatic cancer

e15558

Background: We evaluated safety and efficacy of concurrent chemoradiotherapy (CCRT) with capecitabine in patients with locally advanced pancreatic cancer (LAPC). We also tried to devise a prognostic model for LAPC undergoing definitive CCRT. Methods: Between January 2004 and January 2008, 39 patients with LAPC treated with capecitabine CCRT were reviewed. Capecitabine was administered at 850 mg/m2 bid every day for 5 weeks. Radiotherapy was given 5 days per week, at 1.8 Gy fractions, over the 5 weeks. Results: Thirty seven (94.8%) patients completed CCRT, and 2 patients removed during the treatment for toxicity issues. Of the 36 evaluable patients, 15 (41.7 %) patients achieved partial response, and 13 (36.1 %) had a stable disease with 77.8% of disease control rate. Among the 28 patients who had achieved disease control after CCRT, 8 patients (21.6 %) received gemcitabine-based post-CCRT chemotherapy without dose reduction or delay. With median 1.8 years of follow- up, the overall survival was 14.3 months (95% confidence interval [CI]; 10.6–17.9 months). Median progression free survival was 11.1 (95% CI 7.2–15.1) for all patients, and 7.9 months (95% CI 6.6–9.2) for those not received post-CCRT chemotherapy. No patient had grade 4 hematologic or non-hematologic toxicity. Eight patients (21.6%) had severe grade 3 toxicities, 7 (18.9%) with gastrointestinal toxicity and 1 (2.7%) with hematologic toxicity. Prognostic factors for survival were serum albumin (P=0.014; relative risk [RR], 3.4; 95% CI, 1.4, 8.6), and adjuvant gemcitabine treatment (P = 0.005; RR, 3.5; 95% CI, 1.2, 10.6). The prognostic grouping resulted in three groups with significantly different prognosis: group 1 (0 adverse factor; n=8; 1-year survival, 87.5%), group 2 (1 adverse factor; n=23; 1-year survival, 52.9%) and group 3 (2 adverse factors; n=8; 1-year survival, 25.0%). Conclusions: Combined therapy with capecitabine CCRT was well tolerated. Capecitabine seems to be a promising regimen in the treatment of LAPC, in terms of response, survival, and tolerable adverse effects.

No significant financial relationships to disclose.

The prognostic significance of the number of extranodal sites in the patients with disseminated diffuse large B-cell lymphoma treated with R-CHOP

8570

Background: The combination of rituximab and CHOP chemotherapy (R-CHOP) has improved survival of patients with diffuse large B-cell lymphoma (DLBCL). Recently, several reports have shown that standard International Prognostic Index (IPI) became less powerful prognostic predictor in patients with DLBCL in the era of R-CHOP. We evaluated the prognostic factors of DLBCL patients treated with R-CHOP. Detailed analysis was planned regarding the number of extranodal sites because of its higher frequency in Korea. Methods: Between January 2002 and May 2008, 126 patients with stage III/IV DLBCL treated with R-CHOP were identified. We performed the retrospective analysis of the clinicopathologic factors and verified the predictive power of standard IPI and revised IPI (R-IPI) which was reported by the study group of British Columbia. Various numbers of extranodal sites were analyzed for further stratification and we set E-IPI as the IPI when the number of extranodal sites is stratified in ≤2 vs >2. Results: In the univariate analysis, the number of extranodal sites (≤2 vs >2) was a significant prognostic factor for complete response (CR) (p=0.04), event-free survival (EFS) (p=0.01) and overall survival (OS) (p<0.001). Age was also significant for EFS (p=0.03). When the number of extranodal site was stratified differently (0 vs >0, or ≤1 vs >1), these were not associated with CR, EFS and OS. On the multivariate analysis, the number of extranodal sites (≤2 vs >2) remained significant for EFS (p<0.01, HR 2.6) and OS (p<0.01, HR 3.5). The standard IPI identified 3 risk groups with 2-year EFS; 68%, 55%, 56% (p=0.17) and 2-year OS; 85%, 68%, 58%, respectively (p=0.04). The R-IPI classified 2 risk groups with 2-year EFS; 65%, 50% (p=0.02) and 2-year OS 76%, 62%, respectively (p=0.04). The E-IPI represented 3 risk groups with 2-year EFS; 79%, 56%, 42% (p=0.01) and 2-year OS; 86%, 70%, 39%, respectively (p=0.001). The patient group with survival of less than 50% was only recognized by E-IPI. Conclusions: The number of extranodal sites (≤2 vs >2) is the most significant prognostic factor of EFS and OS. Although all three indices remain predictive, E-IPI is the best model to identify the prognostic group in this cohort with stage III/IV DLBCL treated with R-CHOP.

No significant financial relationships to disclose.