Sexual Well-Being After Nipple-Sparing Mastectomy: Does Preservation of the Nipple Matter?

INTRODUCTION

The primary aim of this study was to evaluate patient-reported outcome measures in patients undergoing mastectomy with and without breast reconstruction (immediate or delayed) with and without nipple preservation.

METHODS

All female patients undergoing mastectomy between 2011 and 2015 at Mayo Clinic Rochester were identified and were mailed the BREAST-Q survey. Breast satisfaction, psychosocial well-being, and sexual well-being were evaluated and compared by surgery type using Wilcoxon rank-sum tests for univariate analysis and linear regression for multivariable analysis adjusting for potential confounders.

RESULTS

Of 1547 patients, 771 completed the BREAST-Q survey (response rate 50%). Of these 771 respondents, 237 (31%) did not have reconstruction, 198 (26%) had nipple-sparing mastectomy with reconstruction (NSM), and 336 (44%) had skin-sparing mastectomy with reconstruction (SSM) ± nipple-areolar complex (NAC) reconstruction (via surgery ± tattoo). Patients with breast reconstruction had consistently higher BREAST-Q scores versus those without. Comparing NSM with all SSMs, there was no difference in satisfaction with breasts (mean 71.8 vs. 70.2, p = 0.21) or psychosocial well-being (mean 81.9 vs. 81.3, p = 0.47); however, sexual well-being was significantly higher in the NSM group on univariate (mean 64.5 vs. 58.0, p = 0.002) and multivariable (β = -4.69, p = 0.03) analysis. Sexual well-being scores were similar for NSM and the SSM subgroups with any type of NAC reconstruction.

CONCLUSIONS

This study demonstrates that NSM positively impacts patient sexual well-being after breast reconstruction compared with SSM, particularly SSM without nipple reconstruction or tattoo. SSM with any type of NAC reconstruction achieved similar satisfaction and sexual well-being to those undergoing NSM.

Abstract P1-04-01: Digital spatial profiling of immune-related proteins in luminal androgen receptor (LAR) vs non-LAR triple-negative breast cancer (TNBC)

Background: The importance of the antitumor immune response in TNBC is well established. TNBC with higher TILs are less likely to recur and more responsive to systemic therapy. Likewise, PD-L1+ TNBC are more likely to benefit from chemoimmunotherapy. However, TNBC is highly heterogeneous. Of the TNBC molecular subtypes, LAR TNBC is less sensitive to systemic therapy, has lower TILs and lower rates of PD-L1 positivity. The role of other immune related proteins in LAR TNBC is not well established. Here, we evaluated differentially expressed (DE) immune related proteins in the stromal and intratumoral compartments of LAR vs non-LAR TNBC tumors. Methods: We used the Nanostring GeoMX DSP platform to quantitate 58 proteins within spatially distinct intraepithelial, cytokeratin (CK)-positive tumor segments and adjacent CK-negative/nuclei-positive stromal segments in 248 TNBC tumors included in a tissue microarray generated from a cohort of pts with centrally confirmed TNBC who underwent breast surgery without prior neoadjuvant therapy. A subset (n=111) underwent bulk tumor RNA sequencing and were classified as LAR or non-LAR TNBC. DE proteins were identified using a negative binomial generalized linear model (SNR>2, p<0.05). A targeted set of DE proteins was dichotomized at the 80th percentile. Results: Of 111 TNBC tumors, 17 (15%) were LAR and 94 (85%) non-LAR. Compared to non-LAR TNBC, pts with LAR TNBC were older (age ≥50: 82% vs 52%, p<0.01), with tumors that were more often of apocrine histology (35% vs 0%, p <0.01), grade 1-2 (24% vs 1%, p<0.01), and had lower Ki67 (Ki67 ≤15: 24% vs 11%, p=0.06). Most tumors were T1-2 (94% vs 93%, p=0.82) and N0 (53% vs 62%, p=0.09), respectively. As expected, expression of most immune-related proteins was higher in the stromal vs the intratumoral compartment for both LAR and non-LAR TNBC. When focusing on the stromal compartment, expression of multiple immune related proteins was significantly lower in LAR compared to non-LAR TNBC, including the pan-leukocyte marker CD45 (log-2 fold change [log2FC]: 0.552, p=0.05), the macrophage marker CD14 (log2FC: 0.834, p=0.06), CD44 (lof2FC: 0.637, p=0.07), and the immune checkpoint proteins IDO1 (log2FC: 0.914, p=0.04), VISTA (log2FC: 0.471, p=0.07), ICOS (log2FC: 0.444, p=0.08), and STING (log2FC: 0.544, p=0.09). Proteins with expression levels too low for comparisons included PD-L1, LAG3, FOXP3 and BCL-2. When focusing on the intratumoral compartment, expression of most immune-related proteins was very low in both LAR and non-LAR TNBC. Like in the stromal compartment, CD45 expression was lower in LAR TNBC (log2FC: 0.78, p=0.02). Expression of the immune checkpoint B7-H3 was lower in LAR TNBC (log2FC: 0.737, p=0.02), while expression of the T cell marker CD127 was higher (log2FC: -0.528, p=0.34). With regards to relevant non-immune markers, expression of Ki67 was lower in LAR TNBC (log2FC: 0.5498, p=0.05), consistent with the clinical assay. Conclusion: In this ultra high-plex spatial analysis, we provide first insights into the differential expression at the protein level of several targetable immune checkpoint molecules in LAR vs non-LAR TNBC. The lower expression of several immune related proteins in LAR TNBC is consistent with the hypothesis that LAR TNBC exhibits a “cold” immune microenvironment compared to other TNBC subtypes, potentially rendering itself less susceptible to immunotherapy-based strategies. These data support the need to consider TNBC molecular subtypes in future evaluations of immune-based therapeutic approaches. Funding: This work was supported by NIH grant P50CA116201 to RLF, JMC, KRK, FJC, DZ, JNI, and MPG; BCRF grant 19-161 to EAT and NCATS grant CTSA KL2 TR002379 to RLF. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH

Citation Format: Roberto A Leon-Ferre, Jodi M. Carter, David M. Zahrieh, David W. Hillman, Saranya Chumsri, Yaohua Ma, Jennifer M. Kachergus, Xue Wang, Judy C. Boughey, Minetta C. Liu, James N. Ingle, Krishna R. Kalari, Jose C. Villasboas Bisneto, Fergus J. Couch, E. Aubrey Thompson, Matthew P. Goetz. Digital spatial profiling of immune-related proteins in luminal androgen receptor (LAR) vs non-LAR triple-negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-04-01.

Abstract PD7-06: Trends in surgical resection for stage IV breast cancer: Less surgery more systemic treatment

Background: There is debate regarding the benefit of breast surgery in women with stage IV breast cancer, especially among those with oligometastatic disease and good response to systemic therapy. Although some retrospective studies have suggested that locoregional therapy may improve survival, this finding has not been universally replicated in randomized controlled trials (RCT) in India, Turkey, and recently the US. To assess need for dissemination of trial results by members of the Alliance/American College of Surgeons Clinical Research Program Dissemination and Implementation (ACS CRP D&I) committee, we sought to determine trends in surgical resection and other therapies for stage IV breast cancer in response to these findings. Methods: The National Cancer Database (NCDB) was queried to identify women diagnosed with clinical stage IV breast cancer of ductal, lobular, or metaplastic histology between 2004-2017. Trends in the rate of women who underwent surgery with breast-conserving surgery (BCS) or mastectomy, radiation, and/or systemic treatments were compared. Possible predictors of breast surgery were examined in univariable and multivariable analysis. Results: We identified 87,331 cases meeting inclusion criteria and assessed demographics for surgery versus no surgery. Of the 87,331 cases, 7,718 (9%) underwent BCS and 17,625 (20%) underwent mastectomy. Rates of breast surgical resection for women with clinically diagnosed stage IV breast cancer rose until 2009, reaching a peak at 37%, followed by a decline to a rate of 18% in 2017 (Table). The largest decline was seen in the hormone receptor positive (HR+) and HER2- subgroup with 71% of patients undergoing surgery in 2007 down to 15% in 2017. Concurrently, the mean number of days between chemotherapy initiation and definitive surgery has been on the rise, ranging from 52 days in 2004 up to 94 days in 2017. In 2004, the rate of systemic therapy alone was slightly more common than locoregional therapy (surgery and/or radiation) with or without systemic therapy (48% vs 37%). By 2017, systemic therapy alone was by far more frequently utilized (69% vs 20%, p<0.001). On multivariable analysis, factors associated with reduced odds of receiving surgery were older age, black race, higher comorbidity index, being uninsured, smaller tumors, lower histologic grade, multiple sites of metastasis, and treatment with chemo-endocrine therapy (all group p values ≤0.001). Factors associated with increased odds of receiving surgery were metaplastic histology, TN subtype, and radiation therapy (all group p values ≤0.001). Conclusions: Rates of surgical resection of the breast primary for stage IV breast cancer have been on the decline in recent years, especially for HR+/HER2- disease, suggesting that providers are responding to the lack of benefit demonstrated in RCTs. Higher rates of surgery in patients with HR-/HER2+ disease and the concurrent rise in the time interval between initiation of systemic therapy and definitive surgical intervention suggest that providers may still be selecting surgery for patients with certain subtypes or those with a durable response to systemic therapy. These areas of continued clinical equipoise could be a target for future studies or de-implementation strategies.

OverallHR+/HER2-HER2+TNUnknownSurgery/Total%Surgery/Total%Surgery/Total%Surgery/Total%Surgery/Total%20041189/351334-55-30-50-3420051202/353834-65-35-23-3420061268/375834-54-36-31-3420071571/433636-71-41-32-3620081992/54203754/925926/544820/41491892/52333620092194/592437172/3604883/1525556/106531883/53063520102318/6419361162/331835554/134841352/80144250/9522620112322/6921341220/378932532/144137384/91542186/7762420122238/7110311177/393830587/163536339/85340135/6842020132147/7579281173/423128534/172831334/92536106/6951520142013/8033251086/442825496/185227306/99831125/7551720151805/794323914/434321517/198126288/9962986/6231420161609/819420829/464018459/196823247/10122474/5741320171477/813618722/467815421/190522256/10372578/51615Percent of women with stage IV breast cancer undergoing surgery by year and receptor subtype. Rows containing any number <10 are not reported by subtype to maintain confidentiality, per NCDB guidelines.

Citation Format: Sasha R Douglas, Ingrid Lizarraga, Judy C Boughey, Anna Weiss, Kelly Hunt, Diana Dickson-Witmer, Preeti D Subhedar, Ko Un Park, Beiqun Zhao, Sarah Blair. Trends in surgical resection for stage IV breast cancer: Less surgery more systemic treatment [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD7-06.

Abstract P4-01-05: Multi-omics data shows downregulation of mismatch repair, purin and tublin pathways in AR-negative triple-negative chemotherapy-resistant tumors

Introduction. The standard treatment for non-metastatic triple-negative breast cancer (TNBC) is neoadjuvant chemotherapy (NAC) and nearly 50% exhibit pathological complete response (pCR). However, patients with residual disease after NAC are at increased risk for recurrence and death. Prior studies examining the transcriptome of TNBC pre/post-NAC have examined a limited number of genes (<500) in heterogeneous subgroups of TNBC (e.g. LAR and non-LAR). We explored the transcriptome of androgen-receptor (AR) negative (non-LAR) TNBC subtype both pre/post NAC to identify pathways associated with NAC response. Methods. Tumors obtained pre/post NAC from TNBC patients enrolled in the Breast Cancer Genome Guided therapy study (BEAUTY) underwent RNA sequencing and reverse-phase protein array (RPPA). EdgeR was applied for differentially expressed (DE) analysis and regression methods for RPPA. Digital deconvolution method (CIBERSORTx) and TNBC single-cell data were used to obtain cell types. Pathway analysis was carried out using 2972 gene sets and gene set variation analysis (GSVA). Functional enrichment analysis was conducted with significant genes. Results. Of the 44 TNBC patients, 32 patients were excluded from the analysis cohort due to: LAR tumor (6 pts.), non-LAR tumor with pCR (23 pts.), and cell type issues with RNA-seq data (3 pt.). Paired RNA-Seq data were available for 12 TNBC patients (4 with progression <2 years [EP]) and 8 who were progression-free > 4 years [NP]) and paired RPPA data were available for 9 of these 12 patients. Differentially expressed genes, proteins and cell types between EP and NP in post-NAC. We identified 489 genes differentially expressed (DE) between EP and NP (logFC=|2|, FDR < 0.05). Analysis of cytobands from these 489 genes showed an enrichment of genes on chromosome 6p22.1-2 and 17q25.3 regions (enrichment ratio >5; p-value <10E-4). Critical genes identified in the AR- network (p-value < 10E-3) were IL1RN, SLAMF9, KRT81, BHLHE22, B3GALT5, PCP4, TREM1, AQP9, NRTN, and COL2A1.In addition, preliminary results from RPPA data of post-NAC tumors showed astrocytic phosphoprotein (PEA-15), involved in apoptosis, proliferation, glucose metabolism, as well as cell proliferation and Y box binding (YB1) proteins (involved in metastases), were more DE in EP than NP (p < 0.05). CIBERSORTx was applied to estimate the proportions of different cell types in post-NAC tumors. Cancer-associated fibroblasts iCAFs were low and myCAFs are high in EP vs NP. It is known that the cross-talk between CAFs and tumor cells may induce tumor resistance to chemotherapy. Differentially expressed pathways in post and pre-NAC EP tumors. Using genome-wide expression data from the paired 12 tumors and the GSVA method, we obtained individual pathway scores for 2972 pathways. One hundred ninety pathways were downregulated and 61 pathways were upregulated (p-value <= 0.05) in the post-NAC residual disease of EP relative to NP. We further examined these 190 pathways in the paired EPs and found 71% of those pathways were upregulated in the pre-NAC. These 190 downregulated pathways were enriched with FOXO, TGF-beta, PI3k, FGFR1, insulin and others. The 61 upregulated pathways in post-NAC EP tumors were enriched with mismatch repair, purine, tubulin, telomere, polymerase and gap-junction related pathways; 77% of those 61 pathways were downregulated in pre-NAC. Conclusions. Using a comprehensive “omics” approach, we have identified novel cancer and drug response pathways associated with recurrence in AR-TNBC disease. Further work to evaluate these as markers of outcome and potential drug targets is warranted.

Citation Format: Krishna R Kalari, Vera J Suman, Xiaojia Tang, Jason P Sinnwell, Kevin J Thompson, Peter T Vedell, Jodi M Carter, Sarah A McLaughlin, Alvaro Moreno Aspitia, Donald W Northfelt, Richard J Gray, Richard Weinshilboum, Liewei Wang, Judy C Boughey, Matthew Goetz. Multi-omics data shows downregulation of mismatch repair, purin and tublin pathways in AR-negative triple-negative chemotherapy-resistant tumors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-01-05.

Abstract P5-13-09: Identifying homologous recombination deficiency in breast cancer: Genomic instability score thresholds differ in breast cancer subtypes

Background: Patients with homologous recombin ation (HR) deficient tumors may benefit from treatment with DNA damaging agents. Markers of genomic instability can be used to identify HR deficiency, including a 3-biomarker Genomic Instability Score (GIS). For patients with ovarian cancer (OC), the FDA-approved GIS threshold for identifying HR deficiency is 42, set as the 5th percentile for BRCA deficient tumors. Recently, a lower 1st percentile cutoff of 33 was explored in OC; this threshold was significantly associated with improved outcome after platinum-based treatment.1,2 Determining an optimal GIS threshold for different types of tumors is crucial, as the GIS distribution may vary between different cancers and even between different cancer subtypes. We propose GIS thresholds for breast cancer separately for triple-negative breast cancer (TNBC) and estrogen receptor-positive (ER+) breast cancer, using the exploratory threshold of 33 for OC as a comparator. Methods: GISs in BRCA deficient tumors were determined for patients newly diagnosed with varying stages of OC, TNBC, or ER+ breast cancer across 5 cohorts (Timms et al,3 TCGA,4 Abkevich et al,5 TBCRC008,6 the OlympiaD trial7). GIS was determined as a combination of loss of heterozygosity, telomeric-allelic imbalance, and large-scale state transitions. BRCA deficiency was defined by loss of function resulting from a pathogenic variant in BRCA1 or BRCA2 or by methylation of the BRCA1 promoter region, with loss of heterozygosity in the affected gene. GIS distributions in different cancer types and subtypes were compared using the Kolmogorov-Smirnov test. A normal distribution was fit to GISs in BRCA deficient ER+ breast tumors. The 1st percentile of the fitted distribution was chosen as the threshold. Results: A total of 561 OC tumors (190 BRCA deficient), 99 TNBC tumors (44 BRCA deficient), and 406 ER+ breast tumors (76 BRCA deficient) were included across the 5 cohorts. When score distributions were evaluated for BRCA deficient tumors, the GIS distribution within ER+ breast cancer was significantly different than for OC (p=9.6x10-5) and TNBC (p=3.2x10-4). This indicates that different GIS thresholds are appropriate for breast cancer subtypes and that the GIS threshold developed for OC is not appropriate for ER+ breast cancer. The 1st percentile of a normal distribution fit in BRCA deficient ER+ breast cancer tumors yields a threshold of 24. Using this threshold, 45.1% (183/406; 75 BRCA deficient, 108 BRCA intact) of ER+ breast tumors were HR deficient. In contrast, the GIS distribution for TNBC was not significantly different than for OC (p=0.77). Using the exploratory threshold of 33, 63.6% (63/99; 44 BRCA deficient, 19 BRCA intact) of TNBC tumors were HR deficient. Conclusions: When compared to OC, the distribution of GIS in BRCA deficient tumors was different for ER+ breast cancer, but not for TNBC. These findings are consistent with the fact that OC and TNBC are known to have similar molecular signatures.8 Exploratory thresholds of 24 for ER+ breast cancer, and 33 for TNBC and OC could be examined to determine if these cutoffs are associated with a benefit from treatment with DNA targeting agents. Clinical validity and utility of these more inclusive 1% thresholds would require demonstration of correlation with clinical outcomes. The threshold difference observed between these cancer subtypes also suggests that cancer or cancer subtype specific thresholds may be needed as evaluations of HR deficiency expands beyond OC to identify candidates for PARP inhibitors. References: 1 Mol Cancer Res. 2018;16(7):1103-11. 2 Cancers. 2021;13(5):946. 3 Br J Cancer. 2012;107(10):1776-82. 4 Nature. 2012;490(7418):61-70. 5 Breast Cancer Res. 2014;16(145):1-9. 6 J Nucl Med. 2015;56(1):31-7. 7 NEJM. 2017;377(17):1700. 8 Int J Mol Sci. 2016;17(5):759.

Citation Format: Kirsten M Timms, Lauren Lenz, Chris Neff, Cara Solimeno, Darl Flake, Judy C Boughey, Matthew P Goetz, Andrea Richardson, Anna Maria Storniolo, Alexander Gutin, Roisin M Connolly, Vered Stearns, Jerry S Lanchbury. Identifying homologous recombination deficiency in breast cancer: Genomic instability score thresholds differ in breast cancer subtypes [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-13-09.

Impact of the COVID-19 Pandemic on Breast Cancer Stage at Diagnosis, Presentation, and Patient Management

INTRODUCTION

The COVID-19 pandemic caused delays in breast cancer management forcing clinicians to potentially alter treatment recommendations. This study compared breast cancer stage at diagnosis and rates of neoadjuvant therapy among women presenting to our institution before and during COVID-19.

METHODS

Retrospective chart review of patients with a new breast cancer diagnosis from March 2020-August 2020 (during-COVID-19) were compared with March 2019-August 2019 (pre-COVID-19). We compared stage at diagnosis, clinical/demographic features, and neoadjuvant therapy use between the time periods.

RESULTS

A total of 573 patients included: 376 pre-COVID-19, 197 during-COVID-19. Method of cancer detection was by imaging in 66% versus 63% and by physical findings/symptoms in 34% versus 37% of patients comparing pre-COVID-19 to during-COVID-19, p = 0.47. Overall clinical prognostic stage did not differ significantly (p = 0.39) between the time periods, nor did cM1 disease (2% in each period); 23% pre-COVID-19 and 27% during-COVID-19 presented with cN+ disease (p = 0.38). Neoadjuvant therapy use was significantly higher during-COVID-19 (39%) versus pre-COVID-19 (29%, p = 0.02) driven by increased neoadjuvant endocrine therapy (NET) use (7% to 16%, p = 0.002), whereas neoadjuvant chemotherapy use did not change (22% vs. 23%, p = 0.72). In HR+/HER2- disease, NET use increased from 10% pre-COVID-19 to 23% during-COVID-19 (p = 0.001) with a significant increase in stage I patients (7 to 22%, p < 0.001) and nonsignificant increases in stage II (18 to 23%, p = 0.63) and stage III (9 to 29%, p = 0.29).

CONCLUSIONS

Breast cancer stage at diagnosis did not differ significantly during-COVID-19 compared with pre-COVID-19. More patients during-COVID-19 were treated with NET, which was significantly increased in stage I HR+/HER2- disease.

MRI Radiomics for Assessment of Molecular Subtype, Pathological Complete Response, and Residual Cancer Burden in Breast Cancer Patients Treated With Neoadjuvant Chemotherapy

RATIONALE AND OBJECTIVES

There are limited data on pretreatment imaging features that can predict response to neoadjuvant chemotherapy (NAC). To extract volumetric pretreatment MRI radiomics features and assess corresponding associations with breast cancer molecular subtypes, pathological complete response (pCR), and residual cancer burden (RCB) in patients treated with NAC.

MATERIALS AND METHODS

In this IRB-approved study, clinical and pretreatment MRI data from patients with biopsy-proven breast cancer who received NAC between September 2009 and July 2016 were retrospectively analyzed. Tumors were manually identified and semi-automatically segmented on first postcontrast images. Morphological and three-dimensional textural features were computed, including unfiltered and filtered image data, with spatial scaling factors (SSF) of 2, 4, and 6 mm. Wilcoxon rank-sum tests and area under the receiver operating characteristic curve were used for statistical analysis.

RESULTS

Two hundred and fifty nine patients with unilateral breast cancer, including 73 (28.2%) HER2+, 112 (43.2%) luminal, and 74 (28.6%) triple negative breast cancers (TNBC), were included. There was a significant difference in the median volume (p = 0.008), median longest axial tumor diameter (p = 0.009), and median longest volumetric diameter (p = 0.01) among tumor subtypes. There was also a significant difference in minimum signal intensity and entropy among the tumor subtypes with SSF = 4 mm (p = 0.009 and p = 0.02 respectively) and SSF = 6 mm (p = 0.007 and p < 0.001 respectively). Additionally, sphericity (p = 0.04) in HER2+ tumors and entropy with SSF = 2, 4, 6 mm (p = 0.004, 0.02, 0.047 respectively) in luminal tumors were significantly associated with pCR. Multiple features demonstrated significant association (p < 0.05) with pCR in TNBC and with RCB in luminal tumors and TNBC, with standard deviation of intensity with SSF = 6 mm achieving the highest AUC (AUC = 0.734) for pCR in TNBC.

CONCLUSION

MRI radiomics features are associated with different molecular subtypes of breast cancer, pCR, and RCB. These features may be noninvasive imaging biomarkers to identify cancer subtype and predict response to NAC.

Residual cancer burden after neoadjuvant chemotherapy and long-term survival outcomes in breast cancer: a multicentre pooled analysis of 5161 patients

BACKGROUND

Previous studies have independently validated the prognostic relevance of residual cancer burden (RCB) after neoadjuvant chemotherapy. We used results from several independent cohorts in a pooled patient-level analysis to evaluate the relationship of RCB with long-term prognosis across different phenotypic subtypes of breast cancer, to assess generalisability in a broad range of practice settings.

METHODS

In this pooled analysis, 12 institutes and trials in Europe and the USA were identified by personal communications with site investigators. We obtained participant-level RCB results, and data on clinical and pathological stage, tumour subtype and grade, and treatment and follow-up in November, 2019, from patients (aged ≥18 years) with primary stage I-III breast cancer treated with neoadjuvant chemotherapy followed by surgery. We assessed the association between the continuous RCB score and the primary study outcome, event-free survival, using mixed-effects Cox models with the incorporation of random RCB and cohort effects to account for between-study heterogeneity, and stratification to account for differences in baseline hazard across cancer subtypes defined by hormone receptor status and HER2 status. The association was further evaluated within each breast cancer subtype in multivariable analyses incorporating random RCB and cohort effects and adjustments for age and pretreatment clinical T category, nodal status, and tumour grade. Kaplan-Meier estimates of event-free survival at 3, 5, and 10 years were computed for each RCB class within each subtype.

FINDINGS

We analysed participant-level data from 5161 patients treated with neoadjuvant chemotherapy between Sept 12, 1994, and Feb 11, 2019. Median age was 49 years (IQR 20-80). 1164 event-free survival events occurred during follow-up (median follow-up 56 months [IQR 0-186]). RCB score was prognostic within each breast cancer subtype, with higher RCB score significantly associated with worse event-free survival. The univariable hazard ratio (HR) associated with one unit increase in RCB ranged from 1·55 (95% CI 1·41-1·71) for hormone receptor-positive, HER2-negative patients to 2·16 (1·79-2·61) for the hormone receptor-negative, HER2-positive group (with or without HER2-targeted therapy; p<0·0001 for all subtypes). RCB score remained prognostic for event-free survival in multivariable models adjusted for age, grade, T category, and nodal status at baseline: the adjusted HR ranged from 1·52 (1·36-1·69) in the hormone receptor-positive, HER2-negative group to 2·09 (1·73-2·53) in the hormone receptor-negative, HER2-positive group (p<0·0001 for all subtypes).

INTERPRETATION

RCB score and class were independently prognostic in all subtypes of breast cancer, and generalisable to multiple practice settings. Although variability in hormone receptor subtype definitions and treatment across patients are likely to affect prognostic performance, the association we observed between RCB and a patient's residual risk suggests that prospective evaluation of RCB could be considered to become part of standard pathology reporting after neoadjuvant therapy.

FUNDING

National Cancer Institute at the US National Institutes of Health.

Hybrid high-definition microvessel imaging/shear wave elastography improves breast lesion characterization

BACKGROUND

Low specificity in current breast imaging modalities leads to increased unnecessary follow-ups and biopsies. The purpose of this study is to evaluate the efficacy of combining the quantitative parameters of high-definition microvasculature imaging (HDMI) and 2D shear wave elastography (SWE) with clinical factors (lesion depth and age) for improving breast lesion differentiation.

METHODS

In this prospective study, from June 2016 through April 2021, patients with breast lesions identified on diagnostic ultrasound and recommended for core needle biopsy were recruited. HDMI and SWE were conducted prior to biopsies. Two new HDMI parameters, Murray's deviation and bifurcation angle, and a new SWE parameter, mass characteristic frequency, were included for quantitative analysis. Lesion malignancy prediction models based on HDMI only, SWE only, the combination of HDMI and SWE, and the combination of HDMI, SWE and clinical factors were trained via elastic net logistic regression with 70% (360/514) randomly selected data and validated with the remaining 30% (154/514) data. Prediction performances in the validation test set were compared across models with respect to area under the ROC curve as well as sensitivity and specificity based on optimized threshold selection.

RESULTS

A total of 508 participants (mean age, 54 years ± 15), including 507 female participants and 1 male participant, with 514 suspicious breast lesions (range, 4-72 mm, median size, 13 mm) were included. Of the lesions, 204 were malignant. The SWE-HDMI prediction model, combining quantitative parameters from SWE and HDMI, with AUC of 0.973 (95% CI 0.95-0.99), was significantly higher than the result predicted with the SWE model or HDMI model alone. With an optimal cutoff of 0.25 for the malignancy probability, the sensitivity and specificity were 95.5% and 89.7%, respectively. The specificity was further improved with the addition of clinical factors. The corresponding model defined as the SWE-HDMI-C prediction model had an AUC of 0.981 (95% CI 0.96-1.00).

CONCLUSIONS

The SWE-HDMI-C detection model, a combination of SWE estimates, HDMI quantitative biomarkers and clinical factors, greatly improved the accuracy in breast lesion characterization.

Breast cancer-The catalyst of contemporary trials design

Surgical trials in breast cancer have catalyzed contemporary trial design for solid organ cancers and are a prime example of surgeons taking the lead in clinical trial design. Surgeons have lead trials that have improved patient outcomes and quality of life without sacrificing oncologic safety. We have evolved from radical mastectomy to breast conservation and sentinel node biopsy. Contemporary trial design in breast cancer now focus on personalizing care based on tumor genomics.

Neoadjuvant T-DM1/pertuzumab and paclitaxel/trastuzumab/pertuzumab for HER2+ breast cancer in the adaptively randomized I-SPY2 trial

HER2-targeted therapy dramatically improves outcomes in early breast cancer. Here we report the results of two HER2-targeted combinations in the neoadjuvant I-SPY2 phase 2 adaptive platform trial for early breast cancer at high risk of recurrence: ado-trastuzumab emtansine plus pertuzumab (T-DM1/P) and paclitaxel, trastuzumab and pertuzumab (THP). Eligible women have >2.5 cm clinical stage II/III HER2+ breast cancer, adaptively randomized to T-DM1/P, THP, or a common control arm of paclitaxel/trastuzumab (TH), followed by doxorubicin/cyclophosphamide, then surgery. Both T-DM1/P and THP arms 'graduate' in all subtypes: predicted pCR rates are 63%, 72% and 33% for T-DM1/P (n = 52), THP (n = 45) and TH (n = 31) respectively. Toxicity burden is similar between arms. Degree of HER2 pathway signaling and phosphorylation in pretreatment biopsy specimens are associated with response to both T-DM1/P and THP and can further identify highly responsive HER2+ tumors to HER2-directed therapy. This may help identify patients who can safely de-escalate cytotoxic chemotherapy without compromising excellent outcome.

Assessment of Residual Cancer Burden and Event-Free Survival in Neoadjuvant Treatment for High-risk Breast Cancer: An Analysis of Data From the I-SPY2 Randomized Clinical Trial

Importance

Residual cancer burden (RCB) distributions may improve the interpretation of efficacy in neoadjuvant breast cancer trials.

Objective

To compare RCB distributions between randomized control and investigational treatments within subtypes of breast cancer and explore the relationship with survival.

Design, Setting, and Participants

The I-SPY2 is a multicenter, platform adaptive, randomized clinical trial in the US that compares, by subtype, investigational agents in combination with chemotherapy vs chemotherapy alone in adult women with stage 2/3 breast cancer at high risk of early recurrence. Investigational treatments graduated in a prespecified subtype if there was 85% or greater predicted probability of higher rate of pathologic complete response (pCR) in a confirmatory, 300-patient, 1:1 randomized, neoadjuvant trial in that subtype. Evaluation of a secondary end point was reported from the 10 investigational agents tested in the I-SPY2 trial from March 200 through 2016, and analyzed as of September 9, 2020. The analysis plan included modeling of RCB within subtypes defined by hormone receptor (HR) and ERBB2 status and compared control treatments with investigational treatments that graduated and those that did not graduate.

Interventions

Neoadjuvant paclitaxel plus/minus 1 of several investigational agents for 12 weeks, then 12 weeks of cyclophosphamide/doxorubicin chemotherapy followed by surgery.

Main Outcomes and Measures

Residual cancer burden (pathological measure of residual disease) and event-free survival (EFS).

Results

A total of 938 women (mean [SD] age, 49 [11] years; 66 [7%] Asian, 103 [11%] Black, and 750 [80%] White individuals) from the first 10 investigational agents were included, with a median follow-up of 52 months (IQR, 29 months). Event-free survival worsened significantly per unit of RCB in every subtype of breast cancer (HR-positive/ERBB2-negative: hazard ratio [HZR], 1.75; 95% CI, 1.45-2.16; HR-positive/ERBB2-positive: HZR, 1.55; 95% CI, 1.18-2.05; HR-negative/ERBB2-positive: HZR, 2.39; 95% CI, 1.64-3.49; HR-negative/ERBB2-negative: HZR, 1.99; 95% CI, 1.71-2.31). Prognostic information from RCB was similar from treatments that graduated (HZR, 2.00; 95% CI, 1.57-2.55; 254 [27%]), did not graduate (HZR, 1.87; 95% CI, 1.61-2.17; 486 [52%]), or were control (HZR, 1.79; 95% CI, 1.42-2.26; 198 [21%]). Investigational treatments significantly lowered RCB in HR-negative/ERBB2-negative (graduated and nongraduated treatments) and ERBB2-positive subtypes (graduated treatments), with improved EFS (HZR, 0.61; 95% CI, 0.41-0.93) in the exploratory analysis.

Conclusions and Relevance

In this randomized clinical trial, the prognostic significance of RCB was consistent regardless of subtype and treatment. Effective neoadjuvant treatments shifted the distribution of RCB in addition to increasing pCR rate and appeared to improve EFS. Using a standardized quantitative method to measure response advances the interpretation of efficacy.

Trial Registration

ClinicalTrials.gov Identifier: NCT01042379.

Characteristics and Spatially Defined Immune (micro)landscapes of Early-stage PD-L1-positive Triple-negative Breast Cancer

PURPOSE

Programmed death ligand 1 [PD-(L)1]-targeted therapies have shown modest survival benefit in triple-negative breast cancer (TNBC). PD-L1+ microenvironments in TNBC are not well characterized and may inform combinatorial immune therapies. Herein, we characterized clinicopathologic features, RNA-based immune signatures, and spatially defined protein-based tumor-immune microenvironments (TIME) in early-stage PD-L1+ and PD-L1- TNBC.

EXPERIMENTAL DESIGN

From a large cohort of chemotherapy-naïve TNBC, clinicopathologic features, deconvoluted RNA immune signatures, and intraepithelial and stromal TIME (Nanostring GeoMX) were identified in subsets of PD-L1+ and PD-L1- TNBC, as defined by FDA-approved PD-L1 companion assays.

RESULTS

228 of 499 (46%) TNBC were PD-L1+ (SP142: ≥1% immune cells-positive). Using PD-L1 22C3, 46% had combined positive score (CPS) ≥ 1 and 16% had CPS ≥10. PD-L1+ TNBC were higher grade with higher tumor-infiltrating lymphocytes (TIL; P < 0.05). PD-L1 was not associated with improved survival following adjustment for TILs and other variables. RNA profiles of PD-L1+ TNBC had increased dendritic cell, macrophage, and T/B cell subset features; and decreased myeloid-derived suppressor cells. PD-L1+ stromal and intraepithelial TIMEs were highly enriched in IDO-1, HLA-DR, CD40, and CD163 compared with PD-L1-TIME, with spatially specific alterations in CTLA-4, Stimulator of Interferon Genes (STING), and fibronectin. Macrophage- and antigen presentation-related proteins correlated most strongly with PD-L1 protein.

CONCLUSIONS

In this early-stage TNBC cohort, nearly 50% were PD-L1+ (SP142 companion assay) while 16% were PD-L1+ with the 22C3 companion assay. PD-L1+ TNBC had specific myeloid-derived and lymphoid features. Spatially defined PD-L1+ TIME were enriched in several clinically actionable immune proteins. These data may inform future studies on combinatorial immunotherapies for patients with PD-L1+ TNBC.See related commentary by Symmans, p. 5446.

Primary tumor resection in patients with stage IV breast cancer: 10-year experience

The role of surgery in the management of stage IV breast cancer is controversial. Existing studies in Stage IV breast cancer have not closely evaluated the role of patient response to induction systemic therapy (IST) in its relationship to survival outcomes. We identified all patients with a diagnosis of de novo stage IV breast cancer who underwent surgery of their primary tumor from January 2008 to December 2018. Patients were grouped according to their response in the primary disease site into progression (progressive primary disease) or no progression (nonprogressive primary; comprising complete, partial and stable response). We identified a total of 45 stage IV breast cancer patients who underwent operative intervention of their primary breast tumor. Prior to surgical intervention, progression in the primary site during IST was identified in 13/42 patients (31%), of whom four patients also had progression in the distant disease. The 5-year survival was higher in the nonprogressive primary (74%) than the progressive primary disease group (52%) which did not reach statistical significance (p = 0.08). Age, pathologic tumor size, clinical nodal status, number of positive lymph nodes, and distant disease response to systemic therapy were significantly associated with survival. In this single institution experience, select patients with stage IV breast cancer at initial diagnosis who underwent resection of the primary tumor following systemic therapy achieved favorable overall and distant progression-free survival. Surgery is reasonable to consider for local palliation or in selected patients who have excellent response to systemic therapy and good performance status.

The Feasibility of Radiation Therapy after Breast-Conserving Surgery for Multiple Ipsilateral Breast Cancer: An Initial Report from ACOSOG Z11102 (Alliance) Trial

Purpose:

Historically, multiple ipsilateral breast cancer (MIBC) has been a contraindication to breast-conserving therapy. We report the feasibility of radiation therapy (RT) after breast-conserving therapy in MIBC from the Alliance Z11102 trial.

Methods and Materials:

Delineation of targets and organs at risk was performed according to the Radiation Therapy Oncology Group contouring consensus definitions. RT was delivered to the whole breast to 45 to 50 Gy in standard daily fractions of 1.8 to 2.0 Gy. A boost of 10 to 16 Gy in 2.0-Gy daily fractions to each tumor bed was mandatory.

Results:

A total of 236 eligible patients were enrolled in the study between July 23, 2012 and August 19, 2016. Of those, 195 (83%) completed RT. No patient underwent mastectomy for failure to meet the RT dose constraints. Higher absolute boost volume was associated with increased incidence of grade 2 or higher dermatitis (odds ratio, 1.21; 95% confidence interval, 1.041.41; P = .014). Higher relative boost volume as a percentage of the overall breast volume was not associated with increased dermatitis. Neither absolute nor relative boost volume appeared to significantly influence overall cosmesis.

Conclusions:

Breast conservation followed by whole breast RT plus boost to each tumor bed was feasible in the majority of patients with MIBC. Increasing radiation boost volume was associated with increased incidence of acute dermatitis, but was not associated with worse overall cosmesis.

Ganitumab and metformin plus standard neoadjuvant therapy in stage 2/3 breast cancer

I-SPY2 is an adaptively randomized phase 2 clinical trial evaluating novel agents in combination with standard-of-care paclitaxel followed by doxorubicin and cyclophosphamide in the neoadjuvant treatment of breast cancer. Ganitumab is a monoclonal antibody designed to bind and inhibit function of the type I insulin-like growth factor receptor (IGF-1R). Ganitumab was tested in combination with metformin and paclitaxel (PGM) followed by AC compared to standard-of-care alone. While pathologic complete response (pCR) rates were numerically higher in the PGM treatment arm for hormone receptor-negative, HER2-negative breast cancer (32% versus 21%), this small increase did not meet I-SPY's prespecified threshold for graduation. PGM was associated with increased hyperglycemia and elevated hemoglobin A1c (HbA1c), despite the use of metformin in combination with ganitumab. We evaluated several putative predictive biomarkers of ganitumab response (e.g., IGF-1 ligand score, IGF-1R signature, IGFBP5 expression, baseline HbA1c). None were specific predictors of response to PGM, although several signatures were associated with pCR in both arms. Any further development of anti-IGF-1R therapy will require better control of anti-IGF-1R drug-induced hyperglycemia and the development of more predictive biomarkers.

Analysis of the Impact of the COVID-19 Pandemic on the Multidisciplinary Management of Breast Cancer: Review from the American Society of Breast Surgeons COVID-19 and Mastery Registries

Background

The coronavirus disease 2019 (COVID-19) pandemic has resulted in rapid and regionally different approaches to breast cancer care.

Methods

In order to evaluate these changes, a COVID-19-specific registry was developed within the American Society of Breast Surgeons (ASBrS) Mastery that tracked whether decisions were usual or modified for COVID-19. Data on patient care entered into the COVID-19-specific registry and the ASBrS Mastery registry from 1 March 2020 to 15 March 2021 were reviewed.

Results

Overall, 177 surgeons entered demographic and treatment data on 2791 patients. Mean patient age was 62.7 years and 9.0% (252) were of African American race. Initial consultation occurred via telehealth in 6.2% (173) of patients and 1.4% (40) developed COVID-19. Mean invasive tumor size was 2.1 cm and 17.8% (411) were node-positive. In estrogen receptor-positive/human epidermal growth factor receptor 2-negative (ER+/HER2−) disease, neoadjuvant endocrine therapy (NET) was used as the usual approach in 6.9% (119) of patients and due to COVID-19 in an additional 31% (542) of patients. Patients were more likely to receive NET due to COVID-19 with increasing age and if they lived in the Northeast or Southeast (odds ratio [OR] 1.1, 2.3, and 1.7, respectively; p < 0.05). Genomic testing was performed on 51.5% (781) of estrogen-positive patients, of whom 20.7% (162) had testing on the core due to COVID-19. Patients were less likely to have core biopsy genomic testing due to COVID-19 if they were older (OR 0.89; p = 0.01) and more likely if they were node-positive (OR 4.0; p < 0.05). A change in surgical approach due to COVID-19 was reported for 5.4% (151) of patients.

Conclusion

The ASBrS COVID-19 registry provided a platform for monitoring treatment changes due to the pandemic, highlighting the increased use of NET.

Prediction of Invasive Breast Cancer Using Mass Characteristic Frequency and Elasticity in Correlation with Prognostic Histologic Features and Immunohistochemical Biomarkers

This purpose of this study is to correlate a new shear-wave elastography (SWE) parameter, mass characteristic frequency (fmass) and other elasticity measure with the prognostic histological factors and immunohistochemical (IHC) biomarkers for the evaluation of heterogeneous breast carcinomas. The new parameter, fmass, first introduced in this paper, is defined as the ratio of the averaged minimum shear wave speed taken spatially within regions of interest to the largest mass dimension. 264 biopsy-proven breast cancerous masses were included in this study. Mean (Emean), maximum (Emax), minimum (Emin) shear wave elasticity and standard deviation (Esd) of shear wave elasticity were found significantly correlated with tumor size, axillary lymph node (ALN) status, histological subtypes and IHC subtypes. The areas under the curve for the ALN prediction are 0.73 (95% confidence interval [CI]: 0.67-0.80) and 0.75 (95% CI: 0.69-0.81) for the combination of Emean with Breast Imaging Reporting and Data System (BI-RADS) score and Emax with BI-RADS score, respectively. fmass was significantly correlated with the presence of calcifications, ALN status, histological grade, the expressions of IHC biomarkers and IHC subtypes. To conclude, poor prognostic factors were associated with high shear wave elasticity values and low mass characteristic frequency value. Therefore, SWE provides valuable information that may help with prediction of breast cancer invasiveness.