P3-13-07: The TARGIT-A Trial Update Confirms No Increase in Local Recurrence

Introduction: In June 2010, we published the results of the TARGIT-A trial (1) that compared “one-size fits” all radiotherapy (whole breast radiotherapy-EBRT group) with risk -adjusted radiotherapy (TARGIT- group: single dose TARGeted Intraoperative radioTherapy with additional whole breast radiotherapy if adverse prognostic factors were found). These results showed that the risk of local recurrence in the TARGIT group was non-inferior to that of the EBRT group (the difference between the two arms was 0.25% at 4 years). We now report the results analyzed after further follow up of the total trial cohort without unblinding.

Method: As often repeated, unplanned analysis comparing two groups in a randomized trial can result in an increased alpha-spent as well as carry the risk of a false positive result, we have remained blinded to the further recurrences in the trial according to allocated treatment, since the original publication in the Lancet. Instead we proposed and performed a blinded analysis of the local recurrence rate for the whole cohort. We plotted the Kaplan Meier plots and compared the estimated 4-year recurrences.

Results: Amongst the 2232 patients randomized, there were 13 recurrences at the time of Lancet publication and since then, we have had 8 additional recurrences. The number of patients who have completed at least 4 years of follow up has increased from 420 to 717. We found that the 4-year Kaplan Meier estimate of local recurrence was 1.08% (95% CI 0.59 −1.96) at the time of the Lancet publication and it is 1.09% (95% CI 0.65 - 1.85) now.

Conclusion: We found that the overall 4-year recurrence rates of the TARGIT-A trial have remained stable with a longer follow up and therefore; it is statistically implausible, that one particular arm has a significantly higher local recurrence.

References

1. Vaidya JS, Joseph DJ, Tobias JS, Bulsara M, Wenz F, Saunders C, Alvarado M, Flyger HL, Massarut S, Eiermann W, Keshtgar M, Dewar J, Kraus-Tiefenbacher U, Sutterlin M, Esserman L, Holtveg HM, Roncadin M, Pigorsch S, Metaxas M, Falzon M, Matthews A, Corica T, Williams NR, Baum M. Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): an international, prospective, randomised, non-inferiority phase 3 trial. Lancet 2010;376(9735):91–102.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-13-07.

Cosmetic outcome 1, 2, 3, and 4 years after intraoperative radiotherapy or external beam radiotherapy for early breast cancer: An objective assessment of patients from a randomized controlled trial

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Background: The randomized controlled TARGIT Trial was designed to determine noninferiority between the novel technique of TARGIT [intra-operative radiotherapy with Intrabeam (Carl Zeiss, Germany)] and conventional external beam radiotherapy (EBRT) in women with early breast cancer. The main outcome objective is risk of local relapse within the treated breast. We report here data from a subprotocol assessing cosmesis in 114 women over 50 years old participating in the TARGIT Trial from one center (Perth, Australia).

Methods: Frontal view digital photographs from were assessed, blind to treatment, using specialist software (BCCT.core 2.0, INESC Porto, Portugal) that produces an objective composite score based on symmetry, color, and scar. Data on patient and tumor characteristics were obtained from hospital notes. Statistical analysis was by generalized estimating equations (GEE) on all data, and logistic regression analysis at year 1 only.

Results: Photographs were taken at baseline (before surgery) and 1, 2, 3, and 4 years after initial breast-conserving surgery; none of the 114 patients had subsequent breast surgery. Median age at randomization was 62 years (IQR 56 to 68). The composite scores were dichotomized into Excellent and Good (EG), and Fair and Poor (FP). There was a nonsignificant 45% increase in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group (OR=1.45, 95%CI 0.78 – 2.69, p=0.245) after adjusting for tumour size. The results were similar when adjusted for tumor grade and age of the patient. For year 1 there was a statistically significant 2.35 fold increase in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group (OR=2.35, 95%CI 1.02 – 5.45, p=0.047) after adjusting for age of the patient, tumor size, and grade.

Conclusions: These results confirm a significantly better cosmetic outcome with TARGIT compared to EBRT in the first year after surgery.

Adherence of pregnant women to dietary counseling and adequacy of total gestational weight gain

INTRODUCTION

in scientific literature there are not published researches which have used a validated assessment method of adherence to dietary counseling capable of being reproduced.

OBJECTIVE

to evaluate the adherence of pregnant women to dietary counseling during the prenatal period using a validated instrument according to the outcome of total gestational weight gain.

METHODS

two hundred and eight adult pregnant women participated in the research. The instrument for adherence classification to dietary counseling was elaborated according to four evaluation criteria: food quantity and quality, meal pattern and adjustment to weekly weight gain. We classified as poor adherence when zero-one criterion was observed, good adherence when 2-3 aspects were observed and excellent when the amount was 4 aspects.

RESULTS

Pregnant women with good or excellent adherence had a higher adjustment proportion of the total gestational weight gain in comparison to those who presented poor adherence in the second and fourth visits, respectively (p < 0.006; p < 0.007). Women with poor adherence to dietary counseling in the second visit presented about three times more chances of having poor adherence in the fourth visit (OR = 3.11; CI = 1.46-6.36).

CONCLUSION

Adherence of pregnant women to dietary counseling had a positive association with the adjustment of total gestational weight gain.

Abstract P3-11-11: A Comparison of Breast Cancer Treatment Rates in British Columbia, Scotland, and Western Australia, and a Comparison with Models of “Optimal” Therapy

Background: Evidence-based optimal utilization models provide estimates of optimal radiotherapy, chemotherapy and hormonal therapy utilization by stage and other clinically relevant patient sub-groups. We therefore compared predicted utilization with actual utilization of radiotherapy, hormone therapy and chemotherapy in 3 jurisdictions with population-based stage and treatment data: British Columbia, Canada; Dundee, Scotland; and Perth, Western Australia.

Methods: Previously published optimal radiotherapy, chemotherapy, and endocrine therapy treatment utilization trees for an Australian population were modified to incorporate epidemiological data from British Columbia, Dundee, and Perth, such that the optimal trees for each region reflected the casemix for each region. Frequency data on patient, tumour, and surgical factors were used to calculate optimal treatment rates for each region. Optimal rates were then compared with actual rates of surgery, radiotherapy, chemotherapy, and endocrine therapy use obtained from 2 population-based and 1 institution-based cancer registries for patients diagnosed with breast cancer between 2000 to 2004. Information on region-specific treatment guidelines was also collected.

Results: Region-specific optimal treatment utilization rates at diagnosis varied between 80% and 81% for radiotherapy (62 to 64% when patient preference is taken into account), 53% to 56% for chemotherapy, and 49% to 54% for endocrine therapy. The predicted ranges were due to local variations in demographics, and tumour stage. Actual radiotherapy utilization was 57%, 49%, and 52%; chemotherapy utilization was 32%, 24%, and 29%; and endocrine therapy utilization was 56%, 64%, and 52% for British Columbia, Dundee, and Perth, respectively. Conclusion: There are significant differences in actual treatment utilisation rates between the study populations. It is unlikely that all of this variation is due to differences in tumour characteristics alone. Actual utilization rates were lower than the calculated optimal rates for radiotherapy and chemotherapy, and higher for endocrine therapy. Differences between actual regional rates of treatment utilization were seen, and were associated with differences in mastectomy rates, and guideline recommendations for treatment use in that region. This methodology allows comparison of the treatment that occurs in a jurisdiction against what would be considered optimal based on evidence.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-11-11.

Abstract P4-11-09: Evidence of Better Cosmetic Outcome after Intra-Operative Radiotherapy with the TARGIT Technique Compared with External Beam Radiotherapy for Early Breast Cancer: Objective Assessment of Patients Enrolled in a Randomised Controlled Trial

Background: The international randomised TARGIT Trial started accrual in 2000 to determine if there is non-inferiority between the novel technique of TARGIT [intra-operative radiotherapy with Intrabeam® (Carl Zeiss, Germany)] and conventional external beam radiotherapy (EBRT) in women with early breast cancer, with the main outcome measure of risk of local relapse within the treated breast. We report here the data from a sub-protocol assessing cosmesis in a sub-set of patients over 50 years old participating in the TARGIT Trial from one centre (Perth, Australia). Materials and methods: Frontal digital photographs from 114 patients (59 TARGIT, 55 EBRT) taken at baseline and 1, 2 and 3 years after completion of breast conserving surgery were assessed blinded to allocated treatment using specialist software (BCCT.core 2.0, INESC Porto, Portugal) which produces a composite score (Excellent, Good, Fair, Poor) based on asymmetry, colour and scar.

Results: Median age at randomisation was 61 (IQR 56-67) years; all patients were free from recurrence. The categories Excellent and Good;

Fair and Poor; were combined to form EG and FP, respectively. Results are shown in Figure 1. On average patients in the TARGIT group attained EG significantly sooner than those in the EBRT group; a higher cumulative proportion of patients in the TARGIT group had attained EG by each of the three annual examinations post surgery, Log Rank test p=0.0244. By 1 year post surgery 74.6% (SE 5.7%) and 56.4% (SE 6.7%) had achieved EG cosmesis in the TARGIT and EBRT groups respectively. Discussion: These results indicate that the cosmetic effects of targeted radiotherapy using Intrabeam® are better than those obtained with conventional EBRT, with the largest difference one year after surgery.

Figure 1. Cosmetic outcome by randomised treatment

Reliability and validity of The Awareness of Social Inference Test (TASIT): A clinical test of social perception

PURPOSE

The Awareness of Social Inference Test (TASIT) is an audiovisual tool designed for the clinical assessment of social perception with alternate forms for re-testing. Part 1 assesses emotion recognition, Parts 2 and 3 assess the ability to interpret conversational remarks meant literally (i.e., sincere remarks and lies) or non-literally (i.e., sarcasm) as well as the ability to make judgments about the thoughts, intentions and feelings of speakers. This paper aims to examine TASIT's reliability and validity.

METHOD

Some 32 adults with severe, chronic brain injuries were administered Form A twice, one week apart. 38 adults with brain injuries were readministered alternate forms over a period of 5 - 26 weeks. Construct validity was examined in subsets of a sample of 116 adults with brain injuries by relating TASIT performance to standard tests of neuropsychological function and specific social perception measures.

RESULTS

Test-retest reliability ranged from 0.74 - 0.88. Alternate forms reliability ranged from 0.62 - 0.83. TASIT performance was associated with face perception, information processing speed and working memory. Socially relevant new learning and executive tasks were significantly associated with TASIT performance whereas non-social tasks showed little association. Social perception tasks such as Ekman photos and theory of mind stories were also associated.

CONCLUSIONS

TASIT has adequate psychometric properties as a clinical test of social perception. It is not overly prone to practice effects and is reliable for repeat administrations. Performance on TASIT is affected by information processing speed, working memory, new learning and executive functioning, but the uniquely social material that comprises the stimuli for TASIT will provide useful insights into the particular difficulties people with clinical conditions experience when interpreting complex social phenomena.

Birth weight variation according to maternal characteristics and gestational weight gain in Brazilian women

OBJECTIVES

This study aims to identify birth weight variation according to maternal characteristics and gestational weight gain.

METHODS

It is a cross-sectional descriptive study with 433 puerperal women (> or = 20 years old) who attended a public maternity hospital in Rio de Janeiro. The data were collected through interviews with the women and access to their medical records. Several models were tested using linear regression, using the stepwise method to identify the predictive variables of birth weight.

RESULTS

The mean maternal age and gestational age at the end of pregnancy were 27 years old (+/- 5.09 years) and 39 weeks (+ 1.68 weeks), respectively. The data shows that the mean number of prenatal and nutritional prenatal care appointments were 8.24 (+/- 2.98) and 2.26 (+/- 2.33), respectively. Among the predictor variables of birth weight, total gestational weight gain (beta = 25.29; p = 0.000), pre-gestational BMI (beta =13.02; p = 0.037), and the number of pre-natal care appointments (beta = 28.21; p = 0.007) were highlighted. The association of weight gain in the three trimesters was also verified.

CONCLUSIONS

This study confirms the interface between adequacy of the pre-gestational and gestational nutritional status and some maternal characteristics with birth weight. Nutritional care should be recognised as part of the actions during pre-natal assistance.

Lymph node micro-architecture can be imaged using optical coherence tomography

Abstract #804

Background: Histological assessment is the gold standard technique for identification of lymph node involvement in breast cancer. However, this may only be performed ex vivo and will often result in the unnecessary excision of healthy lymph nodes. In axillary clearance, this will result in lymphedema in approximately 26% of patients. Optical Coherence Tomography (OCT) is a real-time imaging modality with the potential to perform in vivo optical biopsy of lymph nodes. We undertook ex vivo imaging of excised lymph nodes to identify which aspects of the lymph node micro-architecture could be imaged using OCT, and to identify differences between cancerous and normal nodes.&#x2028; Materials and Methods: 18 lymph nodes were taken from 13 patients undergoing axillary clearance or sentinel lymph node biopsy. Fresh excised lymph tissue was dissected into 2mm slices. A 3D-OCT scan was acquired, with a resolution of ∼11μm in both axial and lateral dimensions. Each sample underwent subsequent histological analysis using Haematoxylin and Eosin (H&E) staining and matched against the 3D-OCT data sets.&#x2028; Results: OCT images demonstrated differentiation of the three major tissue types found in the lymph node: adipose, lymph cortex and lymph capsule. Adipocytes demonstrated a characteristic honeycomb structure that was also visible in H&E stained histology. The cortex, containing a high concentration of lymphocytes, was found to give a strong level of optical backscatter in the OCT image. The capsule, consisting of less dense stroma tissue, could generally be differentiated from the cortex. Small blood vessels in the stroma and cortex presented as areas of low backscatter. Sinuses were identified as contributing to variation in intensity within the cortex. Germinal centers could be distinguished from resting lymphoid tissue by a characteristic circular structure apparent in both OCT and histology. Cancerous regions were found to be devoid of these characteristic micro-architectural structures, as the malignant cells replaced normal lymph tissue. Figure 1 shows the H&E histology image and corresponding OCT scan of a normal lymph node. Adipose, cortex, stroma and small blood vessels are all apparent in this sample.&#x2028; Discussion: These results demonstrate that OCT is able to differentiate relevant structures within lymph nodes. Our findings suggest that lymph node metastasis is evident by the lack of these structures. This corresponds well with histological findings. This work forms a basis for future in vivo studies aimed at assessing lymph node involvement prior to excision.&#x2028; &#x2028;

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 804.

Practical clinical guidelines for assessing and managing menopausal symptoms after breast cancer

BACKGROUND

The purpose of this study was to provide practical, evidence-based guidelines for evaluating and treating common menopausal symptoms following breast cancer.

METHODS

Literature review of the causes, assessment and management of menopausal symptoms in breast cancer patients.

RESULTS

A number of nonhormonal treatments are effective in treating hot flashes. Whether pharmacological treatment is given will depend on the severity of symptoms and on patient wishes. For severe and frequent hot flashes, the best data support the use of venlafaxine, paroxetine and gabapentin in women with breast cancer. Side-effects are relatively common with all these agents. For vaginal dryness, topical estrogen treatment is the most effective but the safety of estrogens following breast cancer is not established. There are limited data on effective treatments for sexual dysfunction during menopause.

CONCLUSION

Menopausal symptoms after breast cancer should be evaluated and managed as warranted using a systematic approach and may benefit from multidisciplinary input.

Double-edged swords? Collective identity and solidarity in the environment movement

Perhaps by virtue of its theoretical slipperiness, collective identity is often hailed as an important feature of social movements for the role it plays in unifying activists and organizations, and so helping them to develop shared concerns and engage in collective action. However, this paper argues that collective identity is the result of group rather than movement level processes, and although it can unite activists within a single movement organization, it is not always beneficial for the broader social movement. Although movements consist of networks of activists and organizations that have a broad shared concern, differing collective identities within the movement can actually be quite divisive. Based on case studies of three organizations in the environmental movement, this paper shows that activists who are most committed to an organization with an encompassing collective identity develop a strong sense of solidarity with other activists similarly committed to that organization. The resultant solidarity leads to the construction of a 'we-them' dichotomy between organizations within the same movement, increasing the chances of hostility between organizations and factions within the movement.