Association study of genes related to bone formation and resorption and the extent of radiographic change in ankylosing spondylitis

OBJECTIVE

To identify genetic associations with severity of radiographic damage in ankylosing spondylitis (AS).

METHOD

We studied 1537 AS cases of European descent; all fulfilled the modified New York Criteria. Radiographic severity was assessed from digitised lateral radiographs of the cervical and lumbar spine using the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). A two-phase genotyping design was used. In phase 1, 498 single nucleotide polymorphisms (SNPs) were genotyped in 688 cases; these were selected to capture >90% of the common haplotypic variation in the exons, exon-intron boundaries, and 5 kb flanking DNA in the 5' and 3' UTR of 74 genes involved in anabolic or catabolic bone pathways. In phase 2, 15 SNPs exhibiting p<0.05 were genotyped in a further cohort of 830 AS cases; results were analysed both separately and in combination with the discovery phase data. Association was tested by contingency tables after separating the samples into 'mild' and 'severe' groups, defined as the bottom and top 40% by mSASSS, adjusted for gender and disease duration.

RESULTS

Experiment-wise association was observed with the SNP rs8092336 (combined OR 0.32, p=1.2×10(-5)), which lies within RANK (receptor activator of NFκB), a gene involved in osteoclastogenesis, and in the interaction between T cells and dendritic cells. Association was also found with the SNP rs1236913 in PTGS1 (prostaglandin-endoperoxide synthase 1, cyclooxygenase 1), giving an OR of 0.53 (p=2.6×10(-3)). There was no observed association between radiographic severity and HLA-B*27.

CONCLUSIONS

These findings support roles for bone resorption and prostaglandins pathways in the osteoproliferative changes in AS.

Abstract P3-08-09: Is it me or is it hot in here? Hot flushes (or flashes): An unmet need. UK NCRI breast clinical studies group working party on symptom management (vasomotor)

Hot Flushes or Flashes are a serious problem. They impact significantly on daily life and sleep quality, affecting employment, relationships and quality of life. The only effective treatment for hot flushes is oestrogen which is contraindicated in 75% of breast cancer patients. An estimated 550,000 people now live in the UK with a diagnosis of breast cancer and up to 70% women experience disabling hot flushes which can continue for years after treatment. Studies have shown that up to 50% of patients stop taking their life-saving antioestrogen drugs before 5 years1 quite probably due to unacceptable side-effects

On the initiative of the patient advocate members of the NCRI Breast Clinical Studies Group, a Working Party on Symptom Management has been established. Members of the group have a particular interest in hot flushes and include representatives from patients, oncology, psychology, gynaecology, acupuncture and the voluntary not-for-profit sector

The Working Party audited current UK clinical practice for hot flushes in cancer with a short questionnaire circulated to the UK Breast Intergroup mailing list (about 800 breast cancer health professionals) and to the Breast Cancer Care Nursing Network (about 850 clinical nurse specialists/breast care nurses). The full results of the questionnaire will be presented

Briefly, a small number of people were prescribed hormone replacement therapy or Progesterone (Megestrol acatate), more Clonidine and Gabapentin and many selective serotonin reuptake inhibitors (SSRIs). Although SSRIs have some effect in reducing the intensity of hot flushes, they have significant side effects including sexual dysfunction, in a group of women, many of whom are already suffering sexual problems due to anti-oestrogen drugs or premature menopause. In addition, available treatments (both pharmacological and non-pharmacological) varied across the UK.

The majority (95%) of respondents to our questionnaire agreed or strongly agreed that treatment and management of hot flushes is an unmet need. The questionnaire also demonstrated inequality of access to treatment in the UK.

An exploration of the US National Cancer Institute and UK clinical trials databases revealed very few studies working in this area. 21 studies in the UK, Europe and the USA since 2006. Most trials investigate non pharmacological approaches and combinations and new versions of existing approaches.

There are no agreed guidelines for managing hot flushes after breast cancer, which may limit the access and availability of appropriate interventions. It is clear from our survey that clinicians are left making individual decisions based on personal experience and availability of local services, which has led to a patchy and inequitable position on the management of this troubling problem. There is a need for research to understand the physiology of flushing and to develop and test new interventions to address this intractable problem, which continues to be a cause of considerable distress to many women after breast cancer.

1. Makubate B et al Cohort study of adherence to adjuvant endocrine therapy, breast cancer recurrence and mortality.Br J Cancer. 2013;108:1515-24.

This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 10/34/01). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-09.

Abstract P1-10-01: Patient advocate involvement shapes UK’s first national breast cancer tissue bank - The breast cancer campaign tissue bank

The Breast Cancer Campaign Tissue Bank (BCCTB) was initiated in 2010 after the charity Breast Cancer Campaign heard from breast cancer experts that insufficient high quality breast cancer tissue was preventing research which would impact people with breast cancer1. The charity decided to involve patient advocates in the development of the BCCTB from the beginning.

Two advocates reviewed the initial applications to form the BCCTB. These included both single and multi-centre applications so they suggested that, rather than choosing one centre to form the Bank, the charity consider a collaboration of centres. Throughout the development of the BCCTB, the patient advocates asked the ‘elephant in the room’ questions and brought a different perspective. They also helped to design the Bank's processes, including the consent process and asking that all tissue applicants produce a lay summary of their research.

There are now two advocates on the Board which provides strategic direction to the BCCTB. The advocates have equal status to other Board members. There are also three advocates on the Tissue Access Committee which controls the use of tissue in the Bank. Lay summaries of projects have to be approved by all advocates before an application can proceed. This means that no precious tissue is released without the approval of a lay person, who can ensure maximum patient benefit will be achieved from any research. The Bank's data return policy was also driven by the patient advocates who were keen that the tissues donated were used to their maximum benefit. This has resulted in the first publication from BCCTB2

Patient advocates have been involved in promoting the use of tissue from the bank presenting at conferences and at BCCTB road shows. Patient advocates have also been involved in asking potential donors to consent to donate to the tissue bank.

The involvement of patient advocates in the development and oversight of the BCCTB has shown researchers that patient and public involvement works. The advocates can also help promote the Bank and the benefits of tissue donation to both professionals and lay groups.

The patient advocates involved in the Breast Cancer Campaign Tissue Bank are members of the charity Independent Cancer Patients’ Voice

1. Thompson P, Brennan K, Cox A, Gee J, Harcourt D, Harris A, Harvie M, Holen I, Howell A, Nicholson R, Steel M, Streuli C. Evaluation of the current knowledge limitations in breast cancer research: a gap analysis. Breast Cancer Res 2008: 10(2); R26.

2. Speirs V, Morgan A. Investment biobanking – increased returns on tissue samples. Nat Rev Clin Onc 2013; 10:128-129.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-10-01.

OPTIMA prelim: Optimal personalized treatment of early breast cancer using multiparameter tests

TPS656

Background: Chemotherapy may have little effect on some subtypes of early breast cancer, identified as being hormonally responsive tumours without HER2 gene amplification and with a low or intermediate grade. Multi-parameter genomic tests such as Oncotype DX are increasingly used to identify patients for whom the addition of chemotherapy may confer little additional benefit. OPTIMA has an adaptive design seeking to advance development of personalised medicine in breast cancer by assessing the value of multi-parameter tests in a UK population of intermediate risk. Methods: OPTIMA prelim, the feasibility phase, has 3 objectives: (1) To evaluate performance and health-economics of multi-parameter tests to determine which test(s) will be used in the main trial; (2) To establish efficient and timely sample collection and analysis essential to deliver multi-parameter test driven treatment; (3) To establish the acceptability to patients and clinicians of randomisation to test-directed treatment assignment. OPTIMA prelim aims to recruit 300 patients with ER+ve HER2-ve tumours with involved nodes (pN1-2). Patients are randomized to the standard arm of chemotherapy with endocrine therapy, or to the “test-directed treatment” arm assigned to either the same chemotherapy with endocrine therapy or endocrine therapy only according to the result of an Oncotype DX test. The decision to continue to a main trial will be determined by concordance, cost and willingness of patients to be randomized to test guided treatment. Cost-effectiveness models will be based on the model developed in preparation for the OPTIMA trial, updated with contemporary evidence from the feasibility study and appropriate external data, e.g. the Ontario prospective cohort study. Results: Optima opened in Sept 2012 with 25 centres involved. To date 22 patients are registered, of which 17 have been randomised. Patient focus groups show the trial design is acceptable and has potential to reduce need for chemotherapy. TSC and DMEC agree that this is an important trial testing the feasibility within this patient population. Decision rules are challenging for this study but employment of adaptive designs gives the flexibility needed for the main trial. Clinical trial information: ISRCTN42400492.

The effectiveness of radon preventive and remedial measures in Irish homes

It is estimated that approximately 100 000 Irish homes have radon concentrations above the reference level of 200 Bq m(-3). To minimise the number of new homes with this problem, building regulations require that all new homes built since July 1998 in high radon areas are installed with radon barriers during construction. Measurements on local authority homes in a number of high radon areas have allowed the impact of these new regulations to be assessed. In County Cork a reduction of up to 70% in the mean radon concentration was observed in homes built since 1998 relative to those built before this date. A reduction in both the number of homes exceeding the reference level and the maximum concentration measured in homes was also measured. Homes exceeding the reference level were remediated with the use of an active sump. The results of this remedial work are also presented and show that the mean reduction in radon concentration achieved was 92%.

Selecting breast cancer patients for chemotherapy: the opening of the UK OPTIMA trial

The mortality from breast cancer has improved steadily over the past two decades, in part because of the increased use of more effective adjuvant therapies. Thousands of women are routinely treated with intensive chemotherapy, which can be unpleasant, is expensive and is occasionally hazardous. Oncologists have long known that some of these women may not need treatment, either because they have a low risk of relapse or because they have tumour biology that makes them less sensitive to chemotherapy and more suitable for early adjuvant endocrine therapy. There is an urgent need to improve patient selection so that chemotherapy is restricted to those patients who will benefit from it. Here we review the emerging technologies that are available for improving patient selection for chemotherapy. We describe the OPTIMA trial, which has just opened to recruitment in the UK, is the latest addition to trials in this area, and is the first to focus on the relative cost-effectiveness of alternate predictive assays.

Facilitating medical withdrawal from opiates in rural Ontario

CONTEXT

The abuse of oxycodone in Northwestern Ontario, Canada, has escalated at alarming rates raising concerns that opiate use has reached epidemic proportions, particularly among the First Nations communities. The authors were involved in establishing Ontario's first rural inpatient medical withdrawal unit to serve patients seeking abstinence.

ISSUES

The development of the medical withdrawal support services (MWSS) required creative and adaptive strategies to respond to the geographical, cultural and institutional circumstances.

LESSONS LEARNED

Key factors to support program efficacy and successful outcomes for clients during the inaugural eight months of operation are interprofessional and collaborative approaches with a cultural awareness.Key words: addiction, Canada, First Nation, medical withdrawal.

Adolescent multiple risk behaviour: an asset approach to the role of family, school and community

BACKGROUND

Engagement in risk behaviours may pose a significant threat to health if involvement spans multiple behaviours. The asset model suggests that contextual aspects of young people's lives, such as factors related to family, school and community, serve as a protective function against health risk behaviours.

METHODS

A risk-taking index was created from the English health behaviour in school-aged children study on 15 years olds, substance use and sexual activity. Using a multinomial regression, potential asset variables relating to school, family, peers, community and family affluence were tested for their association with levels of risk behaviours.

RESULTS

Sense of neighbourhood belonging, strong school belonging and parental involvement in decision-making about leisure time were related to lower engagement in health risk behaviours. A weaker sense of family belonging was associated with increased risk behaviours if connectedness with teachers was also low. Factors related to school and community played a greater role in adolescent participation in health-related risk behaviours than family-related factors, including family affluence.

CONCLUSIONS

Feelings of safety and belonging in the out-of-home settings of adolescents were positively associated with reduced risk behaviours, and indicate the importance of the wider community alongside parents and school as protective assets for health.

OPTIMA prelim: Optimal personalized treatment of early breast cancer using multiparameter analysis: Preliminary study

TPS665

Background: “Multi-parameter” prognostic tests such as Oncotype DX are increasingly used to identify women with ER +ve HER2 -ve breast cancer treated with endocrine therapy who are unlikely to benefit meaningfully from adjuvant chemotherapy. The supporting evidence for predictive testing is retrospective and is strongest for women with negative nodes. Randomised trials to validate testing are in progress but more evidence is needed, especially for node positive disease. There is early evidence that other multi-parameter tests which are in development have a predictive utility. Methods: OPTIMA will assess the value of multi-parameter tests in a UK population. OPTIMA prelim, the feasibility phase, will recruit 300 patients from May 2012 (with a 200 patient bridging extension to the main study). Eligible patients will have ER +ve HER2 -ve tumours with involved nodes (pN1-2). Patients will be randomised to the standard arm of both chemotherapy and endocrine therapy, or to the “test-directed treatment” arm in which patients will be assigned either the same chemotherapy and endocrine therapy or endocrine therapy only according to the result of an Oncotype DX test. OPTIMA prelim has 3 objectives. (1) To establish whether randomisation to test-directed treatment is acceptable to patients and clinicians. This will be done through qualitative research with in-depth interviews with OPTIMA researchers and by recording and analysing consultations when the trial is discussed with potential participants. (2) Alternative multi-parameter tests will be evaluated on all patients’ tumours and their performance will be compared to Oncotype DX using statistical and cost-effectiveness analysis to select a candidate test(s) appropriate for NHS use to be evaluated in the main trial. (3) The success of the main trial depends on efficient tumour sample collection and analysis to avoid treatment delays. The obstacles to this will be analysed in detail using a sample tracking database. The main study is an efficacy trial of 2-3 arms with the same design but uses tests selected in OPTIMA prelim. It will compare 5-year relapse free survival of test-directed vs. conventional treatment with a non-inferiority hypothesis.