Modulation of circulating angiogenic factors and tumor biology by aerobic training in breast cancer patients receiving neoadjuvant chemotherapy

Aerobic exercise training (AET) is an effective adjunct therapy to attenuate the adverse side-effects of adjuvant chemotherapy in women with early breast cancer. Whether AET interacts with the antitumor efficacy of chemotherapy has received scant attention. We carried out a pilot study to explore the effects of AET in combination with neoadjuvant doxorubicin-cyclophosphamide (AC+AET), relative to AC alone, on: (i) host physiology [exercise capacity (VO2 peak), brachial artery flow-mediated dilation (BA-FMD)], (ii) host-related circulating factors [circulating endothelial progenitor cells (CEP) cytokines and angiogenic factors (CAF)], and (iii) tumor phenotype [tumor blood flow ((15)O-water PET), tissue markers (hypoxia and proliferation), and gene expression] in 20 women with operable breast cancer. AET consisted of three supervised cycle ergometry sessions/week at 60% to 100% of VO2 peak, 30 to 45 min/session, for 12 weeks. There was significant time × group interactions for VO2 peak and BA-FMD, favoring the AC+AET group (P < 0.001 and P = 0.07, respectively). These changes were accompanied by significant time × group interactions in CEPs and select CAFs [placenta growth factor, interleukin (IL)-1β, and IL-2], also favoring the AC+AET group (P < 0.05). (15)O-water positron emission tomography (PET) imaging revealed a 38% decrease in tumor blood flow in the AC+AET group. There were no differences in any tumor tissue markers (P > 0.05). Whole-genome microarray tumor analysis revealed significant differential modulation of 57 pathways (P < 0.01), including many that converge on NF-κB. Data from this exploratory study provide initial evidence that AET can modulate several host- and tumor-related pathways during standard chemotherapy. The biologic and clinical implications remain to be determined.

Geriatric oncology: past, present, future

Efforts to integrate geriatric oncology principles in the training of all medical oncologists are underway.

A planned, prospective comparison of short-term quality of life outcomes among older patients with breast cancer treated with standard chemotherapy in a randomized clinical trial vs. an observational study: CALGB #49907 and #369901

OBJECTIVES

Patients ≥ 65 years old ("older") are often not included in randomized clinical trials (RCT), but when they are, care in an RCT might improve quality of life (QoL). We conducted a prospective comparison of QoL among older women receiving standard chemotherapy from the same cooperative group physicians in an RCT vs. an observational study ("off-trial").

METHODS

Older women with invasive, non-metastatic breast cancer (n=150 RCT; 530 off-trial) were included. Linear mixed-effects models tested associations between chemotherapy on- vs. off-trial and changes in EORTC (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire) QoL scores over 24 months, controlling for pre-treatment QoL, age, education, tumor factors, comorbidity, and other covariates.

RESULTS

Anthracycline regimens were used by 58% of women treated on-trial vs. 54% of those treated off-trial. Women in the RCT reported an adjusted mean increase of 13.7 points (95% CI 10.2, 17.1) in global QoL at 24 months (vs. mid-treatment), while women treated off-trial had only an adjusted improvement of 7.0 points (95% CI 3.5, 10.4; p=.007 for difference in mean changes). Women in the RCT had significantly greater improvement in emotional function than those treated off-trial, controlling for baseline; they also had greater reductions in therapy side effects and fatigue at 24 months than women off-trial, controlling for covariates.

CONCLUSION

There may be different QoL trajectories for older women undergoing breast cancer chemotherapy on- vs. off-trial. If confirmed, the results suggest that the extra monitoring and communication within an RCT could provide the infrastructure for interventions to address symptoms and improve QoL for the growing older cancer population.

Multidisciplinary care of patients with early-stage breast cancer

There is a compelling need for close coordination and integration of multiple specialties in the management of patients with early-stage breast cancer. Optimal patient care and outcomes depend on the sequential and often simultaneous participation and dialogue between specialists in imaging, pathologic and molecular diagnostic and prognostic stratification, and the therapeutic specialties of surgery, radiation oncology, and medical oncology. These are but a few of the various disciplines needed to provide modern, sophisticated management. The essential role for coordinated involvement of the entire health care team in optimal management of patients with early-stage breast cancer is likely to increase further.

Six cycles of doxorubicin and cyclophosphamide or Paclitaxel are not superior to four cycles as adjuvant chemotherapy for breast cancer in women with zero to three positive axillary nodes: Cancer and Leukemia Group B 40101

PURPOSE

The ideal duration of adjuvant chemotherapy for patients with lower risk primary breast cancer is not known. Cancer and Leukemia Group B trial 40101 was conducted using a phase III factorial design to define whether six cycles of a chemotherapy regimen are superior to four cycles. We also sought to determine whether paclitaxel (T) is as efficacious as doxorubicin/cyclophosphamide (AC), but with reduced toxicity.

PATIENTS AND METHODS

Between 2002 and 2008, the study enrolled women with operable breast cancer and zero to three positive nodes. Patients were randomly assigned to either four or six cycles of either AC or T. Study stratifiers were estrogen receptor/progesterone receptor (ER/PgR), human epidermal growth factor receptor 2 (HER2), and menopausal status. After 2003, all treatment was administered in dose-dense fashion. The primary efficacy end point was relapse-free survival (RFS).

RESULTS

A total of 3,171 patients were enrolled; 94% were node-negative and 6% had one to three positive nodes. At a median follow-up of 5.3 years, the 4-year RFS was 90.9% and 91.8% for six and four cycles, respectively. The adjusted hazard ratio (HR) of six to four cycles regarding RFS was 1.03 (95% CI, 0.84 to 1.28; P=.77). The 4-year OS was 95.3% and 96.3% for six and four cycles, respectively, with an HR of six to four cycles of 1.12 (95% CI, 0.84 to 1.49; P=.44). There was no interaction between treatment duration and chemotherapy regimen, ER/PgR, or HER2 status on RFS or OS.

CONCLUSION

For women with resected primary breast cancer and zero to three positive nodes, we found no evidence that extending chemotherapy regimens of AC or single-agent T from four to six cycles improves clinical outcome.

Similar survival with single-agent capecitabine or taxane in first-line therapy for metastatic breast cancer

Capecitabine is often offered as a first-line chemotherapy option for metastatic breast cancer (MBC). In this study, we compare characteristics of and survival among women prescribed first-line capecitabine or taxane monotherapy for MBC. Women receiving first-line chemotherapy for MBC from 1998 to 2005 were identified from the North Carolina tumor registry linked with Medicaid and Medicare claims records, and were followed through the end of 2005 with survival data from the National Death Index. T Tests and Chi-square tests were used to compare baseline characteristics. Overall survival and cancer-specific survival were examined using Cox proportional hazard modeling. There were 257 patients with MBC starting first-line chemotherapy with capecitabine (n=71) or a taxane (n=186). No differences in age, race, or Charlson comorbidity status were observed between groups. Hormone receptor negative tumors (31.0 vs. 17.7%, p=0.02) and patients insured by Medicaid (28 vs. 12%, p=0.002) were more prevalent in the capecitabine group. Time from metastasis to first-line chemotherapy was longer in the capecitabine group (52 vs. 26% began after 3 months, p<0.001). In multivariate analysis, treatment received was not associated with overall or cancer-specific survival. Among standard demographics, age was the only factor significantly associated with overall survival (HR 1.02, p=04). In this population-based study, women who received capecitabine as first-line treatment for MBC were more often hormone receptor negative and insured by Medicaid. In multivariate analysis, first-line capecitabine and taxane for MBC yielded similar overall and cancer-specific survival outcomes.

Short- and Long-term Cardiovascular Complications of Cancer Treatment: Overview for the Practicing Oncologist

As new therapies improve survival from cancer, attention to comorbid illness and complications of therapy-both short- and long-term-become much more important to improving not only quality of life but also overall survival. Recognized for its importance as the leading cause of death in the United States, heart disease often coexists with cancer, and cancer treatment may increase risk and/or severity. In addition, there are well-recognized cardiovascular toxicities of cancer treatment, including not only cardiomyopathy, but also hypertension, hypercholesterolemia, and others. Oncologists and cardiologists are working closely to learn more about the complex interaction and to improve management and outcome for patients.

Adjuvant chemotherapy for breast cancer in older women: emerging evidence to aid in decision making

To prevent breast cancer-related recurrence and death, adjuvant therapy, including chemotherapy, is given. The decision to deliver chemotherapy requires careful weighing of the risk of toxicity versus the estimated benefit. The risk and benefit are based on information from clinical trials, statistical models, and past clinical experience . Compared to younger patients, it is perceived that older patients have cancers that are lower risk, gain less benefit from chemotherapy, and are at higher risk of toxicity. There is now strong evidence that healthy older women tolerate treatment and stand to gain the same benefits from treatment as do younger women. Numeric age alone, therefore, does not justify withholding adjuvant chemotherapy. New tools to aid in the decision are needed. Fortunately, the expected great increase in the size of the geriatric population spawned the field of geriatric oncology and the development of brief, practical versions of the Comprehensive Geriatric Assessment (CGA) for use in busy oncology clinics are in sight. It is time for us to incorporate elements of the CGA into practice, to systematically identify older patients at substantial risk of toxicity. For frail older women with breast cancer, no therapy or less toxic therapies can be considered, some of which are suggested herein. In addition, as always in oncology, physicians and patients should look for and participate in clinical trials that will define how to treat cancer, especially in older patients, in the future.

Quality of life of older patients with early-stage breast cancer receiving adjuvant chemotherapy: a companion study to cancer and leukemia group B 49907

PURPOSE

A phase III trial (Cancer and Leukemia Group B CALGB-49907) was conducted to test whether older patients with early-stage breast cancer would have equivalent relapse-free and overall survival with capecitabine compared with standard chemotherapy. The quality of life (QoL) substudy tested whether capecitabine treatment would be associated with a better QoL than standard chemotherapy.

PATIENTS AND METHODS

QoL was assessed in 350 patients randomly assigned to either standard chemotherapy (cyclophosphamide, methotrexate, and fluorouracil [CMF] or doxorubicin and cyclophosphamide [AC]; n = 182) or capecitabine (n = 168). Patients were interviewed by telephone before treatment (baseline), midtreatment, within 1 month post-treatment, and at 12, 18, and 24 months postbaseline by using questionnaires from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30), a breast systemic adverse effects scale (EORTC BR23), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Compared with patients who were treated with standard chemotherapy, patients who were treated with capecitabine had significantly better QoL, role function, and social function, fewer systemic adverse effects, less psychological distress, and less fatigue during and at the completion of treatment (P ≤ .005). Capecitabine treatment was associated with less nausea, vomiting, and constipation and with better appetite than standard treatment (P ≤ .004), but worse hand-foot syndrome and diarrhea (P < .005). These differences all resolved by 12 months.

CONCLUSION

Standard chemotherapy was superior to capecitabine in improving relapse-free and overall survival for older women with early-stage breast cancer. Although capecitabine was associated with better QoL during treatment, QoL was similar for both groups at 1 year. The brief period of poorer QoL with standard treatment is a modest price to pay for a chance at improved survival.

Hot flashes in breast cancer survivors and an association with calcium supplement use

AIMS

In breast cancer survivors, we aimed to describe the frequency of hot flashes and night sweats, frequency and type of treatment, and the association of hot flashes and use of calcium supplements.

METHODS

Charts of breast cancer survivors were reviewed for information about hot flashes, treatment for hot flashes, and calcium supplementation. Associations between variables were explored using the Chi-square test and Fisher's Exact test.

RESULTS

Eighty-six charts were reviewed. Mean age of the women was 58 years and 79% were postmenopausal. Forty-two (49%) of women had hot flashes and 18 (21%) had night sweats. Thirty-one (36%) were treated for hot flashes. Treatment included selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors (n = 19), clonidine (n = 7), Bellergal-S(®) (n = 8), sleep-aid (n = 7), and other (n = 5). Calcium supplementation was recorded in 31%. Of women with hot flashes, 44% took calcium supplements; of women without hot flashes, 18% took calcium supplements (Chi-square P = 0.02).

CONCLUSION

Hot flashes were recorded in 49% of this group of primarily postmenopausal breast cancer survivors. Women with hot flashes were more likely to be taking calcium supplements. Further exploration of the association between hot flashes and calcium supplementation is warranted.

Breast cancer adjuvant chemotherapy decisions in older women: the role of patient preference and interactions with physicians

PURPOSE

Breast cancer chemotherapy decisions in patients > or = 65 years old (older) are complex because of comorbidity, toxicity, and limited data on patient preference. We examined relationships between preferences and chemotherapy use.

METHODS

Older women (n = 934) diagnosed with invasive (> or = 1 cm), nonmetastatic breast cancer from 2004 to 2008 were recruited from 53 cooperative group sites. Data were collected from patient interviews (87% complete), physician survey (93% complete), and charts. Logistic regression and multiple imputation methods were used to assess associations between chemotherapy and independent variables. Chemotherapy use was also evaluated according to the following two groups: indicated (estrogen receptor [ER] negative and/or node positive) and possibly indicated (ER positive and node negative).

RESULTS

Mean patient age was 73 years (range, 65 to 100 years). Unadjusted chemotherapy rates were 69% in the indicated group and 16% in the possibly indicated group. Women who would choose chemotherapy for an increase in survival of < or = 12 months had 3.9 times (95% CI, 2.4 to 6.3 times; P < .001) higher odds of receiving chemotherapy than women with lower preferences, controlling for covariates. Stronger preferences were seen when chemotherapy could be indicated (odds ratio [OR] = 7.7; 95% CI, 3.8 to 16; P < .001) than when treatment might be possibly indicated (OR = 1.9; 95% CI, 1.0 to 3.8; P = .06). Higher patient rating of provider communication was also related to chemotherapy use in the possibly indicated group (OR = 1.9 per 5-point increase in communication score; 95% CI, 1.4 to 2.8; P < .001) but not in the indicated group (P = .15).

CONCLUSION

Older women's preferences and communication with providers are important correlates of chemotherapy use, especially when benefits are more equivocal.

Factor V Leiden mutation and thromboembolism risk in women receiving adjuvant tamoxifen for breast cancer

BACKGROUND

Tamoxifen use has been associated with increased risk of thromboembolic events (TEs) in women with breast cancer and women at high risk for the disease. Factor V Leiden (FVL) is the most common inherited clotting factor mutation and also confers increased thrombosis risk. We investigated whether FVL was associated with TE risk in women with early-stage breast cancer who took adjuvant tamoxifen.

METHODS

A case-control study was conducted among 34 Cancer and Leukemia Group B (CALGB) institutions. We matched each of 124 women who had experienced a documented TE while taking adjuvant tamoxifen for breast cancer (but who were not necessarily on a CALGB treatment trial) to two control subjects (women who took adjuvant tamoxifen but did not experience TE) by age at diagnosis (+/-5 years). DNA from blood was analyzed for FVL mutations. Conditional logistic regression was used to estimate odds ratios (ORs) and to evaluate other potential factors associated with TE and tamoxifen use. All P values are based on two-sided tests.

RESULTS

FVL mutations were identified in 23 (18.5%) case and 12 (4.8%) control subjects (OR = 4.66, 95% confidence interval = 2.14 to 10.14, P < .001). In the multivariable model, FVL mutation was associated with TE (OR = 4.73, 95% confidence interval = 2.10 to 10.68, P < .001). Other statistically significant factors associated with TE risk were personal history of TE and smoking.

CONCLUSIONS

Among women taking adjuvant tamoxifen for early-stage breast cancer, those who had a TE were nearly five times more likely to carry a FVL mutation than those who did not have a TE. Postmenopausal women should be evaluated for the FVL mutation before prescription of adjuvant tamoxifen if a positive test would alter therapeutic decision making.

Breast cancer patients' treatment expectations after exposure to the decision aid program adjuvant online: the influence of numeracy

The decision aid called ''Adjuvant Online'' (Adjuvant! for short) helps breast cancer patients make treatment decisions by providing numerical estimates of treatment efficacy (e.g., 10-y relapse or survival). Studies exploring how patients' numeracy interacts with the estimates provided by Adjuvant! are lacking. Pooling across 2 studies totaling 105 women with estrogen receptor-positive, early-stage breast cancer, the authors explored patients' treatment expectations, perceived benefit from treatments, and confidence of personal benefit from treatments. Patients who were more numerate were more likely to provide estimates of cancer-free survival that matched the estimates provided by Adjuvant! for each treatment option compared with patients with lower numeracy (odds ratios of 1.6 to 2.4). As estimates of treatment efficacy provided by Adjuvant! increased, so did patients' estimates of cancer-free survival (0.37 > r(s) > 0.48) and their perceptions of treatment benefit from hormonal therapy (r(s) = 0.28) and combined therapy (r(s) = 0.27). These relationships were significantly more pronounced for those with higher numeracy, especially for perceived benefit of combined therapy. Results suggest that numeracy influences a patient's ability to interpret numerical estimates of treatment efficacy from decision aids such as Adjuvant!.

Abstract CN09-03: Capitalizing on the teachable moment of the cancer diagnosis to promote healthful lifestyle changes among women with breast cancer and their daughters: Preliminary findings of the DAMES Trial

Introduction: Excessive body weight, as reflected by a body mass index [BMI (kg/m2) &gt; 25] is consistently and independently associated, not only with post-menopausal breast cancer incidence, but mortality as well, with weight gain during adulthood being most strongly associated with risk. In addition, there is consensus that an increased BMI at the time of diagnosis is a poor prognostic indicator, and accumulating evidence that weight gain post-diagnosis is associated with poorer overall and disease-free survival. Thus, to reduce the burden of breast cancer, efforts are needed to promote weight control and to target those most at risk, i.e., women who already have breast cancer (for tertiary prevention of progressive/ recurrent disease and co-morbidity) and their 1st degree relatives (as a means of primary prevention).

Previous studies also suggest that the cancer diagnosis catalyzes a “teachable moment” that may provide an opportune time for health promotion. The DAMES trial (Daughters And MothErS against breast cancer) is currently in the field and will explore whether the momentum of the teachable moment created by the cancer diagnosis, as well as the mother-daughter bond, can be harnessed and used to promote weight loss in overweight women with breast cancer and their overweight adult daughters, and to discern whether team-based vs. independently-delivered interventions offer more promise.

Methods: 68 women diagnosed with loco-regional breast cancer within 5-years and their adult daughters (body mass index [BMI] 25+) were randomized to: 1) a tailored diet-exercise intervention emphasizing the mother-daughter team (TEAM); 2) a tailored diet-exercise intervention delivered to mothers and daughters independently (INDEPENDENT); or 3) an attention control arm that received standardized diet-exercise materials in the public domain (CONTROL); the unit of randomization was the motherdaughter dyad and the distribution of dyads was as follows: 25 dyads in the TEAM; 25 dyads in the INDEPENDENT, and 18 dyads in the CONTROL arms. All interventions consisted of mailed print materials (personalized workbook, plus 6 mailings over the course of the 1-year study period. TEAM & INDEPENDENT participants also received pedometers, portion control tableware, diet/exercise logs, and iPoDs during the intervention (the control arm received iPoDs upon completion of the study). In addition to monitoring accrual, retention and adverse events, effect sizes (variation) regarding changes in weight status and lifestyle behaviors were assessed at baseline, 6-and 12-month follow-up. Survey data (e.g., dietary intake of energy, saturated fat, fruits and vegetables and nutrient density via 2-day dietary recalls, level of physical activity via the Godin Leisure Time Physical Activity Questionnaire [with supporting accelerometry], social support, in general and specific to changing diet and exercise via the Duke Social Support Index and the Sallis et al. Social Support Index for Diet and Exercise, Stage of Readiness and Self-Efficacy for diet and exercise change, perceived risk of recurrence [for mothers] and primary risk of breast cancer [for daughters], health-related quality of life via the SF-36, and strength of the mother-daughter bond via the Interpersonal Closeness Score) were captured at each time point via computer-assisted telephone interviews, and anthropometric measures (weight, height, waist circumference and blood pressure) were assessed inperson by study staff.

Results: While this study is still in the field, at present the full sample has been accrued and randomized; characteristics of the study sample are as follows: Race/Ethnicity (73%White, 18%African American, 7% Hispanic and 2% Asian); Mean Years of Age (Mothers: 61/Daughters: 36), and Mean Distance Separating Dyad Members: 75 miles).

It is noteworthy that although this study was able to achieve its accrual target, a substantial number of breast cancer cases (N=2336) were contacted in order fulfill enrollment. While only a 26% response rate was achieved for the initial screener which accompanied the letter of invitation, the leading reasons for women reporting that they could not participate was because they either did not have an adult-aged daughter, or did not have a daughter who was overweight.

At the time of this abstract submission, data collection is almost complete for the 6-month time point. At this time, attrition is minimal (3%) and only two serious adverse events have been reported (none of which is attributable to the intervention). Preliminary findings from 57 dyads suggest that both the TEAM and INDEPENDENT interventions were associated with significant changes from baseline with decreases in mean dyadic weight (sd) over time being −6.44 (7.49) kg and −6.90 (8.91) kg, respectively as compared to the control −1.61 (6.0) kg (p-values &lt;.05). No significant differences were noted between the experimental interventions, though change scores were −3.2 vs. -3.0 kg (Mothers) and −2.9 vs. −3.5 kg (Daughters) for TEAM vs. INDEPENDENT interventions, respectively. BMI and waist circumference measurements mirror these findings. In addition, baseline to 6-month increases in the level of moderate-to-vigorous physical activity were as follows: CONTROL: Mothers (29 min/week)/Daughters (19 min/week); TEAM: Mothers (53 min/week)/Daughters (55 min/week) and INDEPENDENT: Mothers (33 min/week)/Daughters (87 min/week)(overall p=.19/Team vs. Control p= .08 and Independent vs. Control p=.07).

Conclusions: The mother-daughter weight loss interventions appear feasible as indicated by full enrollment, excellent acceptance, low attrition, and the absence of serious attributable adverse events. Thus far, the lessons learned from this study are as follows: 1) Substantial numbers of women with breast cancer are not eligible on the basis that they don't have a daughter, or one who is interested and eligible; 2) Preliminary data suggest that both interventions perform better than the control; however, data appear somewhat stronger (though not significantly) for mothers assigned to the TEAM intervention, whereas daughters appear to perform better with the INDEPENDENT intervention; and 3) More complete data will be available in the upcoming months to provide some clues as to the effects of the interventions over the longer term (1-year), and will include dietary data, as well as analyses that explore potential moderation by the mother-daughter bond. These additional data will be important in determining the future of family-based lifestyle interventions aimed at the prevalent problem of breast cancer, and for developing future interventions that harness the momentum of the teachable moment and that optimize existing relationships and family dynamics to promote healthful lifestyle change.

Citation Information: Cancer Prev Res 2010;3(1 Suppl):CN09-03.

Quality of Life of Early Stage Breast Cancer Patients 65 Years Old or Older Randomized to Standard Chemotherapy or Capecitabine: A Cancer and Leukemia Group B Study (CALGB 49907)

Background: CALGB conducted a randomized Phase III trial (49907) to test whether older cancer patients receiving capecitabine would have a similar clinical outcome as those receiving standard chemotherapy, but less toxicity. This represented an important quality of life (QoL) paradigm in which treatment recommendations might be based on QoL findings if there was less toxicity for capecitabine with similar clinical outcomes as those achieved with standard chemotherapy. Materials and Methods: A preplanned QoL assessment was preformed in 350 patients randomized to either standard chemotherapy (CMF or AC) (n= 182) or capecitabine (n=168). All patients were interviewed by telephone using standardized questionnaires conducted at baseline, mid-treatment, at 1 month post-treatment, and at 12, 18 and 24 months. Data were analyzed using pattern mixture models and analysis of covariance with repeated measures, in which the sample was divided into groups based on the period of time they had completed assessments. Results: Patients in the capecitabine arm reported a better overall QoL (EORTC p&lt; 0.0001), less fatigue (EORTC p&lt; 0.0001), less nausea and vomiting (EORTC, p&lt; 0.0001), less constipation (EORTC, p&lt; 0.0001), less systemic side effects (EORTC, p&lt; 0.0001), better appetite (EORTC, p&lt; 0.0001), better body image (EORTC, p&lt; 0.0001), less psychological distress (Hospital Anxiety and Depression scale, p&lt; 0.0001), better role (EORTC, p&lt; 0.0001) and social functioning (EORTC, p&lt; 0.0001) than did those in the standard chemotherapy arm at either mid-treatment and/or the end of treatment for those assessed through 24 months. Capecitabine patients reported worse diarrhea (EORTC, p&lt; 0.0001) at mid-treatment, and worse hand–foot symptoms (p&lt; 0.0001) at mid and end of treatment than did those receiving standard chemotherapy. There were no significant differences in most of these measures by 12 months. Discussion: With clinical results showing a significantly improved relapse-free and overall survival for patients who received standard chemotherapy vs. capecitabine (Muss et al., NEJM 2009; 360: 2118), the QoL results will not guide treatment recommendations. However, the QoL results largely confirmed that patients treated with capecitabine experience significantly better QoL vs. those treated with standard chemotherapy due to less toxicity during and at the end of treatment for the sizable group of patients who had completed interviews through 24 months (n=245). These results indicate that despite the worse clinical outcome of patients who receive capecitabine treatment, the majority of capecitabine patients did not experience a worsening QoL from 12 months through 24 months compared to patients receiving standard chemotherapy. Further, these findings are relevant in selecting treatments in the metastatic setting where QoL endpoints often drive decision-making and the goal is to achieve a reasonable level of efficacy while minimizing toxicity.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5035.

Cost impact of oral capecitabine compared to intravenous taxane-based chemotherapy in first-line metastatic breast cancer

OBJECTIVE

Few studies have examined the costs associated with differing first-line chemotherapy regimens in patients with metastatic breast cancer (MBC). This study compares the relative cost impact of women starting first-line chemotherapy with capecitabine versus taxanes.

METHODS

Women receiving first-line chemotherapy for MBC from 1998 to 2002 were identified from a hybrid North Carolina Medicaid-claims-tumour registry linked database and Medicare records, and were followed through to 2005 with claims data. Statistical t- and chi-square tests were used to compare baseline characteristics between patients who received first-line chemotherapy with capecitabine versus taxanes. Projected mean costs for 12 months continuous eligibility were estimated using an ordinary least squares linear regression. Overall cost impact of capecitabine after start of therapy was then examined using a multivariate log-linear regression model.

RESULTS

While patients starting taxanes had significantly lower total costs in the pre-index year than patients starting capecitabine (mean: $20,042 vs. $35,538, p<0.001), in the post-index year, the patients on taxanes experienced significantly higher healthcare utilisation and associated costs compared to patients on capecitabine (mean: $43,353 vs. $35,842, p=0.0089). The differences were primarily attributable to lower expenses in chemotherapy related claims and fewer visit days to outpatient settings for patients on capecitabine. After adjustment with propensity scores and other confounders, the capecitabine group was associated with 32% lower healthcare costs compared to the taxane group (p=0.0001).

CONCLUSIONS

In this population-based study, women who received capecitabine as first-line treatment for MBC had significantly lower costs compared to women starting taxane therapy.

Newer antidepressants and gabapentin for hot flashes: an individual patient pooled analysis

PURPOSE

Nonhormonal treatment options have been investigated as treatments for hot flashes, a major clinical problem in many women. Starting in 2000, a series of 10 individual double-blind placebo-controlled studies has evaluated newer antidepressants and gabapentin for treating hot flashes. This current project was developed to conduct an individual patient pooled analysis of the data from these published clinical trials.

PATIENTS AND METHODS

Individual patient data were collected from the various study investigators who published their study results between 2000 and 2007. Between-study heterogeneity for study characteristics and patient populations was tested via chi2 tests before a pooled analysis. The primary end point, the change in hot flash activity from baseline to week 4, for each agent was calculated via both weighted and unweighted approaches, using the size of the study as the weight. Basic summary statistics were produced for hot flash score and frequency using the following three statistics: raw change, percent reduction, and whether or not a 50% reduction was achieved.

RESULTS

This study included seven trials of newer antidepressants and three trials of gabapentin. The optimal doses (defined by individual study results) of the newer antidepressants paroxetine, venlafaxine, fluoxetine, and sertraline decreased hot flash scores by 41%, 33%, 13%, and 3% to 18% compared with the corresponding placebo arms, respectively. The three gabapentin trials decreased hot flashes by 35% to 38% compared with the corresponding placebo arms.

CONCLUSION

Some newer antidepressants and gabapentin, within 4 weeks of therapy initiation, decrease hot flashes more than placebo.

Patient preference as a determinant of breast cancer adjuvant chemotherapy use in older women: CALGB #369901

9544

Background: Decisions about use of breast cancer chemotherapy in women 65 and older (“older”) can be complex due to comorbidity, uncertain efficacy and limited data on patient preference. Methods: Older women diagnosed with invasive, non-metastatic breast cancer between 2004 and 2008 were recruited from 53 CALGB sites for an observational study of preferences and chemotherapy use. Data on preferences and other factors were collected from patient interviews and clinical data were abstracted from charts. Generalized estimating equation regression was used to assess associations between chart-reported chemotherapy and independent variables; associations were also evaluated in 2 subgroups: “chemotherapy indicated” (estrogen receptor [ER] negative and/or node positive) and “consider chemotherapy” (ER positive and node negative). Results: Among 935 eligible women registered, 815 (87.2%) completed interviews. The mean age of the cohort was 73 years (range 65–100); 38% were node positive, 82% were ER positive and all had tumors ≥ 1 cm (44% were AJCC stage 1, 44% stage 2 and 12% stage 3). Based on ER and nodal status, chemotherapy was “indicated” for 47% and could be “considered” for 53%. Crude chemotherapy rates were 70% in the “indicated” group and 17% in the “considered” group, for an overall rate of 42%. Women who would choose chemotherapy for an increase in survival of ≤12 months were 4.1 times (95% CI 2.5–6.7, p<.0001) more likely to receive chemotherapy than women who would only choose chemotherapy if it added more than 12 months, controlling for age, tumor factors, comorbidity and other covariates. Stronger preferences were seen among women with “indications” for chemotherapy (OR 7.9, 95% CI 3.7–17.0, p<.001) than in those where treatment might be “considered” (OR 1.8, 95% CI 0.9–3.4, p=.08). Higher patient rating of communication with providers was independently related to a decision to use chemotherapy among women where chemotherapy could be “considered” but not among those where chemotherapy was “indicated”. Conclusions: Beyond clinical indications, older women's preferences and communication with providers are important correlates of chemotherapy use.

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Adjuvant hormonal therapy use among insured, low-income women with breast cancer

PURPOSE Use of adjuvant hormonal therapy, which significantly decreases breast cancer mortality, has not been well described among poor women, who are at higher risk of cancer-related death. Here we explore use of adjuvant hormonal therapy in an insured, low-income population. METHODS A North Carolina Cancer Registry-Medicaid linked data set was used. Women with hormone receptor-positive or unknown, nonmetastatic breast cancer, diagnosed between 1998 and 2002, were included. Main outcomes were (1) prescription fill within 1 year of diagnosis, (2) adherence (medication possession ratio), and (3) persistence (absence of a 90-day gap in prescription fills over 12 months). Results The population consisted of 1,491 women (mean age, 67 years). Sixty-four percent filled prescriptions. Predictors of prescription fill included the following: older age (odds ratio [OR], 1.01; P = .017), greater number of prescription medications (OR, 1.06; P < .001), nonmarried status (OR, 1.82; P = .001), higher stage (OR, 1.83; P < .001), positive hormone receptor status (positive v unknown, OR, 1.98; P < .001), not receiving adjuvant chemotherapy (OR, 1.74; P = .001), receipt of adjuvant radiation (OR, 1.55; P = .004), and treatment in a small hospital (OR, 1.49; P = .024). Adherence and persistence rates were 60% and 80%, respectively. Nonmarried status predicted greater adherence (OR, 1.90; P = .006) and persistence (OR, 1.75; P = .031). CONCLUSION Prescription fill, adherence, and persistence to adjuvant hormonal therapy among socioeconomically disadvantaged women are low. Improving use of adjuvant hormonal therapy may lead to lower breast cancer-specific mortality in this population.

A pilot study of predictive markers of chemotherapy-related amenorrhea among premenopausal women with early stage breast cancer

BACKGROUND

Premenopausal women treated for early stage breast cancer (ESBC) are at risk for chemotherapy-related amenorrhea (CRA). Prospectively-validated, predictive markers of CRA are needed.

PATIENTS AND METHODS

Premenopausal women with ESBC and planned chemotherapy (>/= 25% risk of amenorrhea) were evaluated. Follicle stimulating hormone (FSH), estradiol, Inhibin A and B, anti-Müllerian hormone (AMH), and quality of life (QOL) were prospectively evaluated pre-, post-, 6 months and 1 year post-chemotherapy and correlated with age and menstrual status. CRA was defined as absence of menses 1 year post-chemotherapy.

RESULTS

Forty-four women were evaluated at the time of analysis. Median age at diagnosis and FSH 1 year post-chemotherapy were higher among women with CRA (44 yrs [33-51] vs. 40 yrs [31-43]; p = 0.03; 39.8 vs. 5.0 mLU/mL, p = 0.0058, respectively). Median estradiol 1 year post-chemotherapy was higher among women who resumed menses (108.3 vs. 41.3 pg/mL, p = 0.01). Pre-chemotherapy median Inhibin B and AMH were lower among women with CRA (33.2 vs. 108.8 pg/mL; p = 0.03; 0.16 vs. 1.09 ng/mL, p = 0.02, respectively). The risk of CRA was increased among women with lower pre-chemotherapy Inhibin B (RR = 1.67, p = 0.15) and AMH (RR = 1.83, p = 0.05). Amongst women whose pre-chemotherapy Inhibin B and AMH values were below the median, the incidence of CRA was 87.5%.

CONCLUSIONS

RESULTS indicate that pre-chemotherapy Inhibin B and AMH are lower among women experiencing CRA and may be predictive of CRA among premenopausal women facing chemotherapy for ESBC.

Cognitive-behavioral intervention for hot flashes

PURPOSE/OBJECTIVES

To pilot test the acceptability of a DVD platform to deliver a newly created cognitive-behavioral hot flash intervention and estimate the efficacy of the new intervention.

DESIGN

Nonrandomized pretest, post-test design.

SETTING

Midwestern and southeastern outpatient cancer clinics serving urban and rural areas.

SAMPLE

40 participants from two sites completed the study.

METHODS

After completing preintervention assessments, participants watched a DVD of the intervention, practiced the intervention for one week, and then completed post-intervention assessments. Data were collected with a brief interview, questionnaires, objective hot flash monitoring, and wrist actigraphy.

MAIN RESEARCH VARIABLES

Hot flash occurrence, severity, bother, mood disturbance, affect, hot flash disruption, and sleep disturbance.

FINDINGS

The DVD was a feasible and acceptable method for intervention delivery. Although participants expressed difficulty in applying the intervention in certain situations, they also described benefits that included shorter hot flash duration (not measured in this study). Paired t tests showed significant but minor decreases in worst hot flash severity, worst hot flash bother, mood, and disruption of daily activities.

CONCLUSIONS

The DVD was an acceptable way to deliver the intervention. However, the intervention will need to be improved before being tested in a larger study.

IMPLICATIONS FOR NURSING

A cognitive-behavioral intervention may be a useful adjunct or alternative to current hot flash treatments. Findings will be used to modify the intervention and data collection methods before undertaking a larger study.

Response and cardiac toxicity of trastuzumab given in conjunction with weekly paclitaxel after doxorubicin/cyclophosphamide

BACKGROUND

Adjuvant trastuzumab improves relapse-free survival in HER2-overexpressing breast cancer but is associated with cardiac toxicity. This phase II study was undertaken to determine the neoadjuvant clinical and pathologic response rate and the acute and chronic cardiac toxicity of trastuzumab given with weekly paclitaxel after AC (doxorubicin/cyclophosphamide).

PATIENTS AND METHODS

Fifty-two women with newly diagnosed, stage II-IV, HER2-overexpressing breast cancer received AC for 4 cycles, followed by weekly TP (paclitaxel/trastuzumab) for 12 weeks, neoadjuvantly or adjuvantly, followed by 40 weeks of adjuvant trastuzumab.

RESULTS

Congestive heart failure occurred in 4% of patients (95% confidence interval [CI], 0.5%-13.2%). Asymptomatic left ventricular ejection fraction (LVEF) decreases to < 50% occurred in 21% of patients (95% CI, 11.1%-34.7%); all but 1 recovered by 1.5 years. Median LVEF decreased progressively during therapy from 65% before therapy (95% CI, 63%-66%) to 62% after AC (95% CI, 59%-64%) and 58% after AC-TP (95% CI, 56%-64%; P < 0.01 for each decrease). The decrease in LVEF persisted 1.5 years after study entry at 57% (95% CI, 54%-60%), although all but 1 of the most severe decreases to < 50% recovered to normal. Clinical response rate among 37 patients treated neoadjuvantly was 86%, and the pathologic complete response rate was 19% (95% CI, 8%-35.2%). Because of withdrawals for toxicity, refractory disease, and patient preference, only 35% of patients completed the entire regimen.

CONCLUSION

In this study, the AC-TP regimen resulted in a high clinical but moderate pathologic response rate, and although asymptomatic cardiac systolic dysfunction was common, most of the severe decreases recovered over time.

Racial differences in patterns of care among medicaid-enrolled patients with breast cancer

PURPOSE

Suboptimal care among minority and low-income patients may explain poorer survival. There is little information describing patterns of health care in Medicaid-insured women with breast cancer in the United States. Using a previously created and validated database linking Medicaid claims and state-wide tumor registry data, we describe patterns of breast cancer care within a low-income population.

METHODS

Sample characteristics were described by frequencies and means. Logistic regressions were used to determine predictors of type of surgery, use of radiation therapy after breast-conserving surgery (BCS), and use of adjuvant chemotherapy.

RESULTS

The sample consisted of 974 women. The dataset included only white (58%) and black (42%) women. Sixty-seven percent were treated with mastectomy; 43% received adjuvant chemotherapy; and 67% of women receiving BCS received adjuvant radiation. In multivariate analysis, predictors of BCS were young age, black race, and smaller tumor size. Furthermore, there was a trend toward more black than white women with tumors 4 cm or larger having BCS (18% v 8%; P = .06). Race was not related to use of adjuvant radiation therapy after BCS or to use of adjuvant chemotherapy.

CONCLUSION

In this group of patients with breast cancer enrolled in Medicaid, black women were more likely than white women to have BCS. Race was not associated with adjuvant radiation therapy or chemotherapy use. Factors affecting the quality of care delivered to low-income and minority patients are complex, and better care lies in exploring areas that need improvement.

Survival disadvantage among Medicaid-insured breast cancer patients treated with breast conserving surgery without radiation therapy

BACKGROUND

Clinical studies indicate that breast cancer patients treated with breast conserving surgery (BCS) without radiotherapy (RT) have a greater risk of recurrence and mortality compared to those receiving BCS plus RT. However, this relationship has been underdeveloped among low-income women in the community who may face barriers in accessing adjuvant treatment and post-treatment surveillance. It is possible that the prognostic significance of omission of RT in clinical trials underestimates the significance of risk in the community.

METHODS

Using cancer registry, Medicaid claims, and the Social Security Master Death File, we evaluated receipt of RT in women with early stage breast cancer treated with BCS and mean 6-year overall and cancer-specific survival. Logistic regression was used to assess correlates of RT. The Kaplan-Meier method was used to determine survival by RT status and a multivariate Cox proportional hazards regression was used to evaluate the role of RT status on overall and cause-specific survival.

RESULTS

A total of 65% of women received RT, and 82% of the sample survived the study period. Death rates of 16% and 51% were observed among those who did and did not receive RT, respectively (P < 0.001). One-third of women who died from cancer (8 of 24) received radiation. Use of RT was associated with a statistically significant decrease in all-cause (hazard ratio = 0.42, 95% CI 0.21-0.85) and cancer-specific mortality (hazard ratio = 0.22, 95% CI -0.09 to 0.57).

CONCLUSIONS

Adjuvant radiation following BCS was underused in this sample of poor breast cancer patients. Lack of adjuvant RT may be a proxy for inadequate access to care and poor cancer surveillance after treatment.

The influence of radiation therapy on survival among Medicaid-enrolled breast cancer patients treated with breast conserving surgery

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Background: A growing body of evidence indicates that breast cancer patients treated with breast conserving surgery (BCS) without radiotherapy (RT) have a greater risk of cancer recurrence and mortality compared to those receiving BCS plus RT. Most of the research to date has not included or accounted for women with lower socioeconomic status. Methods: Using cancer registry, Medicaid claims, and Social Security death index data, we evaluated receipt of RT and mean 6-year overall and cancer-specific survival among Medicaid-enrolled breast cancer patients treated with BCS (n=230). Logistic regression was used to assess predictors of RT. The Kaplan-Meier method was used to determine survival by RT status and a multivariate Cox proportional hazards regression model was used to evaluate the role of RT on overall and cause-specific survival while controlling for demographic, clinical, and comorbid factors. Results: 65% of women received RT. Overall, 82% of the sample survived the 5–6 year study period, with death rates of 16% compared to 51% among those who did and did not receive RT, respectively (p<.001). Among the 24 individuals who died from cancer, 8 (33.3%) received radiation and 16 (66.7%) had not. After controlling for demographics, clinical factors, and comorbidity, use of RT was associated with a statistically significant decrease in all-cause mortality (hazard ratio = 0.42, 95% CI 0.21–0.85) and cancer-specific mortality (hazard ratio = 0.22, 95% CI −0.09–0.57). Conclusions: We found under-use of radiation following BCS in this Medicaid-enrolled population of breast cancer patients. Furthermore, omission of RT was associated with a greater than two-fold increased risk of death and almost a five-fold increase in cancer-specific death. Measures to improve RT use among poor women receiving BCS need to be implemented.

No significant financial relationships to disclose.

Retrospective study of the effect of comorbidity on use of adjuvant chemotherapy in older women with breast cancer in a tertiary care setting

Use of adjuvant chemotherapy for breast cancer decreases with increasing age. We examined the effect of comorbidity on adjuvant chemotherapy use in older women (age >55 years) in a tertiary care Oncology Clinic. Clinic charts of new, early stage breast cancer patients over age 55 were reviewed. Multivariate analysis was used to determine the effect of age (55-64 versus > or =65 years), tumor stage, and comorbidity (Charlson score) on management. Two hundred and seventy-three charts were reviewed. Older women had a greater mean Charlson comorbidity score (0.72 versus 0.21; p<0.001). Tamoxifen use was similar in both groups (82.8% versus 81.1%, p=0.72). Chemotherapy was less frequently used in older women, regardless of nodal status: overall, 13.1% versus 45.6%, p<0.001; node-negative, 8.2% versus 32.1%, p<0.001; and node-positive, 25% versus 83.8%, p<0.001. In a multivariate analysis, lower stage, older age, and higher comorbidity were predictive of less frequent use of adjuvant chemotherapy. Though higher comorbidity was associated with less use of adjuvant chemotherapy, it did not totally account for the low use of chemotherapy in older compared to younger women. More work should be planned to dissect out specific reasons for differences in treatment by age.

Subcutaneously administered recombinant human interleukin-2 and interferon alfa-2a for advanced breast cancer: a phase II study of the Cancer and Leukemia Group B (CALGB 9041)

New and more effective treatments are needed for metastatic breast cancer. This study aimed to determine the effectiveness of a combination of subcutaneously administered recombinant human interleukin-2 (rIL-2), 1.5 MU/m(2) for 5 consecutive days repeated for 3 weeks, and interferon alpha-2a (IFN), 7.5 MU/m(2), administered subcutaneously three times per week. Women who had previously received 1-2 prior chemotherapy regimens for measurable inoperable, recurrent, or metastatic breast cancer were eligible. Of 40 patients accrued to the study, 32 were evaluable for response assessment. Toxicities were frequent but manageable. The most common grade 3 and 4 toxicities were lymphopenia (17%) and malaise/fatigue (24%). There were no complete responses, one partial response (3%), and six patients with stable disease (19%). Of the seven patients with partial response or stable disease, all had tumors that expressed hormone receptors. The median survival was 8.9 months and all patients have died. Good performance status was the most important predictor of survival. In this group of women with metastatic breast cancer, the overall prognosis was poor. This combination of rIL-2 and IFN was ineffective.

Breast cancer in older patients

Breast cancer is a common problem and a major health concern in our growing geriatric population. Older breast cancer patients are at risk for less than standard management, the appropriateness of which is difficult to discern. Breast tumors tend to have less aggressive characteristics. In addition, planning therapy is not always straightforward because older patients may present with comorbid illnesses and frailty that limit therapeutic choices. Standard management approaches should always be considered first. Here, we outline some data supporting standard treatment for breast cancer in older women. We also describe other options that can be considered in circumstances when the standard treatment is not possible. For instance, primary treatment with tamoxifen or an aromatase inhibitor is justifiable in a patient who is unfit for surgery and axillary dissection may be unnecessary in a patient who is obviously unfit for adjuvant chemotherapy. Adjuvant therapies should be considered, weighing risks and benefits for each patient, though the threshold for using chemotherapy may be higher. The goals in treating metastatic breast cancer in an older patient are not different than for younger patients.

Interpreting measures of treatment effect in cancer clinical trials

The efficacy of a new cancer regimen is usually assessed by analyzing outcomes such as tumor response and overall survival. Many publications summarizing results of cancer clinical trials report measures such as odds ratios and hazard ratios, as these are the estimators of treatment effect obtained from regression models used to analyze the data. However, these measures are sometimes misinterpreted, as they are not necessarily familiar to many readers. The most common mistake is to interpret both measures as relative risks, an interpretation that can lead to an incorrect impression of the impact of the treatment on response and survival.

Breast cancer in older women

More than 50% of breast cancers are diagnosed in women aged 65 years or older, a quickly growing segment of the population. Healthy older women should be offered state-of-the-art screening and treatment for breast cancer, including mammography, surgery, radiation therapy, and adjuvant therapy for early stage tumors. Clinical trials focusing on the role of adjuvant treatment in older women with breast cancer are of chief importance. The optimal treatment for older women with life-threatening, comorbid conditions may be primary treatment with tamoxifen or adjuvant therapy with tamoxifen alone after definitive surgery. Outside the clinical trials setting, metastatic disease should be treated similarly in all age groups.

Rhabdomyolysis and hemolysis associated with sickle cell trait and glucose-6-phosphate dehydrogenase deficiency

We report a case of severe oxidative hemolysis and rhabdomyolysis in a patient with sickle cell trait and glucose-6-phosphate dehydrogenase (G6PD) deficiency. The patient was a 34-year-old black man admitted 24 hours after vigorous exercise with myalgias, malaise, myoglobinuria, anemia, low haptoglobin, and a peripheral blood smear with bite cells consistent with oxidative hemolysis. He had two similar episodes within 21 months of the initial admission. Subsequent evaluation resulted in the diagnosis of sickle cell trait and G6PD deficiency; muscle enzyme levels were normal. G6PD deficiency and sickle cell trait can be expected to occur simultaneously in up to 1% of black males. A second red blood cell defect should be considered when severe hemolysis is seen in a person with sickle cell trait.

Current status of endocrine therapy for metastatic breast cancer

Hormonal manipulation is currently the mainstay of palliative care for metastatic breast cancer because it is well tolerated and produces significant responses in approximately one-third of unselected patients. Tamoxifen, a nonsteroidal antiestrogen, is currently considered first-line therapy. Second-line agents include progestins and aromatase inhibitors. New agents, such as the "pure" antiestrogens and the gonadotropin-releasing hormone (GnRH) agonists, are being tested. Other approaches for affecting the hormonal milieu are also under investigation, including combinations of hormonal agents, hormonal agents plus biologics, and hormonal agents plus antiproliferative agents. This review will address the basis for endocrine therapy and possible mechanisms of hormonal resistance, currently available agents and newer ones on the horizon, and areas of future interest.

A comparison of treatment outcomes for black patients and white patients with metastatic breast cancer. The Piedmont Oncology Association experience

Prior studies have shown that black patients with breast cancer have poorer survival times compared with white patients even when adjusted for stage. Seventy-four black patients treated on six Piedmont Oncology Association (POA) protocols were compared with 74 randomly selected white patients treated with the same protocols to determine if race had any independent effect on response, time to progression, or survival time. Patients were evenly matched for pretreatment characteristics with the exception that white patients had a significantly higher percentage of bone metastases and significantly less skin involvement. Response rates and median time to progression were similar for black patients and white patients at 31% and 25%, and 9.3 and 9.1 months, respectively. Black patients had poorer survival times even when adjusting for covariables; median survival time was 14.3 months for black patients and 20.3 months for white patients (P less than 0.05). The reason for this survival difference in Stage IV patients is unclear, but is unlikely to be related to treatment. Additional research in this area will be necessary to resolve this issue.