Longitudinal Evaluation of the Healthy Living Assessment as an Experiential Learning Activity Provided On-Campus

Objective. To implement and evaluate the effectiveness of healthy living assessments (HLA) conducted on campus by undergraduate pharmacy students. Methods. Because of a shortage of workplace-based placements for undergraduate pharmacy students, a program was developed for students to conduct HLAs on campus for volunteer patients. Pharmacy students underwent training and completed a competency assessment before being approved to conduct HLAs. Staff members and students were recruited to serve as participants. Following the HLA, pharmacy students completed a quantitative and qualitative questionnaires to assess their perceived educational gains and opinions about the experience. Participants who underwent an HLA were asked to complete a questionnaire about the quality of the service they received. Results. From 2011-2019, 896 HLAs were conducted by 764 undergraduate pharmacy students. The students reported that completing an HLA improved their clinical knowledge, counselling skills, professionalism, and confidence when talking to participants. They believed the HLA delivered an authentic learning experience, similar to that achieved during workplace-based placements. The HLA service was rated as good or outstanding by 99% of the participants, and the majority stated that they intended to make lifestyle changes as a result of attending the HLA. Conclusion. Conducting healthy living assessments provided undergraduate pharmacy students a valuable, quality-assured opportunity for experiential learning. The HLAs were well received by participants as they informed them about their current health status and gave them useful advice about making health improvements.

Abstract OT1-02-02: A pilot study to examine the feasibility of measuring CTC and inflammatory biomarker changes resulting from atorvastatin as adjuvant therapy in TNBC and TN-IBC patients with residual disease after neoadjuvant chemotherapy

Background: Patients who have TNBC or triple negative-IBC (TN-IBC) and do not achieve pathological complete response after neoadjuvant chemotherapy are at significant risk for distant relapse and death from recurrent disease. Apart from capecitabine, there are no proven adjuvant therapies that may improve these poor outcomes of patients with chemo-resistant tumors. Therefore, there is an unmet need for effective systemic therapy for this subset of patients with TNBC. Epidemiological evidence reveals that statin use after diagnosis is associated with improved breast cancer relapse-free survival and decreased mortality. However, direct evidence of in vivo mechanisms explaining this association are lacking. Preclinical studies using statins in breast cancer reveal pathways that statins can inhibit proliferation, stem cell self-renewal and metastatic potential.

Trial Design: This is a pilot study designed in 2 phases to assess feasibility of completion while providing a signal of efficacy in biomarker changes. In the first phase, we will follow the initial 30 patients who meet eligibility for atorvastatin treatment for the 2-year treatment window, or until disease recurrence. We will collect blood samples prior to, and during atorvastatin treatment for circulating tumor cells (CTCs), cytokine and inflammatory biomarker analyses. We defined a positive outcome as CTCs remaining non-detected at 6 months when baseline CTC is undetected, or a reduction in the number of CTCs at 6 months compared to baseline. If we observe a positive outcome among the initial 30 patients, then we will open the second phase of this study for an additional 50 patients. Here we will follow both patient cohorts who receive and not receive atorvastatin treatment to collect longitudinal data on biomarkers as a function of the natural history of TNBC to better understand the activity of atorvastatin.

Trial Eligibility: Patients with stage II-III TNBC who have residual cancer burden (RCB)-II or RCB-III or stage 3 TN-IBC with any amount of residual disease, and are not taking a statin or any other anti-lipidemic agent are candidates for the study. Patients must have adequate hematologic, organ, and cardiac function and must have recovered from the acute effects of any prior treatments. Baseline lipid profile will be assessed by a cardiologist to determine the patients’ eligibility to take atorvastatin based on current ACC/AHA guideline, and to select between moderate (20mg) or high intensity treatment (40mg).

Specific Aims: The primary objective is to determine the proportion of patients with undetectable CTCs at 6 months with and without atorvastatin therapy. Secondary objectives include correlation of baseline lipid profiles/lipid profile changes with 2 year-relapse free survival (RFS), CTC counts and inflammatory biomarkers.

Statistical Methods: The total estimated enrollment is 80 patients, including at least 5 treated with adjuvant capecitabine and at least 5 without adjuvant capecitabine. The study overall is powered with the assumption that 48 patients will receive atorvastatin and 32 will not, and this will allow us to estimate the percent of patients with negative CTCs at 6 months with a standard error not larger than 7% and 9%, respectively. All other analyses including inflammatory biomarkers and RFS differences between groups are exploratory and considered hypothesis-generating rather than conclusive.

Citation Format: Angela Alexander, Takeo Fujii, Michael C Stauder, Wendy A Woodward, James M Reuben, Yu Shen, Diane Liu, Sangeetha M Reddy, Vicente Valero, Susan C Gilchrist, Bora Lim, Anthony Lucci, Naoto T Ueno, Carlos H Barcenas. A pilot study to examine the feasibility of measuring CTC and inflammatory biomarker changes resulting from atorvastatin as adjuvant therapy in TNBC and TN-IBC patients with residual disease after neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT1-02-02.

Abstract P6-15-06: Establishing the content domain for a patient-reported outcomes measure to evaluate the unique symptom burden of inflammatory breast cancer

Background: Inflammatory breast cancer (IBC) is an aggressive, locally advanced breast cancer with a poor prognosis including a median survival of less than 4 years and a 5-year survival rate of around 60-70%. Symptom monitoring and management has demonstrated improved cancer patient outcomes, including quality of life, resource utilization, ability to continue treatment, and disease-free survival. The use of disease-specific patient-reported outcomes (PROs) is critical for facilitating individualized symptom monitoring and management. While women with IBC likely experience significant and variable symptom burden from diagnosis through treatment and survivorship that may remain under-reported and unmanaged, there is limited description of the symptom burden in this population and no disease-specific valid and reliable instrument for measuring symptom burden in IBC. In addition, because the diagnosis of IBC is based on clinical criteria as opposed to molecular or pathological diagnostic criteria, attention to defining the disease-related symptoms may assist clinicians in making timely and accurate diagnoses. The purpose of this study was to describe the patient experience of IBC and define the content domain for a PRO measure of IBC symptom burden, using patient input to ensure content validity. Methods: This descriptive study is the first stage in development of a PRO IBC symptom burden measure. Twenty patients with IBC across the disease continuum described their experience in single qualitative interviews. Content analysis was used to describe their experience and define the symptom burden content domain. Results: Mean patient age was 52.8 years (range, 30-73 years); 50% with locally advanced and 50% with metastatic disease, with 85% receiving treatment at the time of the interview. Content analysis found 51 symptoms related to both disease and treatment, with 24 symptoms reported at least 20% of participants. Participants reported, on average, 13.1 symptoms (range, 3-23 symptoms). All participants described localized disease-related symptoms that were present at diagnosis, which included breast rash (40% of participants), changes in the texture of the breast (55%), nipple changes (25%), breast pain (40%), breast discoloration (70%), breast lump (55%), breast warmth (10%), and breast swelling (50%). Treatment-related symptoms varied among participants based on modalities received. Patients volunteered ways in which symptoms impacted daily activities and relationships and how symptoms were managed. Conclusions: We have completed our pilot study. Patients with IBC experience numerous symptoms related to disease and treatment, including many localized disease-related symptoms with various treatments resulting in unique symptom burden. Symptoms may result in interference with daily activities, relationships, life plans, treatment adherence, and mood. Well-designed PROs are essential for accurate symptom assessment and management to maintain patient functioning. The content domain for a PRO symptom-burden measure of IBC encompasses the severity and activity interference of common symptoms of IBC and its treatment.

Citation Format: Meagan Whisenant, Angela Alexander, Loretta A. Williams, Wendy Woodward, Randa El-Zein, Naoto Tada Ueno. Establishing the content domain for a patient-reported outcomes measure to evaluate the unique symptom burden of inflammatory breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-15-06.

Abstract P3-09-12: Peripheral T cell clonality and exhaustion as novel biomarkers for anti-PD-1 (pembrolizumab) maintenance therapy in patients with metastatic inflammatory breast cancer (mIBC) and non-IBC triple negative breast cancer (mTNBC)

Background: Inflammatory breast cancer (IBC) and triple negative breast cancer (TNBC) are more aggressive than other breast cancer subtypes, and up until recently lacked therapy options that maintain acceptable quality of life. While chemotherapy is a treatment option for all subtypes of breast cancer, it is used long-term as maintenance therapy for metastatic TNBC (mTNBC) and often produces cumulative toxicity resulting in discontinuation of treatment. Moreover, responses are rarely durable after discontinuation of chemotherapy. Immune checkpoint blockade has the potential to maintain therapy. To determine factors associated with response to anti-PD-1 therapy (pembrolizumab), we performed minimally invasive blood-based analyses of T-cell repertoire and phenotype to evaluate their association with progression-free survival (PFS) in 15 patients with metastatic IBC (mIBC) or mTNBC.

Materials and Methods: Fifteen patients with mIBC (n=6) or mTNBC (n=9) were enrolled on an ongoing phase II study to receive pembrolizumab as maintenance therapy after achieving a clinical response or stable disease to systemic chemotherapy for metastatic disease. We performed analyses of T-cell repertoire and phenotype on peripheral blood mononuclear cells (PBMC) from samples obtained post induction therapy but before initiation of pembrolizumab (baseline) therapy. Expression of T-cell exhaustion markers 2B4, CTLA4, BTLA, Lag3, PD-1, and Tim3 was evaluated on PBMC by flow cytometry. T-cell receptor (TCR) beta chain CDR3 DNA sequencing by ImmunoSEQ and richness (diversity) and clonality (reactivity) were evaluated. Patients were followed through 5 months of treatment with pembrolizumab to evaluate the association between T-cell repertoire and phenotype with PFS.

Results: Seven patients had stable disease (SD) and 8 had progressive disease (PD) by 5 months. The median follow-up was 14.2 months (range: 4.5 to 27.7 months). Among the patients who progressed within 5 months, the earliest and the latest time to progression was at 1.38 months and 4.82 months, respectively. CTLA4 expression in CD4+ T cells at baseline was significantly higher in patients with PD than in patients with SD (p = 0.040). Patients with a low percentage of CD4+ T cells expressing exhaustion markers (CTLA4, Tim3, and 2B4) at baseline were more likely to have SD (chi-square p = 0.041) and significantly longer median PFS than patients with PD (median time to progression was not reached in SD vs. 4.1 months in PD, p = 0.018). Additionally, patients with high clonality and low CD4+ T exhaustion markers were more likely to have SD (chi-square p = 0.041) and a longer median time to progression (median time to progression was not reached in SD vs. 4.1 months in PD, p = 0.015).

Conclusions: Baseline T-cell clonality and T-cell exhaustion markers have significant translational relevance and can help to explain variable responses to immune checkpoint blockade. Our data suggest that T-cell reactivity at baseline, and a lower percentage of CD4+ T cells expressing CTLA4/Tim3/2B4 were favorable prognostic factors for pembrolizumab maintenance therapy. This proof-of-concept provides compelling data that T-cell clonality and phenotyping of T-cell exhaustion markers can be useful and should be applied to future trials with immune checkpoint inhibitors.

Citation Format: Hui Gao, Kumiko Kida, Evan N Cohen, Angela Alexander, Bora Lim, Charla Parker, Sanda Tin, Vicente Valero, Debu Tripathy, Alexandre Reuben, Naoto T Ueno, James M Reuben. Peripheral T cell clonality and exhaustion as novel biomarkers for anti-PD-1 (pembrolizumab) maintenance therapy in patients with metastatic inflammatory breast cancer (mIBC) and non-IBC triple negative breast cancer (mTNBC) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-09-12.

Abstract OT3-05-04: Phase II study of atezolizumab, cobimetinib, and eribulin in patients with recurrent or metastatic inflammatory breast cancer (IBC)

Background: IBCs that do not completely respond to chemotherapy often have dysregulated immune pathways, and novel therapies are needed to improve outcomes in recurrent/metastatic disease. One-third of IBCs express the atezolizumab target PD-L1, and cobimetinib increases PD-L1 expression; thus, we hypothesize that atezolizumab and cobimetinib may act synergistically in IBC. The FDA-approved agent eribulin is active in IBC and has anti-stem cell activity and can reverse the IBC phenotype of epithelial-to-mesenchymal transition. Hence the use of eribulin as a chemotherapy backbone in combination with other novel agents is well justified.

Trial Design: This single-arm, open-label trial is enrolling patients with recurrent IBC or de novo metastatic IBC that has progressed on at least 1 line of standard chemotherapy. During a 4-week pharmacodynamic window, patients have an upfront biopsy, receive atezolizumab and cobimetinib treatment for 4 weeks, and have a second biopsy. Triple-combination treatment then commences, with standard eribulin dosing. After 4 cycles of eribulin, patients receive maintenance targeted therapy until disease progression or intolerable toxicity.

Eligibility Criteria: Patients with metastatic IBC of any molecular subtype must have measurable disease (per RECIST 1.1) amenable to biopsy. Patients with HER2+ disease must have received both pertuzumab and T-DM1. Patients with treated stable brain metastases are allowed. Patients must have recovered from the acute effects of any prior therapies and have adequate hematologic, organ, and cardiac function. Patients with autoimmune diseases or a history of pneumonitis are ineligible.

Specific Aims: The primary objective is to determine the overall response rate (ORR) of the combination therapy. Secondary objectives include determining the safety and tolerability, clinical benefit rate, response duration, progression-free survival, 2-year overall survival rate and predictive biomarker analyses.

Statistical Methods: The trial will enroll up to 9 patients in its phase I/safety lead-in portion and up to 33 patients total. A Bayesian optimal interval design is used to efficiently determine the maximum tolerated cobimetinib dose in phase I. Patients start cobimetinib at the FDA-approved dose of 60 mg/day with a target toxicity rate is 0.3. Phase II will enroll 24 patients to determine the efficacy of the triple-combination therapy. The historical ORR in metastatic IBC is 10%; our sample size provides 80% power to detect an ORR improvement to 25%.

Accrual: The trial has enrolled 7 patients since its start in August 2017.

Citation Format: Alexander A, Marx AN, Reddy SM, Reuben JM, Le-Petross HC, Lane D, Huang ML, Krishnamurthy S, Gong Y, Gombos DS, Patel N, Tung CI, Allen RC, Kandl TJ, Wu J, Liu S, Patel AB, Futreal A, Wistuba I, Layman RM, Valero V, Tripathy D, Ueno NT, Lim B. Phase II study of atezolizumab, cobimetinib, and eribulin in patients with recurrent or metastatic inflammatory breast cancer (IBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT3-05-04.

Cyclin E Overexpression Sensitizes Triple-Negative Breast Cancer to Wee1 Kinase Inhibition

PURPOSE

Poor prognosis in triple-negative breast cancer (TNBC) is due to an aggressive phenotype and lack of biomarker-driven targeted therapies. Overexpression of cyclin E and phosphorylated-CDK2 are correlated with poor survival in patients with TNBC, and the absence of CDK2 desensitizes cells to inhibition of Wee1 kinase, a key cell-cycle regulator. We hypothesize that cyclin E expression can predict response to therapies, which include the Wee1 kinase inhibitor, AZD1775.

EXPERIMENTAL DESIGN

Mono- and combination therapies with AZD1775 were evaluated in TNBC cell lines and multiple patient-derived xenograft (PDX) models with different cyclin E expression profiles. The mechanism(s) of cyclin E-mediated replicative stress were investigated following cyclin E induction or CRISPR/Cas9 knockout by a number of assays in multiple cell lines.

RESULTS

Cyclin E overexpression (i) is enriched in TNBCs with high recurrence rates, (ii) sensitizes TNBC cell lines and PDX models to AZD1775, (iii) leads to CDK2-dependent activation of DNA replication stress pathways, and (iv) increases Wee1 kinase activity. Moreover, treatment of cells with either CDK2 inhibitors or carboplatin leads to transient transcriptional induction of cyclin E (in cyclin E-low tumors) and result in DNA replicative stress. Such drug-mediated cyclin E induction in TNBC cells and PDX models sensitizes them to AZD1775 in a sequential treatment combination strategy.Conclusions: Cyclin E is a potential biomarker of response (i) for AZD1775 as monotherapy in cyclin E-high TNBC tumors and (ii) for sequential combination therapy with CDK2 inhibitor or carboplatin followed by AZD1775 in cyclin E-low TNBC tumors.

Survivorship and Advocacy in Inflammatory Breast Cancer

In February 2017, the Morgan Welch Inflammatory Breast Cancer (IBC) Research Program and Clinic hosted a scientific conference in Houston to commemorate the tenth anniversary of the opening of the first IBC-dedicated clinic in the world. Attendees included basic science researchers, clinicians who treat IBC, as well as patients and their caregivers. Several US-based and international IBC-focused nonprofit organizations were also represented. In this third paper from the conference, we report on the breakout session regarding survivorship and advocacy issues related to IBC, sharing an overview of the educational content presented and discussions regarding the future of IBC advocacy. Panelists focused on lymphedema research and clinical solutions, integrative medicine, and social work, with time provided for questions in small groups. IBC nonprofits that are leading advocacy efforts were introduced, and ways to become involved in these initiatives were discussed. Priorities for future advocacy and clinical care needs were also highlighted. In addition to summarizing these topics, we provide a suggested integrated IBC-specific plan of care that could be provided to the patient at the beginning of care and referred to throughout treatment and follow-up.

International Consensus on the Clinical Management of Inflammatory Breast Cancer from the Morgan Welch Inflammatory Breast Cancer Research Program 10th Anniversary Conference

National and international experts in inflammatory breast cancer (IBC) from high-volume centers treating IBC recently convened at the 10th Anniversary Conference of the Morgan Welch Inflammatory Breast Cancer Research Program at The University of Texas MD Anderson Cancer Center in Houston Texas. A consensus on the clinical management of patients with IBC was discussed, summarized, and subsequently reviewed. All participants at the conference (patients, advocates, researchers, trainees, and clinicians) were queried using the MDRing electronic survey on key management issues. A summary of the expert consensus and participant voting is presented. Bilateral breast and nodal evaluation, breast magnetic resonance imaging, positron emission tomography/computed tomography, and medical photographs were endorsed as optimal. Neoadjuvant systemic therapy, modified radical mastectomy and level I and II ipsilateral axillary node dissection, post-mastectomy radiotherapy, adjuvant targeted therapy and hormonal therapy as indicated, and delayed reconstruction were agreed-upon fundamental premises of standard non-protocol-based treatment for IBC. Consideration for local-regional therapy in de novo stage IV IBC was endorsed to provide local control whenever feasible. Variation across centers and special circumstances were discussed.

Abstract OT1-02-05: A single arm phase II study of adjuvant anti-PD1 (pembrolizumab) in combination with hormonal therapy in patients with hormone receptor (HR)-positive localized inflammatory breast cancer (IBC) who did not achieve a pathological complete response (pCR) to neoadjuvant chemotherapy

Background: The pCR rate to conventional chemotherapy in hormone receptor positive IBC has historically been low (7.4% for HR+ HER2-, and 30% for HR+ HER2+), and despite the use of adjuvant endocrine therapy, the recurrence rate is still as high as 40%. To date, no targeted agent is proven to improve the efficacy of adjuvant endocrine therapy within the IBC population to improve this poor disease free survival (DFS). One plausible reason for the poor efficacy of endocrine therapy is a suppressed immune system, which allows tumor cells to avoid detection despite expression of potential immunogenic surface antigens.

Trial Design: This is a single arm trial that will enroll stage III HR+ IBC patients who have completed neoadjuvant therapy but had residual disease at mastectomy. Enrollment should be before or within 2 months of beginning endocrine therapy. Monitoring of DFS will be done with radiological imaging every 3 cycles (starting at cycle 4) as clinically indicated, per standard of care. Pembrolizumab is given on day 1 of each 21 day cycle for up to 2 years if the disease is controlled, and hormonal therapy will be administered per standard of care.

Eligibility Criteria: Clinical stage 3 IBC ER+/PR+ and HER2 negative patients who completed neoadjuvant chemotherapy and surgery with evidence of residual cancer in the breast or lymph nodes, but be clinically disease-free with good performance status at the start of study. Patients also must have adequate hematologic and organ function, and have recovered from the acute effects from prior treatments.

Specific Aims: The primary objective is to determine the disease free survival (DFS) at 2 years of patients with adjuvant therapy using Pembrolizumab in combination with standard adjuvant hormonal therapy. The secondary objective is to determine the safety and toxicity profile of this combination.

Statistical Methods: With a sample size of 37 patients, assuming that 80% are alive (20% increase from historical data) and disease-free at 2 years, and all patients are followed for >2 years after enrollment with no dropout, a 95% confidence interval around the 2-year estimate of DFS will be generated. DFS will then be compared with the historical control rate of 60% by year 2 using a one-sided exponential MLE test.

Accrual: To date we have enrolled 3 patients since activation in January 2017, and the target enrollment is 37 patients.

Contact information: For more information or to refer a patient, please contact study coordinator, Angela Alexander - aalexand@mdanderson.org

Citation Format: Alexander A, Willey J, Sun H, Parker CA, Marx AN, Wood AL, Reddy SM, Reuben JM, Bassett RL, Le-Petross HT, Krishnamurthy S, Gong Y, Woodward WA, Valero V, Ueno NT, Lim B. A single arm phase II study of adjuvant anti-PD1 (pembrolizumab) in combination with hormonal therapy in patients with hormone receptor (HR)-positive localized inflammatory breast cancer (IBC) who did not achieve a pathological complete response (pCR) to neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-02-05.

Abstract P4-10-12: Treatment decision making, and strategies for coping with financial stress in Indian women diagnosed with breast cancer and their families

Introduction: In spite of rapid urbanization and modernization the family remains central in the socio-cultural structure of India. The individuals are enmeshed into this unit and tend to be interlinked financially, emotionally and socially. The head of this family unit tends to be a male more often than not. As is well known, despite recent attempts by the governments at the state and centre at providing health coverage for cancer through regional cancer centres, a majority have to raise the money for cancer care by themselves. We have examined the role of the family in treatment decision making and in the strategies employed to raise the money and cope with the financial stress imposed by a diagnosis of breast cancer.

Method: 378 women with breast cancer were enrolled into a longitudinal study at first diagnosis between the years 2008-2012, at two tertiary care hospitals in Bangalore, India. The median follow up as of May 31st 2017 is 78 months with only 2% loss to follow-up over the past 8 years. Follow-up was maintained by frequent meetings between a counselling psychologist (AA) and the patient and/or a family member. The frequency of meetings was monthly during the initial treatment and then quarterly over the next 5 years. Information on demographics was collected during the treatment phase and information on the psychosocial aspects was collected in non-structured interactions subsequently. This information included details of support structure, decision making, and financial arrangements.

Results: This is a predominantly urban cohort with 80% being urban. The median age of patients at first diagnosis was 55 years. Almost all of our patients (99%) had the support of one or more family members. We analysed the pattern of decision making for treatment and in half of all cases either the husband or the son were the decision makers. In an additional 15% daughters and other relatives were the primary decision makers. Approximately a third of women made the decision concerning treatment themselves, and these women tended to be college educated (51% vs 16%) and employed (53% vs 12%).

30% of the patients met the costs incurred through medical insurance plans purchased by the family. Another quarter of patients were able to meet the costs from their savings. 45% had difficulty in finding the money for treatment and 15% took personal loans while 30% had to sell land/gold ornaments or take loans against assets of these sorts. Only (3%) discontinued the treatment due to financial difficulties. As in the case of decision making those who had the financial resources tended to be more educated (41% vs 11%), and were employed (31% vs 21%).

Conclusion: The data from a predominantly urban cohort of breast cancer enrolled between 2008-2012, supports the general belief that in India the family remains the fulcrum of an individual during crises, and not surprisingly education and employment lead to both psychological and economic emancipation of women.

Citation Format: Alexander A, Kaluve R, Prabhu JS, Korlimarla A, BS S, Manjunath S, Patil S, KS G, Sridhar TS. Treatment decision making, and strategies for coping with financial stress in Indian women diagnosed with breast cancer and their families [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-12.

Comparison of Blood Oxygenation Level-Dependent fMRI and Provocative DSC Perfusion MR Imaging for Monitoring Cerebrovascular Reserve in Intracranial Chronic Cerebrovascular Disease

BACKGROUND AND PURPOSE

Loss of hemodynamic reserve in intracranial cerebrovascular disease reduces blood oxygenation level-dependent activation by fMRI and increases asymmetry in MTT measured by provocative DSC perfusion MR imaging before and after vasodilation with intravenous acetazolamide. The concordance for detecting hemodynamic reserve integrity has been compared.

MATERIALS AND METHODS

Patients (n = 40) with intracranial cerebrovascular disease and technically adequate DSA, fMRI and provocative DSC perfusion studies were retrospectively grouped into single vessels proximal to and distal from the circle of Willis, multiple vessels, and Moyamoya disease. The vascular territories were classified as having compromised hemodynamic reserve if the expected fMRI blood oxygenation level-dependent activation was absent or if MTT showed increased asymmetry following vasodilation. Concordance was examined in compromised and uncompromised vascular territories of each group with the Fischer exact test and proportions of agreement.

RESULTS

Extensive leptomeningeal collateral circulation was present in all cases. Decreased concordance between the methods was found in vascular territories with stenosis distal to but not proximal to the circle of Willis. Multivessel and Moyamoya diseases also showed low concordance. A model of multiple temporally displaced arterial inputs from leptomeningeal collateral flow demonstrated that the resultant lengthening MTT mimicked compromised hemodynamic reserve despite being sufficient to support blood oxygenation level-dependent contrast.

CONCLUSIONS

Decreased concordance between the 2 methods for assessment of hemodynamic reserve for vascular disease distal to the circle of Willis is posited to be due to well-developed leptomeningeal collateral circulation providing multiple temporally displaced arterial input functions that bias the perfusion analysis toward hemodynamic reserve compromise while blood oxygenation level-dependent activation remains detectable.

Scientific Summary from the Morgan Welch MD Anderson Cancer Center Inflammatory Breast Cancer (IBC) Program 10th Anniversary Conference

In 2006, a remarkable collaboration between University of Texas MD Anderson Cancer Center clinicians and Texas and New Mexico State legislators led to the formation of a dedicated IBC Research Program and Clinic at MD Anderson. This initiative provided funding and infrastructure to foster coordination of an IBC World Consortium of national and international experts, and launch the first ever IBC international conference in 2008, which brought together experts from around the world to facilitate collaborations and accelerate progress. Indeed great progress has been made since then. National and international experts in IBC convened at the 10^th Anniversary Conference of the MD Anderson IBC Clinic and Research Program and presented the most extensive sequencing analysis to date comparing IBC to non-IBC, gene- and protein-based immunoprofiling of IBC versus non-IBC patients, and converging lines of evidence on the specific role of the microenvironment in IBC. Novel models, unique metabolic mechanisms, and prominent survival pathways have been identified and were presented. Multiple clinical trials based on the work of the last decade are in progress or in development. The important challenges ahead were discussed. This progress and a coordinated summary of these works are presented herein.

Cyclin E overexpression as a biomarker for combination treatment strategies in inflammatory breast cancer

Inflammatory breast cancer (IBC) is a virulent form of breast cancer, and novel treatment strategies are urgently needed. Immunohistochemical analysis of tumors from women with a clinical diagnosis of IBC (n = 147) and those with non-IBC breast cancer (n = 2510) revealed that, whereas in non-IBC cases cytoplasmic cyclin E was highly correlated with poor prognosis (P < 0.001), in IBC cases both nuclear and cytoplasmic cyclin E were indicative of poor prognosis. These results underscored the utility of the cyclin E/CDK2 complex as a novel target for treatment. Because IBC cell lines were highly sensitive to the CDK2 inhibitors dinaciclib and meriolin 5, we developed a high-throughput survival assay (HTSA) to design novel sequential combination strategies based on the presence of cyclin E and CDK2. Using a 14-cell-line panel, we found that dinaciclib potentiated the activity of DNA-damaging chemotherapies treated in a sequence of dinaciclib followed by chemotherapy, whereas this was not true for paclitaxel. We also identified a signature of DNA repair–related genes that are downregulated by dinaciclib, suggesting that global DNA repair is inhibited and that prolonged DNA damage leads to apoptosis. Taken together, our findings argue that CDK2-targeted combinations may be viable strategies in IBC worthy of future clinical investigation.

CDK4/6 Inhibitors Sensitize Rb-positive Sarcoma Cells to Wee1 Kinase Inhibition through Reversible Cell-Cycle Arrest

Research into the biology of soft tissue sarcomas has uncovered very few effective treatment strategies that improve upon the current standard of care which usually involves surgery, radiation, and chemotherapy. Many patients with large (>5 cm), high-grade sarcomas develop recurrence, and at that point have limited treatment options available. One challenge is the heterogeneity of genetic drivers of sarcomas, and many of these are not validated targets. Even when such genes are tractable targets, the rarity of each subtype of sarcoma makes advances in research slow. Here we describe the development of a synergistic combination treatment strategy that may be applicable in both soft tissue sarcomas as well as sarcomas of bone that takes advantage of targeting the cell cycle. We show that Rb-positive cell lines treated with the CDK4/6 inhibitor palbociclib reversibly arrest in the G1 phase of the cell cycle, and upon drug removal cells progress through the cell cycle as expected within 6-24 hours. Using a long-term high-throughput assay that allows us to examine drugs in different sequences or concurrently, we found that palbociclib-induced cell-cycle arrest poises Rb-positive sarcoma cells (SK-LMS1 and HT-1080) to be more sensitive to agents that work preferentially in S-G2 phase such as doxorubicin and Wee1 kinase inhibitors (AZD1775). The synergy between palbociclib and AZD1775 was also validated in vivo using SK-LMS1 xenografts as well as Rb-positive patient-derived xenografts (PDX) developed from leiomyosarcoma patients. This work provides the necessary preclinical data in support of a clinical trial utilizing this treatment strategy. Mol Cancer Ther; 16(9); 1751-64. ©2017 AACR.