Symptoms of endocrine treatment and outcome in the BIG 1-98 study

There may be a relationship between the incidence of vasomotor and arthralgia/myalgia symptoms and treatment outcomes for postmenopausal breast cancer patients with endocrine-responsive disease who received adjuvant letrozole or tamoxifen. Data on patients randomized into the monotherapy arms of the BIG 1-98 clinical trial who did not have either vasomotor or arthralgia/myalgia/carpal tunnel (AMC) symptoms reported at baseline, started protocol treatment and were alive and disease-free at the 3-month landmark (n = 4,798) and at the 12-month landmark (n = 4,682) were used for this report. Cohorts of patients with vasomotor symptoms, AMC symptoms, neither, or both were defined at both 3 and 12 months from randomization. Landmark analyses were performed for disease-free survival (DFS) and for breast cancer free interval (BCFI), using regression analysis to estimate hazard ratios (HR) and 95 % confidence intervals (CI). Median follow-up was 7.0 years. Reporting of AMC symptoms was associated with better outcome for both the 3- and 12-month landmark analyses [e.g., 12-month landmark, HR (95 % CI) for DFS = 0.65 (0.49-0.87), and for BCFI = 0.70 (0.49-0.99)]. By contrast, reporting of vasomotor symptoms was less clearly associated with DFS [12-month DFS HR (95 % CI) = 0.82 (0.70-0.96)] and BCFI (12-month DFS HR (95 % CI) = 0.97 (0.80-1.18). Interaction tests indicated no effect of treatment group on associations between symptoms and outcomes. While reporting of AMC symptoms was clearly associated with better DFS and BCFI, the association between vasomotor symptoms and outcome was less clear, especially with respect to breast cancer-related events.

Abstract P4-12-15: Long term outcome with trastuzumab in HER2-positive metastatic breast cancer: A retrospective analysis at The Royal Marsden Hospital, with a median 6 years follow up

Background

Trastuzumab is currently the standard of care in combination with chemotherapy for patients with early and advanced HER2 positive breast cancer. Some patients with advanced disease have long remissions, but published data on the efficacy and safety of long-term trastuzumab are limited.

Patients and Methods

We have retrospectively assessed efficacy and safety of trastuzumab on all patients with HER2 positive advanced breast cancer, who received first-line trastuzumab-containing therapy between 2001 and 2009 at a single institution, The Royal Marsden Hospital. Patients who received adjuvant trastuzumab were excluded.

The primary endpoints of the study were time to disease progression and response duration. Secondary endpoints included overall response rate, overall survival and cardiac toxicity related to maintenance trastuzumab beyond 12 months. An exploratory analysis of factors predicting long disease remission on trastuzumab beyond 12 months was also performed.

Results

192 patients with HER2 positive locally advanced/metastatic breast cancer treated with trastuzumab containing therapy as first line treatment were identified. The median age at start of treatment was 52 years. The main site of metastatic disease was visceral in 136 (71%) of patients, and 16 patients (8.5%) with central nervous system (CNS) involvement. 152 (79%) patients received trastuzumab in combination with chemotherapy. 18 patients (9%) received trastuzumab with endocrine therapy only. 22 (11%) patients received trastuzumab alone. The median time to progression was 45. weeks (95% CI: 38 – 52 weeks). The overall response rate (ORR) was 63%, including 14 patients (7%) with CR and 107 patients (56%) with PR. Overall disease control (CR+ PR+ SD for at least 6 months) was achieved in 169 (88%) patients. Patients who received trastuzumab with chemotherapy had superior response rate (71%) to trastuzumab alone or in combination with endocrine therapy (37% and 58% respectively).

125 patients (65%) were on trastuzumab for more than 1 year, 88 (46%) for more than 2 years, 63 (33%) for more than 3 years and 25 (13%) for 5 years or more. The median overall survival was 125 weeks, and 28% still alive at 5 years. At the time of the analysis with a median follow-up 6yrs, 46 patients (24%) were still alive. 23 of these (50%) had stopped trastuzumab after discussion. 38 patients (20%) had CNS relapse on trastuzumab, of which 19 (10%) relapsed in the brain alone.

Maintenance trastuzumab therapy was well tolerated. 29 (15%) patients had any grade LV dysfunction during trastuzumab treatment, of which 11 (6%) stopped trastuzumab. No deaths or other serious side effects related to trastuzumab were observed.

Conclusion

Trastuzumab frequently achieves long term control of metastatic breast cancer with more than 25% of patients alive after 5 years. The optimal duration of therapy remains uncertain.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-15.

Provision of home mechanical ventilation and sleep services for England survey

The Department of Health is promoting the generation of specialist networks to manage long term ventilatory weaning and domiciliary non-invasive ventilation patients. Currently the availability of these services in England is not known. We performed a short survey to establish the prevalence of sleep and ventilation diagnostic and treatment services. The survey focussed on diagnostic services and Home Mechanical Ventilation (HMV) provision, and was divided into (a) availability of diagnostics, (b) funding, and (c) patient groups. This survey has confirmed that the majority of Home Mechanical Ventilation set-ups are currently for Obesity Related Respiratory Failure and Chronic Obstructive Pulmonary Disease. We have found that there is variable provision of diagnostic services, with the majority of units offering overnight oximetry (95%) but only 55% of responders providing a home mechanical ventilation service. Even more interestingly, less than two thirds of units charged their primary care trust for this service. These data may assist in the development of regional networks and specialist home mechanical ventilation centres.

Corrupted cultures in mental health inpatient settings. Is restraint reduction the answer?

The early years of the 21st century have seen successful efforts in a number of countries to reduce the use of restraint in services for people with mental health problems. An underlying emphasis on 'cultural change' is characteristic of such initiatives reflecting, it appears, the re-emergence of interest in the therapeutic milieu. Such efforts have though lacked a comprehensive explanation of how organizational culture plays a role in the development of the excessive use of restraint, which seems to respond to such initiatives. This paper seeks to address that deficit and draws in particular on the concepts of corrupted culture, institutional violence, trauma, parallel processing and contemporary research on restraint and seclusion reduction. In doing so it examines whether restraint reduction initiatives represent part of the solution to the problem of corruption, which is intrinsically associated with the legitimatization of coercion.

Working memory training is associated with lower prefrontal cortex activation in a divergent thinking task

Working memory (WM) training has been shown to lead to improvements in WM capacity and fluid intelligence. Given that divergent thinking loads on WM and fluid intelligence, we tested the hypothesis that WM training would improve performance and moderate neural function in the Alternate Uses Task (AUT)-a classic test of divergent thinking. We tested this hypothesis by administering the AUT in the functional magnetic resonance imaging scanner following a short regimen of WM training (experimental condition), or engagement in a choice reaction time task not expected to engage WM (active control condition). Participants in the experimental group exhibited significant improvement in performance in the WM task as a function of training, as well as a significant gain in fluid intelligence. Although the two groups did not differ in their performance on the AUT, activation was significantly lower in the experimental group in ventrolateral prefrontal and dorsolateral prefrontal cortices-two brain regions known to play dissociable and critical roles in divergent thinking. Furthermore, gain in fluid intelligence mediated the effect of training on brain activation in ventrolateral prefrontal cortex. These results indicate that a short regimen of WM training is associated with lower prefrontal activation-a marker of neural efficiency-in divergent thinking.

Abstract P5-18-02: Selective Crossover in Randomized Trials of Adjuvant Trastuzumab for Breast Cancer: Coping with Success

BACKGROUND: Disease-free survival (DFS) is often a primary endpoint of randomized trials of adjuvant therapies for breast cancer, but long-term follow-up of DFS and especially overall survival (OS) remain important. When the primary DFS results favor the experimental arm, patients (pts) assigned to the control group may select the option to crossover to receive the experimental treatment via protocol amendment. Such “selective crossover” disturbs the integrity of the randomized comparison for any efficacy endpoints that rely on further follow-up. Selective crossover, which is motivated by positive results having been observed in the current trial, is distinct from so-called “unplanned crossover,” which refers to non-adherence to protocol. In this abstract, we discuss the consequences of selective crossover for trials evaluating adjuvant trastuzumab, using the HERA (HERceptin Adjuvant) trial as an example, and present a variety of alternative analysis approaches.

METHODS: HERA enrolled 5102 women with HER2-positive early breast cancer who had completed all surgery and (neo)adjuvant chemotherapy to compare 1 or 2 years of trastuzumab treatment vs observation. After a positive first interim analysis at 1y median follow-up (MFU) showed that 1 year of trastuzumab significantly improved DFS vs observation [MJ Piccart-Gebhart et al; NEJM 2005], event-free patients in the observation group were offered crossover to receive trastuzumab. 885 (52%) of the 1698 pts in the observation group selectively crossed over to trastuzumab.

RESULTS: Previously reported intention-to-treat (ITT) analysis of HERA at 4y MFU showed a decreasing effectiveness of trastuzumab with respect to DFS compared with those at 2y MFU [L Gianni et al, Lancet Oncol 2011; I Smith et al, Lancet 2007]. In addition, the ITT analysis of OS at 4y MFU showed little effect of trastuzumab, while the analysis artificially censoring follow-up in the observation group at the time of selective crossover showed a substantial OS advantage for trastuzumab.

First-line bevacizumab-containing therapy for breast cancer: results in patients aged≥70 years treated in the ATHENA study

BACKGROUND

There are limited data on treatment outcomes in the growing population of elderly patients with locally recurrent/metastatic breast cancer (LR/mBC). To gain information on first-line bevacizumab combined with chemotherapy in the elderly, we analyzed data from the ATHENA trial in routine oncology practice.

PATIENTS AND METHODS

Patients with human epidermal growth factor receptor-2-negative LR/mBC received first-line bevacizumab with standard chemotherapy until disease progression, unacceptable toxicity, or physician/patient decision. We carried out a subgroup analysis of safety and efficacy in patients aged≥70 years. Possible correlations between tolerability and baseline comorbidities or Eastern Cooperative Oncology Group status were explored.

RESULTS

Bevacizumab was combined with single-agent paclitaxel in 46% of older patients. Only hypertension and proteinuria were more common in older than in younger patients (grade≥3 hypertension: 6.9% versus 4.2%, respectively; grade≥3 proteinuria: 4.0% versus 1.5%, respectively). Grade≥3 arterial/venous thromboembolism occurred in 2.9% versus 3.3%, respectively. Further analysis revealed no relationship between baseline presence and severity of hypertension and risk of developing hypertension during bevacizumab-containing therapy. Median time to progression was 10.4 months in patients aged≥70 years.

CONCLUSIONS

These findings suggest that bevacizumab-containing therapy is tolerable and active in patients aged≥70 years. Hypertension was more common than in younger patients but was manageable. We find no evidence precluding the use of bevacizumab in older patients, including those with hypertension, although age may influence chemotherapy choice.