Effect of a financial incentive on the acceptance of a smoking cessation programme with service charge: a cluster-controlled trial

INTRODUCTION

Frontline health care professionals in Hong Kong may encounter high refusal rates for the Hospital Authority's Smoking Counselling and Cessation Programme (SCCP) when smokers know it is subject to a service charge. We compared SCCP booking and attendance rates among smokers with or without a financial incentive.

METHODS

In this multicentre non-randomised cluster-controlled trial, adult smokers who attended one of six general out-patient clinics between November 2015 and April 2016 were invited to join an SCCP. Attendees in the three intervention-group centres but not the three control-group centres received a supermarket coupon to offset the service charge.

RESULTS

A total of 173 smokers aged 18 years or older (92 in the intervention group and 81 in the control group) were recruited into the study. In the intervention group, 47 smokers (51%) agreed via a questionnaire that they would join the SCCP, compared with only 23 smokers in the control group (28%). The booking rates were 83% (n=39) in the intervention group and 83% (n=19) in the control group. Among those who had booked a place, 19 (49%) intervention-group participants and 11 (58%) control-group participants attended an SCCP session. Multivariable logistic regression revealed that offering a coupon was associated with agreeing to join an SCCP (odds ratio=4.963, 95% confidence interval=2.173-11.334; P<0.001) and booking an SCCP place (odds ratio=4.244, 95% confidence interval=1.838-9.799; P<0.001).

CONCLUSION

Provision of a financial incentive was positively associated with agreement to join an SCCP and booking an SCCP place. Budget holders should consider providing the SCCP free of charge to increase smokers' access to the service.

The Role of Blood Tumor Marker Measurement (Using a Biochemical Index Score and C-Erbb2) in Directing Chemotherapy in Metastatic Breast Cancer

The role of blood tumor markers in monitoring response in advanced breast cancer is established in endocrine therapy and standard chemotherapy. This study examines marker levels in patients receiving new chemotherapy regimens. Thirty patients were recruited into two multicenter trials in which docetaxel-based regimens were used in 15 patients. The other 15 received doxorubicin-based regimens. Biochemical response calculated from a score using CA15.3, CEA and ESR was compared with UICC response. Marker changes at 2, 4 and 5 months correlated with UICC response at 3, 41/2 and 6 months, respectively (p < 0.03). Eleven patients achieved both clinical/radiological and biochemical response at the end of treatment; markers had not yet returned to below cutoffs in seven, suggesting a possible advantage to continue chemotherapy. No patient showed a biochemical response whilst judged clinically/radiologically progressive. Nineteen patients had progressed either clinically/radiologically or biochemically at six months; of these, eight showed progression assessed earlier by markers so that a median of four cycles of chemotherapy could have been saved. Measurements of serum c-erbB2 showed a correlation with tissue c-erbB2 staining in the primary tumor (p < 0.003). Among the patients with positive tissue staining, sequential changes in serum c-erbB2 completely paralleled initial response.

Abstract P6-12-04: Quality of life of Chinese breast cancer survivors in association with lifestyle changes before and after cancer diagnosis

Background: Epidemiologic studies in the West have found that lifestyle factors, including maintaining normal body weight, being physically active and eating a healthy diet are individually associated with better quality of life (QOL) among breast cancer survivors. Limited data is available on lifestyle modifications in association with quality of life of breast cancer survivors in Asian region. The objectives of this study were to [1] determine the lifestyle changes among Chinese breast cancer survivors at diagnosis and 18-month post diagnosis; and [2] to assess the association of lifestyle changes with QOL.

Methods: In this prospective cohort study, 1300 Chinese breast cancer patients were assessed at breast cancer diagnosis (baseline; reflecting pre-diagnosis) and at 18-month post-diagnosis. During each assessment, individual patient's lifestyle within the previous 12 months were recorded and included exercise, diet, and body mass index (BMI) data; each patient also underwent self-administered QOL assessment. Assessment of lifestyle modifications were based on World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendation adherence scores (range: 0-6).QOL was evaluated by European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire C-30 (EORTC-QLQ-C30). Paired t-test was performed to compare the overall recommendation adherence score before and after diagnosis.To investigate the association between recommendation adherence score and HRQoL, generalized linear models were used to compare the least-square means by tertiles of adherence score (T1, T2, and T3) and continuous adherence score. In the multivariate models, adjustment were made for age, stage of cancer, education level, marital status, comorbidities, smoking status, current hormonal therapy and energy intake.

Results: The mean recommendation adherence score significantly increased from baseline of 3.2 (SD=1.1) to 3.9 (SD=1.1, p&lt;0.001) at 18-month follow-up. Overall, increasing adherence to WCRF/AICR guideline was associated with higher scores of global health status (P=0.01), physical functioning (P&lt;0.001) and role functioning (P=0.03), and lower scores of fatigue (P=0.001), nausea and vomiting (P=0.003), pain (P&lt;0.001), dyspnea (P=0.006), loss of appetite (P=0.001) and diarrhea (P&lt;0.001).

Conclusions: Positive lifestyle changes were made among Chinese breast cancer survivors after cancer diagnosis. Increased adherence to WCRF/AICR recommendations after cancer diagnosis improves QOL, suggesting that Chinese breast cancer survivors should follow the WCRF/AICR guideline for cancer prevention.

Acknowledgments: This study is funded by the World Cancer Research Fund International (Grant Number WCRF 2010/249and WCRF 2014/1197) and Madam Diana Hon Fun Kong Donation for Cancer Research.

Citation Format: Lei Y-Y, Lee IC-K, Cheung KL, Lee R, He Y, Yeo W. Quality of life of Chinese breast cancer survivors in association with lifestyle changes before and after cancer diagnosis [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 P6-12-04.

Abstract P4-04-06: AZD5363, an AKT inhibitor, significantly inhibits key biomarkers of the AKT pathway and Ki67, in a randomized, placebo, controlled study (STAKT) in human breast cancers

Background: AKT is an important intracellular control point through which Type 1 growth factors and IGFR signal. Mutations in PIK3CA, AKT and PTEN are prevalent in estrogen receptor positive (ER+) breast cancer (BC) and have been implicated in resistance to endocrine therapies. AZD5363 is an inhibitor of AKT 1, 2 and 3 currently in Phase 2 trials for BC and other solid cancers.

Design: The study examined whether AZD5363 impacts on key biomarkers within the AKT pathway and their subsequent effects on Ki67, a marker of tumor proliferation. STAKT is a multi-center, two-stage, double blind, randomized, placebo controlled, biomarker 'window-of-opportunity' trial in women with newly diagnosed, previously untreated ER+ BC who were deemed would require chemotherapy as part of their primary treatment regimen. Stage 1 assessed AZD5363 at a dose of 480mg bd p.o. versus matching placebo. Up to 30 patients per arm were permitted, to allow 12 subjects per arm with evaluable paired biopsies - obtained at baseline, and after 4.5 days of AZD5363 / placebo. Primary endpoint markers were pPRAS40, pGSK3β and Ki67 assessed by immunohistochemistry. pPRAS40 and pGSK3β were assessed by H-scores and measured separately for cytoplasmic (cyto), nuclear (nuc) and total (cyto+nuc) staining. Ki67 was assessed as % positive staining of 500 tumor nuclei. Laboratory staff were blinded to treatment arm and whether the biopsies were taken before or after AZD5363/placebo. Changes in marker expression (both absolute and %) between biopsies were calculated, and compared between the two groups. An ANOVA test was applied for normally distributed data and Wilcoxon Mann-Whitney used if not normally distributed.

Results: 28/36 patients were evaluable with patient & tumor characteristics as follows: 17 received AZD5363 and 11 placebo; the median ages were 48 & 49 years respectively. 27 patients were Caucasian and 1 African-American. Tumors were all ER+. For HER2 status 8 were positive & 9 negative in the AZD5363 treated group compared to 2 & 9 respectively in the placebo group.

For pPRAS40 and pGSK3β cyto was the predominant staining while for Ki67 staining was nuclear. Changes in each marker with associated p-values are shown in the table.

MarkerType of change vs baselineDegree of change in AZD5363 arm (n=17)p-value versus placebo arm (n=11)pPRAS40 (H-score)TotalAbsolute-83.8&lt;0.0001Total%-50.2&lt;0.0001CytoAbsolute-90.0&lt;0.0001Cyto%-55.8&lt;0.0001NucAbsolute+6.90.42Nuc%+8.90.94pGSK3β (H-score)TotalAbsolute-55.30.006Total%-39.00.006CytoAbsolute-53.60.006Cyto%-39.20.006NucAbsolute-2.80.065Nuc%-36.50.058Ki67 (% cells+)Absolute-9.60.031%-29.40.052

Conclusions• AZD5363 for 4.5 days caused highly significant falls in pGSK3β and pPRAS40, key markers of AKT pathway activation

• AZD53643 also caused a significant decline in Ki67 even after only 4.5 days of drug. This is one of the shortest 'window'-studies to report such an early effect on proliferation.

• Placebo controlled 'window' studies of this short duration can provide important evidence of the therapeutic potential early in a drug's development.

Citation Format: Robertson JFR, Coleman RE, Cheung KL, Evans A, Holcombe C, Skene A, Rea D, Ahmed S, Jahan A, Kelly S, Horgan K, Rauchhaus P, Littleford R, Foxley A, Lindemann JPO, Pass M, Rugman P, Deb R, Finlay P, Gee JMW. AZD5363, an AKT inhibitor, significantly inhibits key biomarkers of the AKT pathway and Ki67, in a randomized, placebo, controlled study (STAKT) in human breast cancers [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 P4-04-06.

Oestrogen receptor negative early operable primary breast cancer in older women-Biological characteristics and long-term clinical outcome

Background

Older women are at the greatest risk of breast cancer development and a considerable number present with comorbidities. Although the majority of breast cancers in this age group express oestrogen receptor (ER), which makes endocrine therapy (primary or adjuvant) feasible, given the huge size of the elderly population, there remains a significant number of patients, in absolute term, whose tumours do not express ER and their management is challenging.

Methods

Of a consecutive series of 1,758 older (≥70 years) women with early operable primary breast cancer managed in a dedicated service from 1973–2010, 252(14.3%) had ER-negative (histochemical (H) score ≤50) tumours. Their clinical outcome was retrospectively reviewed and tumour samples collected from diagnostic core biopsies were analysed for progesterone receptor (PgR), HER2 and Ki67 using immunohistochemistry.

Results

The commonest primary treatment was surgery (N = 194, 77%) followed by primary endocrine therapy (14.3%), primary radiotherapy (5.6%) and supportive treatment only (3.1%). Among the patients undergoing surgery, most of them had grade 3 (78.1%) and node-negative disease (62.2%). Some of them (21.1%) received postoperative radiotherapy. At a median follow-up of 37.5 months, 117 patients had died, out of which 48.6% were due to breast cancer. For those who underwent surgery, the regional and local recurrence rates were 2% and 1.1% per annum respectively. For those who received primary endocrine therapy, 38% progressed at 6 months, however all patients who had primary radiotherapy achieved clinical benefit at 6 months. Regardless of treatment given, the 5-year breast cancer specific and overall survival rates were 70% and 50% respectively. Biological analysis based on good quality needle core biopsy specimensfrom181 patients showed that 26.8% (N = 49), 16.9% (N = 31) and 70.7% (N = 70)expressed positivity for PgR, HER2 and Ki67 respectively. No correlation between these biomarkers and breast cancer specific survival was demonstrated.

Conclusion

Oestrogen receptor negative early operable primary breast cancer in older women is associated with poor prognostic features in terms of biology and clinical outcome. Surgery appears to produce the best outcome as a primary treatment, however for those where neither surgery nor chemotherapy is appropriate, primary radiotherapy can be beneficial.

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.

Bridging the age gap in breast cancer: evaluation of decision support interventions for older women with operable breast cancer: protocol for a cluster randomised controlled trial

INTRODUCTION

While breast cancer outcomes are improving steadily in younger women due to advances in screening and improved therapies, there has been little change in outcomes among the older age group. It is inevitable that comorbidities/frailty rates are higher, which may increase the risks of some breast cancer treatments such as surgery and chemotherapy, many older women are healthy and may benefit from their use. Adjusting treatment regimens appropriately for age/comorbidity/frailty is variable and largely non-evidence based, specifically with regard to rates of surgery for operable oestrogen receptor-positive disease and rates of chemotherapy for high-risk disease.

METHODS AND ANALYSIS

This multicentre, parallel group, pragmatic cluster randomised controlled trial (RCT) (2015-18) reported here is nested within a larger ongoing 'Age Gap Cohort Study' (2012-18RP-PG-1209-10071), aims to evaluate the effectiveness of a complex intervention of decision support interventions to assist in the treatment decision making for early breast cancer in older women. The interventions include two patient decision aids (primary endocrine therapy vs surgery/antioestrogen therapy and chemotherapy vs no chemotherapy) and a clinical treatment outcomes algorithm for clinicians.

ETHICS AND DISSEMINATION

National and local ethics committee approval was obtained for all UK participating sites. Results from the trial will be submitted for publication in international peer-reviewed scientific journals.

IRAS REFERENCE

115550.

TRIAL REGISTRATION NUMBER

European Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2015-004220-61;Pre-results. Sponsor's Protocol Code Number Sheffield Teaching Hospitals STH17086. ISRCTN 32447*.

Abstract P3-06-03: The short term effects of an AKT inhibitor (AZD5363) on biomarkers of the AKT pathway and anti-tumour activity in a breast cancer paired biopsy study (STAKT trial)

This abstract was withdrawn by the authors.

Cytoplasmic Cyclin E Predicts Recurrence in Patients with Breast Cancer

Purpose: Low molecular weight cyclin E (LMW-E) detected by Western blot analysis predicts for reduced breast cancer survival; however, it is impractical for clinical use. LMW-E lacks a nuclear localization signal that leads to accumulation in the cytoplasm that can be detected by IHC. We tested the hypothesis that cytoplasmic staining of cyclin E can be used as a predictor of poor outcome in different subtypes of breast cancer using patient cohorts with distinct clinical and pathologic features.Experimental Design: We evaluated the subcellular localization of cyclin E in breast cancer specimens from 2,494 patients from 4 different cohorts: 303 from a prospective study and 2,191 from retrospective cohorts [NCI, MD Anderson Cancer Center (MDA), and the United Kingdom (UK)]. Median follow-up times were 8.0, 10.1, 13.5, and 5.7 years, respectively.Results: Subcellular localization of cyclin E on IHC was associated with full-length (nuclear) and low molecular weight isoforms (cytoplasmic) of cyclin E on Western blot analysis. In multivariable analysis, cytoplasmic cyclin E staining was associated with the greatest risk of recurrence compared with other prognostic factors across all subtypes in three (NCI, MDA, and UK) of the cohorts. In the MDA cohort, cytoplasmic cyclin E staining outperformed Ki67 and all other variables as prognostic factors.Conclusions: Cytoplasmic cyclin E identifies patients with the highest likelihood of recurrence consistently across different patient cohorts and subtypes. These patients may benefit from alternative therapies targeting the oncogenic isoforms of cyclin E. Clin Cancer Res; 23(12); 2991-3002. ©2016 AACR.

Relationship between HbA1c and cancer in people with or without diabetes: a systematic review

AIM

To identify the relationship between HbA1c and cancers in people with or without diabetes.

BACKGROUND

Cancer is a major public health problem, accounting for 8.2 million deaths worldwide in 2012. HbA1c level has been associated with the risk of developing certain cancers, although the existing evidence is conflicting.

METHODS

EMBASE, MEDLINE, CINAHL and the Cochrane Library were searched. Eligible articles included randomized controlled trials, cohort studies, case-control studies, systematic reviews and meta-analyses. Participants of either sex, with or without Type 1 or 2 diabetes, were included. The studies were assessed using the Scottish Intercollegiate Guidelines Network (SIGN) criteria by two independent assessors. No meta-analysis was performed because of the heterogeneity of results.

RESULTS

A total of 19 studies from 1006 met the inclusion criteria, of which 14 were cohort studies and five were nested case-control studies. Eight studies investigated outcomes for all cancer sites. Four of these studies reported that higher HbA1c levels were associated with higher incidence and/or mortality risk for all cancers. One study observed a U-shaped relationship between HbA1c and cancer incidence and mortality. Increasing HbA1c levels were associated with increasing risk of developing colorectal, pancreatic, respiratory and female genital tract cancers. No increased risk was observed for breast cancer, gastrointestinal or urological malignancies.

CONCLUSION

HbA1c appears to be associated with cancer incidence and/or cancer mortality, but further studies are needed to fully understand the complex relationship between HbA1c and cancer.

Primary breast cancer in the elderly: a systematic literature review on histological type and clinical outcome

The objective was to determine whether histological types of breast cancer in elderly women influence clinical outcome. Four major databases were searched. All relevant articles, from January 1990 to December 2013, were screened. After applying inclusion and exclusion criteria, 11 studies were included. Invasive ductal carcinoma was the commonest (68.5-87.1%) histological type, followed by lobular carcinoma (6.9-17.7%). Four studies reported on survival. However, none specifically looked at survival according to different histological types. There are very little data on the influence of histological type on clinical outcome in primary breast cancer in elderly patients. Further studies may elucidate any potential influence and its relationship with tumor biology.

No evidence for a direct effect of von Willebrand factor's ABH blood group antigens on von Willebrand factor clearance

BACKGROUND

One of the major determinants of von Willebrand factor (VWF) plasma levels is ABO blood group status, and individuals with blood group O have ~ 25% lower plasma levels. The exact mechanism behind this relationship remains unknown, although effects on clearance have been postulated.

OBJECTIVES

To determine whether clearance of VWF is directly dependent on the presence of ABH antigens on VWF.

METHODS

Three type 3 von Willebrand disease (VWD) patients were infused with Haemate-P, and the relative loading of VWF with ABH antigens at different time points was measured. VWF-deficient mice were injected with purified plasma-derived human VWF obtained from donors with either blood group A, blood group B, or blood group O.

RESULTS

In mice, we found no difference in clearance rate between plasma-derived blood group A, blood group B and blood group O VWF. Faster clearance of the blood group O VWF present in Haemate-P infused in type 3 VWD patients would have resulted in a relative increase in the loading of VWF with A and B antigens over time. However, we observed a two-fold decrease in the loading with A and B antigens in two out of three patients, and stable loading in the third patient.

CONCLUSION

There is no direct effect of ABH antigens on VWF in VWF clearance. We demonstrate that, in a direct comparison within one individual, blood group O VWF is not cleared faster than blood group A or blood group B VWF. Clearance differences between blood group O and non-blood group O individuals may therefore be related to the blood group status of the individual rather than the ABH antigen loading on VWF itself.

Progression from impaired fasting glucose to type 2 diabetes mellitus among Chinese subjects with and without hypertension in a primary care setting

BACKGROUND

The progression from impaired fasting glucose (IFG) to type 2 diabetes mellitus (T2DM) in Chinese subjects, with and without hypertension, in a primary care setting was unknown.

METHODS

The present retrospective multicenter 5-year (2002-2007) cohort study was performed on IFG subjects attending 23 general outpatient clinics who were identified by their elevated fasting blood glucose laboratory results. Development of T2DM was determined by physician diagnosis of T2DM or starting of oral antidiabetic drugs within 5 years. The relationship between the time of T2DM diagnosis and subject characteristics was assessed by adjusted hazard ratios (aHR) from Cox hazards model.

RESULTS

Of the 9161 IFG subjects, 4080 (45%) were men and 5081 (55%) were women. There were 1998 subjects who developed T2DM. The 5-year cumulative incidence was 0.218, whereas the overall annual incidence rate was 5.981/100 person-years. Subjects were more likely to develop T2DM if they were hypertensive (aHR = 1.44; 95% confidence interval [CI] 1.28-1.62; P < 0.001), aged <60 years (aHR = 1.36, 95% CI 1.24-1.49; P < 0.001), female (aHR = 1.18, 95% CI 1.08-1.29; P < 0.001), and had higher fasting glucose levels (6.39 ± 0.49 vs 6.24 ± 0.43 mmol/L in the group that developed T2DM vs the group without T2DM, respectively; aHR = 2.01, 95% CI 1.83-2.20; P < 0.001).

CONCLUSION

Overall, more than one-fifth of IFG subjects in the primary care setting developed T2DM within 5 years. Health care professionals can target interventions to patients with risk factors for disease progression.

Pilot randomised study of early intervention based on tumour markers in the follow-up of patients with primary breast cancer

BACKGROUND

This pilot study aimed to test the possibility of therapeutic benefit imparted by early intervention based on sequential tumour marker (TM) measurements during follow-up of primary breast cancer (PBC) patients.

METHODS

Patients with oestrogen receptor positive PBC with no clinical and/or radiological evidence of metastases were recruited and followed-up 3-monthly with clinical assessment and TM (CA15.3 and CEA) measurements. The clinical team was blinded to the TM results. Asymptomatic patients who developed raised TMs (based on pre-defined cut-offs) were randomised to either 'treatment change' (either start or change of adjuvant endocrine agent to another agent) or 'no change' (control). Patients who developed symptomatic metastases came off the study. The primary and secondary endpoints were intervals from randomisation to symptomatic metastases and to last follow-up/death respectively.

RESULTS

Eighty-five patients (median age = 54 years (30-72)) were recruited with a median follow-up of 81 months (1-124). Sixteen patients were randomised as described. There was no significant difference (treatment change versus no change) with regards to interval from randomisation to symptomatic metastases - 23 (2-62) and 22 (1-63) months respectively (p = 0.9), as well as interval from randomisation to last follow-up/death - 36 (7-63) and 37 (10-63) months respectively (p = 0.9).

CONCLUSIONS

Despite long follow-up (up to 10+ years), this small study has thus far shown no significant difference in outcome. However, we have confirmed the feasibility of this study design but a larger study will be required to show if there is a benefit to this approach.

Human epidermal growth receptor-2 overexpressing early operable primary breast cancers in older (≥70 years) women: biology and clinical outcome in comparison with younger (<70 years) patients

INTRODUCTION

There is dearth of literature reporting the prevalence and biological characteristics as well as the long-term clinical outcome of human epidermal growth factor receptor-2 (HER2) overexpressing tumours in older women. Currently, research involving trastuzumab at large focuses on the younger population. This study aimed to analyse their biological characteristics and to compare them with their younger counterparts from a single centre with a long-term clinical follow-up.

METHODS

Over 37 years (1973-2010), 1758 older (≥70 years) women with early operable (<5 cm) primary breast cancer were managed in a dedicated clinic and have complete clinical information available. Of these, 813 patients underwent primary surgery and 575 had good quality tumour samples available for tissue microarray analysis using indirect immunohistochemistry. Comparison was made with data from a well-characterised younger (<70 years) series (N = 1711) treated between 1986 and 1998 (before adjuvant trastuzumab became standard) in our institution. Forty five (7.6%) and 140 (8.2%) patients from the older and younger series, respectively, had HER2-positive tumours.

RESULTS

HER2 overexpression was seen in 45 (7.6%) older women and 140 (8.2%) in younger patients (P = 0.56). HER2 overexpressing tumours in older women when compared with that in their younger counterparts were associated with low Ki67 and high bcl2 expression (P < 0.05). Only 26% of the younger patients and none of the older patients received adjuvant chemotherapy, and no patients at the time received trastuzumab. However, there was no significant difference in the outcome of the two age groups (5-year breast cancer-specific survival rate: <70 years = 65% versus >70 years = 70%, P = 0.51).

CONCLUSION

HER2 overexpressing tumours in older women showed relatively a less aggressive phenotype and did not show any inferior long-term clinical outcome despite not having received chemotherapy when compared with the younger patients. The precise role of different adjuvant systemic therapies in this population needs to be delineated.

One hertz repetitive transcranial magnetic stimulation over dorsal premotor cortex enhances offline motor memory consolidation for sequence-specific implicit learning

Consolidation of motor memories associated with skilled practice can occur both online, concurrent with practice, and offline, after practice has ended. The current study investigated the role of dorsal premotor cortex (PMd) in early offline motor memory consolidation of implicit sequence-specific learning. Thirty-three participants were assigned to one of three groups of repetitive transcranial magnetic stimulation (rTMS) over left PMd (5 Hz, 1 Hz or control) immediately following practice of a novel continuous tracking task. There was no additional practice following rTMS. This procedure was repeated for 4 days. The continuous tracking task contained a repeated sequence that could be learned implicitly and random sequences that could not. On a separate fifth day, a retention test was performed to assess implicit sequence-specific motor learning of the task. Tracking error was decreased for the group who received 1 Hz rTMS over the PMd during the early consolidation period immediately following practice compared with control or 5 Hz rTMS. Enhanced sequence-specific learning with 1 Hz rTMS following practice was due to greater offline consolidation, not differences in online learning between the groups within practice days. A follow-up experiment revealed that stimulation of PMd following practice did not differentially change motor cortical excitability, suggesting that changes in offline consolidation can be largely attributed to stimulation-induced changes in PMd. These findings support a differential role for the PMd in support of online and offline sequence-specific learning of a visuomotor task and offer converging evidence for competing memory systems.

Biology of primary breast cancer in older women treated by surgery: with correlation with long-term clinical outcome and comparison with their younger counterparts

Background:

As age advances breast cancer appears to change its biological characteristics, however, very limited data are available to define the precise differences between older and younger patients.

Methods:

Over 36 years (1973–2009), 1758 older (⩾70 years) women with early operable primary breast cancer were managed in a dedicated clinic. In all, 813 underwent primary surgery and 575 good quality tumour samples were available for biological analysis. The pattern of biomarkers was analysed using indirect immunohistochemistry on tissue microarrays. Comparison was made with a previously characterised series of younger (<70 years) patients.

Results:

There was high expression of oestrogen receptor (ER), PgR, Bcl2, Muc1, BRCA1 and 2, E-cadherin, luminal cytokeratins, HER3, HER4, MDM2 and 4 and low expression of human epidermal growth factor receptor (HER)-2, Ki67, p53, EGFR and CK17. Oestrogen receptor and axillary stage appeared as independent prognostic factors. Unsupervised partitional clustering showed six biological clusters in older patients, five of which were common in the younger patients, whereas the low ER luminal cluster was distinct in the older series. The luminal phenotype showed better breast cancer-specific survival, whereas basal and HER2-overexpressing tumours were associated with poor outcome.

Conclusion:

Early operable primary breast cancer in older women appears as a distinct biological entity, with existence of a novel cluster. Overall older women showed less aggressive tumour biology and ER appeared as an independent prognostic factor alongside the time-dependent axillary stage. These biological characteristics may explain the differences in clinical outcome and should be considered in making therapeutic decisions.

Long-term efficacy and safety of exemestane in the treatment of breast cancer

Exemestane, a steroidal aromatase inhibitor, is licensed for postmenopausal patients with estrogen receptor (ER)-positive breast cancer as second-line therapy in metastatic disease following antiestrogen failure and as part of sequential adjuvant therapy following initial tamoxifen. This study is a systematic literature review, evaluating exemestane in different clinical settings. The Ovid Medline (1948-2012), Embase (1980-2012), and Web of Science (1899-2012) databases were searched. Forty-two relevant articles covering randomized controlled trials were reviewed for efficacy and safety, and three for adherence. With regard to efficacy in metastatic disease, exemestane is superior to megestrol acetate after progression on tamoxifen. There is evidence for noninferiority to fulvestrant (following a prior aromatase inhibitor) and to nonsteroidal aromatase inhibitors in the first-line setting. Combined use with everolimus is shown to be more efficacious than exemestane alone following previous aromatase inhibitor use. In the adjuvant setting, a switch to exemestane after 2-3 years of tamoxifen is superior to 5 years of tamoxifen. Exemestane is noninferior to 5 years of tamoxifen as upfront therapy, and may have a role as an extended adjuvant therapy. Used as neoadjuvant therapy, increased breast conservation is achievable. As chemoprevention, exemestane significantly reduces the incidence of breast cancer in "at-risk" postmenopausal women. Exemestane is associated with myalgias and arthralgias, as well as reduced bone mineral density and increased risk of fracture, which do not appear to persist at follow-up, with subsequent return to pretreatment values. Compared with tamoxifen, there is a reduced incidence of endometrial changes, thromboembolic events, and hot flashes. Limited evidence shows nonadherence in 23%-32% of patients. Evidence is growing in support of exemestane in all clinical settings. It is generally more efficacious and has a better safety profile than tamoxifen. How it compares with the nonsteroidal aromatase inhibitors remains to be established. Further studies are required on adherence to ensure that maximum benefit is obtained.

Breast nurse practitioner training and assessment: a proposed model

The role of the breast nurse practitioner has been expanding in recent years and many breast units in the UK employ nurse practitioners to carry out a variety of clinical duties. Most of these involve diagnostic assessment of breast diseases and clinical breast examination. While most nurse practitioners have been trained by shadowing breast surgeons, working under supervision, and demonstrating a satisfactory concordance, in terms of clinical opinion with their clinical supervisors, there is a lack of literature describing a training programme that includes assessment. A proposed model including induction, training, assessment (using established tools from a medical school and Royal Surgical Colleges) and audit, with a competency-based 'sign-off', is described in this article and supported by the experience of a nurse practitioner who has been successfully trained in this way. The model can instil confidence and credibility to employers and the public, and can also be adapted and extended to other areas of clinical practice.