Abstract P2-10-23: Lymphovascular Invasion (LVI) and Overall Survival in Node-negative and Node-positive Breast Cancer Patients: A Meta-analysis

Introduction: LVI is an important prognostic factor in patients with lymph node-negative invasive breast cancer. The prognostic value of LVI in lymph node-positive disease or in other subgroups remains unclear. Here we present a meta-analysis of studies assessing the impact of LVI on overall survival (OS) in different subgroups of breast cancer patients.

Methods: A published data meta-analysis was conducted. Studies reporting hazard ratios (HR) for the association of LVI with OS in a multivariable model were included. Those not reporting HR or utilizing only univariable analyses were excluded. HR and 95% confidence intervals (CI) were extracted or computed and pooled using the DerSimonian and Laird random effects model. Subgroup analyses were conducted for the differential effect of lymph node involvement, estrogen receptor (ER) status, extent of LVI and decade in which the study was conducted (pre 1990, 1990–1999 and 2000 onwards).

Results: Twenty studies comprising 40,417 patients were included in the analysis. There was marked heterogeneity in the effect size between studies (Cochran Q p < 0.001, I2=62%). When all studies were pooled, LVI was significantly associated with worse OS (HR:1.70 95% CI 1.49–1.95, p < 0.001). Among studies selecting patients by lymph node status, the association between LVI and OS was similar for lymph node positive and negative patients (HR:2.03 and 2.41 respectively, subgroup difference p = 0.56). There were no significant differences based on ER-status (subgroup difference p = 0.75) or decade of study (subgroup difference p = 0.21). Pooled assessment of the effect of extent of LVI was not possible as this parameter was not consistently reported.

Conclusion: LVI is associated with similarly detrimental OS regardless of lymph-node or ER status. Improvements in adjuvant therapies over the past 20 years do not appear to have diluted the impact of LVI on OS. The marked heterogeneity in the effect size may result from differences in the extent of LVI.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-23.

Abstract P2-05-12: Effects of de-escalated bisphosphonate therapy on bone turnover or metastasis markers and their correlation with risk of skeletal related events – A biomarker analysis in conjunction with the REFORM study

Background: Despite variability in an individual's risk of skeletal related events (SREs) from bone metastases (BM), all patients are treated using a similar dose and schedule (q3-4 wk) of IV bisphosphonate (BP). The REFORM trial (Amir et al., Am J Clin Oncol, in press) was a pilot randomised study evaluating the efficacy of de-escalated (q12 wk) versus standard (q3-4 wk) pamidronate in maintaining C-telopeptide (CTx) levels in the low risk range (<600ng/L) in patients with BM from breast cancer. Here we report a biomarker substudy, where additional biomarkers of bone turnover and BM behaviour were measured and correlated with SRE risk.

Methods: Eligible patients with BM, who had received ≥ 3 months of q3-4 wk IV BP and no systemic treatment change within 4 wks of study entry were enrolled. Serum & urine obtained at baseline and at 12 wks were assessed for urinary N-telopeptide (uNTx), serum procollagen type I amino-terminal propeptide (P1NP), transforming growth factor (TGF)-β, activinA and bone sialoprotein (BSP) by ELISA. Levels were correlated with number of SREs using linear regression analysis. Changes in biomarkers from baseline to 12 wks were used to calculate odds ratios for coming off study (due to either elevated CTx or SRE) or having an SRE alone using logistic regression analysis.

Results: REFORM randomized 19 patients to each treatment arm, and found that the SRE rate at 1 year in both arms was the same (n = 2). Although the mean level of the standard bone turnover marker CTx decreased slightly from baseline to wk 12 in the q3-4 wk group (240±50ng/L to 206±46ng/L), and slightly increased in the q12 wk treated group (263±65ng/L to 313±71ng/L), these changes were not statistically significant (p = 0.8). Mean activinA levels were slightly increased in both treatment arms from baseline to wk 12 (730±93pg/ml to 875±148pg/ml in q3-4 wk group vs 445±35pg/ml to 582±61pg/ml in q12 wk group) but did not quite reach statistical significance (p = 0.1). Levels of TGF-β from baseline to 12 wks in both groups was similar (22±1.6ng/ml to 22±2.3ng/ml for q3-4 wk vs 23±2.2ng/ml to 24±2.4ng/ml for q12 wk group, p = 0.8). Although the number of SREs was small, mean CTx levels at wk 12 were statistically different between patients who experienced SREs vs those that did not (615±72ng/L, n=4 vs 190±26ng/L, n=19, p < 0.0001). Although it did not reach statistical significance, mean activinA levels at wk 12 were also higher in patients who had SREs than those that did not (1069±358pg/ml, n=3 vs 681±83pg/ml, n=18, p = 0.12). Results of NTx, BSP and P1NP and correlations with more mature clinical data will also be presented.

Conclusions: In patients with BM from breast cancer with low levels of bone resorption markers, CTx predicted and activinA trended to predict SRE risk. However the non-significant trends in increasing CTx in de-escalated BP treatment, together with the observation that activinA levels are similar regardless of dosing regimen, suggest that analysis of conventional and experimental biomarkers of SRE risk requires further examination in other larger patient cohorts comparing de-escalated therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-05-12.

Abstract P3-13-05: Evaluating efficacy of de-escalated bisphosphonate therapy in metastatic breast cancer patients at low-risk of skeletal related events. TRIUMPH: A pragmatic multicentre trial

Background: Optimal bisphosphonate (BP) dosing intervals for breast cancer patients (pts) with bone metastases (BM) remain unknown. BP are usually prescribed q3-4 wk regardless of individual pt risk for skeletal related events (SREs). Recent evidence (Amadori J Clin Oncol, 2012 suppl; abstr 9005) shows that q12 wk BP is as effective as q4 wk in pts previously treated with >9 cycles of q4 wk therapy. Hence, further evaluation of modified BP dosing strategies is warranted. The objective of the current study was to show in women with biochemically defined low-risk bone disease that IV BP use every q12 wk for 1 year is sufficient to maintain stability of the bone turnover [measured by serum c-telopeptide (CTx) or bone specific alkaline phosphatase (BSAP)].

Methods: Eligible pts with BM, who had received >3 months of q3-4 wk IV BP and no systemic treatment change within 4 wks of study entry were enrolled. Low risk was defined as serum CTx <600 ng/L. Biochemical failure was defined as CTx levels >600 ng/L at baseline, weeks 6, 12, 24, 36 or 48. Evaluation of palliative benefit of 12-wk IV BP therapy was measured by SREs, analgesic use, and self-reported pain (BPI and FACT-BP).

Results: Between Oct. 2010-Sept. 2011, 85 pts consented to screening, with 13 found ineligible. In the 71 accrued pts baseline characteristics were: mean age 60 (SD 13), median time from breast cancer diagnosis to development of bone metastases 4 months (IQR 82), median duration of prior BP therapy 14 months (IQR 19), and mean number of SREs/yr prior to entering study 0.35 (SD 0.76). Baseline median CTx was 120 ng/L (IQR 240) and BSAP 9.2 IU/L (IQR 3). To date: 26/71 pts (36%) remain on study. Reasons for coming off study include; study completion (18), elevation of CTx >600ng/L (10), or on study SRE (3). An elevation of CTx between baseline and wk 6 was significantly associated with coming off study early (p = 0.008). For pts who had had an SRE before study entry the odds ratios for coming off study early due to an on study SRE or elevated CTx was 1.005 (CI 1.002–1.009; p = 0.007) and for coming off early for an SRE was 0.0245 (CI 0.061–0.094; p = 0.046) respectively. Of the 8/13 pts who were ineligible due to baseline CTx >600ng/L, 6 had an SRE within 1 year of screening.

Conclusion: De-escalating BP therapy to 12 weekly in low risk pts has advantages for both the pt and the health care system. Individual risk of SREs is highly variable, however baseline serum CTx levels <600 ng/L is associated with a low risk of subsequent SREs. While larger trials are required to assess whether increasing CTx with de-escalated therapy will lead to higher rates of SREs or not (Coleman et al. J Clin Oncol 2012 suppl; abstr 511). However, the results of this study and Amadori et al. would suggest that de-escalated BP treatment will likely become a new standard of care after a limited period of q 4wk treatment.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-13-05.

Comparison of absolute benefits of anticancer therapies determined by snapshot and area methods

BACKGROUND

Reporting of relative risk reduction as the measure of treatment effect in randomized clinical trials (RCTs) may be difficult to understand. Here, we compare two methods for assessing absolute benefits of anticancer therapies.

MATERIALS AND METHODS

We searched PubMed for RCTs comparing therapies for breast and colorectal cancers published 1975-2009 (adjuvant setting) and 2000-2010 (metastatic setting). Eligible trials reported statistically significant differences. Kaplan-Meier curves were assessed for absolute differences in time-to-event end points at a single point (snapshot method) and as the area between curves (area method). Pooled absolute benefits determined by both methods were compared by the Pitman-Morgan test.

RESULTS

Eighty-three and 39 paired curves were assessed in the adjuvant and metastatic settings, respectively. In trials of adjuvant therapy, absolute benefits were larger and more variable when assessed at different time points by the snapshot compared with the area method (median and ranges for 60-month difference in overall survival: 7.6% [2.5%-28.4%] and 4.5% [1.8%-13.6%]; P = 0.002, respectively). For metastatic disease, both methods were within 0.5 month of each other in 62% of trials.

CONCLUSIONS

The area method provides an alternative measure of absolute treatment effect, which uses all of the available data and is less dependent on the shape of survival curves.

Treatment Recommendations for the Use of Bone-Targeted Agents in 2011—Report from the 6th Annual Bone and the Oncologist New Updates Meeting

The 6th annual Bone and the Oncologist New Updates conference was held in Ottawa, Ontario, April 14–15, 2011. This meeting traditionally focuses on innovative research into the mechanisms and consequences of treatment-induced and metastatic bone disease. This year, the multidisciplinary audience was polled to produce “treatment recommendations for the use of bone-targeted agents.” In addition, the meeting report itself outlines some of the key topics presented on adjuvant bisphosphonate use and the role of bone-targeted agents in the settings of meta-static and cancer-therapy-induced bone loss.

Mandibular block or maxillary infiltration: does it influence children's opposition to a subsequent dental visit?

PURPOSE

Local anesthesia by mandibular block or maxillary infiltration is commonly administered to children receiving dental treatment of primary molars. Discomfort, when presenting, most often involves the lower lip. The purpose of this study was to investigate whether children would be more opposed to attending a dental treatment following anesthesia by mandibular block than by maxillary infiltration.

METHODS

Each of 102 children in two age groups: 3 to 5 years, and 6 to 9 years, received the two types of local anesthesia at dental appointments one week apart. Their opposition to attending a subsequent appointment was assessed by parent report.

RESULTS

More adverse reactions were observed during and following anesthesia with mandibular block than with maxillary infiltration. Few of the children in either age group expressed opposition to attend a dental visit after receiving mandibular block or maxillary infiltration in the previous visit.

CONCLUSIONS

Though more adverse reactions were observed in children following mandibular block than maxillary infiltration, this did not result in increased opposition to attend a subsequent dental appointment.

How valid are claims for synergy in published clinical studies?

BACKGROUND

Clinical trials evaluating drug combinations are often stimulated by claims of synergistic interactions in preclinical models. Overuse or misuse of the term synergy could lead to poorly designed clinical studies.

METHODS

We searched PubMed using the terms 'synergy' or 'synergistic' and 'cancer' to select articles published between 2006 and 2010. Eligible studies were those that referred to synergy in preclinical studies to justify a drug combination evaluated in a clinical trial.

RESULTS

Eighty-six clinical articles met eligibility criteria and 132 preclinical articles were cited in them. Most of the clinical studies were phase I (43%) or phase II trials (56%). Appropriate methods to evaluate synergy in preclinical studies included isobologram analysis in 18 studies (13.6%) and median effect in 10 studies (7.6%). Only 26 studies using animal models (39%) attempted to evaluate therapeutic index. There was no association between the result of the clinical trial and the use of an appropriate method to evaluate synergy (P=0.25, chi-squared test).

CONCLUSIONS

Synergy is cited frequently in phase I and phase II studies to justify the evaluation of a specific drug combination. Inappropriate methods for evaluation of synergy and poor assessment of therapeutic index have been used in most preclinical articles.

P4-10-02: A Meta-Analysis of the Association of Blood Levels of Vitamin-D and the Risk of Breast Cancer

Background: A considerable body of literature has examined the association of vitamin-D with breast cancer risk and the potential role in its prevention. Geographic studies show higher incidence of breast cancer in patients residing at high latitudes. Other data linking vitamin-D deficiency to breast cancer risk are inconsistent.

Materials and Methods: A literature based meta-analysis was conducted. Odds ratios (OR) for breast cancer based on blood levels of 25-hydroxy or 1,25-hydroxy vitamin-D were computed and pooled. Analysis was conducted separately for studies where blood levels were taken before (group A) or after (group B) breast cancer diagnosis.

Results: Thirteen studies were identified. Nine studies were included in group A and 4 studies included in group B. For group A, there was no significant association between lower vitamin-D levels and breast cancer risk (pooled OR = 1.09, 95% confidence intervals 0.99−1.20, p=0.08). For group B, there was a highly significant association between lower vitamin-D levels and breast cancer (pooled OR = 2.81, 95% confidence intervals 1.70−4.65, p<0.001). The test for interaction between groups was highly significant (p<0.001). When all studies were pooled, the OR was 1.38 (95% confidence intervals 1.13−1.70, p=0.002).

Conclusion: When measured before breast cancer diagnosis, blood levels of vitamin-D are not associated with breast cancer risk. Breast tumors have been shown to differentially express vitamin-D hydroxylase. Therefore, any association of vitamin-D and breast cancer in studies measuring blood levels after breast cancer diagnosis may be confounded by reverse causation bias.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-10-02.

P2-12-07: Pooled Analysis of Outcomes of T1a/bN0, HER2−Amplified Breast Cancer

Background: Breast tumors with HER2 amplification have a worse prognosis than those with normal HER2 expression. This finding is independent of tumor size and other classical prognostic factors used in the adjuvant setting. The prognosis of node negative, sub-centimeter (T1a/bN0) tumors is usually excellent. However, little is known about the prognostic impact of HER2−amplification in this group. This study therefore, aimed to evaluate the relative and absolute prognostic impact of HER2−amplification in T1a/bN0 tumors.

Materials and Methods: Published data from studies assessing the outcomes of patients with HER2−amplified, node negative, T1a/bN0 tumors were included in a pooled analysis. Odds ratios (OR), 95% confidence intervals (CI) and absolute risks were computed for recurrence and distant recurrence at 5 years. Pooled hazard ratios (HR) for disease-free survival (DFS), were also assessed.

Results: A total of 3 case-control studies were included in the analysis and comprised 485 patients with HER2−amplified breast cancer (57.3% were also hormone receptor positive) and 1096 patients with HER2−normal disease (82.2% were hormone receptor positive). Among the HER2−amplified group, 4.1% received trastuzumab and 18.6% received chemotherapy. In the HER2−normal group, 4.3% received chemotherapy Estimated median follow-up was 5.7 years. HER2−amplification was associated worse DFS (HR = 2.60, 95% CI 1.53−4.41, p<.001) and increased odds for recurrence at 5 years (OR = 3.79, 95% CI 2.35−6.10, p<.001). There was a non-significant trend towards increased odds of distant recurrence at 5 years (OR = 2.51, 95% CI 0.82−7.67, p=.11). Compared with HER2−normal cancers, those with HER2−amplification showed lower absolute probability of recurrence-free survival at 5 years (90.1% vs. 94.6%, p<.001) and distant recurrence-free survival at 5 years (95.1% vs. 97.6%, p<.001). Among HER2−amplified cancers, tumor size 0.6−1.0cm (T1b) was associated with a trend for higher odds of recurrence at 5 years compared with those 0.5cm or smaller (T1a, pooled OR = 1.58, 95% CI 0.96−2.60, p=.07).

Conclusions: HER2−amplification is associated with worse outcome in T1a/bN0 tumors. However, recurrence-free and distant recurrence-free survival at 5 years is excellent in this group, particularly in those with T1a tumors. These data question the role of adjuvant chemotherapy and trastuzumab in these patients unless associated with other high risk features. A differentially lower risk for distant recurrence suggests the possible role for more aggressive local therapy such as surgery and/or radiation therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-07.

P4-16-08: Pilot Randomized Trial of De-Escalated (q12 Weekly) Versus Standard (q3-4 Weekly) Intravenous Bisphosphonates in Women with Low-Risk Bone Metastases from Breast Cancer

Background: Bone-targeted agent such as bisphosphonates (BPs) can reduce skeletal complications from bone metastases but have no effect on either disease progression or survival. Despite substantial variability in the frequency and severity of skeletal complications, patients are empirically treated with BPs at the same dose and schedule irrespective of their individual risk.

Materials and Methods: A pilot, randomized, non-inferiority trial was conducted. Patients with low-risk bone metastases (serum C-telopeptide [CTx] <600ng/L after at least 3 cycles of monthly IV BP) were assigned to pamidronate 90mg IV either every 3–4 weeks (control) or every 12 weeks (de-escalated). Data on serum CTx and bone alkaline phosphatase (BAP), pain scores (brief pain inventory [BPI] and functional assessment of cancer therapy-bone pain [FACT-BP]) were collected at 12 weekly intervals for 48 weeks.

Results: Fifty-four patients were approached, 44 provided consent and 38 were eligible for randomization. Median age was 55 (range 29–77) and mean baseline CTx was 319ng/L (range 10–526). Thirty-five participants (92%) completed the trial, 2 withdrew consent and one participant died. Fourteen control group participants (73.7%) and 13 experimental group participants (68.4%) maintained CTx in the low risk range (test for two proportions p=0.64). All patients not maintaining CTx in the low risk range showed evidence of both visceral and bone progression. Compared to the control group, there was a trend towards increasing CTx with time in the experimental group (p=0.10). There was no significant difference in BAP (p=0.37), BPI (p=0.21) or FACT-BP scores (p=0.59) between the two groups. Over the 48 week follow-up, two skeletal events were observed in each group.

Conclusions: Randomized trials of de-escalated BP therapy in women with low-risk bone metastases are feasible. Twelve-weekly pamidronate appears non-inferior to 3–4 weekly treatment. Larger trials are required to assess whether; 1) increasing CTx levels with de-escalated therapy will lead to higher rates of skeletal complications and 2) whether BP should be given every 3–4 weeks in patients with progressive visceral and bone disease.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-16-08.

OT1-01-02: A Multicentre Study Assessing 12-Weekly Intravenous Bisphosphonate Therapy in Women with Low Risk Bone Metastases from Breast Cancer – The TRIUMPH Trial

Background: Metastatic bone disease is a major cause of morbidity and mortality for breast cancer patients. Bisphosphonates (BP) have been shown to significantly delay the onset and frequency of skeletal related events (SREs), improve pain control and overall quality of life. Most patients receive intravenous BP every 3–4 weeks regardless of their individual risk for a SRE. This “one size fits all” strategy could expose those patients at a relatively low risk of SREs to an increased chance of adverse drug effects, as well as to the financial and quality of life burden of multiple visits to the cancer centre for treatments. This study aimed to assess whether IV BP can be safely given at reduced frequency.

Methods: The primary objective of this study is to demonstrate in women with biochemically defined low-risk bone metastases that the administration of IV BP every 12 weeks is sufficient to maintain biochemical stability for one year. Eligibility criteria include; bone metastases from breast cancer, have received at least three months of regular 3–4 weekly IV BP, satisfactory renal function, adequate dental health, no systemic treatment change or recent SRE within 4 weeks of study entry. Low risk disease will be defined as serum CTx levels <600 ng/L Biochemical failure is defined as CTx levels >600 ng/L measured at predefined time points (6, 12, 24, 36 and 48th). Secondary objectives are to evaluate the palliative benefit of 12-weekly IV BP therapy as reflected by occurrence of SREs, analgesic use, self-reported pain using the validated BP and FACT-BP questionnaires. Sample size was calculated at 68 patients. Given the small sample size, nonparametric Bootstrapping will be employed to calculate point estimates, standard deviations and 95% confidence intervals (CIs). An exploratory multivariable analysis will also be undertaken to determine baseline factors that were associated with patient's maintaining their telopeptide levels in the low risk range. Conclusion: TRIUMPH opened in October 2010 and as of June 2011, has quickly accrued 54/68 patients (79%). This trial has the potential to allow lower risk women to receive less frequent dosing of bisphosphonates, thus improving their quality of life with less cancer center visits and reducing their chance of drug induced adverse events.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-01-02.

P4-11-08: Changes in the Distribution of Loco-Regional and Distant Breast Cancer Recurrences over the Last 20 Years: Implications for Patient Care and Future Research

Introduction: Improvements in adjuvant therapy have led to a sustained fall in recurrences after early breast cancer. The differential reduction of both local-regional and systemic recurrences is poorly understood. This study aimed to explore changes in the distribution of loco-regional and distant recurrences in clinical trials reported over the last 20 years. We also aimed to determine the relative impact of adjuvant chemotherapy and endocrine therapy.

Methods: A MEDLINE search for adjuvant, Phase III randomized breast cancer clinical studies between January 1990 and March 2011 was performed. Neo-adjuvant, single agent biologics and studies that did not report the proportion of loco-regional and distant recurrences were excluded. Change in the frequency of recurrences was assessed as the non-parametric correlation between the number of loco-regional recurrences (as a proportion of all recurrences) and time. Studies were weighted by sample size. Pre-specified subgroup analyses were assessed using the interaction test and included type of surgery performed, radiotherapy use, menopausal status and type of systemic therapy delivered. Definition of local and distant recurrences differed between studies. For consistency, loco-regional recurrences were classified as recurrences limited to the ipsilateral breast, chest wall, axillary, supraclavicular and internal mammary lymph nodes. Any other recurrence was defined as distant, with the exception of contralateral breast cancer; that was excluded from this analysis.

Results: Fifty-three randomized clinical trials with a total of 86,598 patients were included in the analysis. Between 1990 and 2011, the proportion of loco-regional recurrences has decreased from approximately 50% to 10% (Spearman's rho = −0.40, p<.001). There was no interaction between type of surgery (mastectomy vs. lumpectomy, p=0.40), adjuvant radiotherapy use (p=0.63) and menopausal status (p=0.95) and the correlation of loco-regional recurrences and time. Chemotherapy use showed a larger negative correlation compared with endocrine therapy (rho = 0.49 vs rho = 0.24, p=0.008).

Conclusion: Advances in treatment of early breast cancer have differentially reduced the proportion of loco-regional recurrences compared with distant recurrences. In recent trials, loco-regional recurrences account for less than 10–15% of all recurrences. These falling event rates may affect patient care, especially when deciding on treatments influencing loco-regional control. This change may also impact on the design of clinical trials assessing loco-regional therapy such as surgery and/or local radiation therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-08.

Immune therapy for breast cancer in 2010-hype or hope?

The identification of numerous breast cancer antigens has generated increasing enthusiasm for the application of immune-based therapies in breast malignancies. Although the use of monoclonal antibodies has revolutionized the "targeted therapy" of breast cancer, and the immunomodulatory effects of bisphosphonates continue to be evaluated, few studies to date have demonstrated widespread utility for other forms of immunotherapy. The present review assesses modern research and explores whether the hopes for immunotherapy can overcome the hype.

Incidence of taxane-induced pain and distress in patients receiving chemotherapy for early-stage breast cancer: a retrospective, outcomes-based survey

INTRODUCTION

With the widespread use of sequential anthracycline/taxane-based chemotherapy for early-stage breast cancer, clinicians are becoming rapidly aware of toxicities associated with those regimens. Despite the low incidence reported in the literature of significant arthralgia and myalgia with those regimens, it is clinically evident that a substantial proportion of patients develop such toxicities. We performed a pilot study to investigate the extent of this problem.

PATIENTS AND METHODS

Patients who had received prior adjuvant or neoadjuvant chemotherapy [doxorubicin-cyclophosphamide followed by paclitaxel (AC-T), doxorubicin-cyclophosphamide followed by docetaxel (AC-D), or 5-fluourouracil-epirubicin-cyclophosphamide followed by docetaxel (FEC-D)] completed a retrospective outcomes-based survey. The survey utilized the Functional Assessment of Cancer Therapy-Taxane Scale, the Memorial Symptom Assessment Scale, and a modified Brief Pain Inventory.

RESULTS

Interviews were conducted with 82 patients. Interviewees had received AC-T (43%), FEC-D (43%), and AC-D (14%). Pain as a side effect of either the anthracycline or the taxane chemotherapy was reported by 87% of patients. Most of the patients (79%) indicated that their worst pain occurred during the taxane component of treatment. Compared with paclitaxel, docetaxel was reported to cause more pain. Narcotics for pain management were required by 35 of 82 patients (43%).

CONCLUSIONS

A significant number of patients receiving sequential anthracycline/taxane-based chemotherapy for early-stage breast cancer experience pain, particularly during the taxane component. Prospective patient-reported outcome assessments are needed to help individualize treatment interventions and to improve symptom management in this population.

Cost effectiveness of outpatient treatment for febrile neutropaenia in adult cancer patients

BACKGROUND

There is uncertainty whether low-risk episodes of febrile neutropaenia (FN) in adult cancer patients are best managed in the in- or outpatient setting.

METHODS

A Monte Carlo cost-utility model was created to compare four treatment strategies for low-risk FN: (1) treatment in hospital with intravenous antibiotics (HospIV); (2) early discharge after 48 h in-patient observation, followed by oral outpatient treatment (EarlyDC); (3) outpatient management with IV antibiotics (HomeIV); and (4) outpatient management with oral antibiotics (HomePO). The model used a health-care payer perspective and a time horizon of one FN episode. Outcome measures were quality-adjusted FN episodes (QAFNE), costs (Canadian dollars) and incremental cost-effectiveness ratios (ICER). Parameter uncertainty was assessed with probabilistic sensitivity analyses.

RESULTS

HomePO was cost saving ($3470 vs $4183), but less effective (0.65 QAFNE vs 0.72 QAFNE) than HomeIV. The corresponding ICER was $10,186 per QAFNE. Both EarlyDC ($6115; 0.66 QAFNE) and HospIV ($13,557; 0.62 QAFNE) were dominated strategies. At a willingness-to-pay (WTP) threshold of $4,000 per QAFNE, HomePO and HomeIV were cost effective in 54 and 38% of simulations, respectively.

INTERPRETATION

For adult cancer patients with an episode of low-risk FN, treatment in hospital is more expensive and less effective than outpatient strategies.

Abstract P6-07-01: CCN3 Impairs Osteoblasts and Stimulates Osteoclast Differentiation To Favor Breast Cancer Metastasis to Bone

Background: The mechanisms underlying the osteotropism of breast cancer are not fully understood. Breast cancer cell lines that aggressively metastasize to bone appear to have increased expression of CCN3 (Nov) compared to those that weakly metastasize to bone. This study aimed to functionally implicate CCN3 in the process of breast cancer metastasis to bone.

Methods: Primary cultures of mouse bone marrow cells were used to assess the effect of recombinant CCN3 protein on RANKL, OPG and on osteoblasts and osteoclasts. To extend data obtained from cell and animal-based models, we have examined CCN3 expression a panel of human breast cancer bone metastases.

Results: CCN3 protein impaired osteoblast differentiation in a dose dependant manner, resulting in an increase in the RANKL/OPG ratio that indirectly favors osteoclast formation. CCN3 also directly induced osteoclast differentiation of RANKL-primer RAW 264.7 monocytes. CCN3 enhanced osteoclast differentiation through its ability to induce calcium mobilization and the subsequent nuclear translocation of NFATc1, a transcription factor essential for osteoclast differentiation. Immunohistochemical staining indicated that CCN3 is readily detectable, both in the breast tumor/stroma and in the majority of breast cancer bone metastasis samples.

Conclusion: Our data support a clinically relevant and important role for CCN3 in modulating the differentiation capacity of bone resident cells to support osteoclast formation and the formation of osteolytic bone metastases.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-07-01.