MRI predicts pathologic complete response in HER2-positive breast cancer after neoadjuvant chemotherapy

BACKGROUND

Neoadjuvant treatment of HER2-positive breast cancer frequently leads to a pathologic complete response (pCR), which is associated with favourable long-term outcome. Treatment regimens typically consist of 6-9 cycles of trastuzumab-based chemotherapy, although many patients achieve early radiologic complete response (rCR). If rCR accurately predicts pCR, the number of chemotherapy cycles can possibly be reduced.

METHODS

We performed a diagnostic accuracy study to determine the association between rCR and pCR in patients with stage II-III HER2-positive breast cancer treated with neoadjuvant trastuzumab-based chemotherapy at the Netherlands Cancer Institute. RCR was defined as the disappearance of pathologic contrast enhancement in the original tumour region on repeated magnetic resonance imaging (MRI). PCR was defined as the absence of invasive tumour cells in the resected breast specimen (ypT0/is). Diagnostic accuracy was estimated in the overall population and in subgroups based on hormone receptor (HR) status. The prognostic value of rCR for recurrence-free interval was evaluated as an exploratory analysis.

RESULTS

We identified 296 eligible patients with 297 HER2-positive tumours (154 HR-negative and 143 HR-positive) treated with neoadjuvant trastuzumab-based chemotherapy between 2004 and 2016. Overall, the rCR rate was 69% (206/297) and the pCR rate was 61% (181/297). Among 206 patients with rCR, 150 also had pCR (negative predictive value [NPV] = 150/206 = 73%). Among 91 patients without rCR, 60 had residual tumour at pathology (positive predictive value [PPV] = 60/91 = 66%). The NPV was better in HR-negative compared to HR-positive tumours (88 vs. 57%), while the PPV was better in HR-positive tumours (50 vs. 78%). Achieving rCR was associated with a 5-year recurrence-free interval of 88% compared to 68% without rCR (hazard ratio 0.34, 95% confidence interval 0.17-0.65, P = 0.001).

CONCLUSION

Achieving rCR corresponds well with pCR in HER2-positive breast cancer, particularly in the HR-negative subgroup. RCR is also associated with improved long-term outcome.

Doctors' reports about palliative systemic treatment: A medical record study

BACKGROUND

Decisions about palliative systemic treatment are key elements of palliative and end-of-life care. Such decisions must often be made in complex, clinical situations.

AIM

To explore the content of medical records of patients with advanced non-small cell lung cancer and pancreatic cancer with specific emphasis on doctors' notes about decisions on palliative systemic treatment.

DESIGN

Medical record review (2009-2012) of 147 cancer patients containing 276 notes about palliative systemic treatment. We described the proportion of notes/medical records containing pre-specified items relevant to palliative systemic treatment. We selected patients using the nationwide Netherlands Cancer Registry.

SETTING

Hospital based.

RESULTS

About 75% of all notes reported doctors' considerations to start/continue palliative systemic treatment, including information about the prognosis (47%), possible survival gain (22%), patients' wish for palliative systemic treatment (33%), impact on quality of life (8%), and patient's age (3%). Comorbidity (82%), smoking status (78%) and drinking behaviour (63%) were more often documented than patients' performance status (16%). Conversations with the patient/family about palliative systemic treatment were reported in 49% of all notes. Response measurements and dose adaptations were documented in 75% and 71% of patients who received palliative systemic treatment respectively.

CONCLUSION

Medical records provide insight into the decision-making process about palliative systemic treatment. The content and detail of doctors' notes, however, widely varies especially concerning their palliative systemic treatment considerations. Registries that aim to measure the quality of (end-of-life) care must be aware of this outcome. Future research should further explore how medical records can best assist in evaluating the quality of the decision-making process in the patient's final stage of life.

Abstract P2-09-16: How population-based data complement trial data in the adjuvant endocrine treatment of ER+/HER2+ breast cancers

Background

This study is part of the Netherlands Breast Cancer Project, initiated to address research questions that are unlikely answered by future randomized controlled trials (RCT). Here we investigated whether aromatase inhibitors (AI) are superior over tamoxifen (TAM), in the treatment of Estrogen Receptor (ER) positive Human Epidermal growth factor Receptor 2 (HER2) positive breast cancer, using treatment and outcome data from the population based Netherlands Cancer Registry (NCR). RCTs showed superiority of AI over TAM in postmenopausal ER+/HER2+ patients while a (non-significant) suggestion for worse outcome was observed among premenopausal patients treated with AI in the SOFT/TEXT trial. Perimenopausal women were not considered in these trials.

Methods

Dutch women without a prior malignancy, diagnosed between 2005-2007 with an ER+/HER2+, endocrine treated, non-metastatic, invasive breast cancer, were identified through the NCR and followed until 2013. Since data on menopausal status were lacking, we used age at diagnosis as a proxy to categorize patients as premenopausal (≤45 years), perimenopausal (45-55 years) and postmenopausal (>55 years). A time-dependent variable was calculated indicating whether AI treatment was given for >50% (denoted AI treated) vs. <50% (denoted TAM treated) of endocrine treatment duration. Recurrence-free survival (RFS) and overall survival (OS) were assessed using an extended Kaplan-Meier survival estimator and Cox proportional hazards regression. Hazard Ratios (HR) for the TAM/AI comparison, were adjusted for chemotherapy, trastuzumab, age at diagnosis, lymph node status, grade, clinical T stage, and ovarian ablation.

Results

We included 1158 patients: 326 pre-, 306 peri- and 526 postmenopausal. Of these, 229 received TAM and 929 AI. During follow-up, 239 RFS and 184 OS events were observed. In the TAM treated group, 56 RFS and 45 OS events were observed, in the AI treated group 183 RFS and 139 RFS events were observed respectively.

No differences in RFS were observed comparing AI to TAM treated patients in the premenopausal (HR 1.33; 95% CI 0.71-2.49; P=0.378) and postmenopausal (HR 0.84, 95%CI 0.54-1.32; P=0.456) group. However, perimenopausal patients benefitted significantly from AI compared with TAM (HR 0.50; 95% CI 0.27-0.95). Results were similar for OS: no significant benefit from AI when compared to TAM in pre- (HR 1.41; 95% CI 0.62-3.19; P=0.408) and postmenopausal (HR 0.75; 95% CI 0.47-1.22; P=0.245) patients while perimenopausal patients derived significant benefit from AI treatment (HR 0.42; 95% CI 0.20-0.85; P=0.016).

Conclusion

In this population based cohort study we observed superiority for AI over TAM in the treatment of ER+/HER2+ perimenopausal patients. Data were suggestive in favor of AI when compared to TAM for postmenopausal patients while an indication of worse outcome with AI was seen in premenopausal patients, consistent with results of the SOFT/TEXT trial. Although we used age as a proxy for menopausal status, our results are consistent with previous RCTs. Population based data may therefore provide a reliable source of information when new RCTs might not be feasible anymore.

Citation Format: Dackus GMHE, Jozwiak K, Sonke GS, Van der Wall E, Van Diest PJ, Hauptmann M, Siesling S, Linn SC. How population-based data complement trial data in the adjuvant endocrine treatment of ER+/HER2+ breast cancers [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-09-16.

Abstract P4-12-03: Estrogen receptor-positive breast cancer in BRCA1 mutation carriers shows a BRCAness profile, suggesting sensitivity to drugs targeting homologous recombination deficiency

Background

As estrogen receptor (ER)-positive breast cancer in BRCA1 mutation carriers arises at an older age with less aggressive tumor characteristics than ER negative BRCA1 mutated breast cancer, it has been suggested that these tumors are 'sporadic' and not BRCA1-driven. With the introduction of targeted treatments specific for tumors with a non-functioning BRCA1 or BRCA2 gene, the question whether the BRCA genes are impaired in the tumor, is highly relevant. Therefore, we performed genomic profiling of BRCA1-mutated ER+ tumors.

Methods

Genomic profiling, BRCA1 promoter methylation assessment, and loss of heterozygosity (LOH) analysis were done on 16 BRCA1-mutated ER+ tumors. Results were compared with 57 BRCA1-mutated ER- tumors, 36 BRCA2-mutated ER+ associated tumors, and 182 sporadic ER+ tumors.

Results

The genomic profile of BRCA1-mutated ER+ tumors was different from BRCA1-mutated ER- breast tumors, but highly similar to BRCA2-mutated ER+ tumors. In 83% of the BRCA1-mutated ER+ tumors, loss of the wildtype BRCA1 allele was observed. Clinico-pathological variables in BRCA1-mutated ER+ cancer were more similar to BRCA2-mutated ER+ and sporadic ER+ breast cancer than to BRCA1 mutated ER- cancers.

Conclusions

As BRCA1-mutated ER+ tumors showed a BRCAness copy number profile and LOH, it is likely that the loss of a functional BRCA1 protein plays a role in tumorigenesis in BRCA1-mutated ER+ tumors. Therefore, we hypothesize that these tumors are sensitive to drugs targeting the BRCA1 gene defect.

Citation Format: Lips EH, Debipersad R, Scheerman E, Mulder L, Sonke GS, van der Kolk LE, Wessling J, Hogervorst FBL, Nederlof PM. Estrogen receptor-positive breast cancer in BRCA1 mutation carriers shows a BRCAness profile, suggesting sensitivity to drugs targeting homologous recombination deficiency [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-12-03.

Abstract P4-22-05: First-line ribociclib plus letrozole in patients with de novo HR+, HER2– advanced breast cancer (ABC): A subgroup analysis of the MONALEESA-2 trial

Background: Around 15,000 US patients per year are diagnosed with de novo ABC. Due to the absence of prior systemic treatment for breast cancer, tumors of patients with de novo ABC may exhibit a different disease biology, which could result in different tumor responses compared with patients who have relapsed breast cancer. Ribociclib is an orally bioavailable cyclin-dependent kinase (CDK) 4/6 inhibitor. Results from MONALEESA-2, a double-blind, placebo-controlled, randomized Phase 3 trial (NCT01958021), demonstrated that first-line therapy with ribociclib + letrozole significantly improved progression-free survival (PFS) vs placebo + letrozole in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) ABC. Many patients with de novo ABC receive endocrine therapy in the first line and in subsequent lines; here we present results from the MONALEESA-2 study in a subpopulation of patients with de novo ABC.

Methods: Postmenopausal women (N=668) with HR+, HER2– ABC who had no prior systemic therapy for ABC were randomized 1:1 (stratified by liver and/or lung metastases) to receive ribociclib (600 mg/day; 3-weeks-on/1-week-off) + letrozole (2.5 mg/day; continuous) or placebo + letrozole. Patients with de novo ABC were eligible. Additional eligibility criteria included measurable disease or ≥1 predominantly lytic bone lesion, Eastern Cooperative Oncology Group performance status ≤1, and adequate bone marrow/organ function. Prior CDK4/6 inhibitors or systemic therapy for ABC were prohibited. Patients may have received ≤14 days of letrozole or anastrozole for ABC. The primary endpoint was locally assessed PFS; a predefined subgroup analysis evaluated PFS in patients with de novo ABC.

Results: In total, 227 patients with de novo ABC were enrolled. Patients with de novo ABC were equally distributed with 114 (34%) and 113 (34%) in the ribociclib + letrozole and placebo + letrozole arms, respectively. Median duration of exposure to study treatment in the ribociclib + letrozole vs placebo + letrozole arms was 14.1 vs 12.8 months. Treatment was discontinued in 84 (37%) patients with de novo ABC (ribociclib + letrozole vs placebo + letrozole, n [%]; 34 [30%] vs 50 [44%]). Reasons for treatment discontinuation (ribociclib + letrozole vs placebo + letrozole, n [%]) included disease progression (21 [18%] vs 41 [36%]), patient/physician decision (5 [4%] vs 6 [5%]), and adverse events (6 [5%] vs 3 [3%]). PFS was increased in patients with de novo ABC who received ribociclib + letrozole vs placebo + letrozole (hazard ratio=0.448 [95% confidence interval: 0.267–0.750]). The 12-month PFS event-free probability in patients with de novo ABC was 82% in the ribociclib + letrozole arm vs 66% in the placebo + letrozole arm.

Conclusions: The combination of ribociclib + letrozole significantly improved PFS compared with placebo + letrozole in postmenopausal women with HR+, HER2– de novo ABC at diagnosis and therefore may become an important treatment option in the de novo ABC setting.

Keywords: Advanced breast cancer; CDK4/6 inhibitor; Letrozole; Ribociclib

Citation Format: O'Shaughnessy J, Petrakova K, Sonke GS, André F, Conte P, Arteaga CL, Cameron DA, Hart LL, Villanueva C, Jakobsen EH, Lindquist D, Souami F, Li X, Germa C, Hirawat S, Hortobagyi GN. First-line ribociclib plus letrozole in patients with de novo HR+, HER2– advanced breast cancer (ABC): A subgroup analysis of the MONALEESA-2 trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-05.

Abstract PD1-07: Comprehensive characterization of matched pre-treatment biopsies and residual disease of doxorubicin treated breast cancer

Background

Neoadjuvant chemotherapy is standard of care for locally advanced breast cancer. Unfortunately not all patients benefit from this treatment. Even after decades of research, we still cannot predict which tumor will or will not respond. This may in part be due to tumor heterogeneity, as the sample taken before treatment not necessarily represents the tumor cell population that causes therapy resistance.

Methods

To test this hypothesis, we collected pre-treatment biopsies, resection specimens, and matched blood from 21 breast cancer patients treated with doxorubicin and cyclophosphamide in a neoadjuvant setting. Specifically, tumors were selected with a tumor percentage >50% after chemotherapy to enrich for resistant samples and ensure high quality data. RNA and whole exome sequencing were performed to characterize somatic mutations, copy number alterations and gene expression profiles. Histopathological characteristics were determined to obtain a comprehensive profile of all tumor samples.

Results

The comparisons of somatic variants and copy number alterations revealed a very diverse image: in several cases, high-level amplifications, large genomic gains or losses, and mutations in known oncogenes or tumor suppressors such as MAP3K1 and RUNX1 were either lost or gained during treatment, while in other cases no such changes were detected. We observed a remarkable number of genetic alterations involved in cell cycle progression and DNA damage checkpoints, including amplification of MDM2, CCND1 and CDK4, and copy number loss or mutations in CDKN1B and ATM. Strikingly, both cases of CDKN1B loss were identified in pre-treatment biopsies and no longer detectable in the surgery specimen. In contrast, CCND1, CDK4 and MDM2 amplifications were retained, although CCND1 expression decreased significantly in CCND1 amplified tumors.

In addition, eighty percent of tumors showed a decreased cell proliferation after chemotherapy, where the high-proliferative ER+ (Luminal B) tumors were most strongly affected. This trend was also visible in a validation cohort of 94 ER+ samples, but the prognosis of Luminal B tumors that showed a decrease in proliferation was still significantly worse than that of Luminal A tumors that did not show an altered proliferation rate.

Conclusion

Our results confirm that biologically relevant genomic alterations can differ between pre- and post-treatment samples, which greatly impacts biomarker discovery. In addition, our findings emphasize the chemotherapy insensitivity of CCND1 amplified ER+ breast cancers, and stress the need for better treatment regimens for these patients. In contrast, genomic loss of CDKN1B may be a marker for sensitivity to doxorubicin.

Citation Format: Lips EH, Hoogstraat M, Mulder L, Nederlof PM, Sonke GS, Rodenhuis S, Wesseling J, Wessels LFA. Comprehensive characterization of matched pre-treatment biopsies and residual disease of doxorubicin treated breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD1-07.

Abstract OT1-01-08: Intensified alkylating chemotherapy in patients with oligo-metastatic breast cancer harboring homologous recombination deficiency: The OLIGO study

Background Approximately 5% of patients with metastatic breast cancer survive more than 10 years. Long-term survival is mostly seen in patients with limited metastatic disease, often referred to as 'oligo'-metastatic disease. Oligo-metastatic breast cancer is variably defined as a maximum of 3-5 metastases beyond the regional lymph nodes. Some believe that oligo-metastatic cancer can be treated with curative intent using a multidisciplinary approach that targets the detected metastases, circulating micro-metastases, and any locoregional disease if present. Optimal patient selection is of vital importance.

Intensified alkylating chemotherapy in the treatment of breast cancer patients is controversial, as older studies have not shown a survival benefit in unselected groups of patients. More recent retrospective analyses, however, have suggested that patients with homologous recombination deficiency (HRD) derive significant benefit from intensified chemotherapy in comparison to conventional chemotherapy.

Trial design In this phase 3 trial patients with oligo-metastatic breast cancer and HRD start with 3 cycles of induction chemotherapy. Chemotherapy schedule includes anthracyclines and taxanes in treatment naïve patients and is personalized according to previously received (neo-)adjuvant chemotherapy in others. Patients with at least stable disease after 3 cycles are 1:1 randomized to receive another 3 cycles of conventional chemotherapy or progenitor cell mobilization with cyclophosphamide followed by 2 cycles of intensified chemotherapy (carboplatin 400 mg/m2 (day 1&2), thiotepa 250 mg/m2 (day 2), and cyclophosphamide 3000 mg/m2 (day 1)) and peripheral blood progenitor cell reinfusion. Following systemic treatment, all patients receive maximal local therapy of locoregional and distant disease with surgery and/or radiotherapy.

Eligibility criteria Eligible patients have histologically proven, HER2 negative, oligo-metastatic breast cancer (1-3 distant metastatic lesions), with or without locoregional disease, either as de novo disease or recurrence. All lesions must be amenable to surgery or radiotherapy with curative intent. The tumor has to be deficient in homologous recombination by array comparative genomic hybridization and no prior chemotherapy for metastatic disease is allowed.

Specific aim To study the difference in event-free survival (EFS) between intensified alkylating chemotherapy compared to standard chemotherapy as part of a multimodality treatment approach in patients with oligo-metastatic breast cancer harboring HRD.

Statistical methods and patient accrual Primary endpoint of the study is EFS at 3 years. Toxicity, time to recurrence, and overall survival will be evaluated as secondary endpoints. A total of 65 EFS events will provide 80% power to detect a hazard ratio of 2.0 between treatment arms at the 0.05 two-sided significance level. Assuming an accrual period of 48 months and a maximum follow-up time of 60 months, 86 patients are required. At the time of abstract submission, 33 patients were randomized.

Contact information Principal investigator: Dr. GS Sonke, g.sonke@nki.nl. Study coordinator: TG Steenbruggen, t.steenbruggen@nki.nl. Clinicaltrials.gov: NCT01646034.

Citation Format: Steenbruggen TG, Vrancken Peeters M-JTFD, Scholten AN, Schot M, Wesseling J, Linn SC, Sonke GS. Intensified alkylating chemotherapy in patients with oligo-metastatic breast cancer harboring homologous recombination deficiency: The OLIGO study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-01-08.

Abstract P5-08-07: The long-term prognosis of breast cancers patients diagnosed ≤40 years in the absence of adjuvant systemic therapy

This abstract was withdrawn by the authors.

Abstract P4-21-30: Long-term survival in HER2-positive metastatic breast cancer: The first blow is half the battle

Introduction: Metastatic breast cancer (MBC) is considered an incurable disease. However, long-term survival is increasingly observed in HER2-positive disease since the introduction of trastuzumab. We explored factors associated with long-term survival in a retrospective series at our Institute.

Methods: All patients with histologically proven HER2-positive (3+ score by IHC or HER2 amplification) MBC treated starting first-line trastuzumab-based palliative therapy between January 2003 to January 2013 were included. Patients were identified from the Institute's tumor registry and data were collected from patient records. The primary endpoint was overall survival. Kaplan-Meier survival estimates were calculated and multivariable survival analyses were performed to identify independent prognostic factors. Radiologic complete response (CR) was a secondary endpoint.

Results: We identified 113 patients with a median age at diagnosis of MBC of 52 years (range 27-82). Median follow-up for MBC was 39 months (range 2-148 months). Thirty-eight percent presented with synchronous metastases; 62% had recurrent disease of whom 42% had received prior trastuzumab as part of (neo-)adjuvant treatment. First-line palliative treatment consisted of trastuzumab plus vinorelbine (56%), a taxane (28%), capecitabine (10%), other chemotherapy (3%), or endocrine therapy (2%), and resulted in a CR in 27 patients (24%). In addition, one patient achieved CR to third-line therapy. Most patients with CR had received trastuzumab with a taxane (57%) followed by vinorelbine (32%). Fourteen out of 28 patients with CR are still alive without evidence of disease at a median follow-up of 91 months (range 23-148 months), of whom 8 still receive trastuzumab. Fourteen patients had disease relapse (8 on maintenance trastuzumab, 6 after discontinuation). Overall, 35 patients (31%) survived more than 5 years. Factors associated with long-term survival in univariable analyses were oligo-metastatic disease (1-3 distant metastases), synchronous metastases, no skin or brain metastases, no prior (neo-)adjuvant trastuzumab, first-line palliative treatment with trastuzumab and taxanes, and achieving a radiologic CR on treatment (see table 1). Achieving CR and the absence of skin metastases remained significant factors in multivariable analyses.

Conclusion: Thirty-one percent of patients with metastatic HER2-positive MBC survive over 5 years. Long-term response is particularly seen in patients who achieve a complete radiologic response on first-line treatment. This finding supports a strategy to administer the most effective agents as first line treatment, as is often but not always applied in clinical practice.

Table 1. Prognostic factors associated with overall survival  Univariable  Multivariable  HR95% CIpHR95% CIpSynchronous metastases      No-  -  Yes0.44(0.27-0.70)<0.0010.80(0.46-1.40)0.43Oligo-metastatic disease      No-  -  Yes0.37(0.22-0.62)<0.010.66(0.36-1.17)0.14Skin metastases      No-  -  Yes5.40(2.91-10.01)<0.014.10(2.08-8.14)<0.01Brain metastases      No-  -  Yes2.25(1.03-4.93)0.041.46(0.55-3.98)0.45(Neo-)adjuvant trastuzumab      No-  -  Yes1.87(1.16-2.99)0.011.66(0.93-2.96)0.09Trastuzumab + taxane      No-  -  Yes0.54(0.32-0.89)0.020.69(0.40-1.20)0.19Complete radiologic response      No-  -  Yes0.13(0.06-0.29)<0.010.22(0.09-0.53)0.001

Citation Format: Steenbruggen TG, van Ramshorst MS, Stouthard JML, Rodenhuis S, Linn SC, Sonke GS, Smorenburg CH. Long-term survival in HER2-positive metastatic breast cancer: The first blow is half the battle [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-30.

Trastuzumab in combination with weekly paclitaxel and carboplatin as neo-adjuvant treatment for HER2-positive breast cancer: The TRAIN-study

AIM

To determine the efficacy and safety of an anthracycline-free neo-adjuvant regimen consisting of weekly paclitaxel, carboplatin and trastuzumab in HER2-positive breast cancer.

PATIENTS AND METHODS

Patients with stage II or III HER2-positive breast cancer received weekly paclitaxel ([P], 70 mg/m²), trastuzumab ([T], 2 mg/kg, loading dose 4 mg/kg) and carboplatin ([C], AUC = 3 mg ml^-1 min) for 24 weeks. In weeks 7, 8, 15, 16, 23 and 24, trastuzumab was administered without chemotherapy. The primary end-point was pathologic complete response in the surgical resection specimen, defined as the absence of invasive tumour cells in breast and axilla.

RESULTS

One hundred and eleven patients were included in the study, and 108 were evaluable for the primary end-point. The pathologic complete response rate was 43% (95% confidence interval [CI]: 33-52). Median follow-up was 52 months, and the 3-year event-free survival was 88% (95% CI: 82-94), and the 3-year overall survival was 92% (95% CI: 88-98). The most common grade 3-4 adverse events were neutropenia (67%) and thrombocytopenia (43%). Less than five percent of patients experienced febrile neutropenia. No symptomatic left ventricular systolic dysfunction was observed during neo-adjuvant treatment.

CONCLUSION

An anthracycline-free neo-adjuvant regimen of weekly paclitaxel, trastuzumab and carboplatin is highly effective in HER2-positive breast cancer with manageable toxicity.

Ribociclib as First-Line Therapy for HR-Positive, Advanced Breast Cancer

BACKGROUND

The inhibition of cyclin-dependent kinases 4 and 6 (CDK4/6) could potentially overcome or delay resistance to endocrine therapy in advanced breast cancer that is positive for hormone receptor (HR) and negative for human epidermal growth factor receptor 2 (HER2).

METHODS

In this randomized, placebo-controlled, phase 3 trial, we evaluated the efficacy and safety of the selective CDK4/6 inhibitor ribociclib combined with letrozole for first-line treatment in 668 postmenopausal women with HR-positive, HER2-negative recurrent or metastatic breast cancer who had not received previous systemic therapy for advanced disease. We randomly assigned the patients to receive either ribociclib (600 mg per day on a 3-weeks-on, 1-week-off schedule) plus letrozole (2.5 mg per day) or placebo plus letrozole. The primary end point was investigator-assessed progression-free survival. Secondary end points included overall survival, overall response rate, and safety. A preplanned interim analysis was performed on January 29, 2016, after 243 patients had disease progression or died. Prespecified criteria for superiority required a hazard ratio of 0.56 or less with P<1.29×10^-5.

RESULTS

The duration of progression-free survival was significantly longer in the ribociclib group than in the placebo group (hazard ratio, 0.56; 95% CI, 0.43 to 0.72; P=3.29×10^-6 for superiority). The median duration of follow-up was 15.3 months. After 18 months, the progression-free survival rate was 63.0% (95% confidence interval [CI], 54.6 to 70.3) in the ribociclib group and 42.2% (95% CI, 34.8 to 49.5) in the placebo group. In patients with measurable disease at baseline, the overall response rate was 52.7% and 37.1%, respectively (P<0.001). Common grade 3 or 4 adverse events that were reported in more than 10% of the patients in either group were neutropenia (59.3% in the ribociclib group vs. 0.9% in the placebo group) and leukopenia (21.0% vs. 0.6%); the rates of discontinuation because of adverse events were 7.5% and 2.1%, respectively.

CONCLUSIONS

Among patients receiving initial systemic treatment for HR-positive, HER2-negative advanced breast cancer, the duration of progression-free survival was significantly longer among those receiving ribociclib plus letrozole than among those receiving placebo plus letrozole, with a higher rate of myelosuppression in the ribociclib group. (Funded by Novartis Pharmaceuticals; ClinicalTrials.gov number, NCT01958021 .).

Phase II Study of WEE1 Inhibitor AZD1775 Plus Carboplatin in Patients With TP53-Mutated Ovarian Cancer Refractory or Resistant to First-Line Therapy Within 3 Months

Purpose AZD1775 is a first-in-class, potent, and selective inhibitor of WEE1 with proof of chemopotentiation in p53-deficient tumors in preclinical models. In a phase I study, the maximum tolerated dose of AZD1775 in combination with carboplatin demonstrated target engagement. We conducted a proof-of-principle phase II study in patients with p53 tumor suppressor gene ( TP53)-mutated ovarian cancer refractory or resistant (< 3 months) to first-line platinum-based therapy to determine overall response rate, progression-free and overall survival, pharmacokinetics, and modulation of phosphorylated cyclin-dependent kinase (CDK1) in skin biopsies. Patients and Methods Patients were treated with carboplatin (area under the curve, 5 mg/mL⋅min) combined with AZD1775 225 mg orally twice daily over 2.5 days every 21-day cycle until disease progression. Results AZD1775 plus carboplatin demonstrated manageable toxicity; fatigue (87%), nausea (78%), thrombocytopenia (70%), diarrhea (70%), and vomiting (48%) were the most common adverse events. The most frequent grade 3 or 4 adverse events were thrombocytopenia (48%) and neutropenia (37%). Of 24 patients enrolled, 21 patients were evaluable for efficacy end points. The overall response rate was 43% (95% CI, 22% to 66%), including one patient (5%) with a prolonged complete response. Median progression-free and overall survival times were 5.3 months (95% CI, 2.3 to 9.0 months) and 12.6 months (95% CI, 4.9 to 19.7), respectively, with two patients with ongoing response for more than 31 and 42 months at data cutoff. Conclusion To our knowledge, this is the first report providing clinical proof that AZD1775 enhances carboplatin efficacy in TP53-mutated tumors. The encouraging antitumor activity observed in patients with TP53-mutated ovarian cancer who were refractory or resistant (< 3 months) to first-line therapy warrants further development.

BRCA1-Mutated Estrogen Receptor-Positive Breast Cancer Shows BRCAness, Suggesting Sensitivity to Drugs Targeting Homologous Recombination Deficiency

Purpose: As estrogen receptor-positive (ER⁺) breast cancer in BRCA1 mutation carriers arises at an older age with less aggressive tumor characteristics than ER-negative (ER^-) BRCA1-mutated breast cancer, it has been suggested that these tumors are "sporadic" and not BRCA1 driven. With the introduction of targeted treatments specific for tumors with a nonfunctioning BRCA1 or BRCA2 gene, the question whether the BRCA genes are impaired in the tumor is highly relevant. Therefore, we performed genomic profiling of BRCA1-mutated ER⁺ tumors.Experimental Design: Genomic profiling, BRCA1 promoter methylation assessment, and loss of heterozygosity analysis were done on 16 BRCA1-mutated ER⁺ tumors. Results were compared with 57 BRCA1-mutated ER^- tumors, 36 BRCA2-mutated ER⁺-associated tumors, and 182 sporadic ER⁺ tumors.Results: The genomic profile of BRCA1-mutated ER⁺ tumors was different from BRCA1-mutated ER^- breast tumors, but highly similar to BRCA2-mutated ER⁺ tumors. In 83% of the BRCA1-mutated ER⁺ tumors, loss of the wild-type BRCA1 allele was observed. In addition, clinicopathologic variables in BRCA1-mutated ER⁺ cancer were also more similar to BRCA2-mutated ER⁺ and sporadic ER⁺ breast cancer than to BRCA1-mutated ER^- cancers.Conclusions: As BRCA1-mutated ER⁺ tumors show a BRCAness copy number profile and LOH, it is likely that the loss of a functional BRCA1 protein plays a role in tumorigenesis in BRCA1-mutated ER⁺ tumors. Therefore, we hypothesize that these tumors are sensitive to drugs targeting the BRCA1 gene defect, providing new targeted treatment modalities for advanced BRCA-deficient, ER⁺ breast cancer. Clin Cancer Res; 23(5); 1236-41. ©2016 AACR.

Adjuvant systemic therapy in early breast cancer: impact of guideline changes and clinicopathological factors associated with nonadherence at a nation-wide level

Over recent years, adjuvant systemic treatment guidelines (AST) for early-stage breast cancer have changed considerably. We aimed to assess the impact of these guideline changes on the administration of AST in early-stage breast cancer patients and to what extent these guidelines are adhered to at a nation-wide level. We used Netherlands Cancer Registry data to describe trends in AST prescription, adherence to AST guidelines, and to identify clinicopathological determinants of nonadherence. Between 1990 and 2012, 231,648 Dutch patients were diagnosed with early breast cancer, of whom 124,472 received AST. Adjuvant endocrine treatment (ET) use increased from 23 % of patients (1990) to 56 % (2012), and chemotherapy from 11 to 44 %. In 2009-2012, 8 % of patients received ET and 3 % received chemotherapy without guideline indication. Conversely, 10-29 % of patients did not receive ET and chemotherapy, respectively, despite a guideline indication. Unfavorable clinicopathological characteristics generally decreased the chance of undertreatment and increased the chance for overtreatment. Remarkable was the increased chance of ET undertreatment in younger women (RR < 35 vs 60-69 years 1.79; 95 % CI 1.30-2.47) and in women with HER2+ disease (RR 1.64; 95 % CI 1.46-1.85). Over the years, AST guidelines expanded resulting in much more Dutch early breast cancer patients receiving AST. In the majority of cases, AST administration was guideline concordant, but the high frequency of chemotherapy undertreatment in some subgroups suggests limited AST guideline support in these patients.

The effect of trastuzumab-based chemotherapy in small node-negative HER2-positive breast cancer

The prognosis of patients with stage II-III Human Epidermal growth factor Receptor 2 (HER2)-positive breast cancer has significantly improved since the addition of trastuzumab to (neo-)adjuvant chemotherapy. Several reports have shown that small (≤2 cm), node-negative, HER2-positive tumors have a relatively poor prognosis and these patients increasingly receive trastuzumab-based chemotherapy. We aimed to provide evidence for this approach in a population-based cohort. All T1N0M0 HER2-positive breast cancer patients diagnosed between 2006 and 2012 were identified from the Netherlands Cancer Registry. Patient, tumor, and treatment characteristics were recorded. Kaplan-Meier statistics were used for overall survival (OS) and breast cancer-specific survival (BCSS) estimations overall and in T1a, T1b, and T1c tumors separately. Cox regression analyses were performed to account for imbalances in baseline characteristics between treated and untreated patients. A total of 3512 patients were identified: 385 with T1a, 800 with T1b, and 2327 with T1c tumors. Forty-five percent of patients received chemotherapy and/or trastuzumab: 92 % received both. Chemotherapy and/or trastuzumab significantly improved 8-year OS (95 vs. 84 %; hazard ratio [HR] 0.29; 95 % confidence interval [CI] 0.21-0.41, P < 0.001). The effect remained significant in multivariable analyses (HR 0.35; 95 % CI 0.23-0.52, P < 0.001). BCSS was also improved with systemic treatment in univariable (96 vs. 92 %; HR 0.41; 95 % CI 0.27-0.63, P < 0.001) and multivariable analyses (HR 0.31; 95 % CI 0.19-0.53, P < 0.001). Treatment effect on OS and BCSS was similar in T1a, T1b, and T1c tumors. Chemotherapy and/or trastuzumab improves OS and BCSS and can be considered in all patients with small node-negative HER2-positive breast cancer.

A phase I followed by a randomized phase II trial of two cycles carboplatin-olaparib followed by olaparib monotherapy versus capecitabine in BRCA1- or BRCA2-mutated HER2-negative advanced breast cancer as first line treatment (REVIVAL): study protocol for a randomized controlled trial

Background

Preclinical studies in breast cancer models showed that BRCA1 or BRCA2 deficient cell lines, when compared to BRCA proficient cell lines, are extremely sensitive to PARP1 inhibition. When combining the PARP1 inhibitor olaparib with cisplatin in a BRCA1-mutated breast cancer mouse model, the combination induced a larger response than either of the two compounds alone. Several clinical studies have investigated single agent therapy or combinations of both drugs, but no randomized clinical evidence exists for the superiority of carboplatin-olaparib versus standard of care therapy in patients with BRCA1- or BRCA2--mutated metastatic breast cancer.

Methods/design

This investigator-initiated study contains two parts. Part 1 is a traditional 3 + 3 dose escalation study of the carboplatin-olaparib combination followed by olaparib monotherapy. The carboplatin dose will be escalated from area under the curve (AUC) 3 to AUC 4 with an olaparib dose of 25 mg BID. Olaparib is subsequently escalated to 50, 75, and 100 mg BID until >1/6 of patients develop dose-limiting toxicity (DLT). The dose level below will be the maximum tolerable dose (MTD). It is expected that 15–20 patients are needed in Part I.

In Part 2 BRCA1- or BRCA2-mutated HER2-negative breast cancer patients will be randomized between standard capecitabine 1250 mg/m² BID day 1–14 q day 22, versus 2 cycles carboplatin-olaparib followed by olaparib monotherapy 300 mg BID. In total 104 events in 110 patients need to be observed to detect a 75 % clinically meaningful improvement in progression-free survival (PFS), from a median of 4 months (control) to 7 months (experimental) assuming a 2-year accrual and ≥6 months of follow-up with 80 % power (5 %, two-sided significance level). After progression on first line treatment, patients will receive physician’s best choice of paclitaxel, vinorelbine, eribulin, or capecitabine (experimental arm only) at standard dose. A compassionate use program of olaparib is available for patients in the standard arm after progression on second line treatment.

Discussion

Results might be pivotal for registration of olaparib as standard first line treatment in advanced BRCA1- or BRCA2-mutated breast cancer.

Trial registration

ClinicalTrials.gov identifier: NCT02418624. Registered on 9 March 2015. EudraCT number: 2013-005590-41. Registered on 15 October 2014. Protocol version 3.0.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1423-0) contains supplementary material, which is available to authorized users.

Contemporary Locoregional Recurrence Rates in Young Patients With Early-Stage Breast Cancer

Purpose

The aim of this study was to evaluate contemporary rates of local recurrence (LR) and regional recurrence (RR) in young patients with breast cancer in relation to tumor biology as expressed by biomarker subtypes.

Patients and Methods

Women < 35 years of age who underwent surgery for primary unilateral invasive breast cancer between 2003 and 2008 were selected from the Netherlands Cancer Registry. Patients were categorized according to biomarker subtypes on the basis of hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status. The 5-year risks of developing LR and regional lymph node recurrence were estimated by using Kaplan-Meier statistics.

Results

A total of 1,000 patients were identified, of whom 59% had a known subtype: 39% HR-positive/HER2-negative; 17% HR-positive/HER2-positive; 10% HR-negative/HER2-positive; and 34% HR-negative/HER2-negative (triple negative). Overall 5-year LR and RR rates were 3.5% and 3.7%, respectively. A decreasing trend for both rates was observed over time and was accompanied by a significant decrease in the risk of distant metastases (DM). LR occurred in 4.2%, RR in 6.1%, and DM in 17.8% of patients in 2003, and in 3.2%, 4.4%, and 10.0%, respectively, in 2008. LR and RR rates varied with biomarker subtype. These differences were borderline significant when analyzed for the entire study period (P = .056 and P = .014, respectively) and leveled off after the introduction of trastuzumab after 2005 (P = .24 and P = .42, respectively). Patients with lymph node metastases at the time of diagnosis had an increased risk of RR. The type of surgery performed—breast-conserving or mastectomy—did not influence rates of LR and RR.

Conclusion

Overall, the rates of LR and RR in young patients with early-stage breast cancer were relatively low and varied by biomarker subtype.

Abstract PD5-02: The effect of trastuzumab-based therapy on overall survival in small, node-negative HER2-positive breast cancer: To treat or not to treat?

Background Since the addition of trastuzumab to (neo)adjuvant chemotherapy, the prognosis of patients with stage II and III HER2-positive breast cancer has significantly improved. Several reports have subsequently shown that small, node-negative tumors also carry a relatively poor prognosis and patients with HER2-positive tumors of 2cm or less increasingly receive trastuzumab-based chemotherapy. We sought to provide evidence for the effect of this approach in a population-based cohort.

Methods All patients diagnosed with T1N0 HER2-positive breast cancer in the Netherlands between 2006 and 2012 were identified from the nationwide Netherlands Cancer Registry. Patient, tumor, and treatment characteristics were recorded. The primary outcome was overall survival and analyses were performed for the whole group and for T1a, T1b, and T1c tumors separately. Kaplan-Meier survival rates were compared between groups with and without systemic treatment and multivariate cox regression analysis was performed to adjust for baseline characteristics.

Results A total of 3512 eligible patients were identified of whom 385 had a T1a tumor (≤0.5cm, including 54 micro-invasive), 800 had a T1b tumor (&gt;0.5 to 1cm), and 2327 had a T1c tumor (&gt;1cm to 2cm). Systemic treatment with chemotherapy and/or trastuzumab was administered in 45% of patients: 7% in T1a, 19% in T1b, and 60% in T1c tumors. Of the treated patients, the majority (92%) received both chemotherapy and trastuzumab. The use of systemic treatment increased significantly over time and varied according to geographic region. Other factors associated with receiving systemic treatment in multivariate analysis were younger age, negative hormone receptor status, higher tumor grade, larger tumor size and presence of isolated tumor cells in the lymph nodes.

At a median follow-up of 49 months (interquartile range [IQR] 30-69), 186 deaths had occurred. Treatment with chemotherapy and/or trastuzumab significantly improved overall survival at seven years follow-up (95% versus 87%; hazard ratio [HR] 0.30; 95% confidence interval [CI] 0.20-0.44, p&lt;0.001). This effect was seen in all three tumor size groups: 100% versus 91% in T1a, 99% versus 91% in T1b, and 95% versus 83% in T1c tumors. When corrected for age the beneficial effect of systemic treatment on overall survival remained highly significant (HR 0.46; 95% CI 0.30-0.70, p&lt;0.001). Due to the small number of events in the treated group, correction for additional variables in multivariate analysis was not feasible. However, the otherwise unfavorable prognostic profile in the treated patients (hormone receptor status, grade, size, isolated tumor cells), suggests an even stronger actual effect of systemic treatment. To ensure that the excess mortality in the non-treated group was due to breast cancer and not the result of other causes, breast-cancer specific survival analyses will follow.

Conclusion Systemic treatment with chemotherapy and/or trastuzumab improves overall survival in T1a, T1b, and T1c node-negative HER2-positive breast cancer.

Citation Format: van Ramshorst MS, van der Heijden-van der Loo M, Dackus GMHE, Linn SC, Sonke GS. The effect of trastuzumab-based therapy on overall survival in small, node-negative HER2-positive breast cancer: To treat or not to treat?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD5-02.

Abstract OT1-03-10: A phase I followed by a randomized phase II trial of two cycles carboplatin-olaparib followed by olaparib monotherapy versus capecitabine in BRCA-1 or -2 mutated Her2 negative advanced breast cancer as first line treatment (REVIVAL study)

Background

Preclinical studies revealed that the combination of platinum compounds and olaparib is additive and possibly even synergistic in cell models with BRCA1 or -2 mutations. Early clinical trials suggested high benefit of olaparib with induction carboplatin in BRCA1 and -2 mutation carrier enriched populations. However, there is no evidence yet that carboplatin-olaparib has a superior benefit-risk compared to current standard therapy in advanced breast cancer in BRCA1 and -2 mutation carriers.

Trial design

We initiated a phase-I/II study due to an olaparib formulation change from capsule to tablet. During phase-I a traditional 3+3 dose escalation study is performed. Carboplatin will be dose escalated in 1 step from AUC 3 to AUC 4 with a constant olaparib dose of 25 mg BID. Olaparib is then dose escalated in 3 steps to 50, 75 and 100 mg BID until &gt; 1/6 patients develop a DLT, the previous safe dose-level will be determined the MTD. After the MTD is established a randomised phase-II trial will be initiated where patients are randomised between standard capecitabine 1250 mg/m2 BID day 1-14, q day 22 or 2 cycles carboplatin-olaparib followed by olaparib monotherapy 300mg BID. After progression, patients in the experimental arm receive capecitabine, all other patients receive physicians choice of paclitaxel, vinorelbine or eribulin at standard dose. A compassionate use program with olaparib is available for patients in the standard arm after progression on second line treatment.

Eligibility criteria

In phase-II patients with histological or cytological proof of advanced BRCA1 or -2 mutated HER2 negative breast cancer are eligible if they are ≥18 years, have measureable disease according to RECIST 1.1 criteria, a WHO performance status of 0–2, a life expectancy ≥ 3 months and a negative pregnancy test. Pretreatment should contain an anthracycline and/or taxane in the (neo)adjuvant setting, unless not indicated. In the advanced setting only hormonal pre-treatment is allowed. Minimal laboratory values ANC ≥ 1.5 x 109 /L, Hb ≥ 6.2 mM (no transfusions in the last 28 days), platelet count ≥ 100 x 109 /L, serum bilirubin &lt; 1.5 x ULN, ASAT and ALAT &lt; 2.5 x ULN and a serum creatinine &lt; 1.5 x ULN or creatinine clearance ≥ 50 mL/min.

Aims

In phase-1 we establish the MTD for treatment in phase-II where we study progression free survival on first line treatment(PFS1) compared with standard of care capecitabine.

Statistical methods

Toxicity analysis in phase-I can take place after all patients completed their 28 day DLT period.

A total of 104 events in 110 patients on first line treatment need to be observed in phase-II to detect a clinical meaningful improvement in median PFS1 in the experimental arm from 4 to 7 months, assuming an accrual of 2 years and a follow-up of ≥6 months, providing a power of 80% (two-sided significance level of 5%). An interim analysis for futility and efficacy will be performed when 52 events have been observed.

Accrual

It is expected that 15-20 patients are needed in phase-I, inclusion is due around November 2015. Phase-II will be multicentre and is expected to start accrual December 2015.

Citation Format: Dackus GMHE, Schouten PC, Geenen JJ, Marchetti S, Sonke GS, Linn SC, Schellens JHM. A phase I followed by a randomized phase II trial of two cycles carboplatin-olaparib followed by olaparib monotherapy versus capecitabine in BRCA-1 or -2 mutated Her2 negative advanced breast cancer as first line treatment (REVIVAL study). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-03-10.

Abstract P5-08-36: Contemporary risk of local breast cancer recurrence after neo-adjuvant chemotherapy: Results of a population-based cohort study

Introduction

Neo-adjuvant chemotherapy (NAC) is increasingly used in breast cancer to enable less extensive surgery and monitor the response to systemic therapy. Little is known about local recurrence (LR) in patients who received NAC. However, this information is important when deciding on optimal local treatment in these patients, especially since NAC is increasingly being offered to patients with smaller tumors. The aim of this study is to assess the contemporary rates of local breast cancer recurrence in patients that received NAC.

Methods

All women treated with NAC for primary invasive breast cancer in the years 2003-2008 were selected from the Netherlands Cancer Registry. The first event within five years after NAC was included for analyses. The 5-year local (LR) recurrence rate was calculated using Kaplan Meier estimates and the prognostic value of various clinicopathological and treatment factors was evaluated.

Results

A total of 2,457 patients were identified of whom 43% had cT1-2, 25% cT3 and 29% cT4 tumors. Two-thirds of the patients had metastatic lymph node involvement and 85% received adjuvant radiotherapy. The overall 5-year risk of LR was 6.7% and decreased from 2003-2008.

Table 1. Overall 5-year rate of local breast cancer recurrence in 2,457 breast cancer patients that received neo-adjuvant chemotherapy in the period 2003-2008.  Local recurrencea  NRate2003N=412309.6%2004N=429288.0%2005N=549398.1%2006N=604234.7%2007N=406164.7%2008N=489245.5%TotalN=2,4571606.7%aLocal recurrence defined as ipsilateral in-breast recurrence or new primary Rates represent Kaplan Meier estimates

The LR-rate was lower in hormone receptor positive (HR+) than HR-negative (HR-) tumors (3.3% vs. 12.9%) and increased with larger residual tumor size (from 1.2% in ypT0 to 13.0% in ypT3 and 16.1% in ypT4 tumors). The LR-rate also increased with the ypN-stage (4.1% in ypN0, 5.7% in ypN1 and 11.3% in ypN&gt;1 patients) and was lower following breast-conserving surgery (BCS) than after mastectomy (4.8% vs. 7.2%).

Currently, we are working on the multivariate analyses, which will be available at the San Antonio Breast Cancer Symposium.

Conclusions

The rate of LR in patients treated with NAC has decreased over time. This will most likely be caused by enhanced imaging and radiotherapy techniques, as well as by increased insight in tumor biology resulting in improvements in both the development and application of systemic treatment modalities. Multivariate analyses will have to provide further insight into the risk of developing LR in patients treated with NAC, as well as into the prognostic value of different clinicopathological factors.

Citation Format: Aalders KC, Sonke GS, van der Heiden-van der Loo M, Boersma LJ, van Diest PJ, Siesling S, van Dalen T. Contemporary risk of local breast cancer recurrence after neo-adjuvant chemotherapy: Results of a population-based cohort study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-36.

Abstract S6-06: The effect of trastuzumab-based therapy on overall survival in small, node-negative HER2-positive breast cancer: To treat or not to treat?

Background Since the addition of trastuzumab to (neo)adjuvant chemotherapy, the prognosis of patients with stage II and III HER2-positive breast cancer has significantly improved. Several reports have subsequently shown that small, node-negative tumors also carry a relatively poor prognosis and patients with HER2-positive tumors of 2cm or less increasingly receive trastuzumab-based chemotherapy. We sought to provide evidence for the effect of this approach in a population-based cohort.

Methods All patients diagnosed with T1N0 HER2-positive breast cancer in the Netherlands between 2006 and 2012 were identified from the nationwide Netherlands Cancer Registry. Patient, tumor, and treatment characteristics were recorded. The primary outcome was overall survival and analyses were performed for the whole group and for T1a, T1b, and T1c tumors separately. Kaplan-Meier survival rates were compared between groups with and without systemic treatment and multivariate cox regression analysis was performed to adjust for baseline characteristics.

Results A total of 3512 eligible patients were identified of whom 385 had a T1a tumor (≤0.5cm, including 54 micro-invasive), 800 had a T1b tumor (&gt;0.5 to 1cm), and 2327 had a T1c tumor (&gt;1cm to 2cm). Systemic treatment with chemotherapy and/or trastuzumab was administered in 45% of patients: 7% in T1a, 19% in T1b, and 60% in T1c tumors. Of the treated patients, the majority (92%) received both chemotherapy and trastuzumab. The use of systemic treatment increased significantly over time and varied according to geographic region. Other factors associated with receiving systemic treatment in multivariate analysis were younger age, negative hormone receptor status, higher tumor grade, larger tumor size and presence of isolated tumor cells in the lymph nodes.

At a median follow-up of 49 months (interquartile range [IQR] 30-69), 186 deaths had occurred. Treatment with chemotherapy and/or trastuzumab significantly improved overall survival at seven years follow-up (95% versus 87%; hazard ratio [HR] 0.30; 95% confidence interval [CI] 0.20-0.44, p&lt;0.001). This effect was seen in all three tumor size groups: 100% versus 91% in T1a, 99% versus 91% in T1b, and 95% versus 83% in T1c tumors. When corrected for age the beneficial effect of systemic treatment on overall survival remained highly significant (HR 0.46; 95% CI 0.30-0.70, p&lt;0.001). Due to the small number of events in the treated group, correction for additional variables in multivariate analysis was not feasible. However, the otherwise unfavorable prognostic profile in the treated patients (hormone receptor status, grade, size, isolated tumor cells), suggests an even stronger actual effect of systemic treatment. To ensure that the excess mortality in the non-treated group was due to breast cancer and not the result of other causes, breast-cancer specific survival analyses will follow.

Conclusion Systemic treatment with chemotherapy and/or trastuzumab improves overall survival in T1a, T1b, and T1c node-negative HER2-positive breast cancer.

Citation Format: van Ramshorst MS, van der Heijden-van der Loo M, Dackus GMHE, Linn SC, Sonke GS. The effect of trastuzumab-based therapy on overall survival in small, node-negative HER2-positive breast cancer: To treat or not to treat?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S6-06.

Abstract P5-08-01: Contemporary local and regional recurrence rates in very young breast cancer patients

Introduction: Historically, young breast cancer patients proved to have a poorer prognosis regarding survival and locoregional recurrence. Over the last two decades, the survival of breast cancer patients has improved substantially, while at the same time locoregional recurrence rates decreased. The diminishing recurrence rates in the overall breast cancer population and acknowledgement of tumor biology and intrinsic subtypes in relation to age, raise the question whether the historically high locoregional recurrence risk in young women has decreased over a time where systemic treatment has evolved, particularly for the aggressive tumor types that occur frequently in young women. The aim of this study was to evaluate contemporary local and regional recurrence rates in very young breast cancer patients in relation to tumor biology in the shape of intrinsic subtypes.

Methods: Women &lt;35 years of age who were operated for primary unilateral invasive breast cancer between 2003-2008 were selected from the Netherlands Cancer Registry. Patients were categorized according to intrinsic subtypes using hormone receptor and HER2 status. The 5-year risks of developing local recurrence (LR) and regional lymph node recurrence (RR) were estimated using Kaplan Meier statistics. The prognostic influence of different clinicopathological and treatment factors was assessed.

Results: A total of 1,000 patients were identified. The overall 5-year LR and RR rates were 3.5% and 3.7% respectively and a decreasing trend for both rates was observed over time.

Overall 5-year local, regional and distant recurrence rates over time in breast cancer patients &lt;35 years (n=1,000)  Local recurrence*Regional recurrenceDistant metastases  NRateNRateNRate2003n=21384.2%116.1%3617.8%2004n=212105.6%105.1%3819.2%2005n=18232.0%53.1%2514.6%2006n=17053.2%21.2%138.2%2007•n=11722.1%10.9%98.1%2008•n=10633.2%44.4%1010.0%Totaln=1,000313.5%333.7%13113.9%*Local recurrence (ipsilateral in-breast recurrence + new primary) •Fewer patients were included in the years 2007-2008 compared to earlier years due to the fact that some hospitals did not provide data for those years. Rates represent Kaplan Meier estimates

Intrinsic subtype proved to be a prognostic factor for both LR and RR (P=0.0556 and P=0.0141, respectively). Particularly HR-/HER2+ tumors were associated with high LR and RR rates. Patients with lymph node metastases at time of diagnosis had a higher RR-risk in both the total population (P=0.0349) as well as within the different intrinsic subtypes, although only significantly in the triple negative group (P=0.0401). Type of surgery did not influence the rate of LR and RR in this study.

Conclusions: Overall, the LR and RR rates in very young breast cancer patients were relatively low and decreased over time. The higher recurrence rates in this population were associated with the presence of more aggressive intrinsic subtypes. We emphasize that tumor biology should guide decision-making towards optimal treatment in this specific population. Although longer follow-up is needed, especially for this very young patient population, the results of this study provide important insight in the locoregional recurrence risks for this historically high-risk population.

Citation Format: Aalders KC, Postma EL, Strobbe LJ, van der Heiden-van der Loo M, Sonke GS, Boersma LJ, van Diest PJ, Siesling S, van Dalen T. Contemporary local and regional recurrence rates in very young breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-01.

Abstract P6-09-03: Time-dependent nomogram for risk of locoregional recurrence in early breast cancer patients: 10 year extension

Background

The objective of this study was to extent the recently developed and validated time-dependent logistic regression model and web-based nomogram. This nomogram is suitable for the annual long term risk prediction of locoregional recurrence (LRR) in individual breast cancer patients and clinical decision support with regard to the follow-up.

Methods

Women first diagnosed with early breast cancer between 2003-2006 in all Dutch hospitals were selected from the Netherlands Cancer Registry with five year of recurrence follow-up (n=37,230). Of the year 2003 follow-up was retrieved for ten years. In the first five years following primary breast cancer treatment 3.7% of the selected patients developed a LRR as a first event, in ten years 6.2%. Risk factors were determined using logistic regression and the risks were calculated per year, conditional on not being diagnosed with recurrence in the previous year. Discrimination and calibration were assessed. Bootstrapping was used for internal validation. Data on primary tumors diagnosed between 2007-2008 in 43 Dutch hospitals was used for external validation of the performance of the nomogram (n=12,308).

Results

The final model included the variables grade, size, multifocality, and nodal involvement of the primary tumor, and whether patients were treated with radio-, chemo- or hormone therapy. Model predictions were well calibrated. Estimates in the validation cohort did not differ significantly from the index cohort. The results were incorporated in a web-based nomogram. In 0.7% of the patients, the risk of LRR between year 5-10 was higher than the average risk of all patients in the first five years. All of these patients were aged below 50, had a tumour size larger than 2 cm, non-negative hormone status, received radiotherapy, but no hormone therapy and 19% developed a recurrence during ten years.

Conclusion/discussion

This validated and time-dependent nomogram for the prediction of annual LRR risks over ten years is simple to use and shows a good predictive ability in the Dutch population. It can be used as an instrument to identify patients with a low or high risk of LRR who might benefit from a less or more intensive and longer follow-up after breast cancer and to aid clinical decision-making for personalized follow-up.

Citation Format: Witteveen A, Vliegen IMH, Sonke GS, Klaase JM, IJzerman MJ, Siesling S. Time-dependent nomogram for risk of locoregional recurrence in early breast cancer patients: 10 year extension. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-09-03.

Ongoing Remission Nineteen Years after High-dose Chemotherapy for Oligometastatic Breast Cancer; What Can We Learn from this Patient?

Metastatic breast cancer is generally considered incurable. However, some patients show an exceptional response to treatment and enjoy long-term survival in good health. Here, we present a remarkable example of a patient who is still in remission 19 years after high-dose chemotherapy and locoregional treatment for limited oligometastatic breast cancer. We will outline our rationale for this treatment to explain her excellent response and suggest strategies to select larger patient groups that could similarly benefit from existing treatment approaches.

Clinical relevance of DPYD variants c.1679T>G, c.1236G>A/HapB3, and c.1601G>A as predictors of severe fluoropyrimidine-associated toxicity: a systematic review and meta-analysis of individual patient data

BACKGROUND

The best-known cause of intolerance to fluoropyrimidines is dihydropyrimidine dehydrogenase (DPD) deficiency, which can result from deleterious polymorphisms in the gene encoding DPD (DPYD), including DPYD*2A and c.2846A>T. Three other variants-DPYD c.1679T>G, c.1236G>A/HapB3, and c.1601G>A-have been associated with DPD deficiency, but no definitive evidence for the clinical validity of these variants is available. The primary objective of this systematic review and meta-analysis was to assess the clinical validity of c.1679T>G, c.1236G>A/HapB3, and c.1601G>A as predictors of severe fluoropyrimidine-associated toxicity.

METHODS

We did a systematic review of the literature published before Dec 17, 2014, to identify cohort studies investigating associations between DPYD c.1679T>G, c.1236G>A/HapB3, and c.1601G>A and severe (grade ≥3) fluoropyrimidine-associated toxicity in patients treated with fluoropyrimidines (fluorouracil, capecitabine, or tegafur-uracil as single agents, in combination with other anticancer drugs, or with radiotherapy). Individual patient data were retrieved and analysed in a multivariable analysis to obtain an adjusted relative risk (RR). Effect estimates were pooled by use of a random-effects meta-analysis. The threshold for significance was set at a p value of less than 0·0167 (Bonferroni correction).

FINDINGS

7365 patients from eight studies were included in the meta-analysis. DPYD c.1679T>G was significantly associated with fluoropyrimidine-associated toxicity (adjusted RR 4·40, 95% CI 2·08-9·30, p<0·0001), as was c.1236G>A/HapB3 (1·59, 1·29-1·97, p<0·0001). The association between c.1601G>A and fluoropyrimidine-associated toxicity was not significant (adjusted RR 1·52, 95% CI 0·86-2·70, p=0·15). Analysis of individual types of toxicity showed consistent associations of c.1679T>G and c.1236G>A/HapB3 with gastrointestinal toxicity (adjusted RR 5·72, 95% CI 1·40-23·33, p=0·015; and 2·04, 1·49-2·78, p<0·0001, respectively) and haematological toxicity (adjusted RR 9·76, 95% CI 3·03-31·48, p=0·00014; and 2·07, 1·17-3·68, p=0·013, respectively), but not with hand-foot syndrome. DPYD*2A and c.2846A>T were also significantly associated with severe fluoropyrimidine-associated toxicity (adjusted RR 2·85, 95% CI 1·75-4·62, p<0·0001; and 3·02, 2·22-4·10, p<0·0001, respectively).

INTERPRETATION

DPYD variants c.1679T>G and c.1236G>A/HapB3 are clinically relevant predictors of fluoropyrimidine-associated toxicity. Upfront screening for these variants, in addition to the established variants DPYD*2A and c.2846A>T, is recommended to improve the safety of patients with cancer treated with fluoropyrimidines.

FUNDING

None.

Bereaved relatives' experiences during the incurable phase of cancer: a qualitative interview study

OBJECTIVE

To examine bereaved relatives' experiences from time of diagnosis of incurable cancer until death with specific emphasis on their role in the (end-of-life) decision-making concerning chemotherapy.

DESIGN

Qualitative interview study.

SETTING

Hospital-based.

PARTICIPANTS AND METHODS

In-depth interviews with 15 close relatives of patients who died from non-small cell lung cancer or pancreatic cancer, using a thematic content analysis.

RESULTS

All relatives reported that patients' main reason to request chemotherapy was the possibility to prolong life. Relatives reported that patients receiving chemotherapy had more difficulty to accept the incurable nature of their disease than patients who did not. They mostly followed the patients' treatment wish and only infrequently suggested ceasing chemotherapy (because of side effects) despite sometimes believing that this would be a better option. Relatives continuously tried to support the patient in either approaching the death or in attaining hope to continue life satisfactorily. Most relatives considered the chemotherapy period meaningful, since it sparked patients' hope and was what patients wanted. Cessation of chemotherapy caused a relief but coincided with physical deterioration and an increased caregivers' role; many relatives recalled this latter period as more burdensome.

CONCLUSIONS

Relatives tend to follow patients' wish to continue or cease chemotherapy, without expressing their own feelings, although they were more inclined to opt cessation. They experience a greater caregiver role after cessation and their feelings of responsibility associated with the disease can be exhausting. More attention is needed to reduce relatives' distress at the end of life, also to fully profit from this crucial form of (informal) healthcare.

Why do patients choose (not) to participate in an exercise trial during adjuvant chemotherapy for breast cancer?

OBJECTIVE

Only between 25% and 50% of patients invited to participate in clinical trial-based physical exercise programs during cancer treatment agree to do so. The purpose of this study was to identify factors associated significantly with the decision (not) to participate in a randomized controlled trial of physical exercise during adjuvant chemotherapy for breast cancer.

METHODS

Based on questionnaire data, we compared trial participants and non-participants on a range of sociodemographic, clinical health-related, practical, behavioral, and attitudinal variables.

RESULTS

Two hundred thirty of 524 patients agreed to participate in the trial (44%). The 294 (56%) non-participants indicated that they wanted to exercise on their own or that they did not wish to exercise in the context of a trial. Those who preferred to exercise on their own were relatively similar to trial participants but were more likely to be in the maintenance exercise stage. Those non-participants who did not wish to exercise had a significantly lower level of education, were less likely to be working, reported more fatigue and lower health-related quality of life, had lower sense of self-efficacy, more negative attitudes towards exercise, less social support, and perceived fewer benefits and more barriers to exercising during treatment than trial participants.

CONCLUSION

Minimizing practical barriers to participation, providing educational materials on the potential benefits of exercise, and giving adequate professional and social network encouragement may increase the number of patients willing to exercise during treatment and to participate in such studies. Copyright © 2015 John Wiley & Sons, Ltd.

The prognostic value of the neoadjuvant response index in triple-negative breast cancer: validation and comparison with pathological complete response as outcome measure

The Neoadjuvant response index (NRI) has been proposed as a simple measure of downstaging by neoadjuvant treatment in breast cancer. It was previously found to predict recurrence-free survival (RFS) in triple-negative (TN) breast cancer. It was at least as accurate as the standard binary system, the absence or presence of a pathological complete remission (pCR), which is the commonly employed outcome measure. The NRI was evaluated in an independent consecutive series of patients to validate the previous findings. Univariable and multivariable analyses were done to assess the predictive value of clinical parameters and of the NRI for RFS. We combined the original and validation series of patients to build a multivariable predictive model for RFS after neoadjuvant chemotherapy in TN breast cancer. The validation set (N = 108) confirmed that patients with a higher-than-median NRI (>0.7) had excellent RFS (P = 0.002), similar to that of patients who had achieved a pCR. Multivariable analysis in 191 patients showed that the NRI was a strong independent predictor of RFS (P = 0.0002), with N-stage (P = 0.001) and T-stage (P = 0.014) ranking second and third, respectively. Importantly, among patients who did not achieve a pCR (NRI values below 1), higher NRI values were still associated with better RFS. The NRI is a simple method and a practical tool to predict RFS in TN breast cancer patients treated with neoadjuvant chemotherapy. It adds prognostic information to the presence or absence of pCR and could be useful to compare the efficacies of different chemotherapy regimens.

Long-term safety and anti-tumour activity of olaparib monotherapy after combination with carboplatin and paclitaxel in patients with advanced breast, ovarian or fallopian tube cancer

BACKGROUND

Olaparib (AZD2281), a PARP-1/2 inhibitor, has been extensively investigated in clinical trials. However, limited clinical data are available about its long-term safety and anti-tumour activity.

METHODS

Patients had first participated in a phase I study of olaparib combined with carboplatin and/or paclitaxel. They continued with olaparib monotherapy in their best interest if they failed to tolerate the combination due to the treatment-related adverse events (TRAEs). Safety data were collected by physical examination and regular laboratory evaluations. Disease evaluations were performed by CT scan.

RESULTS

At data cutoff, 21 patients were included; 10 with breast, 9 with ovarian and 2 with fallopian tube cancer of whom 16 patients had a BRCA mutation (13 BRCA1; 3 BRCA2). TRAEs were mostly haematological and most prominent shortly after switching from combination to monotherapy, probably due to carry-over effects of chemotherapy. Over time, both severity and frequency of TRAEs decreased. Responses to olaparib were durable with a median treatment duration of 52 (range 7-183) weeks. In total, nine (43%) patients were still on study at data cutoff.

CONCLUSION

Continued long-term daily olaparib was found to be safe and tolerable. Encouragingly, patients who showed a favourable response on earlier combination therapy maintained this response on olaparib monotherapy.

Personalisation of breast cancer follow-up: a time-dependent prognostic nomogram for the estimation of annual risk of locoregional recurrence in early breast cancer patients

The objective of this study was to develop and validate a time-dependent logistic regression model for prediction of locoregional recurrence (LRR) of breast cancer and a web-based nomogram for clinical decision support. Women first diagnosed with early breast cancer between 2003 and 2006 in all Dutch hospitals were selected from the Netherlands Cancer Registry (n = 37,230). In the first 5 years following primary breast cancer treatment, 950 (2.6 %) patients developed a LRR as first event. Risk factors were determined using logistic regression and the risks were calculated per year, conditional on not being diagnosed with recurrence in the previous year. Discrimination and calibration were assessed. Bootstrapping was used for internal validation. Data on primary tumours diagnosed between 2007 and 2008 in 43 Dutch hospitals were used for external validation of the performance of the nomogram (n = 12,308). The final model included the variables grade, size, multifocality, and nodal involvement of the primary tumour, and whether patients were treated with radio-, chemo- or hormone therapy. The index cohort showed an area under the ROC curve of 0.84, 0.77, 0.70, 0.73 and 0.62, respectively, per subsequent year after primary treatment. Model predictions were well calibrated. Estimates in the validation cohort did not differ significantly from the index cohort. The results were incorporated in a web-based nomogram (http://www.utwente.nl/mira/influence). This validated nomogram can be used as an instrument to identify patients with a low or high risk of LRR who might benefit from a less or more intensive follow-up after breast cancer and to aid clinical decision making for personalised follow-up.

Abstract P6-08-01: Contemporary risk of local, regional and contralateral breast cancer recurrence

Background

Long-term follow-up of breast cancer patients aims to detect curable recurrence, and focuses on ipsilateral in-breast recurrence (LR), regional lymph node recurrence (RR) and contralateral breast cancer (CBC). In recent years there is mounting evidence of a decrease in locoregional recurrence rates. Non-surgical-treatment modalities have evolved extensively, while surgery has become less invasive over the last fifteen years. The present study aimed to address contemporary loco-regional recurrence rates evaluating time trends and the role of contributing factors.

Material and methods

The Netherlands Cancer Registry was searched for all female patients diagnosed and operated for a unilateral primary breast cancer (pT1-2,anyN,M0) between 1-1-2003 and 31-12-2006. Exclusion criteria were previous cancer, neo-adjuvant chemotherapy or incurable disease. Data on 5-year follow-up were available from hospital records and included the first site of recurrence and contralateral breast cancer (CBC). The 5-year risk of developing LR, RR and CBC were estimated using Kaplan Meier curves. Patients were censored at time of death, lost to follow-up or the development of distant metastases. Prognostic influence of various patient- and disease characteristics was assessed.

Results

A total of 35.006 eligible patients were identified. The 5-year rates of LR, RR, and CBC are presented in Table 1. The risk of CBC was higher than LR and RR. Over time, the rates decreased significantly for all three endpoints.

Table 1. Overall 5-year risk of local, regional and contralateral recurrence and distant metastases over time (period 2003-2006) Local recurrence(a)Regional recurrenceContralateral breast cancer no. of eventsrate (%)no. of eventsrate (%)no. of eventsrate (%)2003 (n=8933)1852,40%861,11%2273,08%2004 (n=9048)1812,35%831,07%1892,51%2005 (n=9055)1441,84%750,95%1902,49%2006 (n=7970)1311,87%500,70%1462,05%Overall (n=35.006)6412,12%2940,96%7522,55%(a)Local recurrence (ipsilateral in-breast recurrence + new primary). Rates represent Kaplan Meier estimates

The LR-rate was lower with breast conserving surgery (BCS) vs. amputation (1.8% vs. 2.5%), T1a-b vs. T1c-T2 tumors (2.0% vs. 2.5%), ER+ vs. ER- tumors (1.8% vs. 3.5%) and inversely related with age (highest in pts. &lt;35 yrs: 2.9%). LR rate seemed independent of HER2 status.

The 5-year RR-rate was 0.9% for N0 patients, and decreased from 1.0% to 0.7% over time. The risk of RR after amputation decreased from 1.8% to 0.9% over time, but was higher than after BCS (1.6% vs. 0.6%). Overall, the RR-rate was highest in the N&gt;1 group (1.4%) and the triple negative group (2.0%).

The CBC-rate was lower for patients who received chemotherapy (CT) than for patients who did not (1.6% vs. 3.1%). The CBC-rate only decreased over the years in the CT-group (3.7% to 2.5%).

Conclusions

Loco-regional recurrence rates have decreased substantially in recent years and have become very low. For the vast majority of patients the risk of LR is substantially lower than the risk of CBC and the risk of RR is rarely larger than 1.0%. These low rates might reflect improvements in systemic treatment.

Citation Format: Kim C Aalders, Annelotte CM van Bommel, Thijs van Dalen, Gabe S Sonke, Paul J van Diest, Liesbeth J Boersma, Margriet van der Heiden-van der Loo. Contemporary risk of local, regional and contralateral breast cancer recurrence [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-08-01.

Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial

PURPOSE

We evaluated the effectiveness of a low-intensity, home-based physical activity program (Onco-Move) and a moderate- to high-intensity, combined supervised resistance and aerobic exercise program (OnTrack) versus usual care (UC) in maintaining or enhancing physical fitness, minimizing fatigue, enhancing health-related quality of life, and optimizing chemotherapy completion rates in patients undergoing adjuvant chemotherapy for breast cancer.

PATIENTS AND METHODS

We randomly assigned patients who were scheduled to undergo adjuvant chemotherapy (N = 230) to Onco-Move, OnTrack, or UC. Performance-based and self-reported outcomes were assessed before random assignment, at the end of chemotherapy, and at the 6-month follow-up. We used generalized estimating equations to compare the groups over time.

RESULTS

Onco-Move and OnTrack resulted in less decline in cardiorespiratory fitness (P < .001), better physical functioning (P ≤ .001), less nausea and vomiting (P = .029 and .031, respectively) and less pain (P = .003 and .011, respectively) compared with UC. OnTrack also resulted in better outcomes for muscle strength (P = .002) and physical fatigue (P < .001). At the 6-month follow-up, most outcomes returned to baseline levels for all three groups. A smaller percentage of participants in OnTrack required chemotherapy dose adjustments than those in the UC or Onco-Move groups (P = .002). Both intervention groups returned earlier (P = .012), as well as for more hours per week (P = .014), to work than the control group.

CONCLUSION

A supervised, moderate- to high-intensity, combined resistance and aerobic exercise program is most effective for patients with breast cancer undergoing adjuvant chemotherapy. A home-based, low-intensity physical activity program represents a viable alternative for women who are unable or unwilling to follow the higher intensity program.

Survival after locoregional recurrence or second primary breast cancer: impact of the disease-free interval

The association between the disease-free interval (DFI) and survival after a locoregional recurrence (LRR) or second primary (SP) breast cancer remains uncertain. The objective of this study is to clarify this association to obtain more information on expected prognosis. Women first diagnosed with early breast cancer between 2003–2006 were selected from the Netherlands Cancer Registry. LRRs and SP tumours within five years of first diagnosis were examined. The five-year period was subsequently divided into three equal intervals. Prognostic significance of the DFI on survival after a LRR or SP tumour was determined using Kaplan-Meier estimates and multivariable Cox regression analysis. Follow-up was complete until January 1, 2014. A total of 37,278 women was included in the analysis. LRRs or SP tumours were diagnosed in 890 (2,4%) and 897 (2,4%) respectively. Longer DFI was strongly and independently related to an improved survival after a LRR (long versus short: HR 0.65, 95% CI 0.48–0.88; medium versus short HR 0.81, 95% CI 0.65–1.01). Other factors related to improved survival after LRR were younger age (<70 years) and surgical removal of the recurrence. No significant association was found between DFI and survival after SP tumours. This is the first study to explore the association between the DFI and survival after recurrence in a nationwide population-based cancer registry. The DFI before a LRR is an independent prognostic factor for survival, with a longer DFI predicting better prognosis.

Olaparib combined with chemotherapy for recurrent platinum-sensitive ovarian cancer: a randomised phase 2 trial

BACKGROUND

The poly(ADP-ribose) polymerase inhibitor olaparib has shown antitumour activity in patients with platinum-sensitive, recurrent, high-grade serous ovarian cancer with or without BRCA1 or BRCA2 mutations. The aim of this study was to assess the efficacy and tolerability of olaparib in combination with chemotherapy, followed by olaparib maintenance monotherapy, versus chemotherapy alone in patients with platinum-sensitive, recurrent, high-grade serous ovarian cancer.

METHODS

In this randomised, open-label, phase 2 study, adult patients with platinum-sensitive, recurrent, high-grade serous ovarian cancer who had received up to three previous courses of platinum-based chemotherapy and who were progression free for at least 6 months before randomisation received either olaparib (200 mg capsules twice daily, administered orally on days 1-10 of each 21-day cycle) plus paclitaxel (175 mg/m(2), administered intravenously on day 1) and carboplatin (area under the curve [AUC] 4 mg/mL per min, according to the Calvert formula, administered intravenously on day 1), then olaparib monotherapy (400 mg capsules twice daily, given continuously) until progression (the olaparib plus chemotherapy group), or paclitaxel (175 mg/m(2) on day 1) and carboplatin (AUC 6 mg/mL per min on day 1) then no further treatment (the chemotherapy alone group). Randomisation was done by an interactive voice response system, stratified by number of previous platinum-containing regimens received and time to disease progression after the previous platinum regimen. The primary endpoint was progression-free survival according to Response Evaluation Criteria in Solid Tumors version 1.1, analysed by intention to treat. Prespecified exploratory analyses included efficacy by BRCA mutation status, assessed retrospectively. This study is registered with ClinicalTrials.gov, number NCT01081951, and has been completed.

FINDINGS

Between Feb 12 and July 30, 2010, 173 patients at 43 investigational sites in 12 countries were enrolled into the study, of whom 162 were eligible and were randomly assigned to the two treatment groups (81 to the olaparib plus chemotherapy group and 81 to the chemotherapy alone group). Of these randomised patients, 156 were treated in the combination phase (81 in the olaparib plus chemotherapy group and 75 in the chemotherapy alone group) and 121 continued to the maintenance or no further treatment phase (66 in the olaparib plus chemotherapy group and 55 in the chemotherapy alone group). BRCA mutation status was known for 107 patients (either at baseline or determined retrospectively): 41 (38%) of 107 had a BRCA mutation (20 in the olaparib plus chemotherapy group and 21 in the chemotherapy alone group). Progression-free survival was significantly longer in the olaparib plus chemotherapy group (median 12.2 months [95% CI 9.7-15.0]) than in the chemotherapy alone group (median 9.6 months [95% CI 9.1-9.7) (HR 0.51 [95% CI 0.34-0.77]; p=0.0012), especially in patients with BRCA mutations (HR 0.21 [0.08-0.55]; p=0.0015). In the combination phase, adverse events that were reported at least 10% more frequently with olaparib plus chemotherapy than with chemotherapy alone were alopecia (60 [74%] of 81 vs 44 [59%] of 75), nausea (56 [69%] vs 43 [57%]), neutropenia (40 [49%] vs 29 [39%]), diarrhoea (34 [42%] vs 20 [27%]), headache (27 [33%] vs seven [9%]), peripheral neuropathy (25 [31%] vs 14 [19%]), and dyspepsia (21 [26%] vs 9 [12%]); most were of mild-to-moderate intensity. The most common grade 3 or higher adverse events during the combination phase were neutropenia (in 35 [43%] of 81 patients in the olaparib plus chemotherapy group vs 26 [35%] of 75 in the chemotherapy alone group) and anaemia (seven [9%] vs five [7%]). Serious adverse events were reported in 12 (15%) of 81 patients in the olaparib plus chemotherapy group and 16 of 75 (21%) patients in the chemotherapy alone group.

INTERPRETATION

Olaparib plus paclitaxel and carboplatin followed by maintenance monotherapy significantly improved progression-free survival versus paclitaxel plus carboplatin alone, with the greatest clinical benefit in BRCA-mutated patients, and had an acceptable and manageable tolerability profile.

FUNDING

AstraZeneca.

Prognostic factors for survival in metastatic breast cancer by hormone receptor status

Hormone receptor (HR) status is an important prognostic factor for patients with metastatic breast cancer (MBC) and is also correlated with other prognostic factors, such as initial lymph node status, HER2-Neu status and age. The prognostic value of these other factors, however, is unknown when stratified by HR positive versus HR negative patients. The aim of this study was to evaluate prognostic factors for MBC survival in relation to HR status. Dutch women diagnosed with breast cancer in 2003-2006 treated with curative intent who developed MBC within 5 years of follow-up were selected from the Netherlands cancer registry (N = 2,001). Independent prognostic factors for survival after metastatic occurrence were determined by multivariable Cox survival analyses stratified by HR status. Interactions between HR status and prognostic factors were determined. Median survival for MBC patients with HR negative (HR-) tumours was 8 months, compared to 19 months for HR positive (HR+) patients. The prognostic value of lymph node status, HER2-Neu status, adjuvant endocrine treatment and first-line palliative chemotherapy was dependent on HR status. Initial lymph node status was independently associated with survival in HR- patients, but not in HR+ patients. HER2-Neu positive status was associated with better survival in both HR+ and HR- patients, although the association was stronger in HR- patients. Similarly, patients treated with first-line palliative chemotherapy fared better, especially HR- patients. HR+ patients had worse survival if they had received adjuvant endocrine treatment. This study shows that the prognostic value of various factors depends on HR status in MBC. This information may help physicians to determine individual prognostic profiles and therapeutic strategies for MBC patients.

Abstract OT1-1-01: Optimizing neoadjuvant systemic treatment in HER2 positive breast cancer - The TRAIN-2 study

Background Anthracycline-based regimens are still commonly used in HER2 positive (HER2+) breast cancer (BC), despite added toxicity compared to non-anthracycline containing regimens. The benefit of antracyclines in the era of trastuzumab containing regimens is controversial. Moreover, the value of anthracyclines in combination with dual-HER2 blockade is uncertain. We recently showed high pathologic complete response (pCR) rates with a weekly neoadjuvant paclitaxel-trastuzumab-carboplatin (PTC) regimen. We now aim to evaluate the effect of replacing 3 PTC cycles in this regimen with 3 FE90C-trastuzumab cycles, while adding pertuzumab to all cycles in both arms.

Secondly, combined blockade of the estrogen-receptor (ER) pathway and the HER2-pathway in the presence of chemotherapy has not previously been investigated in HER2+/ER+ tumors.

Trial design This is a randomized comparative trial evaluating pCR rate (ypT0/is ypN0) at surgery as primary endpoint after neoadjuvant systemic therapy with 9 cycles PTC plus pertuzumab q3w (paclitaxel 80mg/m2 day 1, 8 – trastuzumab 6mg/kg (loading dose 8mg/kg) day 1 – carboplatin AUC = 6 day 1 – pertuzumab 420mg (loading dose 840mg) day 1) versus 3 cycles FE90C-T plus pertuzumab q3w followed by 6 cycles PTC plus pertuzumab q3w.

An optional second randomization (2×2 factorial design) will compare concurrent endocrine treatment with an aromatase inhibitor (and ovarian function suppression in premenopausal women and men) during neoadjuvant chemotherapy in combination with dual HER2-blockade, in patients with HER2+/ER+ tumors.

Eligibility criteria Patients aged ≥18 year with histologically confirmed invasive HER2+ BC, stage II or III. Eligible patients have a performance status of 0 to 1 and adequate cardiac and organ function.

Specific aims The primary objective is to compare the efficacy of 6 cycles neoadjuvant PTC plus pertuzumab preceded by either 3 cycles FE90C-T plus pertuzumab or 3 cycles PTC plus pertuzumab in stage II and III HER2+ BC.

Secondary objectives are to describe the efficacy of combined HER2 and ER pathway blockade in HER2+/ER+ BC, to describe the safety of the various regimens and to identify prognostic and predictive biomarkers for pCR.

Statistical methods The sample size of the study will be based on the primary objective. To detect an increase in pCR rate from 44% in the PTC arm to 58% in the FE90C-T arm at the 5% (2-sided) level of significance with an 80% power 437 patients need to be randomized (assuming ∼10% of patients will be not evaluable).

Target accrual Recruitment will start in the summer of 2013 across ∼30 sites in the Netherlands. Unrestricted research support and pertuzumab are kindly provided by Roche Netherlands. The trial is sponsored by the Dutch Breast Cancer Trialists’ Group (BOOG).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-1-01.

The facilitating role of chemotherapy in the palliative phase of cancer: qualitative interviews with advanced cancer patients

Objective

To explore the extent to which patients have a directing role in decisions about chemotherapy in the palliative phase of cancer and (want to) anticipate on the last stage of life.

Design

Qualitative interview study.

Methods

In depth-interviews with 15 patients with advanced colorectal or breast cancer at the medical oncology department in a Dutch teaching hospital; interviews were analysed following the principles of thematic content-analysis.

Results

All patients reported to know that the chemotherapy they received was with palliative intent. Most of them did not express the wish for information about (other) treatment options and put great trust in their physicians’ treatment advice. The more patients were aware of the severity of their disease, the more they seemed to ‘live their life’ in the present and enjoy things besides having cancer. Such living in the present seemed to be facilitated by the use of chemotherapy. Patients often considered the ‘chemotherapy-free period’ more stressful than periods when receiving chemotherapy despite their generally improved physical condition. Chemotherapy (regardless of side-effects) seemed to shift patients’ attention away from the approaching last stage of life. Interestingly, although patients often discussed advance care planning, they were reluctant to bring on end-of-life issues that bothered them at that specific moment. Expressing real interest in people ‘as a person’ was considered an important element of appropriate care.

Conclusions

Fearing their approaching death, patients deliberately focus on living in the present. Active (chemotherapy) treatment facilitates this focus, regardless of the perceived side-effects. However, if anxiety for what lies ahead is the underlying reason for treatment, efforts should be made in assisting patients to find other ways to cope with this fear. Simultaneously, such an approach may reduce the use of burdensome and sometimes costly treatment in the last stage of life.

Paclitaxel, carboplatin, and trastuzumab in a neo-adjuvant regimen for HER2-positive breast cancer

To evaluate a nonanthracycline-containing regimen consisting of 24 weekly administrations of paclitaxel, carboplatin, and trastuzumab as neo-adjuvant therapy for human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Patients with stage II or III breast cancer, including inflammatory disease, with HER2 overexpression (immunohistochemistry and/or fluorescent in situ hybridization) were treated with 24 weekly administrations of paclitaxel 70 mg/m(2) , carboplatin AUC = 3 mg/mL/minute, and trastuzumab 2 mg/kg (loading dose 4 mg/kg). In cycles 7, 8, 15, 16, 23, and 24, only trastuzumab was given. The primary end point was pathologic complete response (pCR) in both breast and axilla. Of 61 evaluable patients, 61% had stage II disease and 75% were node-positive. The median NRI (Neoadjuvant Response Index, a measure of the degree of downstaging by chemotherapy) of all patients was 0.86. Twenty-seven (44%) had a NRI of 1.0, which corresponds to pCR in breast and lymph nodes. The most commonly reported grade 3/4 toxicities were neutropenia (72%) and thrombocytopenia (36%). Dose reduction was necessary in 51% of the patients. A weekly carboplatin-paclitaxel-trastuzumab neo-adjuvant regimen is highly active in HER2-positive breast cancer with an acceptable toxicity profile. A multicenter phase 2 trial has recently reached its accrual target and will serve as a basis for a subsequent randomized phase 3 study comparing this regimen to a similar regimen preceded by anthracyclines.

A prospective evaluation of a breast cancer prognosis signature in the observational RASTER study

The 70-gene signature (MammaPrint™) has been developed on retrospective series of breast cancer patients to predict the risk of breast cancer distant metastases. The microarRAy-prognoSTics-in-breast-cancER (RASTER) study was the first study designed to prospectively evaluate the performance of the 70-gene signature, which result was available for 427 patients (cT1–3N0M0). Adjuvant systemic treatment decisions were based on the Dutch CBO 2004 guidelines, the 70-gene signature and doctors' and patients' preferences. Five-year distant-recurrence-free-interval (DRFI) probabilities were compared between subgroups based on the 70-gene signature and Adjuvant! Online (AOL) (10-year survival probability <90% was defined as high-risk). Median follow-up was 61.6 months. Fifteen percent (33/219) of the 70-gene signature low-risk patients received adjuvant chemotherapy (ACT) versus 81% (169/208) of the 70-gene signature high-risk patients. The 5-year DRFI probabilities for 70-gene signature low-risk (n = 219) and high-risk (n = 208) patients were 97.0% and 91.7%. The 5-year DRFI probabilities for AOL low-risk (n = 132) and high-risk (n = 295) patients were 96.7% and 93.4%. For 70-gene signature low-risk–AOL high-risk patients (n = 124), of whom 76% (n = 94) had not received ACT, 5-year DRFI was 98.4%. In the AOL high-risk group, 32% (94/295) less patients would be eligible to receive ACT if the 70-gene signature was used. In this prospective community-based observational study, the 5-year DRFI probabilities confirmed the additional prognostic value of the 70-gene signature to clinicopathological risk estimations such as AOL. Omission of adjuvant chemotherapy as judged appropriate by doctors and patients and instigated by a low-risk 70-gene signature result, appeared not to compromise outcome.

SERPINA6, BEX1, AGTR1, SLC26A3, and LAPTM4B are markers of resistance to neoadjuvant chemotherapy in HER2-negative breast cancer

Response rates to chemotherapy remain highly variable in breast cancer patients. We set out to identify genes associated with chemotherapy resistance. We analyzed what is currently the largest single-institute set of gene expression profiles derived from breast cancers prior to a single neoadjuvant chemotherapy regimen (dose-dense doxorubicin and cyclophosphamide). We collected, gene expression-profiled, and analyzed 178 HER2-negative breast tumor biopsies ("NKI dataset"). We employed a recently developed approach for detecting imbalanced differential signal (DIDS) to identify markers of resistance to treatment. In contrast to traditional methods, DIDS is able to identify markers that show aberrant expression in only a small subgroup of the non-responder samples. We found a number of markers of resistance to anthracycline-based chemotherapy. We validated our findings in three external datasets, totaling 456 HER2-negative samples. Since these external sets included patients who received differing treatment regimens, the validated markers represent markers of general chemotherapy resistance. There was a highly significant overlap in the markers identified in the NKI dataset and the other three datasets. Five resistance markers, SERPINA6, BEX1, AGTR1, SLC26A3, and LAPTM4B, were identified in three of the four datasets (p value overlap < 1 × 10(-6)). These five genes identified resistant tumors that could not have been identified by merely taking ER status or proliferation into account. The identification of these genes might lead to a better understanding of the mechanisms involved in (clinically) observed chemotherapy resistance and could possibly assist in the recognition of breast cancers in which chemotherapy does not contribute to response or survival.

Novel surgical technique to selectively remove metastatic axillary lymph nodes in breast cancer patients after neoadjuvant chemotherapy: The MARI procedure—Marking of the axilla with radioactive iodine seeds

196

Background: An important benefit of neoadjuvant chemotherapy (NAC) is the increase in breast-conserving surgery. At present the response of axillary lymph node metastases to chemotherapy cannot be accurately assessed. Therefore axilla-conserving therapy is not yet a benefit. We aimed to assess a new surgical method to evaluate the axillary response: the MARI procedure, which stands for Marking of the Axillary lymph node with Radioactive Iodine seeds. Methods: Prior to NAC, proven tumor-positive axillary lymph nodes were marked with a Iodine-125 seed. After NAC, the marked lymph node was selectively removed with the use of a gamma-detection probe. A complementary axillary lymph node dissection was performed to assess whether pathological response in the marked node was indicative for the pathological response in the additional lymph nodes. Results: Tumor-positive axillary lymph nodes were successfully marked with Iodine-125 seeds in 68 patients. The marked lymph node (MARI-node) was surgically detected and selectively removed after NAC in all patients. The pathological response to chemotherapy in the MARI-node was indicative for the overall response in the additionally removed lymph nodes. In 47 patients the MARI-node contained residual disease (n=45 macrometastasis, n= 2 ITC). Thirty-five of them had macro- or micro metastases in the complementary axillary lymph node dissection specimen. In 21 patients the MARI-node was tumor negative. In 2 patients a macro metastasis was found in the additionally removed nodes, in 2 patients ITC were found and in the remaining 17 patients no residual tumor was found in the additionaly removed lymphnodes. (false negative rate of the MARI procedure: 9.5%). Conclusions: This study shows that marking and selectively removing metastatic lymph nodes after NAC is feasible. The tumor-response in the marked lymph node may be used to tailor further axillary treatment, and herewith enabling axilla-conserving surgery after neoadjuvant chemotherapy.

Olaparib plus paclitaxel plus carboplatin (P/C) followed by olaparib maintenance treatment in patients (pts) with platinum-sensitive recurrent serous ovarian cancer (PSR SOC): A randomized, open-label phase II study

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Background: The oral PARP inhibitor olaparib has shown antitumor activity in pts with SOC. Our multicenter study compared the efficacy of (Arm A) olaparib capsules plus P/C for 6 cycles then maintenance olaparib monotherapy vs (Arm B) P/C alone for 6 cycles and no further therapy in pts with PSR SOC (NCT01081951). Methods: Pts received 6 x 21-day(d) cycles of olaparib (200 mg bid, d1–10/21) + P (175 mg/m2 iv, d1) + C (AUC4 iv, d1), then olaparib monotherapy as maintenance (400 mg bid, continuous) (Arm A), or 6 x 21d cycles of P (175 mg/m2 iv, d1) + C (AUC6 iv, d1) then no further therapy (Arm B), until progression. Randomization (1:1) was stratified by number of platinum treatments and platinum-free interval. Primary endpoint: progression-free survival (PFS) by central review (RECIST 1.1). Secondary endpoints: overall survival (OS), objective response rate (ORR), safety. Archival tissue was collected where available for analysis of biomarker correlation. Results: Of 162 pts randomized (n=81 per arm), 156 received treatment (Arm A, n=81; Arm B, n=75) and 121 began the maintenance/no further therapy phase (Arm A, n=66; Arm B, n=55). Olaparib + P/C (AUC4) followed by maintenance olaparib showed a significant improvement in PFS vs P/C (AUC6) alone (HR = 0.51, 95% CI 0.34, 0.77; P=0.0012; median = 12.2 vs 9.6 months). OS data are immature (total events: 14%). ORR was similar for Arm A and Arm B (64 vs 58%). Most common AEs during the combination phase were alopecia (74 vs 59%), nausea (69 vs 57%) and fatigue (64 vs 57%) for Arm A vs Arm B, respectively. Pts with grade ≥3 AEs (65 vs 57%), serious AEs (SAEs: 15 vs 21%) and AEs leading to treatment discontinuation (19 vs 16%) were similar for Arm A vs Arm B. Most common AEs during maintenance/no further therapy were nausea (50 vs 6%) and vomiting (29 vs 7%). 29 vs 16% of pts had grade ≥3 AEs, 9 vs 7% had SAEs and 8% vs N/A discontinued due to AEs in the olaparib vs no treatment arms, respectively. There were no fatal AEs. Conclusions: In pts with PSR SOC, olaparib plus P/C (AUC4) followed by olaparib 400 mg bid monotherapy maintenance treatment resulted in a significant improvement in PFS vs P/C (AUC6) alone.

P3-14-17: Paclitaxel, Carboplatin, and Trastuzumab in a Neoadjuvant Regimen for HER2−Positive Breast Cancer: The TRAIN Study

Background: Treatment with trastuzumab is highly active in HER2 positive breast cancer, although cardiotoxicity is a well known side effect. The cardiotoxicity of trastuzumab may be aggravated by combined treatment with anthracyclines. Consequently, treatment with trastuzumab is often delayed pending the administration of anthracyclines. Both in vitro and in vivo data suggest that trastuzumab synergizes with a range of chemotherapeutic drugs, including taxoid drugs and carboplatin. In addition, prolonged pre-operative treatment leads to higher pathologic complete remission (pCR) rates. We report the results of a fase 2 trial integrating trastuzumab at the start of a non-anthracycline containing weekly paclitaxel-carboplatin based neo-adjuvant chemotherapy regimen in HER2−positive breast cancer. Patients and methods: One-hundred patients with stage II or III breast cancer, including inflammatory disease, with HER2 overexpression (immunohistochemistry and/or in situ hybridization) were treated with 24 weekly administrations of paclitaxel 70 mg/m2, carboplatin AUC=3 mg.ml-1.min, and trastuzumab 2 mg/kg (loading dose 4 mg/kg). In cycles 7, 8, 15, 16, 23, and 24 only trastuzumab was given. The primary end point was pathologic complete response (pCR) in both breast and axilla. The trial was preceded by an initial pilot cohort of 55 patients treated with the same regimen.

Results: Final efficacy and safety results of all patients included in the phase 2 trial will be reported at the meeting. In the pilot cohort of 55 similarly treated patients, 33% had stage II disease, 69% was clinically node positive, and 49% was ER and PgR negative. Twenty-four patients (41%) had a pCR in breast and lymph nodes. pCR in ER negative patients was 67%, pCR in ER positive patients was 21%. The most commonly reported grade 3/4 toxicities were neutropenia (30%) and thrombocytopenia (27%). Dose reduction was required in 24% of the patients. Grade 3/4 left ventricular systolic dysfunction was not observed.

Conclusion: A weekly carboplatin-paclitaxel-trastuzumab neo-adjuvant regimen is highly active in HER2 positive breast cancer with a good safety profile. A subsequent multicenter phase 3 trial will compare this regimen to a similar 16 week regimen preceded by 4 cycles of anthracyclines plus cyclophosphamide.

The study protocol was developed at the joint ECCO-AACR-EORTC-ESMO Workshop on Methods in Clinical Cancer Research in Flims, Switserland.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-17.

Design of the Physical exercise during Adjuvant Chemotherapy Effectiveness Study (PACES): a randomized controlled trial to evaluate effectiveness and cost-effectiveness of physical exercise in improving physical fitness and reducing fatigue

Background

Cancer chemotherapy is frequently associated with a decline in general physical condition, exercise tolerance, and muscle strength and with an increase in fatigue. While accumulating evidence suggests that physical activity and exercise interventions during chemotherapy treatment may contribute to maintaining cardiorespiratory fitness and strength, the results of studies conducted to date have not been consistent. Additional research is needed to determine the optimal intensity of exercise training programs in general and in particular the relative effectiveness of supervised, outpatient (hospital- or physical therapy practice-based) versus home-based programs.

Methods

This multicenter, prospective, randomized trial will evaluate the effectiveness of a low to moderate intensity, home-based, self-management physical activity program, and a high intensity, structured, supervised exercise program, in maintaining or enhancing physical fitness (cardiorespiratory fitness and muscle strength), in minimizing fatigue and in enhancing the health-related quality of life (HRQoL). Patients receiving adjuvant chemotherapy for breast or colon cancer (n = 360) are being recruited from twelve hospitals in the Netherlands, and randomly allocated to one of the two treatment groups or to a 'usual care' control group. Performance-based and self-reported outcomes are assessed at baseline, at the end of chemotherapy and at six month follow-up.

Discussion

This large, multicenter, randomized clinical trial will provide additional empirical evidence regarding the effectiveness of physical exercise during adjuvant chemotherapy in enhancing physical fitness, minimizing fatigue, and maintaining or enhancing patients' quality of life. If demonstrated to be effective, exercise intervention programs will be a welcome addition to the standard program of care offered to patients with cancer receiving chemotherapy.

Trial registration

This study is registered at the Netherlands Trial Register (NTR 2159)