Can oncologists predict survival for patients with progressive disease after standard chemotherapies?

BACKGROUND

Prediction of prognosis is important for patients so that they can make the most of the rest of their lives. Oncologists could predict survival, but the accuracy of such predictions is unclear.

METHODS

In this observational prospective cohort study, 14 oncologists treating 9 major adult solid malignancies were asked to complete questionnaires predicting survival based on performance status, oral intake, and other clinical factors when patients experienced progressive disease after standard chemotherapies. Clinically predicted survival (cps) was calculated by the oncologists from the date of progressive disease to the predicted date of death. Actual survival (as) was compared with cps using Kaplan-Meier survival curves, and factors affecting inaccurate prediction were determined by logistic regression analysis. The prediction of survival time was considered accurate when the cps/as ratio was between 0.67 and 1.33.

RESULTS

The study cohort consisted of 75 patients. Median cps was 120 days (interquartile range: 60-180 days), and median as was 121 days (interquartile range: 40-234 days). The participating oncologists accurately predicted as within a 33% range 36% of the time; the survival time was overestimated 36% of time and underestimated 28% of the time. The factors affecting the accuracy of the survival estimate were the experience of the oncologist, patient age, and information given about the palliative care unit.

CONCLUSIONS

Prediction of cps was accurate for just slightly more than one third of all patients in this study. Additional investigation of putative prognostic factors with a larger sample size is warranted.

Survival of HER2-positive primary breast cancer patients treated by neoadjuvant chemotherapy plus trastuzumab: a multicenter retrospective observational study (JBCRG-C03 study)

We investigated the disease-free survival (DFS) of HER2-positive primary breast cancer patients treated with neoadjuvant chemotherapy plus trastuzumab, as well as predictive factors for DFS and pathologic response. Data from 829 female patients treated between 2001 and 2010 were collected from 38 institutions in Japan. Predictive factors were evaluated using multivariate analyses. The 3-year DFS rate was 87 % [95 % confidence interval (CI) 85-90]. The pathologic complete response (pCR: ypT0/is + ypN0) rate was 51 %. The pCR rate was higher in the ER/PgR-negative patients than in the ER/PgR-positive patients (64 vs. 36 %, P < 0.001). Patients with pCR showed a higher DFS rate than patients without pCR (93 vs. 82 %, P < 0.001). Multivariate analysis revealed three independent predictors for poorer DFS: advanced nodal stage [hazard ratio (HR) 2.63, 95 % CI 1.36-5.21, P = 0.004 for cN2-3 vs. cN0], histological/nuclear grade 3 (HR 1.81, 95 % CI 1.15-2.91, P = 0.011), and non-pCR (HR 1.98, 95 % CI 1.22-3.24, P = 0.005). In the ER/PgR-negative dataset, non-pCR (HR 2.63, 95 % CI 1.43-4.90, P = 0.002) and clinical tumor stage (HR 2.20, 95 % CI 1.16-4.20, P = 0.017 for cT3-4 vs. cT1-2) were independent predictors for DFS, and in the ER/PgR-positive dataset, histological grade of 3 (HR 3.09, 95 % CI 1.48-6.62, P = 0.003), clinical nodal stage (HR 4.26, 95 % CI 1.53-13.14, P = 0.005 for cN2-3 vs. cN0), and young age (HR 2.40, 95 % CI 1.12-4.94, P = 0.026 for ≤40 vs. >40) were negative predictors for DFS. Strict pCR (ypT0 + ypN0) was an independent predictor for DFS in both the ER/PgR-negative and -positive datasets (HR 2.66, 95 % CI 1.31-5.97, P = 0.006 and HR 3.86, 95 % CI 1.13-24.21, P = 0.029, respectively). These results may help assure a more accurate prognosis and personalized treatment for HER2-positive breast cancer patients.

Pregnancy in women with a history of Kawasaki disease: management and outcomes

OBJECTIVE

To characterise the obstetrical management and outcomes in a series of women with a history of Kawasaki disease (KD) in childhood.

DESIGN

Retrospective case series.

SETTING

Tertiary healthcare setting in the USA.

POPULATION

Women with a history of KD in childhood.

METHODS

Women completed a detailed health questionnaire and participated in research imaging studies as part of the San Diego Adult KD Collaborative Study.

MAIN OUTCOME MEASURES

Obstetrical management, complications during pregnancy and delivery, and infant outcomes.

RESULTS

Ten women with a history of KD in childhood carried a total of 21 pregnancies to term. There were no cardiovascular complications during labour and delivery despite important cardiovascular abnormalities in four of the ten subjects. Pregnancy was complicated by pre-eclampsia and the post-partum course was complicated by haemorrhage in one subject each. Two of the 21 progeny subsequently developed KD.

CONCLUSIONS

Women with important cardiovascular sequelae from KD in childhood should be managed by a team that includes both a maternal-fetal medicine specialist and a cardiologist. Pre-pregnancy counselling should include delineation of the woman's current functional and structural cardiovascular status and appropriate adjustment of medications, but excellent outcomes are possible with appropriate care. Review of the English and Japanese literature on KD and pregnancy revealed the occurrence of myocardial infarction during pregnancy in women with missed KD and aneurysms that were not diagnosed until their acute event. Our study highlights the need for counselling with regard to the increased genetic risk of KD in offspring born to these mothers.

Immune-monitoring in Kawasaki disease patients treated with infliximab and intravenous immunoglobulin

The expansion of regulatory T cells (Treg ) controls inflammation in children with acute Kawasaki disease (KD). Blockade of tumour necrosis factor (TNF)-α is an emerging therapy for KD patients with refractory inflammation, but there is concern that this therapy could impede the host immune regulation. To define the effect of TNF-α blockade, we conducted ex-vivo immune-monitoring in KD subjects who participated in a randomized, double-blind, placebo-controlled clinical trial of the addition of infliximab to standard intravenous immunoglobulin (IVIG) therapy. We enumerated circulating myeloid and plasmocytoid dendritic cells (DC), regulatory T cells (Treg ) and memory T cells (Tmem ) in 14 consecutive, unselected KD patients (seven treated with IVIG, seven with IVIG + infliximab) at three time-points: (i) acute phase prior to treatment, (ii) subacute phase and (iii) convalescent phase. Myeloid DC (mDC), but not plasmacytoid DC (pDC), were numerous in the peripheral blood in acute KD subjects and decreased in the subacute phase in both IVIG(-) and IVIG (+)  infliximab-treated groups. The co-stimulatory molecule for antigen presentation to T cells and CD86 decreased in mDC from acute to subacute time-points in both treatment groups, but not in the single patient who developed coronary artery aneurysms. We also defined tolerogenic mDC that expand in the subacute phase of KD not impaired by infliximab treatment. Treg and Tmem expanded after treatment with no significant differences between the two groups. Treatment of KD patients with infliximab does not adversely affect generation of tolerogenic mDC or the development of T cell regulation and memory.

Abstract P5-08-12: Histopathological and immunohistochemical findings for epithelial-to-mesenchymal transition were associated with clinical progressive disease of triple-negative breast cancers during neoadjuvant chemotherapy

Background: Clinical progressive disease (cPD) occurs during neoadjuvant therapy (NAC) in 3 to 5% of breast cancer patients. By gene expression profiling analyses using DNA microarray, the expression of epithelial-to-mesenchymal transition (EMT)-associated genes were shown to be correlated with chemoresistant phenotype of breast cancer cell lines. In order to reveal clinical implication of EMT-associated molecules on the acquisition of cPD property, we designed a retrospective histopathilogical and immunohistochemical case-control study. Patients and Methods: From pathology database of patients who received surgical resection, 86 patients with early triple-negative breast cancer (TNBC) were identified: 23 patients suffered cPD during NAC (PD group) and 63 control group patients did not receive NAC (C group), in whom &gt;95% of patients was estimated to be non-PD group if NAC was performed. For these 86 cases, histopathological classification was performed and negativity of hormone receptors and HER2 was confirmed. As EMT markers, we immunohistochemically examined the expressions of vimentin, Twist, Twist NB and Snail. The chi-square test was used to assess statistically significant differences between the groups.Results: Histologically, PD group comprised 12 invasive ductal carcinomas (IDCs) (52%) and 11 metaplastic carcinomas (MPCs) (48%), and they all were nuclear grade 3. In C group, 52 (83%) were IDCs and 10 (16%) were histological types other than IDC or MPC, and there was only 1 MPC (1%) (p = 4.31E-08). Nuclear grade was 1, 2, and 3 in 1, 9, and 53, respectively. Vimentin was positive in cytoplasm of 74% of PD group and the incidence was higher than that in C group (49%) (p = 0.016). Cytoplasmic twist-2 and cytoplasmic and nuclear Snail expressions were detected almost equally between PD group and C group. Cytoplasmic Twist NB expression was more frequent in PD group (26%) than in C group (1.6%) (p = 0.0002). In PD group, a total of 17 cases comprising 9 MPCs and 8 IDCs, were positive for vimentin. In these 17 vimentin-positive cases, 14 were stable disease or partial response with an anthracyclin-containing regimen while all 16 patients receiving a taxane-containing regimen became cPD during the taxane-containing regimen.

Patient characteristics PD group (N = 23)Control group(N = 63)Age median (range)42(25-62)55(25-77)Clinical stage:I/II/III0/11/127/44/12Diagnosi at operation:IDC/MPC or MPC containing/others12/11/052/1/10Nuclear grade:1/2/30/0/231/9/53Tumor size at diagnosis4.8(2-14)2.8(1.2-12.0)Neoadjuvant chemoterapy regimen  Anthracyclin containing:AC/CEF11/12-Taxane: paclitaxel/docetaxel20/2-

Conclusion: EMT features detected by metaplastic phenotype and cytoplasmic vimentin expression could be predictors for cPD during NAC for TNBC. The tumors of these phenotypes were likely to be resistant to a taxane-containing regimen.

Immunohistochemical profilingantibodyPD group (N = 23)Control group (N = 63)p-valueVimentin(cytoplasm)17 (74%)31 (49%)0.0411Twist-2(cytoplasm)21(91%)59 (94%)0.7849Snail-2(cytoplasm)12 (52%)38 (60%)0.5548Snail-2(nucleus)14 (61%)34 (54%)0.4677Twist NB(cyroplasm)6 (26%)1 (1.6%)0.0002

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-08-12.

Abstract P6-06-20: Predictive factors for pathologic complete response and disease-free survival after neoadjuvant chemotherapy with trastuzumab: A multicenter retrospective observational study in patients with HER2-positive primary breast cancer (JBCRG-C03 study)

BACKGROUND:

Addition of trastuzumab to neoadjuvant chemotherapy (NAC) improved pathologic complete response (pCR) rate in HER2-positive breast cancer. Although recent trials have shown favorable prognosis with NAC plus trastuzumab, clinicopathological factors to predict the outcome have not been fully understood. The aim of this study was to investigate the survival after NAC with trastuzumab and to explore the predictive factors.

PATIENTS AND METHODS:

This is a multicenter retrospective observational study. Patients with HER2-positive primary breast cancer treated with NAC plus trastuzumab from 2001 to 2010 were identified from the institutional database. Primary end point was disease-free survival (DFS). pCR was defined as ypT0/is+ypN0. Kaplan-Meier method was used to estimate DFS. Logistic regression and proportional hazard analysis were used to identify clinicopathological factors to predict pCR and DFS, respectively.

RESULTS:

733 patients were included in the analysis (whole dataset). 425 were ER/PgR-negative (HR- dataset) and 306 were ER/PgR-positive (HR+ dataset). Radiation therapy was performed in 90% of lumpectomy and 31% of mastectomy. Hormonal therapy was performed in 84% of HR+ dataset. pCR rate was 45% in whole dataset, 60% in HR- dataset, and 34% in HR+ dataset. Table 1 showed the result of multivariate analysis for pCR in whole dataset. When HR+ and HR- dataset were analyzed separately, no definitive predictors for pCR were identified in multivariate analysis. Although the patients with pCR showed a significantly favorable prognosis than those without pCR at 3 years DFS, in whole dataset (93% vs 83%, p&lt;0.0001) and HR- dataset (94% vs 80%, p&lt;0.0001), there was no significant difference in HR+ dataset (89% vs 86%, p = 0.10). Different predictors were selected for DFS when multivariate analysis was conducted separately between HR- and HR+ dataset (Table 2).

CONCLUSIONS:

In this observational study, we clarified predictors for pCR and DFS in HER2-positive patients treated with neoadjuvant trastuzumab containing therapy based on tumor subtype. Our results may help us to predict the prognosis more precisely and to simulate the disease course.

Table 1) Multivariate logistic regression analysis for pCR in whole datasetFactorsOR95%CIp-valuePost- vs Pre-menopause1.50(1.05-2.15)0.026*cT1-2 vs cT3-41.72(1.16-2.59)0.008*ER/PgR-negative vs ER/PgR-positive3.32(2.30-4.82)&lt;0.0001*Grade 3 vs 1-21.28(0.89-1.84)0.183

Table 2) Multivariate proportional hazard analysis for DFSFactors†HR95%CIp-valueWhole dataset   Pre- vs Post-menopause1.61(1.04-2.52)0.033*cN2-3 vs cN03.06(1.58-6.24)0.001*cN1 vs cN02.26(1.23-4.41)0.007*Grade 3 vs 1-21.87(1.20-2.97)0.006*non-pCR vs pCR1.90(1.18-3.13)0.008*HR- dataset   Pre- vs Post-menopause1.70(1.01-2.85)0.046*cT3-4 vs cT1-21.86(1.09-3.17)0.024*non-pCR vs pCR3.28(1.90-5.87)&lt;0.0001*HR+ dataset   cN2-3 vs cN05.01(1.79-16.19)0.002*cN1 vs cN03.50(1.40-10.61)0.006*Grade 3 vs 1-22.95(1.52-5.87)0.001*†Only factors with statistical significance

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-20.

Abstract P2-11-02: Perception and practice of reproductive specialists towards fertility preservation of young breast cancer patients

Background: The potential for infertility caused by treatment is one of the important quality-of-life issues in young breast cancer (YBC) patients. Insufficient communication and partnership between oncologists and reproductive specialists has been identified as a major barrier to meeting their needs. However, the perception of reproductive specialists towards fertility preservation (FP) of YBC has not been evaluated.

Objective: To investigate the perception and needs of reproductive specialists towards FP of YBC patients.

Methods: A cross-sectional survey was developed and sent to 423 certified reproductive specialists registered to the Japan Society for Reproductive Medicine to self-evaluate their perceptions and practices regarding FP in YBC patients.

Results: Two hundred reproductive specialists (47%) responded to the survey.

P4-01-21: An Estrogen-Inducible Transcription Factor FOXP1 Promotes Estrogen-Dependent Cell Proliferation of Breast Cancer Cells and Is Associated with 5-Year Disease-Free Survival in Patients with Tamoxifen-Treated Breast Cancer

Estrogen signaling pathways are involved in the growth and development of breast tumors through the activation of estrogen receptor a (ERα). ERα is expressed in most breast cancers and involves in estrogen-dependent proliferation by acting as transcription factors activating the expression of target genes. Various coregulators and transcription factors are associated with ERα-mediated transcriptional control of target genes. Therefore, a comprehensive understanding of estrogen signaling pathways in breast cancer is required for both treatment and diagnosis of the disease. Forkhead box P1 (FOXP1) is a member of the forkhead box transcription factor family and has been reported to be associated with various types of tumors. Here, we investigated the expression pattern of FOXP1 by immunohistochemistry in a series of 133 invasive breast cancers and compared it with clinicopathological factors. The expression of FOXP1 was detected in nuclei in 89 cases (67%) and correlated positively with tumor grade and hormone receptor status, including ERα and progesterone receptor (PgR), and negatively with pathological tumor size (pT). And in ERα-positive MCF-7 breast cancer cells, we demonstrated that FOXP1 mRNA was upregulated by estrogen and that ERα recruitment to ER binding sites within the FOXP1 gene region identified by ChIP-chip analysis was increased. We also demonstrated that proliferation of MCF-7 cells was increased by exogenously transfected FOXP1 and decreased by FOXP1-specific siRNA. Moreover, in MCF-7 cells, FOXP1 enhanced estrogen response element (ERE)-driven transcription. Finally, FOXP1 immunoreactivity was significantly more elevated in relapse-free breast cancer patients treated with tamoxifen than in relapse patients treated with it. Taken together, these results suggest that FOXP1 plays an important role in proliferation of breast cancer cells by modulating estrogen signaling and that FOXP1 immunoreactivity might be associated with the estrogen dependency of breast cancer clinically, which may predict favorable prognosis in the patients treated with tamoxifen.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-01-21.

P2-12-21: Impact of Recent Parity on Histopathological Tumor Features and Outcome of Young Women with Breast Cancer

Background

Younger age has been associated with worse outcome in breast cancer patients (pts) and recent parity has been epidemiologically identified as worse prognostic factor among women with breast cancer. The objective of this study was to explore potential factors associated with worse prognosis in young breast cancer pts, and to demonstrate the impact of parity on the histopathological tumor feature and patient outcome.

Materials and Methods: We retrospectively analyzed 634 early breast cancer pts younger than 45 years old who underwent surgery between 2000 and 2009. For statistical analysis, Pearson's and Fisher's exact test were used. Survival analysis was performed only for pts diagnosed before 2006 in order to obtain a minimum follow up 5 years.

Results: 108 women were diagnosed within 5 years since last parity (Group A), 216 were diagnosed &gt; 5 years since last parity (Group B) and 310 were nulliparous (Group C). Median age at diagnosis was 37 (range 26–44), 41 (range 32–44), and 38.5 (range 22–44) and family history (FH) of breast and/or ***ovarian cancer within second degree was found in 23, 22, and 23% of the pts in Groups A, B, and C, respectively. In Groups A, B and C, clinical stage was III in 22, 10 and 12% (p= .025), ER was positive in 65, 69 and 70% (p= .650), PgR was positive in 64, 75 and 74% (p= .057), and HER2 was positive in 25, 14 and 14% (p=.017), respectively. Tumors in Group A had higher histological grade (grade 3: 60/44/47%, p=.019), higher nuclear grade (grade 3: 61/47/48%, p=.036) and more lymph vessel invasion (61/52/45%, p=.015) compared to those in Groups B and C, respectively. Median follow up time was 85.1 months (range 1.8−137.1 months) during which there were 61 deaths. In univariate analysis, age and FH were not correlated with overall survival (OS). OS in Group A was significantly lower than in Group B (hazard ratio (HR) 3.51, 95% confidential interval (CI) 1.80−6.84, p&lt;.001) and in Group C (HR 2.42, 95%CI 1.36−4.29, p=.002), while OS did not differ significantly between Groups B and C. In the pts without FH, the HR of cancer death was more pronounced in Group A than in Group B (HR 4.25, 95%CI 1.97−9.14, p&lt;.001) or Group C (HR 2.67, 95%CI 1.43−5.01, p=.002), while there was no significant difference among the groups in pts with FH. In multivariate analysis among the pts without FH, lymph vessel invasion (HR 4.51, 95%CI 1.89−10.76, p=.001), Group A women (HR 2.28, 95%CI 1.25−4.17, p=.007), histological grade 3 (HR 2.72, 95%CI 1.28−5.77, p=.009), PgR negativity (HR 2.23, 95%CI 1.19−4.18, p=.013) and clinical stage II and III (HR 2.92, 95%CI 1.04−8.21, p=.04) were significantly associated with poor prognosis, adjusting for age.

Conclusion: Recent parity was associated with worse histopathological features in breast cancer of women younger than 45. It was also associated with worse outcome, especially among pts without FH. Recent parity seems to be a confounding factor for the worse outcome in young breast cancer patients, which justifies further studies to elucidate underlying biology.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-21.

P5-23-02: Clinicopathological Features of Young Patients Age &lt;35 Years with Breast Cancer in Japan

Background: The aim of this study is to clarify clinicopathological features of breast cancer in young women.

Materials and methods: Clinicopathological characteristics were compared between young (&lt;35) patients and non-young (≥35) patients among 109,617 records of JBCS database registered from 2004 to 2009, and overall survival (10-yr OS) were calculated among 146,690 records from 1975 to 2000 with 8.6 years of median follow up period. Results: Clinicopathological factors of 2,982 young patients (2.7%) were compared with 106,295 non-young patients. Young patients had more familial history of breast cancer, more subjective symptom, less bilateral tumor, lower BMI, larger tumor, more inflammatory breast cancer, more positive node, less ER-positive, more HER2−positive, more triple-negative tumor, and more advanced TNM-stage.

Comparison of clinicopathological factors between young and non-young patients with breast cancer

P5-14-27: Prognostic Factors of Node-Negative, High Risk and 1–3 Positive Lymph Nodes Breast Cancer by Intrinsic Subtype in Patients with Adjuvant Chemotherapy

Purpose: St. Gallen 2007 categorized high risk, node-negative breast cancer (HNBC) and 1–3 lymph nodes positive BC (LNBC) without HER2 overexpression as intermediate risk. We hypothesized that triple negative BC (TNBC) and hormone-receptor positive without HER2 overexpression (H-BC) in intermediate risk have different prognostic factor in patients with adjuvant chemotherapy (AdC).

Methods: We examined disease-free survival (PFS) and overall survival (OS) of TNBC and H-BC with regard to potential prognostic factors. All the patients included in this study were categorized intermediate risk by St.Gallen 2007 and received AdC.

Results: A total of 470 patients were identified; H-BC (n=360) and TNBC (n=110). Age (&lt;35) was significantly associated with DFS in TNBC while it was not in H-BC (p=0.0.1 and p=0.63, respectively). Tumor size (&gt;2cm) and tumor grade related to DFS in H-BC but not in TNBC. Tumor grade was not associated with DFS in both H-BC and TNBC (p=0.64 and p=0.91, respectively). Lymph node metastasis was a significant factor of DFS only for H-BC (p=0.009 and p=0.19). Conclusions: In TNBC, age was only a significant factor associated with DFS while in H-BC, lymph node status and tumor size rather age related to DFS.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-27.