Electron-Vibration Coupling in Molecular Materials: Assignment of Vibronic Modes from Photoelectron Momentum Mapping

Electron-phonon coupling is one of the most fundamental effects in condensed matter physics. We here demonstrate that photoelectron momentum mapping can reveal and visualize the coupling between specific vibrational modes and electronic excitations. When imaging molecular orbitals with high energy resolution, the intensity patterns of photoelectrons of the vibronic sidebands of molecular states show characteristic changes due to the distortion of the molecular frame in the vibronically excited state. By comparison to simulations, an assignment of specific vibronic modes is possible, thus providing unique information on the coupling between electronic and vibronic excitation.

A Review of Integrative Medicine in Gynaecological Oncology

In recent years complementary and alternative medicine (CAM) has increasingly been the focus of international research. Numerous subsidised trials (7903) and systematic reviews (651) have been published, and the evidence is starting to be integrated into treatment guidelines. However, due to insufficient evidence and/or insufficient good quality evidence, this has mostly not translated to practice recommendations in reviews by the Cochrane collaboration gynaecology group. There is nevertheless a not insignificant number of CAM providers and users. The percentage of oncology patients who use CAM varies between 5 and 90 %. Doctors have been identified as the main providers of CAM. Half of gynaecologists offer CAM because of personal conviction or on suggestion from colleagues. This must be viewed in a critical light, since CAM is mostly practiced without appropriate training, often without sufficient evidence for a given method - and where evidence exists, practice guidelines are lacking - and lack of safety or efficacy testing. The combination of patient demand and lucrativeness for doctors/alternative medicine practitioners, both based on supposed effectiveness CAM, often leads to its indiscriminate use with uncertain outcomes and significant cost for patients. On the other hand there is published, positive level I evidence for a number of CAM treatment forms. The aim of this article is therefore to review the available evidence for CAM in gynaecological oncology practice. The continued need for research is highlighted, as is the need to integrate practices supported by good evidence into conventional gynaecological oncology.

Abstract OT3-01-13: MetaPHER: A phase IIIb multicenter, open-label, single-arm safety study of subcutaneous trastuzumab, in combination with pertuzumab and docetaxel in patients with HER2-positive advanced breast cancer

Background: In patients (pts) with HER2-positive metastatic breast cancer (BC), the phase III CLEOPATRA study (NCT00567190) demonstrated significant improvement in progression-free (PFS) and overall survival (OS) from first-line treatment with intravenous (IV) pertuzumab (PERJETA® [P IV]) plus trastuzumab (Herceptin® [H IV]) plus docetaxel (D IV). HannaH (NCT00950300), a phase III trial in pts with HER2-positive early BC demonstrated that fixed-dose trastuzumab subcutaneous (Herceptin® [H SC]) is non-inferior to weight-based H IV infusion in the co-primary endpoints of serum trough concentration and pathologic complete response, which was supported by the long-term efficacy endpoints of event-free survival (EFS) and OS. The safety profile of H SC was consistent with the known safety profile of H IV. H SC is comprised of 600 mg trastuzumab and recombinant human hyaluronidase (rHuPH20) as an excipient, allowing a significantly reduced administration time compared with H IV (5 mins versus 30–90 mins, respectively). The MetaPHER study is designed to investigate the safety and efficacy of H SC in combination with P IV and D IV in pts with HER2-positive advanced BC.

Trial design: MetaPHER is a phase IIIb multicenter, open-label, single-arm study, with eligible pts receiving H SC 600 mg/5 mL q3w, P IV (840 mg loading dose, then 420 mg at each subsequent cycle q3w), and D IV (at least 6 cycles at 75 mg/m2 q3w with possible escalation to 100 mg/m2 q3w; after Cycle 6, continuation of docetaxel is at the investigator's discretion). Study treatment is administered until disease progression, unacceptable toxicity, withdrawal of consent, death, or predefined study end, whichever occurs first. Pts will receive post-treatment follow-up for safety and survival.

Eligibility: Women aged ≥18 years with metastatic or locally recurrent HER2-positive BC, ECOG performance status 0 or 1, and a left ventricular ejection fraction ≥50% are eligible. Exclusion criteria include disease-free interval of <6 months from completion of adjuvant or neoadjuvant non-hormonal treatment to disease recurrence; previous systemic non-hormonal therapy for metastatic or locally recurrent BC; history of persistent grade ≥2 hematological toxicity; current grade ≥3 peripheral neuropathy; or clinically significant cardiovascular disease.

Aims: The primary objective is to evaluate the safety and tolerability of H SC in combination with P IV and D IV in pts with HER2-positive advanced BC. Secondary endpoints include PFS, OS, objective response rate and incidence of anti-trastuzumab and anti-rHuPH20 antibody formation.

Statistical methods: Safety and efficacy results will be summarized descriptively to include all enrolled pts who received at least one dose of any study drug; the study is not designed for formal hypothesis testing. A sample size of 400 pts provides reasonable precision for the estimation of grade ≥3 AEs and cardiac AEs.

Accrual: MetaPHER is enrolling, FPI was May 2015, and target enrollment is 400 pts; clinicaltrials.gov ID: NCT02402712.

Contact information: For more information or to refer a patient, email global.rochegenentechtrials@roche.com or call 1-888-662-6728 (USA only).

Citation Format: Kümmel S, Crepelle-Fléchais A, Schlegel M, Hillenbach C, Swat A, Franz M, Girase P, Schneider A, Heinzmann D, Shing M. MetaPHER: A phase IIIb multicenter, open-label, single-arm safety study of subcutaneous trastuzumab, in combination with pertuzumab and docetaxel in patients with HER2-positive advanced breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-01-13.

Abstract P1-14-11: nab-paclitaxel at a dose of 125 mg/m2 weekly is more efficacious but less toxic than at 150 mg/m2. Results from the neoadjuvant randomized GeparSepto study (GBG 69)

Background: We previously reported that nab-paclitaxel (nP) increases the pathological complete response (pCR, ypT0 ypN0) rate when it replaces solvent-based paclitaxel (P) as part of a sequential taxane followed by epirubicin/cyclophosphamide (EC) neoadjuvant chemotherapy for patients with early breast cancer (Untch et al. SABCS 2014). Here, we report efficacy and safety of patients being treated either with 150 mg/m2 nab-paclitaxel (nP150) before an amendment or with 125 mg/m2 nab-paclitaxel (nP125) thereafter in comparison to solvent-formulated paclitaxel at 80 mg/m2 (P80).

Methods: In the GeparSepto study (NCT01583426), 1207 patients were randomized to either nP150 or P80 q1w for 12 weeks followed by 4 cycles of conventionally dosed EC (E: 90mg/m2; C: 600 mg/m2) q3w. The primary objective of the study was to compare the pCR rate (pCR, ypT0 ypN0). Patients with untreated, histologically confirmed uni- or bilateral, cT2- cT4d carcinoma, and no clinically relevant cardiovascular and other co-morbidities were included. Patients with HER2+ tumors received trastuzumab (loading dose 8mg/kg; 6 mg/kg) plus pertuzumab (loading dose 840 mg; 420 mg) q3w concomitantly to all chemotherapy cycles. After a safety analysis showed a higher rate of dose reductions and treatment discontinuations with nP150 compared to P80, weekly dose of nP was reduced to 125 mg/m2.

Results: nP was given for the majority of cycles at a dose of 150 mg/m2 to 179 patients and at a dose of 125 mg/m2 to 426 patients. Treatment characteristics were fairly balanced between these two sequential cohorts as well as compared to 601 patients receiving P80 except for HER2 status (HER2-positive: nP150 22%, nP125 37% and P80 33%) and Ki67 (<20%: nP150 60%, nP125 73% and P80 69%). Taxane treatment was discontinued in 16% (nP150), 11% (nP125) and 6% (P80) of patients, respectively. Median dose per cycle (based on relative total dose intensity (RTDI)) was 129 mg/m2 with nP150, 119 mg/m2 with nP125 and 78 mg/m2 with P80, respectively. Peripheral sensory neuropathy (PNP) grade 3/4 (NCI-CTCAE v4.0) was observed in 15% with nP150, 8% with nP125 and 3% with P80, respectively. pCR was 32% with nP150, 41% with nP125 and 29% with P80 in all patients and 46% with nP150, 49% with nP125 and 26% with P80 in 277 patients with triple-negative breast cancer, respectively.

Conclusions: Risk-benefit ratio of nP125 was improved over nP150 with better drug adherence and RTDI, lower frequency of PNP but a higher pCR rate. It should therefore be considered as the preferred schedule when nP is used as neoadjuvant treatment for primary breast cancer.

The trial was financially supported by Celgene and Roche.

Citation Format: von Minckwitz G, Untch M, Jakisch C, Schneeweiss A, Conrad B, Aktas B, Denkert C, Eidtmann H, Weibringhaus H, Kümmel S, Hilfrich J, Warm M, Paepke S, Just M, Hanusch C, Hackmann J, Blohmer J-U, Clemens M, Costa SD, Gerber B, Nekljudova V, Loibl S. nab-paclitaxel at a dose of 125 mg/m2 weekly is more efficacious but less toxic than at 150 mg/m2. Results from the neoadjuvant randomized GeparSepto study (GBG 69). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-14-11.

Abstract OT1-02-02: The DETECT study program – Personalized treatment in metastatic breast cancer based on circulating tumor cells

Circulating tumor cells (CTCs) are found in patients with primary and metastatic breast cancer (MBC), respectively, and discordance in HER2 and hormone-receptor status between primary tumor, metastases and CTCs is well described. Treatment decisions are still based on the expression profile of solid tumor samples whereas CTCs are thought to cause tumor progression by blood-derived metastases. Nevertheless, targeted therapy based on expression profile of CTCs is not established in clinical routine. Individualized treatment decisions based on presence and phenotype of CTCs will be analyzed within the DETECT study program.

Metastatic breast cancer patients with HER2-negative MBC are screened in DETECT III and IV for presence of CTCs by using the CellSearch System (Janssen Diagnostics) which is FDA approved for enumeration of CTCs. Patients are enrolled into the different cohorts according to HER2-phenotype of CTCs. Since February 2012, women with HER2-negative MBC and HER2-positive CTCs are treated in the multicenter randomized Phase III study DETECT III with standard therapy with or without additional HER2-targeted therapy with Lapatinib. For standard therapy, physicians can choose between exemestane, letrozole and anastrozole for endocrine therapy, or docetaxel, paclitaxel, capecitabine, vinorelbine and non-pegylated liposomal doxorubicin for chemotherapy. Efficacy of CTC-based anti-HER2 treatment is evaluated by analyzing CTC-clearance rate after treatment.

Patients with only HER2-negative CTCs are recruited for the multicenter open-label phase II study DETECT IV. Since December 2013, women with hormone-receptor positive MBC receive endocrine therapy (tamoxifen, exemestane, letrozole or anastrozole) plus everolimus in DETECT IVa. In February 2015, DETECT IV was extended by the eribulin-cohort which offers a cytotoxic treatment with eribulin for women with triple-negative or hormone-receptor positive, chemotherapy demanding MBC (DETECT IVb). Progression free survival is used for assessment of clinical efficacy with overall survival and disease control rate as secondary objectives.

DETECT V, a multicenter open-label phase III study starting in summer 2015, randomizes patients with hormone-receptor positive, HER2-positive MBC to a dual HER2 targeted therapy (Trastuzumab and Pertuzumab) combined with either endocrine therapy or cytotoxic treatment. Quality of life determined by occurrence of adverse events is compared between both treatment arms. For prediction of endocrine treatment response, an "Endocrine Responsiveness Score" is calculated based on expression of estrogen-receptor and HER2 on detected CTCs.

More than 1200 patients are already screened in the DETECT study concept. Thus, it is the worldwide largest study concept with therapy decisions resulting from CTC-testing and CTC-phenotypization. The accompanying translational research programs evaluates further markers for molecular characterization of CTCs and prediction of therapy response.

Conclusion and Contact

The value of CTC phenotypes for making decisions on therapy interventions and predicting treatment responses in patients with MBC is tested in the DETECT study concept. The findings will help to move a step forward towards a more personalized anti-cancer therapy.

Citation Format: Schramm A, Friedl TWP, Huober J, Jäger B, Rack B, Trapp E, Fasching PA, Taran F-A, Hartkopf A, Schneeweiss A, Müller V, Aktas B, Pantel K, Meier-Stiegen F, Wimberger P, Kümmel S, Gebauer G, Müller L, Janni W, Fehm T. The DETECT study program – Personalized treatment in metastatic breast cancer based on circulating tumor cells. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-02-02.

[Documentation Time and Effort and Associated Resources for Patients with Primary Breast Cancer from Diagnosis to End of Follow-Up - Results of a Multicentre Validation]

INTRODUCTION

Tumour documentation is essential for quality assurance of oncological therapies and as a source of reliable information about the in- and outpatient care. The documentation effort and the associated resource consumption were analysed for the example of breast cancer.

MATERIAL AND METHODS

The different steps in the care of patients with primary breast cancer in a standardised disease situation were defined from initial diagnosis to the end of the follow-up. After the pilot phase, a multicentre validation (n=7 centres) was performed with the support of the Federal Ministry of Health. The documentation time points were horizontally collected and analysed with regard to amount, duration and personnel expenses.

RESULTS

57% of the documentation costs are caused by the physicians. Regarding the different centres, documentation costs were calculated between € 352.82 and € 1 084.08 per patient from diagnosis to completion of aftercare. Non-certified centres had a reduced documentation effort and thus lower costs.

CONCLUSIONS

The results demonstrate the need for a reduction of the documentation effort - particularly for physicians - the most expensive profession in the health system. A quality improvement is expected from the certification with its special requirements. In this context, there is a justified demand for an adequate remuneration of the documentation effort for certified centres. Furthermore, it is necessary to reduce the number of variables for quality assurance and to define them centrally. A comprehensive multi-disciplinary documentation should be achieved. Investments in a single data set and interface enhancements of existing documentation systems should be realised.

Prognostic Factors for Local, Loco-regional and Systemic Recurrence in Early-stage Breast Cancer

Aim: The risk of recurrence in breast cancer depends on factors such as treatment but also on the intrinsic subtype. We analyzed the risk factors for local, loco-regional and systemic recurrence, evaluated the differences and analyzed the risk of recurrence for different molecular subtypes. Material and Methods: A total of 3054 breast cancer patients who underwent surgery followed by adjuvant treatment at HSK hospital or Essen Mitte Hospital between 1998 and 2011 were analyzed. Based on immunohistochemical parameters, cancers were divided into the following subgroups: luminal A, luminal B (HER2-), luminal B (HER2+), HER2+ and TNBC (triple negative breast cancer). Results: 67 % of tumors were classified as luminal A, 13 % as luminal B (HER2-), 6 % as luminal B (HER2+), 3 % as HER2+ and 11 % as TNBC. After a median follow-up time of 6.6 years there were 100 local (3.3 %), 32 loco-regional (1 %) and 248 distant recurrences (8 %). Five-year recurrence-free survival for the overall patient collective was 92 %. On multivariate analysis, positive nodal status, TNBC subtype and absence of radiation therapy were found to be independent risk factors for all forms of recurrence. Age < 50 years, tumor size, luminal B (HER2-) subtype and breast-conserving therapy were additional risk factors for local recurrence. Compared to the luminal A subtype, the risk of systemic recurrence was higher for all other subtypes; additional risk factors for systemic recurrence were lymphatic invasion, absence of systemic therapy and mastectomy. Conclusion: Overall, the risk of local and loco-regional recurrence was low. In addition to nodal status, subgroup classification was found to be an important factor affecting the risk of recurrence.

Local and Systemic Therapies for Breast Cancer Patients: Reducing Short-term Symptoms with the Methods of Integrative Medicine

With improved prognosis due to advances in the diagnosis and therapy of breast cancer, physicians and therapists now focus on aspects such as quality of life and the management of side effects from breast cancer treatment. Therapy- and disease-related side effects often reduce the patient's quality of life and can place a further burden on patients, with non-compliance or discontinuation of therapy a potential consequence. Study data have shown that therapy- and disease-related side effects can be reduced using the methods of integrative medicine. Reported benefits include improving patients' wellbeing and quality of life, reducing stress, and improving patients' mood, sleeping patterns and capacity to cope with disease. Examining the impact of integrative medicine on the side effects of cancer treatment would be beyond the scope of this review. This article therefore looks at short-term side effects of cancer treatment which are usually temporary and occur during or after local and systemic therapy. The focus is on mind-body medicine, acupuncture and classic naturopathic treatments developed by Sebastian Kneipp as complementary therapies. The latter includes hydrotherapy, phytotherapy, nutritional therapy, exercise therapy and a balanced lifestyle.

Breast Cancer Update 2014 - Focus on the Patient and the Tumour

The therapy for patients with breast cancer has developed markedly in the past ten years. Our understanding of the molecular biology of tumours and the characteristics of the patients has shaped the recent advances. In this review we present the latest knowledge about the therapy for breast cancer. There are new tests and options not only in the field of anti-HER2 therapy but also in the management of triple negative and hormone receptor-positive patients. Comprehension of prognosis and therapeutic response to chemotherapies is little by little helping to define patient groups who will not respond to chemotherapy or who do not need treatment because their prognosis is extremely good. In the field of anti-HER2 therapy, work is continuing on the development of drugs suitable for and able to overcome trastuzumab resistance. For hormone receptor-positive cancers, we now have a better understanding of which therapy groups will benefit from which anti-endocrine drugs, and which will be able to overcome a possible resistance (treatment of the PI3K pathways, inhibition of the cell cycle). Molecular tests are still being evaluated with regard to the clinical situations in which they may have the greatest relevance for therapeutic decision-making; however, evidence is also increasing as to the fields in which good predictions for the prognosis can be obtained. On the whole, more work is needed to promote our understanding of the new developments in diagnostics and therapy and to involve both physicians and patients equally in the procedures.

Evaluation of Therapy Management and Patient Compliance in Postmenopausal Patients with Hormone Receptor-positive Breast Cancer Receiving Letrozole Treatment: The EvaluateTM Study

Introduction: The EvaluateTM study (Evaluation of therapy management and patient compliance in postmenopausal hormone receptor-positive breast cancer patients receiving letrozole treatment) is a prospective, non-interventional study for the assessment of therapy management and compliance in the routine care of postmenopausal women with invasive hormone receptor-positive breast cancer receiving letrozole. The parameters for inclusion in the study are presented and discussed here. Material and Methods: Between January 2008 and December 2009 a total of 5045 patients in 310 study centers were recruited to the EvaluateTM study. Inclusion criteria were hormone receptor-positive breast cancer and adjuvant treatment or metastasis. 373 patients were excluded from the analysis for various reasons. Results: A total of 4420 patients receiving adjuvant treatment and 252 patients with metastasis receiving palliative treatment were included in the study. For 4181 patients receiving adjuvant treatment, treatment with the aromatase inhibitor letrozole commenced immediately after surgery (upfront). Two hundred patients had initially received tamoxifen and started aromatase inhibitor treatment with letrozole at 1-5 years after diagnosis (switch), und 39 patients only commenced letrozole treatment 5-10 years after diagnosis (extended endocrine therapy). Patient and tumor characteristics were within expected ranges, as were comorbidities and concurrent medication. Conclusion: The data from the EvaluateTM study will offer a good overview of therapy management in the routine care of postmenopausal women with hormone receptor-positive breast cancer. Planned analyses will look at therapy compliance and patient satisfaction with how information is conveyed and the contents of the conveyed information.

Additional prognostic value of lymph node ratio over pN staging in different breast cancer subtypes based on the results of 1,656 patients

PURPOSE

Although the impact of lymph node ratio (LNR: ratio of metastatic to resected LNs) in breast cancer (BC) has been investigated, its prognostic value in molecular subtypes remains unclear. Our aim was to evaluate the impact of LNR compared to pN-stage in BC subtypes.

PATIENTS/METHODS

We analyzed the impact of LNR and pN-stage on disease-free (DFS) and overall survival (OS) in 1,656 patients with primary BC who underwent primary axillary surgery (removal of ≥10 LNs) between 1998 and 2011. The cut-off points for LNR were previously published. Using immunohistochemical parameters tumors were grouped in luminalA, luminalB/HER2-, luminalB/HER2+, HER2+ and triple negative (TNBC).

RESULTS

For the entire cohort 5/10-year DFS and OS rates were 88/77% and 88/75%, respectively. LNR and pN-stage were independent prognostic parameters for DFS/OS in multivariate analysis in the entire cohort and each molecular subgroup (p < 0.001). However, increasing LNR seemed to discriminated 10-year DFS slightly better than pN-stage in luminalA (intermediate/high LNR 65/44% versus pN2/pN3 71/53%), luminalB/HER2- (intermediate/high LNR 48/24% versus pN2/pN3 41/42%), and TNBC patients (intermediate/high LNR 49/24% versus pN2/pN3 56/33%).

CONCLUSIONS

LNR is an important prognostic parameter for DFS/OS and might provide potentially more information than pN-stage in different molecular subtypes.

Surgical treatment of primary breast cancer in the neoadjuvant setting

Background

Neoadjuvant chemotherapy (NACT) is a standard treatment option for primary operable breast cancer when adjuvant chemotherapy is indicated.

Methods

This article reviews the use of NACT in breast cancer treatment.

Results

Pathological complete response (pCR) rates of up to 60 per cent have been reached for certain breast cancer subgroups. Patients achieving a pCR have a lower locoregional recurrence rate. Nevertheless, the rate of breast-conserving surgery seems to be stable at around 65–70 per cent, although more than 80 per cent of patients respond to NACT. The risk of local relapse does not appear to be higher after NACT, which supports the recommendation to operate within the new margins, as long as there is no tumour in the inked area of the surgical specimen. However, tumours do not shrink concentrically and the re-excision rate is higher after NACT. Mastectomy rates for lobular carcinomas remain high irrespective of tumour response. The role of sentinel lymph node biopsy (SLNB) in the context of NACT has been studied in recent years, and it is not yet completely clear which type of axillary staging is the most suitable. SLNB before NACT in clinically node-negative patients has been the preferred option. However, this practice is currently changing, and it seems advisable to have the SLNB after NACT to reduce the risk of a false-negative SLNB.

Conclusion

Overall, patients do benefit from NACT, especially those with human epidermal growth factor receptor 2-positive and triple-negative breast cancer, but surgical/local procedures need to be adapted.