Disease-free survival at intervals during and following completion of adjuvant chemotherapy: the NSABP experience from three breast cancer protocols

Findings from the National Surgical Adjuvant Breast and Bowel Project (NSABP) trials evaluating three different regimens of adjuvant chemotherapy (L-PAM, L-PAM + 5-FU, L-PAM + 5-FU + MTX) in patients with primary breast cancer and positive axillary nodes indicate that each regimen has significantly contributed toward achieving the initial goal of such therapy, namely to diminish or prevent treatment failure in all or major subsets of patients during the first two years following operation when women are at greatest risk for a recurrence. Because of this hazard, chemotherapy was administered in all protocols for two years. Findings were examined at the end of the first year of therapy and at the termination of the second year for those who entered that year of therapy disease-free in order to determine whether the second year of treatment contributed a benefit beyond that achieved from the first year of therapy. A reduction in the incidence of treatment failure was evident in every subgroup of patients at completion of the first year of therapy. There was evidence of added improvement during the second year of treatment in patients aged 49 years or younger but not in those aged 50 years or older. Despite the finding, it is not possible from these studies to be absolutely certain that a second year of therapy is or is not advantageous. Findings obtained to date from the three studies indicate that patients completing two years of chemotherapy who are disease-free display a subsequent treatment failure rate that is no greater than that observed in untreated patients who survived two years without recurrence. Consequently, any advantage in disease-free survival observed at completion of therapy has been subsequently sustained for several years, suggesting this represents a real decrease rather than a postponement of treatment failure.

Treatment of primary breast cancer with chemotherapy and tamoxifen

We studied the possibility that the addition of tamoxifen to L-phenylalanine mustard combined with 5-fluorouracil enhances the benefit from the latter two drugs that has been observed in women with primary breast cancer and positive axillary nodes. Recurrence of disease was reduced at two years in patients given the three-drug regimen whose tumor estrogen-receptor levels were greater than or equal to 10 fmol. Among patients greater than or equal to 50 years old treatment failure was significantly reduced (P less than 0.001): by 51 per cent in those with one to three positive nodes and by 64 per cent in those with four or more. Higher receptor levels were associated with a greater probability of disease-free survival. Patients less than or equal to 49 years old were less responsive: those with one to three positive nodes received no benefit from tamoxifen at any receptor level, whereas those with four or more appeared to have reduced treatment failure associated with higher receptor levels. This adjuvant chemotherapy is not indicated in patients less than or equal to 49 years old whose tumor receptor levels are below 10 fmol; there is a suggestion of benefit in patients greater than or equal to 50 years old whose levels are low.

Acute toxicity during adjuvant chemotherapy for breast cancer: the National Surgical Adjuvant Breast and Bowel Project (NSABP) experience from 1717 patients receiving single and multiple agents

Since 1972, the National Surgical Adjuvant Breast and Bowel Project (NSABP) has carried out a series of clinical trials evaluating the worth of adjuvant chemotherapy in the management of patients with primary breast cancer. This report provides information concerning (a) protocol compliance relative to drug administration and (b) acute toxicity encountered by patients in three separate trials who were given one-, two- or three-drug chemotherapy within 1 month of operation. The findings are derived from 1548 women who received 20,765 courses of chemotherapy, the most extensively documented experience yet reported. They indicate that despite the large number of physicians and the heterogeneity of the institutions participating, large cooperative efforts can be accomplished with credibility. Only 13 (0.8%) of the women failed to complete all courses of therapy for reasons directly related to nonprotocol compliance by physicians. Only 4.3% failed to complete therapy for miscellaneous reasons other than toxicity, treatment failure, occurrence of a second primary, or death unrelated to tumor. While almost all patients experienced toxic reactions during the therapy, only 3%--4% of recipients of melphalan (L-PAM; P) and 4%--5% of recipients of L-PAM + 5-FU(F)(PF) failed to complete 2 years of therapy because of toxicity. Of those patients receiving PF + methotrexate (MTX; M) (PMF), 15% did not finish their treatment for that reason. While there was little difference in hematologic and nonhematologic toxicity between those patients receiving P or PF, and such toxicity was generally acceptable to both patients and physicians, the addition of MTX (PMF) resulted in greater toxicity (vomiting, stomatitis, and alopecia) which was less readily accepted. Tolerance of any of these regimens was unrelated to patient age, despite the belief that older women are less tolerant of chemotherapy. The earlier toxicity occurred, the greater was the number of subsequent courses associated with toxicity, and the lower was the total amount of drug received. The extent of the toxicity produced by the NSABP regimens and the end results obtained with them, must be compared with the end results and toxicity obtained by other regimens before making a choice of the adjuvant therapy to be used.

Correlation of primary breast cancer histopathology and estrogen receptor content

We studied the association of estrogen receptor (ER) with several histologic variables that correlate with breast tumor differentiation and with patient prognosis. Contingency table analysis revealed highly statistically significant correlations between ER content and histologic and nuclear grades, tumor necrosis, and the degree of elastosis and lymphoid cell infiltration. ER positive tumors were more likely than ER negative tumors to demonstrate histological evidence of tumor differentiation. All tumors with histologic grade 1 or nuclear grade 1 (best differentiated) were ER positive or borderline positive. Eighty-nine percent of ER negative tumors were histologic grade 3 and 78.4% were nuclear grade 3 (poor differentiation). ER positive tumors were also correlated with absent tumor necrosis, higher elastic content, and absent lymphoid cell infiltration, all features of good differentiation. Medullary carcinomas were frequently (73%) ER negative, but no relationship between ER and other morphologic types of breast cancer or 9 other morphologic variables was found. ER appears to be a biochemical marker for the degree of differentiation of human breast cancer providing a rationale for the observed differences in biological behavior between receptor positive and negative tumors.

A commentary on the role of the surgeon in primary breast cancer

The function of the surgeon remains the same relative to the management of primary breast cancer. What has changed is our perception of the biology of the disease and our understanding of data evaluation and analysis. This presentation provides an overview of some of the more important findings which have altered our understanding of breast cancer and which have led to a reassessment of the basis for cancer surgery. It also emphasizes why controlled clinical trials are necessary for obtaining credible data. To most succinctly summarize the author's position regarding a number of critical controversies related to primary breast cancer surgery, answers are presented to ten of the questions most frequently posed by surgeons regarding surgical therapy.

Cellular cytotoxicity in tumor-bearing mice after transfer of normal or tumor-sensitized lymphoid cells

The present investigations are a continuation of those indicating that the administration to normal inbred C3HeB/-FeJ mice of syngeneic tumor-sensitized cells or cells from F344 Mai rats (xenogeneic) sensitized to mouse tumor imparted "information" that resulted in the production of tumor-specific cytotoxic cells by recipients. Current findings revealed that normal but not tumor-sensitized spleen cells when transferred to syngeneic tumor-bearing recipients enhanced the cytotoxicity ofrom F344 Mai rats (xenogeneic) sensitized to mouse tumor imparted "information" that resulted in the production of tumor-specific cytotoxic cells by recipients. Current findings revealed that normal but not tumor-sensitized spleen cells when transferred to syngeneic tumor-bearing recipients enhanced the cytotoxicity of lymphoid cells in the recipients. This enhanced cytotoxicity was specific for the immunizing tumor. Inoculation of normal or tumor-sensitized lymph node cells failed to produce such an effect. Our present and previous findings suggested that in the presence of a tumor, uncommitted cells that reside in the spleen and that are available for recruitment and "instruction" may become depleted, whereas no comparable deficit may exist in cells that are capable of information transfer.

Pathologic findings from the National Surgical Adjuvant Breast Project (Protocol no. 4). VI. Discriminants for five-year treatment failure

Thirty-six pathologic and six clinical characteristics observed in 581 patients enrolled in protocol no. 4 of the National Surgical Adjuvant Breast Project were treated by radical mastectomy and were correlated with five-year treatment failure. The cases were initially stratified according to pathologic nodal status, the most important discriminant in breast cancer. The presence of tumor necrosis, poor tumor differentiation (histologic grade 3) and a tumor size > 4 cm were found by multivariate analyses to influence treatment failure in patients without nodal metastases. Prognosis was usually worse in individuals whose tumors exhibited all of these features than in those in whom only one or two could be detected. Although the sample size was small, life-table analysis also disclosed a highly significant relationship between treatment failure and a germinal center predominance pattern in regional nodes in this subset of patients. Except for this latter, these same discriminants were similarly noted to affect treatment failure in those patients with four or more nodal metastases but not those with only 1--3 positive nodes. A possible explanation for this inconsistency among nodal categories is discussed. Nevertheless, it is concluded that these rather easily measured pathologic parameters represent important discriminants for the prognosis and the design of treatment schemes and subsequent protocols for patients with breast cancer, particularly those without regional nodal metastasis. The findings amplify the importance of intrinsic tumor characteristics as well as possibly host factors in accounting for the clinical behavior of patients with breast cancer.

The contribution of recent NSABP clinical trials of primary breast cancer therapy to an understanding of tumor biology--an overview of findings

Disagreement about local-regional management of primary breast cancer is related to differences in perception of the biology of the disease. Other factors are secondary and obscure the reality that all treatment must be related to biological considerations; otherwise, the basis for therapy is relegated to speculation and to personal experience. As a result of extensive laboratory and clinical studies during the past two decades, there has arisen an altered concept of cancer biology. The National Surgical Adjuvant Project for Breast and Bowel Cancers (NSABP) has made a major contribution to the change through findings from a series of prospective randomized clinical trials. That group of American and Canadian investigators has implemented a series of trials aimed at answering biological as well as clinical questions. Those studies have not only been concerned with defining proper local-regional treatment but have also pointed out the need for, and value of, systemic therapy when used in conjunction with operation. This report will provide an overview of past and present NSABP contributions and will consider those findings in relation to observations from other clinical trials of pertinence. It will emphasize that controversies concerning breast cancer management are related to biological issues that cannot be resolved by "populism" or appeals to emotion.

Diagnosis of invasive aspergillosis by passive hemagglutination assay of antibody

Sheep red cells treated with concanavalin A and sensitized with a partially purified aspergillus antigen were used to detect antibody to Aspergillus by passive hemagglutination (PHA). Sera from eight patients with aspergillomas or allergic aspergillosis had PHA titers of greater than or equal to 1:800 and antibody detectable by immunodiffusion (ID). Of 122 hospitalized cancer patients without invasive aspergillosis, 118 had titers of less than or equal to 1:80, 86 of < 1:10, two of 1:160, and two of 1:320. None had antibody by ID. Antibody was detectable by PHA in sera from 12 of 14 healthy microbiology laboratory workers. Of 55 cancer patients who had sera available for testing within two weeks before diagnosis of invasive aspergillosis, 18 patients seroconverted: 13 by both PHA and ID, two by PHA alone, and three by ID alone. PHA titers rose from < 1:10 to between 1:40 and 1:1,280. In immunosuppressed patients who were at risk of developing invasive aspergillosis, the appearance of antibody correlated with the diagnosis of invasive aspergillosis.

Cellular cytotoxicity and serum inhibition in normal mice following transfer of syngeneic tumor-sensitized cells

Investigations were performed to elucidate changes in normal syngeneic recipients after they received tumor-sensitized cells. Transfer of regional or nonregional lymph node cells or spleen cells from tumor-bearing inbred C3HeB/FeJ mice to normal syngeneic recipients caused the recipients to produced bone marrow, which mediated in vitro cytolysis of immunizing tumor target cells. This finding was not entirely limited to transfer of lymphoid cells. The transfer of myeloid cells, granulocytes, and cultured macrophages from tumor-bearing mice also produced cytotoxic cells. The extent of cytotoxicity following cell transfer was related to the duration of tumor growth in cell donors, to the degree of cytotoxicity, and to the number of cells transferred. Both the iv and ip routes were equally effective. Treatment of cells before transfer with trypsin or pronase, mitomycin C, or sublethal irradiation failed to prevent development of cytotoxicity in cells of the recipient, whereas freeze-thawing abolished this event. Serum from the cell recipient could inhibit the cytotoxicity demonstrated by lymphoid cells derived from the recipient or from a tumor-bearing animal. The findings indicate that "information" transferred to normal animals not previously exposed to a tumor results in production of tumor-specific cytotoxic cells in these animals.

Pathologic findings from the National Surgical Adjuvant Breast Project (protocol no. 4). VI. Invasive papillary cancer

Although papillary forms of intraductal cancer are a common component of amny mammary cancers, invasive papillary cancer of the breast is relatively rare. Only 35 examples were encountered in the specimens obtained from 1603 women participating in a prospective randomized study of invasive mammary cancer. Contingency-table analysis disclosed that invasive papillary cancer, as opposed to the non-papillary histologic types, is significantly more likely to show circumscription, cytoplasmic oxyphilia, microcalcification, intermediate histologic grade, moderate or marked mucin and an intraductal component of papillary type. Although patients who have invasive papillary cancer are frequently judged by clinical criteria to have regional nodal metastases, in pathologic analysis these metastases are not commonly found and, if present, involve fewer than four nodes. There is a significant frequency of marked sinus histiocytosis in regional nodes. The lesion occurs with a significantly high frequency among non-Caucasian and postmenopausal women. Only three patients with invasive papillary cancer experienced treatment failure after five years of observation. Life-table probabilities showed that the treatment failure rate was significantly lower for the group of patients who had any other histologic type, and in this regard invasive papillary cancer was similar to the tubular and mucinous varieties. Although apocrine metaplasia, fibrous supporting stalks and cellular differentiation have been espoused as important criteria distinguishing intraductal papi-loma from intraductal cancer, these features were also not uncommonly observed in the examples of invasive papillary cancer studied. It is concluded that invasive papillary cancer represents a unique histologic type of invasive mammary cancer attendant with a favorable prognosis.

Correlation of estrogen receptor and pathologic characteristics of invasive breast cancer

Estrogen receptor (ER) status was correlated with a large number of pathological and clinical characteristics of 178 invasive breast cancers. Positive ER was found to be significantly associated with high nuclear and low histologic grades, absence of tumor necrosis, presence of marked tumor elastosis, and older patients. These pathologic parameters enumerated are either directly or indirectly related to tumor differentiation suggesting that ER represents another index of this latter. Multivariate analyses disclosed that both age and tumor differentiation are associated with the ER status. Well-differentiated tumors were more frequently ER+ in older women. Inclusion of an estimate of tumor necrosis as well as patient age appears to allow for further discrimination of ER status in poorly differentiated lesions. Considerations relative to ER and tumor differentiation provide a possible explanation for the dichotomy of response to adjuvant chemotherapy observed in pre and postmenopausal women.

The significance of concordance in mammographic interpretations

Twenty-eight women participating in a screening program had a breast cancer diagnosed subsequent to the report of a negative mammogram which was read by only one of a group of radiologists. Fourteen occurred prior to a scheduled routine screening visit (interval cancers) and 14 were detected during such an examination. The negative mammograms from the 28 cancer patients, together with those from 120 women without cancer (controls) were independently reviewed by each member of a panel of three radiologists. Forty-six percent of the cancer cases and 5.8% of the controls were interpreted as positive by two or more of the radiologists. These findings suggest that agreement among several independent reviewers enchances the value and accuracy of mamography by reducing the number of false negative interpretations.

Effect of surgical removal on the growth and kinetics of residual tumor

Findings from this study using a transplantable C3H mammary tumor failed to indicate interaction relative to growth parameters between two foci present in the same host. Whether they were growing alone or in the presence of a second focus, tumor growth rates were similar until the combined mass of multiple tumors approached that which was incompatible with survival. Only then was a difference in growth observed. Cytokinetic parameters, i.e., labeling index, primer-dependent DNA polymerase index or growth fraction, DNA synthesis time, tumor doubling time, and cell cycle time, were also similar whether tumors grew alone or in the presence of a second focus. Following removal of a tumor, changes were observed within 24 hr in the kinetics of the residual focus. There was an increase in labeling index (duration approximately equal to 10 days) and primer-dependent DNA polymerase index with a decrease in the tumor doubling time. Minimal change was noted in DNA synthesis time and cell cycle time. The kinetic changes observed were reflected in a measureable increase in tumor size approximately equal to a week following tumor removal. Absence of an alteration in DNA synthesis time and cell cycle time indicates that the increase in tumor growth was probably due to a conversion of noncycling cells in G0 phase into proliferation. Relationship of the findings to the use of adjuvant chemotherapy is considered.