Oral nystatin prophylaxis and neonatal fungal infections

BACKGROUND

The value of antifungal prophylaxis depends partly on the incidence of neonatal fungal infection. We compared the incidence of fungal infection in babies in neonatal units which do and do not give antifungal prophylaxis using oral nystatin.

METHODS

Prospective, multi-centre surveillance study from 1993 to 2006 of invasive fungal infection, defined as positive blood or cerebrospinal fluid culture, in babies <1500 g birth weight in neonatal units in Australia and New Zealand.

RESULTS

There were 118 episodes of invasive fungal infection in 14 778 babies <1500 g, an incidence of 0.80% (95% confidence interval (CI) 0.66 to 0.94%). All infections were due to Candida species, mostly C. albicans (74, 62.7%) and C. parapsilosis (39, 33.1%). The mortality was 16.5%. The incidence was 0.54% (0.38 to 0.70%) for babies <1500 g in units using selective or universal oral nystatin prophylaxis and 1.23% (0.84 to 1.62%) in units using no prophylaxis (p<0.001). The incidence of infection in babies <1000 g was 1.78% (106/5948) (95% CI 1.44 to 2.12%). The incidence was 1.23% (0.92 to 1.54%) for babies <1000 g in units using nystatin prophylaxis and 2.67% (1.97 to 3.37%) in units using no prophylaxis (p<0.001).

CONCLUSIONS

The incidence of neonatal fungal infection was low in Australia and New Zealand, even without antifungal prophylaxis. Antifungal prophylaxis with oral nystatin was associated with a significantly lower incidence of fungal infection compared with no prophylaxis.

Addition of pathology and biomarker information significantly improves the performance of the Manchester scoring system for BRCA1 and BRCA2 testing

BACKGROUND

Selection for genetic testing of BRCA1/BRCA2 is an important area of healthcare. Although testing costs for mutational analysis are falling, costs in North America remain in excess of US$3000 (UK price can be 690 pounds). Guidelines in most countries use a 10-20% threshold of detecting a mutation in BRCA1/2 combined within a family before mutational analysis is considered. A number of computer-based models have been developed. However, use of these models can be time consuming and difficult. The Manchester scoring system was developed in 2003 to simplify the selection process without losing accuracy.

METHODS

In order to increase accuracy of prediction, breast pathology of the index case was incorporated into the Manchester scoring system based on 2156 samples from unrelated non-Jewish patients fully tested for BRCA1/2, and the scores were adapted accordingly. Results/

DISCUSSION

Data from breast pathology allowed adjustment of BRCA1 and combined BRCA1/2 scores alone. There was a lack of pathological homogeneity for BRCA2, therefore specific pathological correlates could not be identified. Upward adjustments in BRCA1 mutation prediction scores were made for grade 3 ductal cancers, oestrogen receptor (ER) and triple-negative tumours. Downward adjustments in the score were made for grade 1 tumours, lobular cancer, ductal carcinoma in situ and ER/HER2 positivity. Application of the updated scoring system led to four and nine more mutations in BRCA1 being identified at the 10% and 20% threshold, respectively. Furthermore, 65 and 58 fewer cases met the 10% and 20% threshold, respectively, for testing. Moreover, the adjusted score significantly improved the trade-off between sensitivity and specificity for BRCA1/2 prediction.

The effect of intermittent versus continuous energy restriction on biomarkers of breast cancer risk

Abstract #506

Excess energy, whether it is the form of high energy diets or low energy expenditure (sedentary lifestyle), is a risk factor for breast cancer. Observational studies show that continuous energy restriction (CER) and exercise reduce risk, particularly of postmenopausal breast cancer. Animal data indicate that intermittent energy restriction (IER) may be superior or at least as effective as continuous energy restriction in preventing or reducing the growth rate of mammary tumours. IER may also be more acceptable than CER which has been difficult to implement.&#x2028; We have tested the effectiveness and acceptability of IER and have performed a randomised trial of IER (n=53) versus CER (n=54) in overweight or obese premenopausal women. Energy restriction was 25% in both arms. IER subjects had approximately 550 kcal on 2 days per week and add lib food on other days; CER subjects had approximately 1500 kcal / day over 7 days. Nineteen women (18 %) withdrew from the study before 6 months (IER = 12, CER = 7, main reasons: stress = 4, pregnancy = 3, change in employment = 3, couldn't stick to diet = 3).&#x2028; Change in weight and biomarkers for last observation carried forward are reported.&#x2028; At 6 months. Both IER and CER are effective for loss of weight -7.9 vs. - 6.7% P = 0.26 and waist circumference -6.3 vs. -5% P = 0.13, and for lowering serum levels of leptin -43.3 vs. -39.8% P = 0.53; C – reactive protein -14.8 vs.-20.3% P = 0.15 and free androgen index -9.8 vs.-14.4% P = 0.90. Both IER and CER increased circulating levels of sex hormone binding globulin + 18.1 vs. 10.8% P = 0.51, and plasma adiponectin +11 vs. +1% P = 0.09. IER is better at lowering insulin resistance at 6 months than CER -29.6 vs. -15.3 % P &lt;0.05.&#x2028; These data indicate that 2 days IER gives similar results to CER with respect to weight loss and many of the risk parameters measured and may be an alternative approach to continuous energy restriction. The superior reductions in insulin resistance with IER which may be related to periods of very low calorie intake (approximately 70% restriction). We are waiting data of the effects of IER vs. CER on the IGF-1 axis and oxidative stress. Future studies will investigate the mechanism of IER, its optimal duration and its influence on mammary cell function.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 506.

Cyclin-dependent kinase inhibitors and basement membrane interact to regulate breast epithelial cell differentiation and acinar morphogenesis

OBJECTIVE

The cyclin-dependent kinase inhibitors (CDKIs), p21(CIP1) and p27(KIP1) regulate growth and differentiation in diverse tissue types. We aimed to determine whether p21(CIP1) or p27(KIP1) could induce a terminally differentiated phenotype in breast cells, and to examine if CDKI expression is regulated by basement membrane interactions.

MATERIALS AND METHODS

Effects of increased CDKI expression on the phenotype of MCF-10A breast epithelial cells were examined by retroviral transduction of p21(CIP1) or p27(KIP1) cDNA.

RESULTS

Overexpression of p21(CIP1) or p27(KIP1) reduced MCF-10A growth rates in monolayer cultures, altered cellular morphology and stimulated accumulation of neutral lipid droplets, suggesting partial lactational differentiation. However, markers of luminal differentiation (oestrogen and progesterone receptors, alpha-lactalbumin, beta-casein and adipophilin) were absent when examined by reverse transcriptase-polymerase chain reaction and immunohistochemistry. Cell-basement membrane contacts are known to be essential for full mammary epithelial cell differentiation and therefore parental MCF-10A cells were cultured on a basement membrane preparation (Matrigel) in which they form acini. Immunocytochemistry showed that Ki67, the cell proliferation marker, was initially expressed at high levels and as growth decreased p27(KIP1) expression steadily increased. Surprisingly, p21(CIP1) was highest at the early stages of acinus growth and was detected in proliferating cells, as demonstrated by colocalization in dual Ki67/p21(CIP1) immunofluorescence. Overexpression of p21(CIP1) or p27(KIP1) impaired formation of acini, whereas their knockdown, using siRNA, increased acinus formation.

CONCLUSION

We conclude that both p21(CIP1) and p27(KIP1) induce partial secretory differentiation of mammary cells in monolayer, but during acinus morphogenesis in 3D culture they have a highly regulated temporal expression pattern.

Growth factor-assisted chemotherapy--the Manchester experience

Stimulation of red cell production by erythropoietin and of granulocyte production by granulocyte colony-stimulating factor (G-CSF) and granulocyte macrophage-CSF (GM-CSF) has been demonstrated in several clinical studies. The first study to show that a human CSF could be used to shorten the period of neutropenia and reduce the risk of serious infection following intensive combination chemotherapy was carried out in Manchester using G-CSF. The period of neutropenia was significantly shortenened (by a median of 80%) and the neutrophil count levels were restored and above normal by 14 days after chemotherapy. In view of these results a further study was undertaken to examine the possibility of using intensive two weekly chemotherapy under cover of G-CSF. Treatment with Doxorubicin at doses of 75, 100, 125 and 150 mg/m2 was followed by infusion of G-CSF for 11 days. The neutrophil counts returned to normal within 12-14 days, allowing the delivery of up to three cycles of high dose chemotherapy at 14 day intervals. These studies demonstrated that intensive chemotherapy with dose-limiting myelodepression can be given with increased frequency under cover of G-CSF. Our studies using GM-CSF have also shown that administration by continuous i.v. infusion can reduce the period of life-threatening neutropenia following high dose Melphalan (120 mg/m2) without resort to autologous bone marrow transplantation (ABMT). In this study the period of granulocytopenia following Melphalan (less than 500 g x 10(9)/m2) was less than 15 days. This compares favourably with other series using high dose Melphalan followed by ABMT without CSF, where the duration of severe neutropenia was prolonged beyond three weeks. Although it appears that G-CSF and GM-CSF should be given either by continuous i.v. infusion or s.c. injection at doses between 3-10 micrograms/kg/day to obtain maximum biological effect, a great deal more work is required to determine optimum schedules and investigate the possibility of using more than one bioregulator.

Cranberry products inhibit adherence of p-fimbriated Escherichia coli to primary cultured bladder and vaginal epithelial cells

PURPOSE

Cranberry proanthocyanidins have been identified as possible inhibitors of Escherichia coli adherence to uroepithelial cells. However, little is known about the dose range of this effect. Furthermore, it has not been studied directly in the urogenital system. To address these issues we tested the effect of a cranberry powder and proanthocyanidin extract on adherence of a P-fimbriated uropathogenic E. coli isolate to 2 new urogenital model systems, namely primary cultured bladder epithelial cells and vaginal epithelial cells.

MATERIALS AND METHODS

E. coli IA2 was pre-incubated with a commercially available cranberry powder (9 mg proanthocyanidin per gm) or with increasing concentrations of proanthocyanidin extract. Adherence of E. coli IA2 to primary cultured bladder epithelial cells or vaginal epithelial cells was measured before and after exposure to these products.

RESULTS

Cranberry powder decreased mean adherence of E. coli IA2 to vaginal epithelial cells from 18.6 to 1.8 bacteria per cell (p <0.001). Mean adherence of E. coli to primary cultured bladder epithelial cells was decreased by exposure to 50 mug/ml proanthocyanidin extract from 6.9 to 1.6 bacteria per cell (p <0.001). Inhibition of adherence of E. coli by proanthocyanidin extract occurred in linear, dose dependent fashion over a proanthocyanidin concentration range of 75 to 5 mug/ml.

CONCLUSIONS

Cranberry products can inhibit E. coli adherence to biologically relevant model systems of primary cultured bladder and vaginal epithelial cells. This effect occurs in a dose dependent relationship. These findings provide further mechanistic evidence and biological plausibility for the role of cranberry products for preventing urinary tract infection.

TPD52 and NFKB1 gene expression levels correlate with G2 chromosomal radiosensitivity in lymphocytes of women with and at risk of hereditary breast cancer

PURPOSE

To evaluate a transcriptomic approach to identify healthy women at increased risk of breast cancer due to G2-radiosensitivity and look at transcripts that are differentially expressed between individuals.

MATERIALS AND METHODS

We perform the first study to assess the association of G2 radiosensitivity with basal gene expression in cultured T-lymphocytes from 11 women with breast cancer and 12 healthy female relatives using Affymetrix GeneChips.

RESULTS

Transcripts associated with radiosensitivity and breast cancer risk were predominantly involved in innate immunity and inflammation, such as interleukins and chemokines. Genes differentially expressed in radiosensitive individuals were more similarly expressed in close family members than in un-related individuals, suggesting heritability of the trait. The expression of tumour protein D52 (TPD52), a gene implicated in cell proliferation, apoptosis, and vesicle trafficking was the most strongly correlated with G2 score while nuclear factor (kappa)-B (NFKB1) was highly inversely correlated with G2 score. NFKB1 is known to be activated by irradiation and its inhibition has been previously shown to increase radiosensitivity.

CONCLUSIONS

Gene expression analysis of lymphocytes may provide a quantitative measure of radiation response potential and is a promising marker of breast cancer susceptibility.

Older women with operable breast cancer are less likely to have surgery

Background

Older women are less likely to receive standard management for breast cancer than younger postmenopausal women. Whether differences in general health explain variations in the rates of surgery is not known.

Methods

In this prospective cohort study, 76 women aged 65 years or more attending breast units in Greater Manchester completed a survey measuring functional status (Elderly Population Health Status Survey's Activity of Daily Living), generic health status (Short Form 12) and health-related quality of life (European Organization for Research on Treatment of Cancer Quality of Life Questionnaire C30). Case-note review assessed co-morbidity (Charlson Index) and management. Primary surgery for operable breast cancer was investigated using logistic regression.

Results

A Charlson Index of 1 or more did not predict the use of surgery (P = 0·363). However, for each point increase on the 1–4 scale indicating worsening functional status, the odds of having surgery decreased by 16 times (odds ratio 0·063). The odds of a woman of 80 years or more having surgery decreased by a factor of 44 (odds ratio 0·023) compared with women aged 65–79 years, accounting for co-morbidity, functional status, pretreatment stage, social deprivation and type of hospital.

Conclusion

Older women were less likely to have surgery for operable breast cancer than younger women, even after accounting for differences in general health and co-morbidity.

Optimal use of aromatase inhibitors for adjuvant treatment of hormone-sensitive early breast cancer: Up front or sequenced after tamoxifen?

541

Background: The aromatase inhibitors (AIs) are more effective than tamoxifen when used for the adjuvant treatment of early breast cancer. However, it is still unclear whether it is better to start initially with an AI or use it after a 2–3-year period of tamoxifen treatment. No clinical trial data are likely to be available until 2008, although earlier modeling data have shown that an upfront strategy may be more favorable (Cuzick et al. Br J Cancer 2006: 27; 460–464). Here we update the model with all newly reported data. Methods: A model has been constructed to compare the use of an AI upfront with AI sequencing after varying periods of initial treatment with tamoxifen. Recurrence rates and time lost to recurrence for the first 10 years of follow-up are modeled for a range of efficacy parameters. Results: Results predicted from the model are presented in the table . For a 5-year carryover period, the predicted recurrence rate at 10 years is 17.7% for upfront use of an AI compared with 22.9% for 5 years of tamoxifen, leading to one less recurrence for every 19 women treated. The average time lost to recurrence is reduced by 2.8% or 3.4 months. With updated data, the model predicts an AI upfront strategy will dominate a sequencing strategy. However, the model also demonstrates that using 10 years of tamoxifen, or a sequence of 5 years of tamoxifen followed by 5 years of an AI, is superior to using 5 years of tamoxifen. This indicates that longer duration of treatment with an AI is likely to be beneficial, especially for younger women, and deserves further investigation. Conclusion: The current modeling data suggest that using an AI as upfront adjuvant treatment is better than using an AI in sequence after 2 or more years of tamoxifen.

[Table: see text]

No significant financial relationships to disclose.

Non-standard management of breast cancer increases with age in the UK: a population based cohort of women > or =65 years

Evidence suggests that compared to younger women, older women are less likely to receive standard management for breast cancer. Whether this disparity persists once differences in tumour characteristics have been adjusted for has not been investigated in the UK. A retrospective cohort study involving case note review was undertaken, based on the North Western Cancer Registry database of women aged > or =65 years, resident in Greater Manchester with invasive breast cancer registered over a 1-year period (n=480). Adjusting for tumour characteristics associated with age by logistic regression analyses, older women were less likely to receive standard management than younger women for all indicators investigated. Compared to women aged 65-69 years, women aged > or =80 years with operable (stage 1-3a) breast cancer have increased odds of not receiving triple assessment (OR=5.5, 95% confidence interval (CI): 2.1-14.5), not receiving primary surgery (OR=43.0, 95% CI: 9.7-191.3), not undergoing axillary node surgery (OR=27.6, 95% CI: 5.6-135.9) and not undergoing tests for steroid receptors (OR=3.0, 95% CI: 1.7-5.5). Women aged 75-79 years have increased odds of not receiving radiotherapy following breast-conserving surgery compared to women aged 65-69 years (OR=11.0, 95% CI: 2.0-61.6). These results demonstrate that older women in the UK are less likely to receive standard management for breast cancer, compared to younger women and this disparity cannot be explained by differences in tumour characteristics.