Extended follow-up of an antibiotic cycling program for the management of febrile neutropenia in a hematologic malignancy and hematopoietic cell transplantation unit

BACKGROUND

Febrile neutropenia is a common complication during treatment of hematological malignancies and hematopoietic cell transplantation. Empiric antibiotic therapy in this setting, while standard of care, commonly leads to microbial resistance. We have previously shown that cycling antibiotics in this patient population is feasible. This report provides long-term follow-up of cycling antibiotics in this patient population.

METHODS

In a prospective cohort of hematological malignancy patients with neutropenic fever, we sought to evaluate the role of empiric antibiotic cycling in preventing antibiotic resistance. Antibiotic cycling was initiated in March 2002 and, until June 2005, antibiotics were cycled every 8 months (Cycling Period A). From July 2005 to December 2009, antibiotics were cycled every 3 months (Cycling Period B). The rates of bacteremia, resistance, and complications were compared to a retrospective cohort (Pre-cycling Period).

RESULTS

The rate of gram-negative bacteremia decreased when compared to Cycling Periods A and B (5.3 vs. 2.1 and 3.3 episodes/1000 patient-days, respectively, P < 0.0001), most likely owing to implementation of quinolone prophylaxis. The resistance profile of the gram-negative organisms isolated remained stable over the 3 time periods, with the exception of an increase in quinolone resistance during the cycling periods. Gram-positive bacteremia rates remained stable, but vancomycin-resistant Enterococcus (VRE) increased significantly (0.1 vs. 1.0 and 1.6 episodes/1000 patient-days, respectively, P = 0.005) during cycling periods. Mortality rates were comparable.

CONCLUSIONS

Antibiotic cycling for neutropenic fever was effectively implemented and followed over an extended time period. Gram-negative resistance remained stable, but there is some concern for selection of resistant gram-positive bacteria, specifically VRE. Although antibiotic cycling did not seem to cause resistance in our study, further study is necessary to clarify the effect of cycling on antibiotic resistance, patient outcomes, and hospital cost.

Abstract PD07-09: Zoledronate versus ibandronate comparative evaluation (ZICE) trial - first results of a UK NCRI 1,405 patient phase III trial comparing oral ibandronate versus intravenous zoledronate in the treatment of breast cancer patients with bone metastases

Introduction Bone metastases in patients with breast cancer have serious effects on health including pain, poor mobility, skeletal fractures, spinal cord compression and the need for radiotherapy/surgery. The introduction of intravenous (IV) bisphosphonates, such as zoledronic acid (Z) has significantly delayed the onset of skeletal-related events (SRE). However, prolonged IV bisphosphonates place burdens upon patient and hospital, and can also cause renal and acute phase toxicities. Ibandronic acid (I), a third generation amino-bisphosphonate in its oral form has previously been compared with placebo and was shown to be well tolerated and effective. Indirect comparisons with IV Z indicated similar efficacy in reducing bone events, but adverse events were overall comparable with placebo. One might therefore assume that oral ibandronate would be more acceptable to patients, and the ZICE Trial is the only large scale direct randomised comparison between IV Z and oral I to report.

Methods Between January 2006 and October 2010, 1405 newly diagnosed metastatic breast cancer patients with proven bone metastases were randomised 1:1 to IV Z (4mg 15 min infusion every 3–4 weeks) or oral I (50mg per day) for up to 96 weeks. All patients were prescribed daily calcium & vitamin D supplementation, and patients with current active dental problems including infection were excluded. Patients also received chemotherapy, and or endocrine therapy as determined by their physician. The primary objective was to demonstrate non-inferiority of oral I in comparison with IV Z in terms of the SRE rate, defined as the number of SREs reported per year (using multiple event analysis). Secondary endpoints included time to 1st SRE, proportion of patients with SRE, Pain Scores, side effect profiles including ONJ and renal toxicities, quality of life and Health resources and overall survival. The trial was run under the auspices of the NCRI, sponsored by Velindre NHS Trust, coordinated by the Wales Cancer Trials Unit, funded by an educational grant from Roche and peer reviewed/endorsed by Cancer Research UK (CRUKE/04/022).

Results At the time of this analysis the last randomised patient had completed 96 weeks of therapy, median follow up was 18.4 months and total number of SREs was 865 (468 in I and 397 in Z). For the primary objective, the SRE rate was 0.543 and 0.444 in I and Z groups respectively (Hazard ratio, 1.22; 95% CI, 1.04 to 1.45; P = .017). Ibandronate failed to meet the criteria for non-inferiority to Zoledronate, but was similar in delaying time to first SRE (hazard ratio, 1.11; 95% CI, 0.94 to 1.31; P = .233). Overall survival (disease progression), was very similar between groups but renal AEs occurred more frequently with Z than I; Compliance with oral therapy was 82%. ONJ rate was very low in both arms (0.71%, I; 1.29%, Z; P = 0.28).

Conclusion Oral I is inferior to Z in terms of the SRE rate in metastatic breast cancer patients with bone metastases, but is similar to Z in delaying time to first SRE. Both drugs had acceptable safety profiles, with adverse events consistent with those reported previously.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD07-09.

Heparin-binding EGF-like growth factor expression and biological action in human pancreatic cancer cells

The epidermal growth factor (EGF) receptor is activated by EGF and other EGF-like growth factors, including heparin-binding epidermal growth factor-like growth factor (HB-EGF). We characterized the biological actions of HB-EGF in PANC-1 and COLO-357 human pancreatic cancer cell lines, and determined whether the presence of HB-EGF in human pancreatic carcinomas correlates with patient survival. HB-EGF enhanced the growth of both cell lines in a dose-dependent manner, with a potency that was generally similar to that of EGF and transforming growth factor-alpha (TGF-alpha). HB-EGF also readily induced tyrosine phosphorylation of the EGF receptor in these cells. Immunohistochemical analysis of 47 pancreatic cancer tissues revealed the presence of HB-EGF immunoreactivity in the cancer cells in 50% of the tumors. However, the presence of HB-EGF was not associated with a statistically significant decrease in the post-operative survival period. Furthermore, coexpression of HB-EGF and the EGF receptor was not associated with shorter patient survival. These findings suggest that HB-EGF activates the EGF receptor in human pancreatic cancer cells, but that it is not involved in enhancing the biological aggressiveness of this malignancy in vivo.

Evaluation of Non-fatal Work-related Injuries Presenting to Al Khor Hospital Emergency Department in Qatar

Work-related injuries constitute a large sector of patients seen at Al Khor Hospital's Emergency Department. The aim of this study is to describe the characteristics, frequency and mechanism of work-related injuries presenting to the emergency department. Patients of all ages with work-related injuries presenting to the Emergency Department at Al Khor Hospital at any time, from May to November 2009, were included in the study. Domestic injuries were excluded from the study. Character of the patients and injuries were described. The study included 903 patients. The mean age was 32.73 years (standard deviation 8.565). Most patients were construction workers, 346 (39.1%), and mechanical workers, 262 (29.6%). The types of non-fatal work related injury were: hands injuries, 329 (36.4%), contusions, 239 (26.5%) and cuts, 205 (22.7%). The main mechanisms of injury involved heavy objects falling on patients, 191 (21.2%). Wearing personal protective gear was reported in 546 (60.5%) patients, and having training to use it was reported in 510 (56.5%) cases. Wearing protective equipment was lower in mechanical workers (62.6%) and construction workers (57.4%) who had the higher percentage of work related injuries (29.6% and 39.1 % respectively), [E1] P value < 0.001. There was a positive correlation between the level of education and wearing protective equipment (P value 0.002). Our findings affirm that safety precaution and proper training on how to use the personal protective equipment is needed from companies in industrial areas to reduce the incidence of work related injury.

A phase I dose-escalation study evaluating weekly paclitaxel with neratinib and trastuzumab in women with metastatic HER2-positive breast cancer, NSABP FB-8

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Background: Dual blockade of ErbB receptors combined with chemotherapy compared with single-agent blockade improves efficacy in HER2-positive disease. FB-8 is single arm, Phase I dose-escalation study to determine safety and tolerability of weekly paclitaxel (P), the irreversible tyrosine kinase inhibitor, neratinib (N) and trastuzumab (T) in women with metastatic, HER2-positive breast cancer (MBC). Methods: Women with measurable or non-measurable MBC (ECOG PS 0 - 2) received P (80 mg/m2 IV days 1, 8, 15 of 28-day cycle), T (4 mg/kg IV, then 2 mg/kg IV weekly), and N (oral, daily). N was dose-escalated using 3+3 design at 120 mg, 160 mg, and 240 mg, dose-limiting toxicity (DLT) determined in cycle 1. All patients (pts) received prophylactic anti-diarrheals. Results: All pts were taxane and trastuzumab pre-treated, with mean of 4 prior regimens. At N=120 mg, there was 1 DLT, grade (gr) 3 diarrhea with dehydration. Three more pts were enrolled; none experienced DLT. At N=160 mg, there were no DLTs. At N=240 mg, 2 of 3 pts had DLTs: one gr 3 diarrhea and dehydration, one gr 3 diarrhea, dehydration, and gr 3 mucositis. After de-escalation to N=160 mg, 3 more pts were added. If N=160 mg is well tolerated, a 200 mg cohort is planned. 12 pts completed cycle 1. Efficacy data are available on 10: CR 1, PR 3, SD 1 (8+months). One pt* had resolution of non-target disease (skin and breast mass). 4 pts were off-study before the first scan (DLT 3 and progressive disease 1) and are considered non-responders (NR). The most frequent grade 3-4 adverse event was diarrhea, 3 pts. Conclusions: Dual anti-HER blockade with N, T combined with P is tolerable and highly active in pts pre-treated with anti-HER2 agents and chemotherapy. This combination will be studied in a phase II neoadjuvant breast cancer trial (NSABP FB-7). We thank Pfizer, Inc and Puma Biotechnology, Inc for their support. [Table: see text]

Medical education in India: time to make some changes

India is in need of well-trained doctors. We highlight and analyse some of the problems affecting medical education in India and their possible solutions. The medical education system can be reviewed under four heads: selection of students, medical training, evaluation, and the development and accreditation of faculty. In India, students enter medical colleges without receiving sufficient orientation about the profession. If students were given some exposure to various professions in the final years of school, it would help address this issue. Medical students are selected on the basis of pre-medical tests consisting of multiple-choice questions, the validity of which is being questioned increasingly. There is no coordination between the scheduling of lectures on various diseases and their management and the clinical exposure of the students. Active involvement in treatment is limited to the final year, called internship, which is hampered by preparation for postgraduate entrance examinations. Efforts should be made to provide hands-on experience at an earlier time in the course. A systematic and reliable programme for evaluation is a must. There is a need for a shift in the focus of evaluation, which should assess the application of knowledge rather than the ability to recall facts. The replacement of the traditional long-/short-case examinations with more valid and reliable instruments for the assessment of clinical skills should be considered. 'Vision 2015', a document developed by the Medical Council of India, contains many notable recommendations for the improvement of the current system. If these are implemented effectively, the impact of improvement in Indian medical education will be felt globally.

mTOR as a target in breast cancer: the emerging role of everolimus

SUMMARY The majority of patients with breast cancer are estrogen- and progesterone-receptor positive, and have benefited from the development of anti-estrogen therapies, such as tamoxifen and aromatase inhibitors. Unfortunately, metastatic patients will eventually develop resistance to these agents. Inhibitors of the mTOR, particularly everolimus, show promising activity in this group of patients. mTOR inhibition appears to reverse resistance to anti-estrogen therapy in the estrogen-receptor-/progesterone-receptor-positive subset. Additionally, they may have a similar effect by reversing anti-HER2 resistance in patients who overexpress HER2. This article reviews the mechanism of action of mTOR inhibitors and summarizes the available clinical data of their use in breast cancer.

Higher infused CD34+ cell dose and overall survival in patients undergoing in vivo T-cell depleted, but not t-cell repleted, allogeneic peripheral blood hematopoietic cell transplantation

BACKGROUND AND OBJECTIVES

Understanding the effect of cellular graft composition on allogeneic hematopoietic cell transplantation (AHCT) outcomes is an area of great interest. The objective of the study was to analyze the correlation between transplant-related outcomes and administered CD34+, CD3+, CD4+ and CD8+ cell doses in patients who had undergone peripheral blood, AHCT and received either in vivo T-cell depleted or T-cell replete allografts.

DESIGN AND SETTING

Comparison of consecutive patients who underwent peripheral blood AHCT in our institution between January 2003 and December 2009.

PATIENTS AND METHODS

The cohort of 149 patients was divided into two groups; non T-cell depleted (NTCD) (n=54) and T-cell depleted (TCD) (n=95). Study endpoints were overall survival (OS), progression free survival (PFS), engraftment kinetics (neutrophil and platelet recovery), incidence of acute graft versus host disease (acute GVHD), chronic GVHD, nonrelapse mortality (NRM) and disease relapse.

RESULTS

Multivariate analysis showed that higher infused CD34+ cell dose improved OS (relative risk 0.58, 95% CI 0.34-0.98, P=.04), PFS (relative risk 0.59, 95% CI 0.35-1.00, P=.05) and NRM (relative risk 0.49, 95% CI 0.24-0.99, P=.048) in the TCD group. By multivariate analysis, there was no difference in engraftment, grades II-IV acute GVHD, extensive chronic GVHD and relapse in the two groups relative to the infused cell doses. There was a trend towards improved OS (relative risk 0.54, 95% CI 0.29-1.01, P=.05) with higher CD3+ cell dose in the TCD group.

CONCLUSION

Our findings suggest that higher CD34+ cell dose imparts survival benefit only to in vivo TCD peripheral blood AHCT recipients.

Successful rechallenge after ixabepilone-induced radiation recall dermatitis using an alternative dosing strategy

Radiation recall dermatitis (RRD) is an inflammatory reaction occurring in a previously irradiated area, precipitated by the administration of certain drugs. The drugs most commonly associated with RRD are intravenous antineoplastic agents. The frequency of development of this toxicity in clinical practice is unclear. We report a case of RRD induced by ixabepilone, an epothilone antineoplastic agent, with successful rechallenge utilizing an alternative dosing regimen.

P3-17-09: Neutralizing the Prolactin Receptor with Therapeutic Antibody LFA102: A Novel Approach for the Treatment of Breast Cancer

The prolactin receptor (PRLR) is a class I cytokine receptor required for the normal development of the mammary gland and is frequently found to be overexpressed in breast tumors. The polypeptide hormone prolactin (PRL) has been demonstrated to induce PRLR signaling through the Jak/Stat, PI3-kinase/AKT and MAPK pathways, leading to cell proliferation and survival. Mammary gland-specific overexpression of PRL in transgenic mice leads to a higher incidence of ER+ and ER- mammary tumors. In addition, the PRLR locus is the site of frequent viral integrations in MMTV-induced mammary tumors. Elevated serum PRL levels in humans have been correlated with an increased risk for breast cancer, especially for ER+ cases, implicating a role for this hormone in the development of human breast tumors. An analysis of more than 3000 breast tumor specimens indicates that PRLR is expressed with high prevalence (60-70% of tumors) across all breast cancer subtypes, with a trend towards higher expression in ER+ tumors. All of these lines of evidence support the hypothesis that targeting the PRL/PRLR axis may be a new approach for addressing unmet medical need in breast cancer. LFA102 is a Human Engineered™ anti-PRLR antibody of the IgG1 isotype that neutralizes the function of PRLR through a non-ligand competitive binding interaction. LFA102 blocks PRL-induced signaling and proliferation in T47D and MCF7 ER+ human breast cancer cells in vitro, and abolishes PRL-induced phosphorylation of Stat5 in T47D xenograft tumors in vivo. An examination of disaggregated primary human breast tumors ex vivo has indicated that PRL frequently induces signaling through Stat5 in the cells and that LFA102 is capable of completely antagonizing this signaling. LFA102 also neutralizes rat PRLR and the antibody potently regresses PRL-dependent Nb2-C11 pre-T cell lymphoma tumors in vivo. Preliminary data suggests that LFA102 is also capable of inhibiting the growth of carcinogen-induced rat mammary tumors. In vitro studies have shown that LFA102 can also mediate antibody-dependent cellular cytotoxicity (ADCC) and inhibit the PRL-dependent release of the pro-angiogenic factor VEGF from breast cancer cells. Thus, there are multiple potential mechanisms through which LFA102 could show anti-tumor activity in vivo. Preclinical toxicological studies of LFA102 indicate that this therapeutic is well tolerated and exhibits a normal pharmacokinetic profile in relevant animal species. The safety and pharmacokinetics of LFA102 in humans are currently being evaluated in a phase I healthy volunteer trial. At the three dose levels explored so far, no infusion reactions or severe adverse events related to the drug have been reported. Preliminary results suggest that LFA102 has an adequate pharmacokinetic profile for further clinical development. An assessment of LFA102 in a population of metastatic breast cancer patients predicted to have the highest probability of benefit is imminent.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-17-09.

P4-12-14: Pilot Study Utilizing Fluorine-18 Fluorodeoxyglucose (F-18 FDG) Positron Emission Tomography–Computed Tomography Scan (PET-CT Scan) To Investigate Brain Metabolic Changes during Treatment in Women with Breast Cancer

BACKGROUND: Approximately 25% of the patients undergoing chemotherapy develop cognitive changes. Similarly, significant neurocognitive changes in verbal memory and executive functioning have been reported in patients undergoing endocrine therapy. Though extensively studied, specific changes in the brain associated with cognitive dysfunction are still not clear. We performed an IRB-approved retrospective pilot study utilizing brain images from standard PET-CT scans in patients being treated for breast cancer. Comparison was made between patients initial and follow-up scans to look for metabolic changes.

MATERIALS AND METHODS: Thirty nine patients with a diagnosis of breast cancer were identified from radiology database of West Virginia University Hospitals, who underwent at least two PET-CT scans during their treatment for breast cancer from 2004–2009. Patients with brain metastasis were excluded. NeuroMIM® software analysis program was used to compare a comprehensive database of physiologic brain anatomy and metabolism with F-18 FDG perfusion brain images from the patients. Comparison was made in sixty-three defined brain regions. For each patient, two scans at approximately twelve month intervals were analyzed. The data sets from initial scans were compared with the follow up.

RESULTS: A total of 37 patients received cytotoxic chemotherapy, 2 patients received only endocrine therapy. Data analysis using the signed-rank test shows that the collective Z-score values change between the initial and follow up scans. When data analysis is applied to the individual brain regions, the Lingual Gyrus (p=0.012) and the Angular Gyrus (p=0.056)show statistically significant and near significant decreases in brain metabolism respectively. These regions are attributed with language, mathematics and cognition. Several additional regions such as the fusiform gyrus and the primary visual cortex show p-values between 0.05 and 0.10, which indicate “trending”. These regions may demonstrate statistically significant decrease in metabolism if the sample size is increased.

DISCUSSION: The Lingual and the Angular Gyrus show a statistically significant and near significant decrease in glucose metabolism respectively, in patients receiving treatment for breast cancer. Limitations of this study include lack of baseline brain imaging and its clinical correlation with cognitive function. Based upon these preliminary findings prospective studies are being planned.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-14.

Abstract A73: Integrating in vitro signaling and drug response data from single cell network profiling (SCNP) to inform on individual's AML biology

Background: SCNP is a multiparametric flow cytometry-based assay that allows for simultaneous measurement of multiple signaling nodes (stimulus intracellular signaling molecule) in cell subsets from heterogeneous tissues, such as whole blood or PBMC (Kornblau et al. CCR 2010). SCNP has proven useful for functional pathway analysis of AML patient (pt) samples without the need for cell isolation.

Objectives/Design: 1) Functionally characterize intrinsic and extrinsic signals implicated in the growth/survival of primary AML cells; 2) Concurrently assess the in vitro effects of a wide variety of kinase inhibitors (KIs) and cytotoxic agents on those signaling networks; and 3) Evaluate any association between signaling profiles and effects upon cell cycle and survival.

Methods: Cryopreserved AML samples (N=8; 3 pre-induction, 3 post-induction, 2 relapsed) and healthy bone marrow (BM) samples (N=5) were analyzed via SCNP in 2 experimental arms: Arm 1 assessed basal and growth factor (GF) (SCF, FLT3L, G-CSF, IL-3, TPO) induced signaling in the JAK/STAT, PI3K/mTor, and MEK/ERK pathways ± specific KIs (GDC-0941, BEZ235, AZD6244, AC220, and CP-690550). Signaling readouts were measured simultaneously in multiple myeloid subsets (present in each individual AML sample) identified by expression of CD34, CD117 (cKit), CD45, and light scatter properties. Arm 2 assessed the cytotoxic and cytostatic impact of commercial and investigational drugs (n=23) as single agents and in selected combinations after 48-hr exposure at clinically relevant concentrations. Measures included cell viability (AQUA), apoptosis (cPARP), S/G2 phase (Cyclin B1), M-Phase (p-HistoneH3), and DNA damage (H2AX).

Results: In Arm 1, analysis of signaling patterns within the multiple myeloid subsets in individual AML samples demonstrated inter patient morphologic and functional heterogeneity (i.e., GF and/or KIs hypo/hypersensitivity) contrasting with the more homogeneous cellular and signaling patterns observed in the healthy BM. In Arm 2, using unsupervised hierarchical clustering, broad heterogeneity in drug sensitivity (as measured by both cytostasis and apoptosis) among the same AML samples was also observed, again contrasting with the relatively homogeneous responses observed in healthy BM samples. Of note, cluster analysis of apoptosis and cytostasis data grouped together drugs which share mechanisms of action such as JAK inhibitors (CYT387, CP-690550, INCB018424); mTor inhibitors (BEZ235, RAD001); and chemotherapeutics (AraC, clofarabine, etoposide) thus supporting the biologic relevance of the assay. Combined analyzes of Arm 1 and 2 data revealed one AML sample with a distinguishing signaling profile (unresponsive to G-CSF and FLT3L and hypersensitivity to TPO) which was refractory, as measured by induced apoptosis, to most treatments except for bortezomib and an HSP90 inhibitor.

Conclusion: SCNP allows for simultaneous assessment of signaling and apoptotic/cytostatic effects of anti-AML drugs. Integrating these data provides insight into the aberrant tumor biology underlying each individual AML pt sample, potentially informing pt-specific strategies for treatment and selection of rational drug combinations. The clinical relevance of the above observations is the focus of ongoing clinical studies.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr A73.

Prognosis by breast cancer subtypes in patients treated with adjuvant chemotherapy in a clinical trial

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Background: Breast cancer can be classified into molecular subtypes that have distinct survival patterns. The purpose of this study was i) to evaluate the prognostic significance of breast cancer subtypes in a cohort of women taking part in the NEAT and BR9601 clinical trials comparing CMF with ECMF, and ii) to evaluate whether the subtypes were predictive of the added benefit of epirubicin in these trials.

Methods: Tumor tissue microarrays were stained and scored for ER, PR, HER2, EGFR and CK5/6. These were used to classify the tumors into six intrinsic subtypes (1). We used Cox regression to compare overall survival (OS), breast cancer specific survival (BSS) and relapse free survival (RFS) in the different subgroups. We also compared the effect of ECMF with CMF by subgroup.

Results: IHC data were available for 1725 cases of whom 805 were Luminal 1-basal negative, 153 were Luminal 1-basal positive, 174 were Luminal 2, 192 were HER2-like, 230 were core basal phenotype and 171 were 5-negative phenotype. Median follow-up time was 7 years. The prognostic effects of the subtypes were similar to those reported for unselected breast cancer cases irrespective of adjuvant therapy (Blows FM, et al. PLoS Med 2010;75:e1000279.). In particular, the luminal 1-basal negative tumors were associated with the best prognosis in five years after surgery and the HER2-like tumors were associated with the poorest prognosis. ECMF has previously shown to be associated with a 33% relative risk reduction for OS compared to CMF (Poole CJ et al. N Engl J Med 2006;35518:1851-62.). There was little evidence for significant heterogeneity of effect by tumor subtype for any end point (OS P= 0.40, BSS P=0.53 RFS P=0.50). However, there was an observed trend towards the largest additional benefit from ECMF being in women with tumors of the 5-negative phenotype (OS HR=0.39 95% CI 0.21-0.73) and the smallest being in Luminal 1-basal negative tumors (OS HR=0.86 95% CI 0.64-1.16).

Conclusions: In a clinical trial in which all patients received chemotherapy, we confirmed that breast cancer subtypes show distinct behaviour with differences in short and long term survival. The benefit of ECMF over CMF was statistically similar in all disease subtypes.

Initial clinical test of a breast-PET scanner

INTRODUCTION

The goal of this initial clinical study was to test a new positron emission/tomography imager and biopsy system (PEM/PET) in a small group of selected subjects to assess its clinical imaging capabilities. Specifically, the main task of this study is to determine whether the new system can successfully be used to produce images of known breast cancer and compare them to those acquired by standard techniques.

METHODS

The PEM/PET system consists of two pairs of rotating radiation detectors located beneath a patient table. The scanner has a spatial resolution of ∼2 mm in all three dimensions. The subjects consisted of five patients diagnosed with locally advanced breast cancer ranging in age from 40 to 55 years old scheduled for pre-treatment, conventional whole body PET imaging with F-18 Fluorodeoxyglucose (FDG). The primary lesions were at least 2 cm in diameter.

RESULTS

The images from the PEM/PET system demonstrated that this system is capable of identifying some lesions not visible in standard mammograms. Furthermore, while the relatively large lesions imaged in this study where all visualised by a standard whole body PET/CT scanner, some of the morphology of the tumours (ductal infiltration, for example) was better defined with the PEM/PET system. Significantly, these images were obtained immediately following a standard whole body PET scan.

CONCLUSIONS

The initial testing of the new PEM/PET system demonstrated that the new system is capable of producing good quality breast-PET images compared standard methods.

Smoking behaviors among cancer survivors: an observational clinical study

PURPOSE

Smoking is a well-recognized risk factor for several cancers including cancers of the lung, bladder, and head and neck. Studies have shown that smoking can adversely affect the outcomes of different modalities of cancer treatment. This study examines smoking behaviors among cancer survivors to collect information necessary to create successful smoking cessation interventions.

METHODS

For this observational clinical study, questionnaires were sent to 1,000 randomly selected patients diagnosed with cancer between 2003 and 2007 in one cancer center. Data were statistically analyzed to determine the likelihood of a patient quitting smoking after being diagnosed with cancer.

RESULTS

We received 187 responses from the 1,000 surveys sent (18.7%). Of these, 166 were usable for analysis. The mean age of respondents was 64 (± 13) years. Men were more likely than women to be past smokers (55% of men and 32% of women respectively, P = .003). Fifty-two percent of respondents reported having a history of smoking. However, only 20% of patients reported having been active smokers at the time they were diagnosed with cancer. Furthermore, only 44% of these reported having quit smoking after their diagnosis with cancer. Only 62% of all respondents reported that they had been informed of the dangers of smoking by their health care provider during cancer treatment.

CONCLUSION

In our study sample, less than one half (44%) of smoking cancer patients quit smoking after their cancer diagnosis, and only 62% of smoking cancer patients received smoking cessation counseling from their physicians. Intervention programs are needed to help cancer survivors to quit smoking. Prospective clinical trials may help identify the ideal intervention for smoking cessation.

Higher busulfan dose intensity does not improve outcomes of patients undergoing allogeneic haematopoietic cell transplantation following fludarabine, busulfan-based reduced toxicity conditioning

We evaluated the impact of busulfan dose intensity in patients undergoing reduced toxicity/intensity conditioning allogeneic transplantation in a multicenter retrospective study of 112 consecutive patients. Seventy-five patients were conditioned with busulfan (0.8 mg/kg/dose IV × 8 doses), fludarabine (30 mg/m(2) /day, days -7 to -3), and 6 mg/kg of ATG [reduced intensity conditioning (RIC) group], while 37 patients received a more-intense conditioning with busulfan (130 mg/m(2) /day IV, days -6 to -3), fludarabine (40 mg/m(2) /day, days -6 to -3) and 6 mg/kg of ATG [reduced toxicity conditioning (RTC) group]. At baseline both groups were matched for median age, unrelated donor allografts, and human leukocyte antigen-mismatched allografts. More patients in RIC group had high-risk disease, and higher median comorbidity index. There were no graft rejections. Median time to neutrophil (17 days vs. 15 days; p = 0.003) and platelet engraftment (16 days vs. 11 days; p < 0.001) was significantly longer in the RIC group. RTC group had significantly more bacterial (62.2% vs. 32%; p = 0.004) and fungal infections (13.5% vs. 1.3% p = 0.01). For RIC and RTC groups rates of grades II-IV acute GVHD (34% vs. 40%; p-value = 0.54), and chronic GVHD (45% vs. 57%; p-value = 0.30) were not significantly different. In similar order at 1 year the cumulative-incidence of non-relapse mortality (NRM; 12% vs. 21%; p-value = 0.21) and relapse rates (38% vs. 39%; p = 0.96) were not significantly different. Patients in RIC and RTC groups had similar 1-year overall survival (61% vs. 50%, p = 0.11) and progression-free survival (50% vs. 36%, p-value = 0.39). Our data suggest that the merits of higher busulfan dose intensity in the context of fludarabine/busulfan-based RTC may be offset by higher early morbidity.

A population-based gene signature is predictive of breast cancer survival and chemoresponse

It remains a critical issue to improve the survival rate in patients with recurrent or metastatic breast cancer. This study sought to develop a prognostic scheme based on a 28-gene signature in a broad patient population, including those with advanced disease. Clinically annotated transcriptional profiles of 1,734 breast cancer patients were obtained to validate the 28-gene signature in prognostic categorization. The 28-gene signature generated significant patient stratification with regard to breast cancer disease-free survival (log-rank P<0.0001; n=1,337) and overall survival (log-rank P<0.0001; n=806) in Kaplan-Meier analyses. The gene expression signature provides refined prognosis of disease-free survival (log-rank P<0.006; Kaplan-Meier analysis) within each classic clinicopathologic factor-defined subgroup, including LN-, LN+, ER-, ER+ and tumor grade II. Furthermore, it was investigated whether this gene signature predicts chemoresponse to drugs commonly used to treat breast cancer. The mRNA expression levels of this gene signature in NCI-60 cell lines were used to predict chemoresponse to CMF, tamoxifen, paclitaxel, docetaxel, and doxorubicin (adriamycin). The 28-gene prognostic signature accurately (P<0.02) predicted chemotherapeutic response to the studied drugs. This study confirmed the prognostic applicability of the breast cancer gene signature in a broad clinical setting. This prognostic signature is also predictive of drug response in cancer cell lines.

Circulating tumor cells in the management of breast cancer

Most deaths from breast cancer are from metastatic disease. Tests that predict an individual's risk of developing metastatic disease could be useful. There is growing evidence that circulating tumor cells (CTC) could help predict recurrence and effectiveness of therapy. However, there are unresolved issues with CTC detection methods and their implementation in the community. The utility of CTC testing in the management of breast cancer is unclear based on current studies. This article reviews the role of CTC testing in the management of early and metastatic breast cancer.

Role of obesity and exercise in breast cancer survivors

Over 60% of the American population meets the criteria for obesity, and obesity is very common in patients with breast cancer. Many studies have shown that obese patients with breast cancer have a worse prognosis compared to normal weight individuals. Tumor characteristics and other factors contribute to this. Exercise could reverse some of the pathophysiologic factors that contribute to this increased risk, and has been shown in some studies to improve survival in patients with breast cancer. In addition to administering anticancer therapy, cancer clinicians should make concerted attempts to get patients to enroll in weight management and exercise programs, which could improve survival in patients with breast cancer.