Abstract P1-09-05: The RAZOR trial: a phase II prevention trial of screening plus goserilin and raloxifene versus screening alone in pre-menopausal women at increased risk of breast cancer

Background: Observational studies indicate that oophorectomy at about age 40 reduces breast cancer risk by approximately a half in high risk women. Widespread use of risk reducing oophorectomy is unlikely to be acceptable to these women. We explored the feasibility of giving goserelin to produce reversible ovarian suppression together with raloxifene to maintain bone mineral density (BMD).

Objectives: The primary study objective was adherence to treatment. Secondary objectives were uptake of randomisation, side effects/quality of life and measures of effect on bone and in serum.

Methods: Recruitment was from 3 UK Family History Clinics. Consenting women at ≥ 1 in 3 lifetime risk of breast cancer were randomised to control or monthly subcutaneous goserelin 3.6 mg and raloxifene 60 mg/d orally for two years. Questionnaires (Endocrine Symptom Checklist, Trait & State Anxiety, Sexual Activity & Cancer Worry) measuring toxicity/quality of life were administered by nurses. Dual energy X-ray absorptiometry (DXA) BMD measurements were performed in the treatment arm annually. Lipids and collagen breakdown products were measured by standard methods.

Results: 75 of 511 (14.7%) women approached agreed to randomisation (38 to treatment and 37 to control). The major reason for non-entry was fear of side effects (85%). Median age was 37 and 35 years, for the experimental (A) and control arm (B), respectively. Median follow up is 8.8 years. 20/38 in arm A and 27/37 of controls completed the 24 m study. 18/38 women in arm A withdrew (13 [34%] because of side effects) and 10/37 in arm B for various reasons including the desire for risk reducing surgery (n = 4). No significant differences were seen in the Endocrine Symptom Sub-scale, State or Trait anxiety or Cancer Worry. However, Hot flushes, night and cold sweats (together p <0.005), vaginal dryness (p = 0.006); loss of interest in sex, dyspareunia and reduced sexual pleasure (together p < 0.005) were significantly more in arm A. Despite this, 11 of 23 women in arm A when asked would have been happy to complete a potential five years of treatment. BMD declined by 3–7% and Ctx significantly increased (p < 0.005 each) but both returned to baseline by year 3. Lipids were unchanged. 4 women later developed breast cancer in arm B and 2 in arm A.

Conclusions: Uptake and adherence to treatment was relatively low in this group of women at high risk. The major reason for low uptake was fear of side effects and these were the major reason for drop out from treatment. Raloxifene did not maintain BMD. This approach to breast cancer prevention induced significant symptoms and bone loss, thus methods to ameliorate these need to be developed if ovarian suppression is to play a role in breast cancer prevention.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-09-05.

Abstract P3-08-01: The prospective risk of ovarian cancer in 1433 women in a breast cancer family history clinic: no increased risk in families testing negative for BRCA1 and BRCA2

Since the identification of the BRCA1 and BRCA2 genes speculation has continued regarding the breast and ovarian cancer risk associated with mutations in these genes. Also, as to whether mutations in these genes account for the majority of the association between breast and ovarian cancer. Identification of RAD51C and RAD51D mutations in breast/ovarian cancer families has reawakened the debate as to whether it is safe to reassure women from BRCA negative families that they are not at increased risk of ovarian cancer. 1433 women from breast cancer families that had tested negative for BRCA1/2 were followed for a total of between 0.04 and 25 years and checked against a cancer registry for ovarian cancer incidence. Data was censored at ovarian cancer diagnosis, oophorectomy or death. During 16358 women years of follow up no invasive epithelial ovarian cancer occurred, although 2 borderline tumors were diagnosed. Expected rates for this cohort from cancer registry data were 2.75 epithelial ovarian tumors with 2.52 for invasive cancer and 0.23 for borderline tumors. The upper confidence limit for invasive RR was 1.3 and for borderline tumors 0.97–31. In conclusion this the largest prospective follow up of a BRCA negative cohort has demonstrated that there is no increase in risk of invasive ovarian cancer in families that have tested negative for BRCA1/2.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-08-01.

Abstract P2-14-01: Fulvestrant vs exemestane for treatment of metastatic breast cancer in patients with acquired resistance to non-steroidal aromatase inhibitors – a meta-analysis of EFECT and SoFEA (CRUKE/03/021 & CRUK/09/007)

Background: Optimal endocrine treatment (trt) for post-menopausal women with ER+ advanced breast cancer (ABC) progressing on or following a non-steroidal (NS) aromatase inhibitor (AI) is unclear. The EFECT study showed no difference in efficacy between the steroidal antiestrogen fulvestrant (F) & steroidal AI exemestane (E) in this setting (HR = 0.96, 95%CI: 0.82, 1.13; p = 0.65). Pre-clinical data suggest F may be more effective in a low estrogen environment. SoFEA investigated F combined with anastrozole (F+A) in patients (pts) with acquired resistance to previous AI compared with F alone & F alone vs. E. The combination of F+A was no better than F (HR = 1.00, 95%CI: 0.83, 1.21; p = 0.98) nor F alone better than E (HR = 0.95, 95%CI: 0.79, 1.14; p = 0.56); the lack of added benefit for F+A is consistent with previous 1st-line studies that have assessed this combination versus A alone (FACT & SWOG-S0226).

Methods: SoFEA is a multi-center partially blinded randomized phase III study postmenopausal women were allocated to F plus A (F+A n=243), F plus placebo (n = 231) or E (n = 249). Similarly, EFECT is a randomized, double-blind, placebo controlled, multi-center phase III trial of F (n = 351) versus E (n = 342) in postmenopausal women (see table). However, given the differences in prior endocrine therapy/responsiveness within SoFEA & EFECT populations, an individual pt meta-analysis combining data from SoFEA & EFECT will be conducted enabling exploration of putative effects within specific pt subgroups to establish evidence in support, or not, of a pt subgroup sensitive to F at the dose used in these trials. Subgroups to be analysed include receptor status, visceral involvement, AI sensitivity, age, NSAI setting & time on NSAI.

Results: 723 pts (480 in F & E) were enrolled from 82 UK & 4 South Korean centers (03/2004-04/2010) in SoFEA. 693 pts were enrolled from 138 centers worldwide (08/2003-11/2005) in EFECT. Trt was well tolerated in both trials; serious adverse events were rare. The meta-analysis will be conducted in July 2012 & results presented.

Conclusion: Combining individual pt data from SoFEA & EFECT via meta-analysis will provide definitive clinical information on pt's response to F at the dose used in these studies, in particular whether certain pts with acquired resistance to NSAI do experience benefit of use of this antiestrogen as opposed to E.

Prevention of breast cancer in the context of a national breast screening programme

Breast cancer is not only increasing in the west but also particularly rapidly in eastern countries where traditionally the incidence has been low. The rise in incidence is mainly related to changes in reproductive patterns and lifestyle. These trends could potentially be reversed by defining women at greatest risk and offering appropriate preventive measures. A model for this approach was the establishment of Family History Clinics (FHCs), which have resulted in improved survival in younger women at high risk. New predictive models of risk that include reproductive and lifestyle factors, mammographic density and measurement of risk-associated single nucleotide polymorphisms (SNPs) may give more precise information concerning risk and enable better targeting for mammographic screening programmes and of preventive measures. Endocrine prevention using anti-oestrogens and aromatase inhibitors is effective, and observational studies suggest lifestyle modification may also be effective. However, referral to FHCs is opportunistic and predominantly includes younger women. A better approach for identifying older women at risk may be to use national breast screening programmes. Here were described pilot studies to assess whether the routine assessment of breast cancer risk is feasible within a population-based screening programme, whether the feedback and advice on risk-reducing interventions would be welcomed and taken up, and to consider whether the screening interval should be modified according to breast cancer risk.

P3-09-02: Intermittent Dietary Carbohydrate Restriction Enables Weight Loss and Reduces Breast Cancer Risk Biomarkers

Background: Energy restriction is a potential strategy for breast cancer prevention but is difficult to achieve and maintain. We found that intermittent energy restriction (2 days strict dieting week) is comparable to the standard approach of moderate daily restriction for weight loss and marginally better for improving insulin sensitivity, but no easier to follow1. In this follow on study we wished to test whether 2 novel intermittent low carbohydrate/low energy diets were feasible and easier to follow than a standard daily energy restriction. Design: Randomised comparison of 3 dietary types over 4 months in 115 overweight or obese (mean body mass index 31.0 [±5.3 SD] kg/m2) women at increased risk of breast cancer (lifetime risk > 1 in 6).

Diets:

1. A restricted low carbohydrate diet (RLCD): 650 kcal and <50g carbohydrate / day for 2 days per week

2. Ad lib low carbohydrate diet (ALCD): <50g / day for 2 days per week with other food types (e.g. protein) ad lib

3. A standard daily restricted Mediterranean diet (DRMD): ∼ 1500kcal/day for 7 days per week

Methods: Weight, anthropometrics, blood markers for breast cancer; insulin resistance, oxidative stress markers, leptin, adiponectin, lipids, inflammatory markers IGF-1 were assessed at baseline, 1, 3 and 4 months.

Results: 88/114 completed the study (77%, drop outs 6 RLCD, 8 ALCD 12 DRMD). Last observation carried forward analyses show both intermittent low carbohydrate diets were superior to standard daily restriction for reducing weight and body fat: mean (95% confidence interval [CI]) change in body fat for RLCD was −4.3 (−5.6 to −3.0) kg, for ALCD −4.1 (−5.2 to −3.1) kg vs. −2.4 (−3.4 to −1.2) kg for DRMD (P value for difference between groups = 0.02). The intermittent groups had greater improvement in insulin resistance: mean (95% CI) change for RLCD was −22 (−35 to −11) %, ALCD −14 (−27 to −5%) % vs. −4 (−16 to 9) % for DRMD (P = 0.02). Other biomarkers are being assayed currently.

Conclusion: Greater weight loss, fewer drop outs and greater reductions in insulin resistance with the novel intermittent low carbohydrate diets indicate that these are alternative approaches for energy restriction for potentially reducing risk of breast cancer and other diseases.

Reference:

1Harvie MN, Pegington M, Mattson MP, Frystyk J, Dillon B, Evans G et al. The effects of intermittent or continuous energy restriction on weight loss and metabolic disease risk markers: a randomized trial in young overweight women. Int.J Obes (Lond) 35; 714–27, 2011. This study is funded by the Genesis Breast Cancer Prevention Appeal: www.genesisuk.org

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-09-02.

P4-11-07: Feasibility and Acceptability of Offering Breast Cancer Risk Estimation in the Context of the UK National Health Service Breast Cancer Screening Programme: A New Paradigm for Cancer Prevention

Background: Currently there are no real attempts internationally to tailor breast screening programmes to individual risk Methods: We have assessed the feasibility of collecting breast cancer risk information during routine mammographic screening in the National Health Service Breast Screening Programme (NHSBSP) in England, in order to consider, ultimately, adapting the screening interval to risk of breast cancer and introducing preventive strategies in women at high risk. The study Predicting Risk Of Cancer At Screening (PROCAS) aims to recruit 60,000 women over 3 years. Results: 26,000 women (June 8th 2011) have so far given consent to join the study. Thirty six percent of the first 20,000 women in nineteen screening sites in Manchester consented to enter the study and completed a risk factor questionnaire. The median 10 year breast cancer risk was 2.65%, with 926 (9.26%) of the first 10,000 women having a 10 year risk of ≥5% and 92 (0.92%) having a 10 year risk of ≥8% (Tyrer-Cuzick), IQR:1.35. 832 (8.32%) women had a mammographic density of 60% or greater (Visual Analogue Scale). We collected saliva samples from 1019 women for genetic analysis and will extend this to 18% of participants. Of those who agreed to participate in the study, 94% indicated that they wished to know their breast cancer risk. Women with a 10-year risk of ≥8%, and women with a 10-year risk of ≥5% and mammographic density ≥60% were invited to attend or be telephoned to be counselled. To date 138 have accepted with 135, so far, having received risk counselling. Nineteen percent of the high-risk women identified subsequently decided to enter a randomised breast cancer prevention study with either a dietary or drug intervention (IBIS2, anastrazole vs placebo). Results from the first 1,000 women who provided DNA samples suggest that the risk information from the 18 validated SNPS may enhance existing risk models. Conclusion: This study demonstrates that it is feasible to determine individual breast cancer risk and offer women appropriate risk-reducing interventions within the context of a population-based mammographic screening programme.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-07.

P4-12-01: The Breast-Activity and Healthy Eating after Diagnosis (B-AHEAD) Study – A Randomised Comparison of Weight Control Programmes during Adjuvant Treatment

Background: Excess weight at diagnosis and weight gain during treatment are linked to increased mortality from breast cancer. Since 60% of breast cancer patients are overweight at diagnosis and 75% gain weight during treatment, weight control should improve outcome but the optimal intervention is unknown.

Aim: To compare 3 programmes for weight control after surgery for primary breast cancer.

Methods: We have recruited a randomised trial of 2 diet and exercise weight control interventions (1. a community based supervised group programme, 2. a mail and phone programme) compared to standard written advice (control). We are comparing the relative effects of the 3 programmes on body weight and composition (by dual energy x-ray absorptiometry), cardiovascular risk parameters (lipids, blood pressure), a marker of breast cancer prognosis (insulin resistance), fitness and quality of life over the first year after diagnosis.

In total 409 women have been randomised (45% of eligible women) and 21 women have left the trial (5.1%), 357 have completed the 6 month assessments, all are due to complete the trial in December 2011.

Results:

P2-12-01: Immunohistochemical (IHC) BAG1 Expression Improves the Estimation of Residual Risk (RR) by IHC4 in Postmenopausal Patients Treated with Anastrozole or Tamoxifen: A TransATAC Study

Aim: To determine whether the incorporation of BAG1 staining improves the estimate of RR after endocrine therapy in postmenopausal patients with ER+ve tumours treated with endocrine therapy. Background: BAG1 encodes a protein (BCL2-associated athanogene 1) that binds to BCL2 and enhances its anti-apoptotic effects. BAG1 is included as a separate subgroup in the 21-gene OncotypeDx Recurrence Score (RS) that is used to assess RR after endocrine therapy in primary ER+ breast cancer. IHC4 is a 4-panel set of IHC markers (ER, PgR, HER2, Ki67) that was shown to provide as much prognostic accuracy as RS in the translational arm of the ATAC trial (TransATAC) of anastrozole versus tamoxifen alone or combined and subsequently independently validated (Cuzick et al, JCO, 2011, in press). Addition of extra markers such as BAG1 to IHC4 may improve the accuracy of the IHC4 and provide extra discriminatory power for oncologists.

Methods: Samples in triplicate TMAs from the TransATAC cohort were stained for BAG1 using the Genetex 3.10G3E2 antibody after validation using siRNA knockdown. Staining was scored separately as nuclear or cytoplasmic and categorized by intensity as 0, 1, 2 or 3. BAG1 IHC values were assessed for their correlation with BAG1 mRNA levels. The statistical analysis plan was pre-specified and tested possible additional information from BAG1 expression to the IHC4 in patients not treated with chemotherapy by change in the likelihood ratio chi-square (ΔLR-X2). Results were included only if there was also complete data for ER, PgR, Ki67 and HER2. Primary analysis was on the HER2−ve node-negative (N-neg) population; secondary analysis was on all N-neg patients. Follow-up was to 10 years and the primary end-point was time to distant recurrence (TTDR).

Results: Data on both nuclear and cytoplasmic BAG1 as well as the other 4 IHC parameters was available on 961 cases of which 855 were HER2−ve. There was a significant correlation between cytoplasmic and nuclear BAG1 (p=0.23, p<0.0001) but the nuclear staining correlated better with mRNA levels and was therefore considered further. Weak but significant correlations were also seen with ER, PgR and tumour grade. In the univariate analysis nuclear BAG1 was significantly associated with worse TTDR in HER2−ve and all N-neg cases (X2=7.91, p=0.005 and X2=10.63, p=0.001 respectively). Nuclear BAG1 also contributed significantly in multivariate analyses in the 2 populations firstly when added to the clinical model (X2=4.99, p=0.02 and X2=5.93, p=0.015 respectively) and secondly when subtracted from clinical plus the IHC4 parameters (X2=5.55, p=0.02 and X2=4.50, p=0.03 respectively).

Conclusions: Nuclear BAG1 expression has significant value for estimating RR that is independent of standard clinical and IHC parameters and it improves the prediction of TTDR in the TransATAC population beyond that with the validated IHC4 score. Unlike IHC4 markers, BAG1 is not commonly measured in pathology work-up of breast cancers. The clinical utility of its addition to IHC4 will be tested by measuring its discrimination of high and low risk patients in clinical practice.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-01.

Weight change associated with anastrozole and tamoxifen treatment in postmenopausal women with breast cancer or at high risk of developing it

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Background: Weight gain is commonly reported by patients with breast cancer. Aromatase inhibitors are being tested in the preventive setting in high risk women and it is important to evaluate the association between treatment and weight change as this may effect the patient’s decision to continue to take the drug.

Methods: Weight change in postmenopausal women from three large clinical trials (ATAC, IBIS-I, IBIS-II) investigating endocrine treatment for the treatment and prevention of breast cancer have been analysed. The objective of this retrospective study was to assess the effects of anastrozole and tamoxifen on weight change in postmenopausal women.

Results: In the ATAC trial, a mean increase of 1.4 kg was observed after 12 months of follow-up and no statistically significant differences between treatment arms (anastrozole vs. tamoxifen) were found. The majority of women kept their weight stable and only 11.2% gained more than 5 kg within this time period. Significant baseline predictors for gaining more than 5 kg of weight after 12 months of follow-up were being younger than 60 years old at entry, smoking at entry, and mastectomy. Results for the two prevention studies IBIS-I and IBIS-II were quite similar. In the IBIS-II trial, the overall mean weight change after 12 months of follow-up was 0.5 kg. In the IBIS-I study women gained an average of 0.9 kg within the first 12 months of follow up. In both studies no differences between treatment and placebo (IBIS-I: tamoxifen vs. placebo; IBIS-II: anastrozole vs. placebo) were observed. Overall, women in the adjuvant setting gained more than 5 kg of weight (11.2%) after 12 months of follow up compared to those in the preventive setting (5.3% IBIS-I, 5.7% IBIS-II), but similar overall weight gain was seen after 60 months of follow up in both settings (5.7% IBIS-I vs. 6.1% ATAC).

Conclusions: All three trials have demonstrated that weight gain occurs primarily within the first 12 months of active treatment and are similar to those on placebo. Weight stabilises after 12 months of follow up and major weight gain was rare in all trials, and unrelated to treatment.

Menopausal symptoms and bone health in women undertaking risk reducing bilateral salpingo-oophorectomy: significant bone health issues in those not taking HRT

BACKGROUND

Women at high ovarian cancer risk, especially those with mutations in BRCA1/BRCA2, are encouraged to undergo bilateral risk-reducing salpingo-oophorectomy (BRRSPO) prior to the natural menopause. The decision to use HRT to cover the period of oestrogen deprivation up to 50 years of age is difficult because of balancing the considerations of breast cancer risk, bone and cardiovascular health.

METHODS

We reviewed by questionnaire 289 women after BRRSPO aged ≤48 years because of high ovarian cancer risk; 212 (73%) of women responded.

RESULTS

Previous HRT users (n=67) had significantly worse endocrine symptom scores than 67 current users (P=0.006). A total of 123 (58%) of women had ≥24 months of oestrogen deprivation <50 years with 78 (37%) never taking HRT. Bone density (DXA) evaluations were available on 119 (56%) women: bone loss with a T score of ≤-1.0 was present in 5 out of 31 (16%) women with no period of oestrogen deprivation <50 years compared with 37 out of 78 (47%) of those with ≥24 months of oestrogen deprivation (P=0.03).

INTERPRETATION

Women undergoing BRRSPO <50 years should be counselled concerning the risks/benefits of HRT, taking into consideration the benefits on symptoms, bone health and cardiovascular health, and that the risks of breast cancer from oestrogen-only HRT appear to be relatively small.

RASSF1A polymorphism in familial breast cancer

Inactivation or loss of the tumour suppressor Ras associated domain family 1 isoform A (RASSF1A) allele has been described in breast cancer. Recently, a missense polymorphism predicting p.A331S in RASSF1A was associated with an increased risk of breast cancer and early-onset breast cancer in BRCA1 and BRCA2 mutation carriers. We genotyped p.A331S RASSF1A in 854 independent, familial, white breast cancer patients (645 BRCA mutation negative, 119 BRCA1 and 90 BRCA2 positive) and compared the genotype in 331 healthy women. The RASSF1A p.A331S variant was not more common in the familial breast cancer cases than in the controls (P = 0.27). Subset analysis demonstrated no association in the BRCA1 (P = 0.26), BRCA2 (P = 0.16) or BRCA negative (P = 0.30) samples. Hence, the RASSF1A p.A331S polymorphism is not confirmed as a significant germline contributor to familial breast cancer susceptibility.

Significant differences in UK and US female bone density reference ranges

In the United Kingdom (UK), T- and Z-scores are usually calculated using reference ranges derived from United States (US) populations. In the UK arm of a recent randomised trial (International Breast Cancer Intervention Study II (IBIS-II)), substantially, fewer women than expected were recruited into the osteopenic (-2.545 years with a typical body mass index of 28 kg m(-2) have spine and hip bone mineral density (BMD) 0.6 standard deviation higher than their US counterparts.

INTRODUCTION

Dual energy X-ray absorptiometry (DXA) is widely used for the diagnosis of osteoporosis and to investigate the effect of pharmacological treatments on BMD. In both routine and research settings, it is important that DXA results are correctly interpreted.

METHODS

T- and Z-scores for the first 650 UK Caucasian women enrolled in the IBIS-II study were compared with data from two independent studies of unrelated, unselected UK Caucasian women: (1) 2,382 women aged 18 to 79 recruited to the Twins UK Adult Twin Registry; (2) 431 women aged 21 to 84 with no risk factors for osteoporosis recruited at Guy's Hospital. All DXA measurements were performed on Hologic densitometers. Subjects were divided into six age bands, and T- and Z-scores were calculated using the manufacturer's US reference range for the spine and the National Health and Nutrition Examination Survey III reference range for the femoral neck and total hip.

RESULTS

The overall mean Z-scores for the IBIS-II, Twin, and Guy's groups were: spine: +0.61, +0.29, +0.33; femoral neck: +0.42, +0.36, +0.45; total hip: +0.65, +0.38, +0.39 (all p<0.001 compared with the expected value of 0). The mean body weight of subjects in the three studies was 74.4, 65.5, and 65.4 kg, respectively. Analysis revealed a highly significant relationship between Z-score and weight at each BMD site with a slope of 0.03 kg(-1).

CONCLUSIONS

In general, US spine and hip reference ranges are not suitable for the calculation of Z-scores in UK women. For some research study designs, the differences may significantly influence the pattern of subject recruitment.