Excess mortality in postmenopausal high-risk women who only receive adjuvant endocrine therapy for estrogen receptor positive breast cancer

BACKGROUND

Omission of chemotherapy may affect mortality in postmenopausal high-risk women despite appropriate adjuvant endocrine therapy for estrogen receptor (ER) positive breast cancer. The aim of this study was to determine how all-cause mortality rate in these patients compares to that of the general female population. Furthermore, to identify a subset without excess mortality using clinical and pathological characteristics.

PATIENTS AND METHODS

From the population-based database of the Danish Breast Cancer Cooperative Group we included 6529 postmenopausal patients with ER positive high-risk breast cancer who in 1996 through 2004 by nationwide guidelines were allocated to five years of tamoxifen, an aromatase inhibitor (AI) or both in sequence. Multivariate categorical and fractional polynomials (MFP) models were used to construct prognostic subsets by clinicopathologic characteristics.

RESULTS

In a multivariate model excess mortality was inversely (p < 0.0001) associated with increasing age at surgery while recurrence-free survival (RFS) was not. Non-adherence to endocrine therapy was associated with excess mortality (p = 0.0008) while treatment with an AI was associated with a less pronounced mortality excess (p = 0.03). A prognostic standard mortality rate (SMR) index (PSI) was built using the regression coefficients obtained in the MFP model, and the same risk factors were used to construct a flowchart algorithm. Both allocated 75% to a group with increased all-cause mortality as compared to the general female population, but the SMR was significantly increased (SMR 1.38; 95% CI 1.16-1.65) in 462 patients who were allocated to low-risk group by the Flowchart algorithm and to a high-risk group by PSI.

CONCLUSION

Only one quarter of postmenopausal ER positive breast cancer patients are free of excess mortality when omitting adjuvant chemotherapy. Patients should be informed about importance of adherence to adjuvant endocrine therapy and inclusion of an AI. A PSI may better guide recommendations regarding adjuvant chemotherapy.

Robust and validated models to predict high risk of non-sentinel node metastases in breast cancer patients with micrometastases or isolated tumor cells in the sentinel node

BACKGROUND

Benefit from axillary lymph node dissection in sentinel node positive breast cancer patients is under debate. Based on data from 1820 Danish breast cancer patients operated in 2002-2008, we have developed two models to predict high risk of non-sentinel node metastases when micrometastases or isolated tumor cells are found in sentinel node. The aim of this study was to validate these models in an independent Danish dataset.

MATERIAL AND METHODS

We included 720 breast cancer patients with micrometastases and 180 with isolated tumor cells in sentinel node operated in 2009-2010 from the Danish Breast Cancer Cooperative Group database. Accuracy of the models was tested in this cohort by calculating area under the receiver operating characteristic curve (AUC) as well as sensitivity and specificity.

RESULTS

AUC for the model for patients with micrometastases was comparable to AUC in the original cohort: 0.63 and 0.64, respectively. The sensitivity and specificity for predicting risk of non-sentinel node metastases over 30% was 0.36 and 0.81, respectively, in the validation cohort. AUC for the model for patients with isolated tumor cells decreased from 0.73 in the original cohort to 0.60 in the validation cohort. When dividing patients with isolated tumor cells into high and low risk of non-sentinel node metastases according to number of risk factors present, 37% in the high-risk group had non-sentinel node metastases. Specificity and sensitivity was 0.48 and 0.88, respectively, in the validation cohort when using this cut-point.

CONCLUSION

In this independent dataset, the model for patients with micrometastases was robust with accuracy similar to the original cohort, while the model for patients with isolated tumor cells was less accurate. The models may be used to identify patients where axillary lymph node dissection should still be considered.

Divergent estrogen receptor-positive and -negative breast cancer trends and etiologic heterogeneity in Denmark

Long-term breast cancer trends in incidence in the United States (US) show rising estrogen receptor (ER)-positive rates and falling ER-negative rates. We hypothesized that these divergent trends reflect etiologic heterogeneity and that comparable trends should be observed in other countries with similar risk factor profiles. Therefore, we analyzed invasive female breast cancers in Denmark, a country with similar risk factors as the US. We summarized the overall trend in age-standardized rates with the estimated annual percentage change (EAPC) statistic (1993-2010) and used age-period-cohort models to estimate age-specific EAPCs, cohort rate ratios and projections for future time periods (2011-2018). In Denmark, the overall rate of ER-positive cancers rose between 1993 and 2010 by 3.0% per year (95% CI: 2.8-3.3% per year), whereas the overall rate of ER-negative cancers fell by 2.1% per year (95% CI: -2.5 to -1.6% per year). The ER-positive rate increased fastest among postmenopausal women and the ER-negative rate decreased fastest among premenopausal women, reflecting that cohorts born after 1944 were at relatively higher risk of ER-positive tumors and lower risk of ER-negative tumors. If current trends continue, ER-positive cancers will increase at least 13% by 2018 in Denmark, ER-negative cancers will fall 15% by 2018, and breast cancer overall will increase at least 7% by 2018. Divergent ER-specific trends are consistent with distinct etiologic pathways. If trends in known risk factors are responsible, the Danish and US experience may foreshadow a common pattern worldwide.

Abstract 132: Divergent estrogen receptor positive and negative breast cancer trends and etiologic heterogeneity in Denmark

Background: Long-term breast cancer trends in incidence in the United States (US) show rising ER positive rates and falling ER negative rates. We hypothesized that these divergent trends reflect etiologic heterogeneity and that comparable trends should be observed in other countries with similar risk factor profiles.

Methods: We analyzed invasive female breast cancers in Denmark from 1993-2010. We summarized the overall trend in age-standardized rates with the estimated annual percentage change (EAPC) statistic, and used age-period-cohort models to estimate age-specific EAPCs, cohort rate ratios (CRRs), and projections for future time periods (2011-2018).

Results: In Denmark, the overall rate of ER positive cancers rose between 1993 and 2010 by 3·0%/year (95% CI: 2·8 to 3·3%/yr) while the overall rate of ER negative cancers fell by 2·1%/year (95% CI: -2·5 to -1·6%/yr). The ER positive rate increased fastest among postmenopausal women and the ER negative rate decreased fastest among premenopausal women, reflecting that cohorts born after 1944 were at relatively higher risk of ER positive tumors and lower risk of ER negative tumors. If current trends continue, ER positive cancers will increase at least 13% and ER negative cancers will fall as much as 15% by 2018.

Conclusion: Divergent ER-specific trends are consistent with distinct etiologic pathways. If trends in known risk factors are responsible, the Danish and US experience may foreshadow a common pattern worldwide.

Citation Format: William F. Anderson, Philip Rosenberg, Lucia Petito, Hormuzd A. Katki, Bent Ejlertsen, Marianne Ewertz, Birgitte B. Rasmussen, Maj-Britt Jensen, Niels Kroman. Divergent estrogen receptor positive and negative breast cancer trends and etiologic heterogeneity in Denmark . [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 132. doi:10.1158/1538-7445.AM2013-132

Risk of ischemic heart disease in women after radiotherapy for breast cancer

BACKGROUND

Radiotherapy for breast cancer often involves some incidental exposure of the heart to ionizing radiation. The effect of this exposure on the subsequent risk of ischemic heart disease is uncertain.

METHODS

We conducted a population-based case-control study of major coronary events (i.e., myocardial infarction, coronary revascularization, or death from ischemic heart disease) in 2168 women who underwent radiotherapy for breast cancer between 1958 and 2001 in Sweden and Denmark; the study included 963 women with major coronary events and 1205 controls. Individual patient information was obtained from hospital records. For each woman, the mean radiation doses to the whole heart and to the left anterior descending coronary artery were estimated from her radiotherapy chart.

RESULTS

The overall average of the mean doses to the whole heart was 4.9 Gy (range, 0.03 to 27.72). Rates of major coronary events increased linearly with the mean dose to the heart by 7.4% per gray (95% confidence interval, 2.9 to 14.5; P<0.001), with no apparent threshold. The increase started within the first 5 years after radiotherapy and continued into the third decade after radiotherapy. The proportional increase in the rate of major coronary events per gray was similar in women with and women without cardiac risk factors at the time of radiotherapy.

CONCLUSIONS

Exposure of the heart to ionizing radiation during radiotherapy for breast cancer increases the subsequent rate of ischemic heart disease. The increase is proportional to the mean dose to the heart, begins within a few years after exposure, and continues for at least 20 years. Women with preexisting cardiac risk factors have greater absolute increases in risk from radiotherapy than other women. (Funded by Cancer Research UK and others.).

Characterization of chromium species in urban runoff

Little is known about the presence of the element Cr in its toxic hexavalent form Cr(VI) in stormwater runoff from urban areas. Most studies report only total Cr concentration, i.e., including also the nontoxic Cr(III) molecular form. The objective of this study was to evaluate a field method based on cation-exchange for characterization of Cr species in urban stormwater runoff and soil leachate. We used a 0.05 mol L Na and Ca solution and a soil leachate as matrices and spiked these with Cr(III), Cr(VI), or both in the concentration range of 1 to 100 μg L. We then filtered the test samples through cation-exchange cartridges. In the Na-Ca salt matrix, the Cr(III) was retained 100% and recovery values of Cr(VI) were 86 to 100%. Furthermore, in such a matrix, each cartridge could be reused at least nine times without a drop in retention of Cr(III) or recovery of Cr(VI). In a soil leachate matrix, the method appeared less applicable. Apparently Cr(III) forms complexes with dissolved organic matter, allowing it to bypass the cartridge, resulting in incomplete Cr(III) retention and thus incomplete speciation. The complexes are formed rapidly after spiking, thus changes in the Cr-species distribution are likely to occur within a few hours when fresh samples are stored. Furthermore, we concluded that Cr(III) at neutral pH in pure solution or complexed with dissolved organic C can sorb irreversibly to polyethylene and polypropylene containers. Our findings show that there is still a need for a method that can be applied to urban runoff in the field. Furthermore, cartridge speciation methods should ideally be tested before being applied on solutions containing organic matter.

Water Sensitive Urban Design retrofits in Copenhagen - 40% to the sewer, 60% to the city

Water Sensitive Urban Design (WSUD) is emerging in Denmark. This interdisciplinary desk study investigated the options for WSUD retrofitting in a 15 km(2) combined sewer catchment area in Copenhagen. The study was developed in collaboration with the City of Copenhagen and its water utility, and involved researchers representing hydrogeology, sewer hydraulics, environmental chemistry/economics/engineering, landscape architecture and urban planning. The resulting catchment strategy suggests the implementation of five sub-strategies. First, disconnection is focused within sites that are relatively easy to disconnect, due to stormwater quality, soil conditions, stakeholder issues, and the provision of unbuilt sites. Second, stormwater runoff is infiltrated in areas with relatively deep groundwater levels at a ratio that doesn't create a critical rise in the groundwater table to the surface. Third, neighbourhoods located near low-lying streams and public parks are disconnected from the sewer system and the sloping terrain is utilised to convey runoff. Fourth, the promotion of coherent blue and green wedges in the city is linked with WSUD retrofits and urban climate-proofing. Fifth, WSUD is implemented with delayed and regulated overflows to the sewer system. The results are partially adopted by the City of Copenhagen and currently under pilot testing.

Abstract P6-07-07: Influence of comorbidity on survival after early breast cancer

Withdrawn by Author

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-07.

Prognostic impact of pregnancy after breast cancer according to estrogen receptor status: a multicenter retrospective study

PURPOSE

We questioned the impact of pregnancy on disease-free survival (DFS) in women with history of breast cancer (BC) according to estrogen receptor (ER) status.

PATIENTS AND METHODS

A multicenter, retrospective cohort study in which patients who became pregnant any time after BC were matched (1:3) to patients with BC with similar ER, nodal status, adjuvant therapy, age, and year of diagnosis. To adjust for guaranteed time bias, each nonpregnant patient had to have a disease-free interval at least equal to the time elapsing between BC diagnosis and date of conception of the matched pregnant one. The primary objective was DFS in patients with ER-positive BC. DFS in the ER-negative cohort, whole population, and overall survival (OS) were secondary objectives. Subgroup analyses included DFS according to pregnancy outcome and BC-pregnancy interval. With a two-sided α = 5% and β = 20%, 645 ER-positive patients were required to detect a hazard ratio (HR) = 0.65.

RESULTS

A total of 333 pregnant patients and 874 matched nonpregnant patients were analyzed, of whom 686 patients had an ER-positive disease. No difference in DFS was observed between pregnant and nonpregnant patients in the ER-positive (HR = 0.91; 95% CI, 0.67 to 1.24, P = .55) or the ER-negative (HR = 0.75; 95% CI, 0.51 to 1.08, P = .12) cohorts. However, the pregnant group had better OS (HR = 0.72; 95% CI, 0.54 to 0.97, P = .03), with no interaction according to ER status (P = .11). Pregnancy outcome and BC-pregnancy interval did not seem to impact the risk of relapse.

CONCLUSION

Pregnancy after ER-positive BC does not seem to reduce the risk of BC recurrence.

Persistent pain, sensory disturbances and functional impairment after adjuvant chemotherapy for breast cancer: cyclophosphamide, epirubicin and fluorouracil compared with docetaxel + epirubicin and cyclophosphamide

BACKGROUND

Taxanes used in adjuvant therapy for breast cancer are neurotoxic, and thereby being a potential risk factor for persistent pain after breast cancer treatment (PPBCT) and sensory disturbances. The purpose was to compare patients treated with cyclophosphamide, epirubicin and fluorouracil (CEF) and cyclophosphamide and epirubicin + docetaxel (CE + T) in relation to PPBCT, sensory disturbances, peripheral sensory disturbances and functional impairment.

MATERIAL AND METHODS

A comparative nationwide cross-sectional questionnaire study on two cohorts treated with CEF respectively CE + T, based on the Danish Breast Cancer Cooperative Groups database.

INCLUSION CRITERIA

women treated with chemotherapy as adjuvant treatment for primary breast cancer, age 18-69 years, without recurrence.

RESULTS

One thousand two hundred and forty-one patients allocated to CEF in 2005-2006 and 1652 patients allocated to CE + T in 2007-2008 were included. Six hundred and sixty-four (53%) with CEF and 861 (53%) patients with CE + T reported pain. In the multivariate analysis including available risk factors, CE + T did not confer an increased risk of PPBCT, OR 0.95 (95% CI 0.81-1.11), p = 0.52, compared to CEF. Patients treated with CE + T had a lower risk of sensory disturbances in the area of surgery compared with CEF, OR 0.75 (95% CI 0.62-0.90), p = 0.002. More CE + T patients reported peripheral sensory disturbances in the hands, OR 1.56 (95%CI 1.27-1.92), p < 0.0001, and in the feet, OR 2.0 (95% CI 1.66-2.42) p < 0.0001, compared to CEF. There was no difference in functional impairment (p = 0.62).

CONCLUSION

Docetaxcel as adjuvant treatment for breast cancer does not increase the risk of PPBCT, sensory disturbances in the surgical area or functional impairment, but increase risk for peripheral sensory disturbances.

PIK3CA mutations, PTEN, and pHER2 expression and impact on outcome in HER2-positive early-stage breast cancer patients treated with adjuvant chemotherapy and trastuzumab

BACKGROUND

This study was conducted to determine the frequency of PIK3CA mutations and human epidermal growth factor receptor-2 (HER2) phosphorylation status (pHER2-Tyr1221/1222) and if PIK3CA, phosphatase and tensin homolog (PTEN), or pHER2 has an impact on outcome in HER2-positive early-stage breast cancer patients treated with adjuvant chemotherapy and trastuzumab.

PATIENTS AND METHODS

Two hundred and forty HER2-positive early-stage breast cancer patients receiving adjuvant treatment (cyclophosphamide 600 mg/m2, epirubicin 60 mg/m2, and fluorouracil 600 mg/m2) before administration of 1 year trastuzumab were assessable. PTEN and pHER2 expression were assessed by immunohistochemistry. PIK3CA mutations (exons 9 and 20) were determined by pyrosequencing.

RESULTS

Five-year overall survival (OS) and invasive disease-free survival were 87.8% and 81.0%, respectively. Twenty-six percent of patients had a PIK3CA mutation, 24% were PTEN low, 45% pHER2 high, and 47% patients had increased PI3K pathway activation (PTEN low and/or PIK3CA mutation). No significant correlations were observed between the clinicopathological variables and PIK3CA, PTEN, and pHER2 status. In both univariate and multivariate analyses, patients with PIK3CA mutations or high PI3K pathway activity had a significant worse OS [multivariate: hazard ratio (HR) 2.14, 95% confidence interval (CI) 1.01-4.51, P=0.046; and HR 2.35, 95% CI 1.10-5.04, P=0.03].

CONCLUSION

Patients with PIK3CA mutations or increased PI3K pathway activity had a significantly poorer survival despite adequate treatment with adjuvant chemotherapy and trastuzumab.

Persistent pain, sensory disturbances and functional impairment after adjuvant chemotherapy for breast cancer

Background

Persistent pain after breast cancer treatment (PPBCT) is a considerable clinical problem affecting between 25 and 60% of breast cancer survivors [1]. Several risk factors have been proposed, among them nerve damage caused by adjuvant treatment [2]. Taxanes used in adjuvant therapy for breast cancer are neurotoxic, and thereby being a potential risk factor for PPBCT and sensory disturbances. However, the long term influence of taxanes on PPBCT is not well documented. Thus, the aim of this study was therefore to compare a nationwide cohort treated with cyclophosphamide and epirubicin + docetaxel (CE + T) versus a nationwide cohort treated with cyclophosphamide, epirubicin and fluoruracil (CEF), in order to assess differences in reporting of PPBCT, sensory disturbances in surgical area, symmetric peripheral sensory disturbances, and functional impairment.

Methods

A comparative nationwide cross-sectional questionnaire study on two cohorts treated with CEF respectively CE + T, based on the Danish Breast Cancer Cooperative Groups database. Inclusion criteria were identical i both cohorts: women treated with adjuvant chemotherapy for primary breast cancer, age 18–69 years, without recurrence. Exclusion criteria: bilateral or previous breast surgery, including reconstructive surgery. The same questionnaire [1] was used for both cohorts and contained detailed questions regarding pain intensity and frequency and sensory disturbances in the breast area, side of chest, axilla and arm, bilateral peripheral sensory disturbances in the hands and feet, and questions regarding daily activities.

Results

1241 patients treated with CEF in 2005-2006 and 1652 patients treated with CE + T in 2007–2008 were included. 664 (54%) with CEF and 861 (53%) patients with CE+T reported PPBCT. In the multivariate analysis including available risk factors, CE + T did not increase risk of PPBCT, adjusted OR 0.95 (95%C10.81–1.11), p = 0.52, compared to CEF. Patients treated with CE + T had a lower risk of sensory disturbances in the area of surgery compared with CEF, adjusted OR 0.75 (95%C1 0.62–0.90), p = 0.002. More CE+T patients reported peripheral sensory disturbances in the hands, adjusted OR 1.56 (95%C11.27–1.92), p < 0.0001, and in the feet, adjusted OR 2.0 (95%C1 1.66–2.42), p < 0.0001, compared to CEF. There was no difference in functional impairment (p = 0.62).

Conclusion

Docetaxcel as adjuvant treatment for breast cancer does not increase the risk of PPBCT, sensory disturbances in the surgical area or functional impairment, but increase the risk for peripheral sensory disturbances.

ESR1 gene status correlates with estrogen receptor protein levels measured by ligand binding assay and immunohistochemistry

The Estrogen Receptor (ER) is an established predictive marker for the selection of adjuvant endocrine treatment in early breast cancer. During the 1990s Immunohistochemistry (IHC) replaced cytosol based assays for determination of ER status. This study examined the association between ER protein level determined by two different methods and ESR1 gene copy number. From 289 primary high-risk breast cancer patients, randomized in the Danish Breast Cancer Cooperative Group (DBCG) 77C trial, results from cytosolic ER levels were available from ligand binding assays. Archival tumor tissue was retrieved from 257 patients. ESR1/CEN-6 ratio was analyzed successfully by Fluorescence In Situ Hybridization (FISH) in 220 (86%) patients. ESR1 amplification (ESR1/CEN-6 ≥ 2.00) was observed in 23% of the patients and ESR1 deletion (ESR1/CEN-6 < 0.80) was observed in 32%. Further, we identified ESR1 gain (ratio ESR1/CEN-6 from 1.30 to 1.99) in 19% of the patients. A positive correlation of ESR1 FISH with both ER-cytosol and ER IHC was found (p < 0.0001). Amplification and gain of the ESR1 gene are associated with higher ER protein content measured by ligand binding assay and a more intense nuclear staining by IHC compared to tumors with normal ESR1 gene status. Major variations in ER measured by ligand binding assay and IHC are observed within all ESR1 copy number subgroups and other mechanisms than gene copy number seem to contribute to the ER protein content in the tumors.

Quantifying the number of lymph nodes identified in one-stage versus two-stage axillary dissection in breast cancer

PURPOSE

To establish whether a different number of lymph nodes is identified in a delayed versus an immediate axillary lymph node dissection (ALND) in breast cancer patients.

METHODS

Using data from the Danish National Patient Register and the Danish Breast Cancer Cooperative Group Database we identified 864 breast cancer patients with sentinel lymph node dissection (SLND) and delayed ALND and 7393 breast cancer patients with SLND and immediate ALND operated between 2002 and 2010. We compared the number of lymph nodes identified in the two groups by a student's t-test.

RESULTS

The mean number of lymph nodes identified in patients with immediate and delayed ALND was 16.55 and 15.59, respectively. This difference was statistically significant (P < 0.0001).

CONCLUSION

The number of lymph nodes identified in breast cancer patients is slightly reduced if delayed ALND is performed. However, the difference is small and considered to be without clinical significance.

High risk of non-sentinel node metastases in a group of breast cancer patients with micrometastases in the sentinel node

Axillary lymph node dissection (ALND) in breast cancer patients with positive sentinel nodes is under debate. We aimed to establish two models to predict non-sentinel node (NSN) metastases in patients with micrometastases or isolated tumor cells (ITC) in sentinel nodes, to guide the decision for ALND. A total of 1,577 breast cancer patients with micrometastases and 304 with ITC in sentinel nodes, treated by sentinel lymph node dissection and ALND in 2002-2008 were identified in the Danish Breast Cancer Cooperative Group database. Risk of NSN metastases was calculated according to clinicopathological variables in a logistic regression analysis. We identified tumor size, proportion of positive sentinel nodes, lymphovascular invasion, hormone receptor status and location of tumor in upper lateral quadrant of the breast as risk factors for NSN metastases in patients with micrometastases. A model based on these risk factors identified 5% of patients with a risk of NSN metastases on nearly 40%. The model was however unable to identify a subgroup of patients with a very low risk of NSN metastases. Among patients with ITC, we identified tumor size, age and proportion of positive sentinel nodes as risk factors. A model based on these risk factors identified 32% of patients with risk of NSN metastases on only 2%. Omission of ALND would be acceptable in this group of patients. In contrast, ALND may still be beneficial in the subgroup of patients with micrometastases and a high risk of NSN metastases.

A conceptual framework for addressing complexity and unfolding transition dynamics when developing sustainable adaptation strategies in urban water management

To achieve a successful and sustainable adaptation to climate change we need to transform the way we think about change. Much water management research has focused on technical innovation with a range of new solutions developed to achieve a 'more sustainable and integrated urban water management cycle'. But Danish municipalities and utility companies are struggling to bring such solutions into practice. 'Green infrastructure', for example, requires the consideration of a larger range of aspects related to the urban context than the traditional urban water system optimization. There is the need for standardized methods and guidelines to organize transdisciplinary processes where different types of knowledge and perspectives are taken into account. On the basis of the macro-meso-micro pattern inspired by complexity science and transition theory, we developed a conceptual framework to organize processes addressing the complexity characterizing urban water management in the context of climate change. In this paper the framework is used to organize a research process aiming at understanding and unfolding urban dynamics for sustainable transition. The final goal is to enable local authorities and utilities to create the basis for managing and catalysing the technical and organizational innovation necessary for a sustainable transition towards climate change adaptation in urban areas.

Incidence of heart disease in 35,000 women treated with radiotherapy for breast cancer in Denmark and Sweden

PURPOSE

To study incidence of radiation-related heart disease in a large population of breast cancer patients followed for up to 30 years.

MATERIAL AND METHODS

72,134 women diagnosed with breast cancer in Denmark or Sweden during 1976-2006 and followed prospectively. Radiation-related risk was studied by comparing women with left-sided and right-sided tumours.

RESULTS

34,825 women (48%) received radiotherapy. Among unirradiated women tumour laterality had little relevance to heart disease. Among irradiated women mean dose to the whole heart was 6.3 Gy for left-sided tumours and 2.7 Gy for right-sided tumours. Mortality was similar in irradiated women with left-sided and right-sided tumours, but incidence ratios, left-sided versus right-sided, were raised: acute myocardial infarction 1.22 (95% CI 1.06-1.42), angina 1.25 (1.05-1.49), pericarditis 1.61 (1.06-2.43), valvular heart disease 1.54 (1.11-2.13). Incidence ratios for all heart disease were as high for women irradiated since 1990 (1.09 [1.00-1.19]) as for women irradiated during 1976-1989 (1.08 [0.99-1.17]), and were higher for women diagnosed with ischaemic heart disease prior to breast cancer than for other women (1.58 [1.19-2.10] versus 1.08 [1.01-1.15], p for difference=0.01).

CONCLUSIONS

Breast cancer radiotherapy has, at least until recently, increased the risk of developing ischaemic heart disease, pericarditis and valvular disease. Women with ischaemic heart disease before breast cancer diagnosis may have incurred higher risks than others.

Feeding motivation and plasma metabolites in pregnant sows fed diets rich in dietary fiber either once or twice daily

The present study investigated the effects of source and level of dietary fiber (DF) and feeding frequency (once vs. twice daily) on feeding motivation and plasma metabolites at 4 different time points post feeding. Sixty pregnant sows (Sus scrofa, 4 blocks of 15 sows) were allocated to 1 of 5 diets within blocks. Four diets were restricted (approximately 35 MJ ME/d): a barley and wheat control diet (171 g DF/kg DM; 12 g DF/MJ ME), and 3 fiber diets formulated to contain 35% DF by including pectin residue (323 g DF/kg DM; 25 g DF/MJ ME), potato pulp (404 g DF/kg DM; 29 g DF/MJ ME), or sugar beet pulp (367 g DF/kg DM; 25 g DF/MJ ME). The fifth diet was a mixture including an equal amount of the 3 fiber diets offered semi ad libitum (ad libitum access to feed during 6 periods of 1 h starting at 0300, 0600, 1100, 1500, 1800, and 2300; 354 g DF/kg DM; 25 g DF/MJ ME). The experimental period included 2 periods of 4 wk each. Restricted-fed sows were fed once daily (0800 h) during the first period and twice daily (0800 and 1500 h) during the second period, or vice versa. Semi ad libitum fed sows had access to feed 6 times a day in both periods. In each period, the feeding motivation was assessed in an operant conditioning test, and samples of peripheral blood were taken in a balanced design, at 0900, 1200, 1900, and 0700 h, corresponding to 1, 4, 11, and 23 h after feeding for restricted sows fed once daily. No differences in the feeding motivation were found between the 4 restricted diets at any of the time points post feeding, but semi ad libitum fed sows had a decreased feeding motivation (P < 0.001). Among the restricted-fed sows, feeding twice daily resulted in decreased feeding motivation at 1900 h (P < 0.001) and at 0700h (P < 0.05) compared with feeding once daily, but not at 0900 and 1200 h, indicating that feeding twice daily reduced feeding motivation during the night compared with feeding once daily. Among restricted-fed sows, plasma concentrations of short-chain fatty acids (SCFA) were greater in sows fed high-fiber diets compared with the control (P = 0.02). Nonesterified fatty acid was least in sows on the control diet and greatest in sows on the potato diet, whereas sows on the pectin and sugar beet diets were intermediate (P < 0.001). Less diurnal variation in glucose (P < 0.001) was seen in sows on high-fiber diets. In spite of the found effects on plasma metabolites, the applied level of fiber in the diet of restrictedly fed sows did not reduce their feeding motivation irrespective of fiber source.

TIMP-1 in combination with HER2 and TOP2A for prediction of benefit from adjuvant anthracyclines in high-risk breast cancer patients

HER2 amplification, TOP2A aberrations, and absence of tissue inhibitor of metalloproteinase (TIMP-1) expression in breast carcinomas have been shown to be associated with incremental benefit from anthracycline-containing adjuvant chemotherapy, and this study was undertaken to validate these findings in a similar, but independent, randomized clinical trial. TIMP-1 was examined by immunohistochemistry in archival tumor tissue from 403 of 716 premenopausal high-risk patients with known HER2 and TOP2A status who were randomized to cyclophosphamide, epirubicin, and fluorouracil (CEF) or cyclophosphamide, methotrexate, and fluorouracil (CMF) in the MA.5 trial. Ninety-eight (24%) patients had no TIMP-1 staining of tumor cells, 27% were HER2 amplified, and 18% were TOP2A aberrant. Forty-four percentage was classified as HT responsive (HER2 amplified and/or TIMP-1 negative) and 37% as 2T responsive (TOP2A aberrant and/or TIMP-1 negative). There was no heterogeneity in treatment effect of CEF versus CMF according to TIMP-1. In HT-responsive patients, CEF was superior to CMF with an improved RFS (adjusted HR, 0.64; 95% CI, 0.42-0.97), but this was not significant for OS (adjusted HR, 0.66; 95% CI, 0.42-1.04). A significant HT profile versus treatment interaction was detected for OS (P = 0.03). In 2T-responsive patients, CEF seemed to improve RFS compared to CMF (adjusted HR, 0.67; 95% CI, 0.43-1.03) and improved OS (adjusted HR, 0.58; 95% CI, 0.36-0.93). A significant 2T profile versus treatment interaction was detected for OS (P = 0.01). With this study, we validate a more substantial reduction in mortality by CEF compared to CMF in patients with an HT- or 2T-responsive profile; however, we could not show a similarly significant reduction in RFS events, where a benefit of CEF over CMF was found irrespective of TIMP-1 status. Further studies are necessary before the HT and 2T profiles may be used to direct the use of anthracyclines.

Lack of independent prognostic and predictive value of centromere 17 copy number changes in breast cancer patients with known HER2 and TOP2A status

The clinical benefit of anthracyclines has been connected to HER2 status, TOP2A status and centromere 17 copy numbers (CEN-17). Data from a clinical trial randomizing patients to anthracyclines was used to assess whether the number of CEN-17 in breast cancers may predict incremental responsiveness to anthracyclines besides what is obtained when used relatively to TOP2A and HER2. As cut sections of paraffin-embedded tissue are prone to truncation of nuclei, strict definition of ploidy levels is lacking. We therefore used normal breast tissue to assist define ploidy levels in cut sections. Fluorescence in situ hybridization (FISH) with centromere 17 (CEN-17) and TOP2A was performed on 120 normal breast specimens. The diploid CEN-17 copy number was reduced from the expected two signals in whole nuclei to an average of 1.68 signals per nucleus in cut sections of normal breast. Ploidy levels determined in normal breast were applied to data on 767 patients with known HER2 and TOP2A status randomized to anthracyclines in the DBCG 89D trial. CEN-17 ploidy levels were in cut sections from the 767 breast cancer patients established as: Haploid: ≤1.25 (10%), diploid: 1.26-2.09 (60%), triploid: 2.10-2.93 (21%), tetraploid: 2.94-3.77 (5%) or higher ploidy: ≥3.78 (4%). Amplification of HER2 and deletion of TOP2A were frequently observed in tumors with a high ploidy level. In univariate analyses increasing ploidy was associated with decreased disease-free survival (DFS) (P=0.0001) and overall survival (OS) (P<0.0001). However, in multivariate analysis CEN-17 was not established as an independent prognostic factor and was neither a statistically significant predictor of benefit from CEF (Cyclophosphamide/Epirubicin/5-Fluorouracil) compared to CMF (Cyclophosphamide/Methotrexate/5-Fluorouracil) (P(Interaction) 0.39 for DFS and 0.67 for OS). In conclusion, CEN-17 levels do not independently from TOP2A/CEN-17 ratio identify breast cancer patients who achieve an incremental benefit from adjuvant anthracyclines.

Impact of comorbidity on mortality: a cohort study of 62,591 Danish women diagnosed with early breast cancer, 1990-2008

The incidence of breast cancer, as well as other chronic disease, increases with age, older breast cancer patients being more likely than younger to suffer from other diseases at time of diagnosis. Our objective was to assess the effect of comorbidity on mortality after early breast cancer. 62,591 women diagnosed with early breast cancer 1990-2008 were identified using the Danish Breast Cancer Cooperative Group Registry. Data were linked to the Danish National Patient Register and the Danish Register of Causes of Death. Main outcome measures were mortality from all causes, breast cancer, and non-breast cancer causes in relation to Charlson comorbidity index (CCI). Compared with patients without comorbidity (CCI 0), the presence of comorbidity increased the risk of dying from breast cancer as well as other causes with adjusted hazard ratios (HRs) for all-cause mortality of 1.45 (CI 95% 1.40-1.51) for CCI 1, 1.52 (95% CI 1.45-1.60) for CCI 2, and 2.21 (95% CI 2.08-2.35) for CCI 3+. Equivalent HRs for breast cancer-specific mortality were 1.30 (95% CI, 1.24-1.36) for CCI 1, 1.31 (95% CI 1.23-1.39) for CCI 2, and 1.79 (95% CI, 1.66-1.93) for CCI 3+ (all P values < 0.0001). For patients with CCI 0, 5-year overall survival increased over time from 72.5% (95% CI, 71.7-73.3%) in 1990-1994 to 81.6% (95% CI, 80.9-82.2) in 2000-2004, whereas the 5-year overall survival remained stable around 43% among the patients with CCI 3+. This population-based cohort study shows that compared with patients without comorbidity, the risk of dying from breast cancer as well as other causes increased significantly with increasing CCI score. While survival improved over time for patients without comorbidity, no improvement was seen among patients with severe comorbidity (CCI 3+).

Iatrogenic displacement of tumor cells to the sentinel node after surgical excision in primary breast cancer

Isolated tumor cells (ITC) are more common in the sentinel node (SN) after needle biopsy of a breast cancer, indicating iatrogenic displacement of tumor cells. We here investigate whether similar iatrogenic displacement occurs after surgical excision of a breast tumor. We compared the incidence of ITC in the SN of 414 breast cancer patients with recent surgical excision to a group of 16,960 patients without recent surgical procedure in a multivariate analysis by linking data from the Danish Breast Cancer Cooperative Group database and the Danish National Health Register. Moreover, the incidence of spread to non-SNs in patients with ITC in the SN after recent surgical excision was analyzed. We found an adjusted odds ratio on 3.73 (95% CI 2.57-5.43; P < 0.0001) for having ITC in the SN after surgical excision. The increase in ITC after surgical excision was especially seen in patients with ductal carcinomas (OR 4.66; 95% CI 3.03-7.19). None of the patients with ITC in SN after surgical excision had further spread to non-SNs compared to 12% in the group without recent surgical excision (P = 0.09). The nearly fourfold increase in ITC in the SN after surgical excision indicates that this procedure induces iatrogenic displacement of tumor cells. This displacement was more common in ductal carcinomas. We found no further dissemination to non-SNs in patients with ITC in the SN after recent surgical excision, and it is questioned whether these patients benefit from an axillary lymph node dissection.

Postoperative changes in fatigue, physical function and body composition: an analysis of the amalgamated data from five randomized trials on patients undergoing colorectal surgery

AIM

Changes in postoperative fatigue, physical function and body composition were described in patients after open colorectal surgery, and factors that predicted postoperative fatigue 1 month after surgery were identified.

METHOD

Data from five clinical intervention studies from 1991 to 2005 were amalgamated. Patients (n = 385) were examined preoperatively, at discharge and 1 month postoperatively. The level of fatigue was scored subjectively from 1 'fit' to 10 'fatigued' on a modified visual analogue scale and by objective measurements of hand grip and knee extension strength, work capacity, weight, lean body mass and fat mass. A logistic regression analysis was used to identify the predictors of a high fatigue score 1 month postoperatively.

RESULTS

Preoperatively, only 17% had a high fatigue score (≥ 5.5), whereas 65 and 30% had a high fatigue score at discharge and 1 month postoperatively, respectively. Postoperatively, there was a significant fall in physical performance, weight, lean body mass and fat mass that did not normalize by 1 month. High preoperative and discharge fatigue scores, major complications and the loss of lean body mass significantly increased the risk of fatigue 1 month postoperatively.

CONCLUSION

Open colorectal surgery was associated with a significant increase in postoperative fatigue and a decline in physical performance, weight and lean body mass. Major complications, a high perioperative fatigue score and the loss of lean body mass increased the risk of long-term fatigue.