Characterizing breast cancer treatment pathways in Kumasi, Ghana from onset of symptoms to final outcome: outlook towards cancer control

BACKGROUND

Cancer rates are increasing in Africa, including Ghana. Breast cancer is the second most common cancer in incidence and mortality in Ghana.

OBJECTIVE

We outlined both breast cancer patient characteristics and management at the Komfo Anokye Teaching Hospital (KATH), the main cancer management hospital in central Ghana. Moreover, we identified the treatment interventions predictive of patient outcome.

METHODS

Medical records of 597 breast cancer patients seen in 2008-2011 were abstracted to investigate management and treatment patterns. Abstracted variables included type and extent of surgery, number and cycles of chemotherapy and radiotherapy, as well as the course of treatment completed.

RESULTS

Late stage at diagnosis was common, treatment plans of the study hospital were relatively standardized according to disease severity, and defaulting/interrupting treatment in the records was also common. Patients diagnosed with late stage cancer who received adjuvant therapy and patients with hormone status evaluation were more likely to have complied with treatment guidelines and continued oncotherapy at the study hospital than those who never had hormone status requested or reported.

CONCLUSIONS

Our study lends support to improving patient outcomes in low- and middle-income countries through raising knowledge and reporting of tumor hormonal status and providing appropriately tailored treatment. Achieving improved outcomes should also consider enhancing public understanding of the importance of early detection and completion of treatment.

A comparison of criteria to identify inflammatory breast cancer cases from medical records and the Surveillance, Epidemiology and End Results data base, 2007-2009

Inflammatory breast cancer (IBC) is a relatively rare and extremely aggressive form of breast cancer that is diagnosed clinically. Standardization of clinical diagnoses is challenging, both nationally and internationally; moreover, IBC coding definitions used by registries have changed over time. This study aimed to compare diagnostic factors of IBC reported in a U.S. Surveillance, Epidemiology, and End Results (SEER) registry to clinical criteria found in the medical records of all invasive breast cancer cases at a single institution. We conducted a medical record review of all female invasive breast cancers (n = 915) seen at an NCI-designated comprehensive cancer center in Detroit from 2007 to 2009. IBC cases were identified based on the presence of the main clinical characteristics of the disease (erythema, edema, peau d'orange). We compared the proportion of IBC out of all breast cancers, using these clinical criteria and the standard SEER IBC codes. In the reviewed cases, the clinical criteria identified significantly more IBC cases (n = 74, 8.1%) than the standard IBC SEER definition (n = 19, 2.1%; p < 0.0001). No IBC cases were identified in the cancer center records using the SEER pathologic coding, which requires the diagnosis of inflammatory carcinoma on the pathology report, a notation that is rarely made. Emphasis must be placed on the documentation of clinical and pathologic characteristics of IBC in the medical record, so that analysis of putative IBC subtypes will be possible. Our results indicate the need for a consensus on the definition of IBC to be utilized in future research.

Promoters of and barriers to cervical cancer screening in a rural setting in Tanzania

OBJECTIVE

To investigate promoters and barriers for cervical cancer screening in rural Tanzania.

METHODS

We interviewed 300 women of reproductive age living in Kiwangwa village, Tanzania. The odds of attending a free, 2-day screening service were compared with sociodemographic variables, lifestyle factors, and knowledge and attitudes surrounding cervical cancer using multivariable logistic regression.

RESULTS

Compared with women who did not attend the screening service (n=195), women who attended (n=105) were older (OR 4.29; 95% CI, 1.61-11.48, age 40-49years versus 20-29years), listened regularly to the radio (OR 24.76; 95% CI, 11.49-53.33, listened to radio 1-3 times per week versus not at all), had a poorer quality of life (OR 4.91; CI, 1.96-12.32, lowest versus highest score), had faced cost barriers to obtaining health care in the preceding year (OR 2.24; 95% CI, 1.11-4.53, yes versus no), and held a more positive attitude toward cervical cancer screening (OR 4.64; 95% CI, 1.39-15.55, least versus most averse).

CONCLUSION

Efforts aimed at improving screening rates in rural Tanzania need to address both structural and individual-level barriers, including knowledge and awareness of cervical cancer prevention, cost barriers to care, and access to health information.

Trends in breast cancer stage and mortality in Michigan (1992-2009) by race, socioeconomic status, and area healthcare resources

The long-term effect of socioeconomic status (SES) and healthcare resources availability (HCA) on breast cancer stage of presentation and mortality rates among patients in Michigan is unclear. Using data from the Michigan Department of Community Health (MDCH) between 1992 and 2009, we calculated annual proportions of late-stage diagnosis and age-adjusted breast cancer mortality rates by race and zip code in Michigan. SES and HCA were defined at the zip-code level. Joinpoint regression was used to compare the Average Annual Percent Change (AAPC) in the median zip-code level percent late stage diagnosis and mortality rate for blacks and whites and for each level of SES and HCA. Between 1992 and 2009, the proportion of late stage diagnosis increased among white women [AAPC = 1.0 (0.4, 1.6)], but was statistically unchanged among black women [AAPC = −0.5 (−1.9, 0.8)]. The breast cancer mortality rate declined among whites [AAPC = −1.3% (−1.8,−0.8)], but remained statistically unchanged among blacks [AAPC = −0.3% (−0.3, 1.0)]. In all SES and HCA area types, disparities in percent late stage between blacks and whites appeared to narrow over time, while the differences in breast cancer mortality rates between blacks and whites appeared to increase over time.

Abstract 1695: Quantification of mitochondria in MCF-10A, MDA-MB-231, and SUM149 cells to understand potential defects in oxidative phosphorylation in cancer

Cancer cells are known to exhibit altered metabolism. The Warburg effect, whereby cancer cells preferentially use glycolysis instead of oxidative phosphorylation to produce ATP, plays an important role in the tumorigenic capacity of breast cancer. Previously, we found that SUM149 (inflammatory breast cancer) and MDA-MB-231 (invasive breast cancer) cells have decreased oxidative phosphorylation. Since mitochondria are the powerhouses of oxidative phosphorylation, examining their concentrations, phenotypes, and the distribution of their key enzymes can provide crucial information. These data can be used to further clarify whether the observed metabolic discrepancies stem from abundance differences or from other sources, such as defective enzymes and/or intermediate participation in alternate metabolic pathways. The purpose of our research was to elucidate if differential mitochondria concentrations accounted for the observed marked decrease in oxidative phosphorylation in cancer cells. Specifically, we focused on quantifying the number of mitochondria in two aggressive cancer cell lines, MDA-MB-231 and SUM149, and a normal-like breast cell line, MCF-10A.

In order to measure the number of mitochondria in the cancerous and noncancerous cells, a commercially available antibody conjugated to green fluorescent protein (GFP) and directed against the E1-alpha subunit of pyruvate dehydrogenase was used in each cell line. The resulting cells were imaged under high-resolution confocal microscopy and their relative fluorescence assessed. The average intensity of GFP in each cell was calculated and used as an indicator for the amount of mitochondria in each cell line. Additionally, these results were compared to transmission electron microscopy (TEM) images of each of these cell lines to validate the immunofluorescent quantifications.

Our results showed that there is no significant difference among the number of mitochondria in MDA-MB-231, SUM149, and MCF-10A cells. Additionally, the distribution of mitochondria among all three cell lines was relatively uniform, with a slightly greater abundance of mitochondria around the nuclei. These findings are surprising given that the published research on the Warburg effect, as well as our own prior observations on these three specific cell lines, suggested that cancer cells may have different numbers of mitochondria, although the previous work did not offer definitive proof of this interpretation. Therefore, these results contradict that hypothesis, and direct further studies to identify qualitative functional defects within mitochondria such as mutated or silenced mitochondrial genes, and to explore alternate pathways that breast cancer cells use to derive energy. Our investigation highlights the importance of taking a multi-facetted approach to studying cancer cell metabolism.

Citation Format: Sepideh Ashrafzadeh, Lauren D. Van Wassenhove, Sofia D. Merajver. Quantification of mitochondria in MCF-10A, MDA-MB-231, and SUM149 cells to understand potential defects in oxidative phosphorylation in cancer. [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 1695. doi:10.1158/1538-7445.AM2013-1695

Abstract 5239: Unraveling the complex regulatory relationship between PI3K signaling and metabolic transformation in breast cancer

Cancer cells exhibit a metabolic phenotype characterized by high rates of glucose uptake and lactate production, known as the Warburg effect. While the Warburg effect and normal proliferative metabolism appear similar, important molecular differences exist. We hypothesize that molecular and metabolic drivers of the Warburg effect can be modulated to impede cancer proliferation without substantial effects on normal tissue growth. Intracellular networks exhibit a variety of emergent non-linear behaviors and, as a result, the use of experimental intuition alone will not be enough to identify these drivers. Using a combination of experimental and theoretical methods, we developed a model of breast cancer progression that includes metabolism and the phosphatidylinositol-3 kinase (PI3K) signaling pathway, an important regulator of carbon metabolism. A key component of our model is a detailed logic network of molecular interactions associated with PI3K signaling as well as regulatory connections to central carbon metabolism, including the ATP/AMP ratio, GLUT receptor activation, hexokinase activation, and changes in the catalytic activity of pyruvate kinase. To validate our model, a series of phospho Western blot analyses were performed using a normal-like breast cell line and a diverse set of breast cancer cell lines exposed to PI3K pathway inhibitors. From these data, a series of predictive network models were constructed representing distinct stages of breast cancer progression. We also generated detailed metabolic flux maps for each cell line using metabolic flux analysis (MFA), a method that relies on carbon-13 tracers, mass-spectrometry, and measurements of extracellular flux to infer intracellular flux. In agreement with recent studies, we found an increase in the reductive carboxylation of glutamine derived alpha-ketoglutarate in cells constitutively adapted to hypoxia. We also identified a potentially important metabolic vulnerability in aggressive breast cancers. Moreover, we found important PI3K network differences at the RNA and protein levels, some of which were isoform specific. Together our data indicate that very different system-level properties are associated with distinct stages of breast cancer progression and metabolic transformation. Our model is suitable for performing in silico molecular perturbations to predict a normal as well as tumor level response to a targeted therapy or combination of therapies. Our approach also serves as a prototype for the use of systems biology methods in personalized medicine where molecular and metabolic data collected from a patient's biopsied tumor is input into a predictive model designed to develop a strategic treatment plan for the patient. The use of predictive models to integrate data from an individual patient will have a profound impact on cancer care decisions and patient outcomes in the future.

Citation Format: Michelle L. Wynn, Megan Egbert, Lauren D. Van Wassenhove, Zhi Fen Wu, Firas Midani, Charles Evans, Charles F. Burant, Santiago Schnell, Sofia D. Merajver. Unraveling the complex regulatory relationship between PI3K signaling and metabolic transformation in breast cancer. [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 5239. doi:10.1158/1538-7445.AM2013-5239

Abstract 5223: Elucidating the complex cross-talk between the MAPK and PIK3 pathways

Targeted molecular inhibitors have emerged as a leading anti-cancer strategy; however, despite promising pre-clinical data, many targeted inhibitors induce undesirable off-target effects in the clinic. The large number of off-target effects associated with molecular inhibitors was recently termed the ‘‘whack a mole problem’’ because inhibiting one molecular target often unintentionally activates another molecule. It is increasingly clear that the high incidence of off-target effects associated with targeted inhibitors is related to the complex interactions and emergent behaviors inherent to the highly complex and dysregulated intracellular networks of cancer. Both the mitogen activated protein kinase (MAPK) and phosphatidylinositol-3 kinase (PI3K) pathways are known to be dysregulated in cancer. In previous work, we and others have demonstrated that the MAPK pathway promotes motility, invasion, and angiogenic factors while the PI3K pathway plays an important role in controlling anchorage independent growth. In addition, the PI3K pathway plays an essential role in stimulating glucose metabolism and the Warburg effect. We hypothesize that robust interactions exist between these two pathways that influence efficacy and potentially also acquired resistance to targeted therapies. Using a combination of experimental and theoretical techniques, we developed a predictive network model linking growth factor signaling to the MAPK and PI3K pathways as well as to glucose metabolism. Specifically, we constructed a logic-based network of the cross-talk between MAPK and PI3K signaling that relied on a detailed literature survey to identify known molecular interactions as well as proposed interactions and regulatory feedback connections in the literature. We next performed a set of experiments using a normal-like breast epithelial cell line and a series of pathway specific inhibitors with and without growth factor stimulation to validate our model. Finally, we repeated these experiments using a diverse set of breast cancer cell lines and integrated this data to produce a series of cancer networks representative of different stages of breast cancer progression. Our model was able to recapitulate both our own experimental data and published data in the literature using a smaller subset of regulatory feedback mechanisms than we started with. Together, our results suggest that some proposed interactions and feedback mechanisms attributed to MAPK and PI3K cross-talk in the literature may not be valid.

Citation Format: Megan E. Egbert, Michelle L. Wynn, Zhi Fen Wu, Santiago Schnell, Sofia D. Merajver. Elucidating the complex cross-talk between the MAPK and PIK3 pathways. [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 5223. doi:10.1158/1538-7445.AM2013-5223

Logic-based models in systems biology: a predictive and parameter-free network analysis method

Highly complex molecular networks, which play fundamental roles in almost all cellular processes, are known to be dysregulated in a number of diseases, most notably in cancer. As a consequence, there is a critical need to develop practical methodologies for constructing and analysing molecular networks at a systems level. Mathematical models built with continuous differential equations are an ideal methodology because they can provide a detailed picture of a network's dynamics. To be predictive, however, differential equation models require that numerous parameters be known a priori and this information is almost never available. An alternative dynamical approach is the use of discrete logic-based models that can provide a good approximation of the qualitative behaviour of a biochemical system without the burden of a large parameter space. Despite their advantages, there remains significant resistance to the use of logic-based models in biology. Here, we address some common concerns and provide a brief tutorial on the use of logic-based models, which we motivate with biological examples.

Using a state cancer registry to recruit young breast cancer survivors and high-risk relatives: protocol of a randomized trial testing the efficacy of a targeted versus a tailored intervention to increase breast cancer screening

Background

The Michigan Prevention Research Center, the University of Michigan Schools of Nursing, Public Health, and Medicine, and the Michigan Department of Community Health propose a multidisciplinary academic-clinical practice three-year project to increase breast cancer screening among young breast cancer survivors and their cancer-free female relatives at greatest risk for breast cancer.

Methods/design

The study has three specific aims: 1) Identify and survey 3,000 young breast cancer survivors (diagnosed at 20–45 years old) regarding their breast cancer screening utilization. 2) Identify and survey survivors’ high-risk relatives regarding their breast cancer screening utilization. 3) Test two versions (Targeted vs. Enhanced Tailored) of an intervention to increase breast cancer screening among survivors and relatives. Following approval by human subjects review boards, 3,000 young breast cancer survivors will be identified through the Michigan Cancer Registry and mailed an invitation letter and a baseline survey. The baseline survey will obtain information on the survivors’: a) current breast cancer screening status and use of genetic counseling; b) perceived barriers and facilitators to screening; c) family health history. Based on the family history information provided by survivors, we will identify up to two high-risk relatives per survivor. Young breast cancer survivors will be mailed consent forms and baseline surveys to distribute to their selected high-risk relatives. Relatives’ baseline survey will obtain information on their: a) current breast cancer screening status and use of genetic counseling; and b) perceived barriers and facilitators to screening. Young breast cancer survivors and high-risk relatives will be randomized as a family unit to receive two versions of an intervention aiming to increase breast cancer screening and use of cancer genetic services. A follow-up survey will be mailed 9 months after the intervention to survivors and high-risk relatives to evaluate the efficacy of each intervention version on: a) use of breast cancer screening and genetic counseling; b) perceived barriers and facilitators to screening; c) self-efficacy in utilizing cancer genetic and screening services; d) family support related to screening; e) knowledge of breast cancer genetics; and f) satisfaction with the intervention.

Discussion

The study will enhance efforts of the state of Michigan surrounding cancer prevention, control, and public health genomics.

Trial registration

NCT01612338

Global comparative healthcare effectiveness research: evaluating sustainable programmes in low & middle resource settings

The need to focus healthcare expenditures on innovative and sustainable health systems that efficiently use existing effective therapies are the major drivers stimulating Comparative Effectiveness Research (CER) across the globe. Lack of adequate access and high cost of essential medicines and technologies in many countries increases morbidity and mortality and cost of care that forces people and families into poverty due to disability and out-of-pocket expenses. This review illustrates the potential of value-added global health care comparative effectiveness research in shaping health systems and health care delivery paradigms in the "global south". Enabling the development of effective CER systems globally paves the way for tangible local and regional definitions of equity in health care because CER fosters the sharing of critical assets, resources, skills, and capabilities and the development of collaborative of multi-sectorial frameworks to improve health outcomes and metrics globally.

Nanoroughened surfaces for efficient capture of circulating tumor cells without using capture antibodies

Circulating tumor cells (CTCs) detached from both primary and metastatic lesions represent a potential alternative to invasive biopsies as a source of tumor tissue for the detection, characterization and monitoring of cancers. Here we report a simple yet effective strategy for capturing CTCs without using capture antibodies. Our method uniquely utilized the differential adhesion preference of cancer cells to nanorough surfaces when compared to normal blood cells and thus did not depend on their physical size or surface protein expression, a significant advantage as compared to other existing CTC capture techniques.

Characterizing inflammatory breast cancer among Arab Americans in the California, Detroit and New Jersey Surveillance, Epidemiology and End Results (SEER) registries (1988-2008)

Introduction

Inflammatory breast cancer (IBC) is characterized by an apparent geographical distribution in incidence, being more common in North Africa than other parts of the world. Despite the rapid growth of immigrants to the United States from Arab nations, little is known about disease patterns among Arab Americans because a racial category is rarely considered for this group. The aim of this study was to advance our understanding of the burden of IBC in Arab ethnic populations by describing the proportion of IBC among different racial groups, including Arab Americans from the Detroit, New Jersey and California Surveillance, Epidemiology and End Results (SEER) registries.

Methods

We utilized a validated Arab surname algorithm to identify women of Arab descent from the SEER registries. Differences in the proportion of IBC out of all breast cancer and IBC characteristics by race and menopausal status were evaluated using chi-square tests for categorical variables, t-tests and ANOVA tests for continuous variables, and log-rank tests for survival data. We modeled the association between race and IBC among all women with breast cancer using hierarchical logistic regression models, adjusting for individual and census tract-level variables.

Results

Statistically significant differences in the proportion of IBC out of all breast cancers by race were evident. In a hierarchical model, adjusting for age, estrogen and progesterone receptor, human epidermal growth receptor 2, registry and census-tract level education, Arab-Americans (OR=1.5, 95% CI=1.2,1.9), Hispanics (OR=1.2, 95% CI=1.1,1.3), Non-Hispanic Blacks (OR=1.3, 95% CI=1.2, 1.4), and American Indians/Alaskans (OR=1.9, 95% CI=1.1, 3.4) had increased odds of IBC, while Asians (OR=0.6, 95% CI=0.6, 0.7) had decreased odds of IBC as compared to Non-Hispanic Whites.

Conclusions

IBC may be more common among certain minority groups, including Arab American women. Understanding the descriptive epidemiology of IBC by race may generate hypotheses about risk factors for this aggressive disease. Future research should focus on etiologic factors that may explain these differences.

Establishing effective registration systems in resource-limited settings: cancer registration in Kumasi, Ghana

Cancer control programs are needed worldwide to combat the increases in cancer incidence and mortality predicted for sub-Saharan Africa in the next decades. The effective design, implementation, and evaluation of such programs require population-based cancer registries. Ghana's second largest medical center, the Komfo Anokye Teaching Hospital (KATH) in Kumasi, has made initial progress at developing a cancer registry. This registry, however, is housed in the medical oncology/radiotherapy center at KATH and does not currently include data from other departments that also interact with cancer patients. The aim of this study was to improve KATH cancer registration by compiling cancer data from other major departments that see cancer patients. Using recent population estimates, we calculated crude cancer incidence rates of the "minimally-reported cases" for the Ashanti region. The most common cancers found in this study were breast (12.6 per 100,000), cervix (9.2 per 100,000), and prostate (8.8 per 100,000). These cancers occur at similar crude incidence rates in other West African countries. Females had overall higher incidence rates than males, which is consistent throughout the West African region. This study identified a number of methodological challenges facing cancer registries in Ghana that can be addressed to improve the quality of cancer registries in other resource-limited settings. Such registries should be tailored to the local health system context. A lack of coordination among the sources reporting cancer cases and a lack of understanding of local health-care systems and payment plans may interfere with the quality, completeness, and comparability of data from cancer registries in resource-limited settings. Steps, barriers, and solutions for improving cancer registration in Ghana and countries at similar levels are discussed.

Abstract A61: Characterizing inflammatory breast cancer among Arab Americans in the California, Detroit, and New Jersey Surveillance, Epidemiology and End Results (SEER) registries (1988-2008)

Introduction: Inflammatory breast cancer (IBC) is characterized by an apparent geographical distribution in incidence, being more common in North Africa than other parts of the world. Despite the rapid growth of immigrants to the United States from Arab nations, because a racial category is rarely appropriated for this group, little is known about disease patterns among Arab Americans. The aim of this study was to describe the proportion of IBC among different racial groups, including Arab Americans from the Detroit, New Jersey and California Surveillance, Epidemiology and End Results (SEER) registries.

Methods: We utilized a validated Arab surname algorithm to identify women of Arab descent from the SEER registries. Differences in the proportion of IBC out of all breast cancer and IBC characteristics by race and menopausal status were evaluated using chi-square tests for categorical variables, t-tests and ANOVA tests for continuous variables, and log-rank tests for survival data. We modeled the association between race and IBC among all women with breast cancer using hierarchical logistic regression models, adjusting for individual and county-level variables.

Results: Statistically significant differences in the proportion of IBC out of all breast cancers by race were evident. In a hierarchical model, adjusting for age, estrogen and progesterone receptor, human epidermal growth receptor 2, registry and county-level socioeconomic position, Arab-Americans (OR=1.5, 95% CI=1.2,1.9), Hispanics (OR=1.2, 95% CI=1.1,1.3), Non-Hispanic Blacks (OR=1.3, 95% CI=1.2, 1.4), and American Indians/Alaskans (OR=1.9, 95% CI=1.1, 3.4) had increased odds of IBC, while Asians had decreased odds of IBC as compared to Non-Hispanic Whites (OR=0.6, 95% CI=0.6, 0.7).

Conclusions: IBC may be more common among certain minority groups, including Arab American women. Understanding the descriptive epidemiology of IBC by race may generate hypotheses about risk factors for this aggressive disease. Future research should focus on etiologic factors that may explain these differences.

Citation Format: Kelly A. Hirko, Amr S. Soliman, Mousumi Banerjee, Julie Ruterbusch, Joe B. Harford, Robert Chamberlain, Jon J. Graff, Sofia D. Merajver, Kendra Schwartz. Characterizing inflammatory breast cancer among Arab Americans in the California, Detroit, and New Jersey Surveillance, Epidemiology and End Results (SEER) registries (1988-2008). [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A61.

Inflammatory and non-inflammatory breast cancer survival by socioeconomic position in the Surveillance, Epidemiology, and End Results database, 1990-2008

Although it has been previously reported that patients with inflammatory breast cancer (IBC) experience worse survival than patients with other breast cancer (BC) types, the socioeconomic and ethnic factors leading to this survival difference are not fully understood. The association between county-level percent of persons below the poverty level and BC-specific (BCS) survival for cases diagnosed from 1990 to 2008 in the Surveillance, Epidemiology, and End Results (SEER) database linked to census derived county attributes was examined. A sub-analysis of cases from 2000 to 2008 also examined BCS survival by an index combining percent below poverty and less than high school graduates as well as metropolitan versus non-metropolitan county of residence. The Kaplan-Meier estimator was used to construct survival curves by stage, inflammatory status, and county-level socioeconomic position (SEP). Stage and inflammatory status stratified proportional hazards models, adjusted for age, race/ethnicity, tumor and treatment characteristics were used to determine the hazard of BCS death by county-level SEP. Kaplan-Meier survival curves indicated IBC has worse survival than stage matched non-IBC, (stage III IBC median survival = 4.75 years vs. non-IBC = 13.4 years, p < 0.0001). Residing in a lower SEP, non-metro county significantly worsens BCS survival for non-IBC in multivariate proportional hazards models. African American cases appear to have worse survival than non-Hispanic Whites regardless of inflammatory status, stage, county-level SEP, tumor, or treatment characteristics. This is the first study to examine IBC survival by SEP in a nation-wide population-based tumor registry. As this analysis found generally poorer survival for IBC, regardless of SEP or race/ethnicity, it is important that interventions that help educate women on IBC symptoms target women in various SEP and race/ethnicity groups.

Pre-operative chemoradiation followed by post-operative adjuvant therapy with tetrathiomolybdate, a novel copper chelator, for patients with resectable esophageal cancer

Introduction This phase II trial investigated chemoradiation followed by surgery and 2 years of adjuvant tetrathiomolybdate (TM) for resectable esophageal cancer. Methods Patients with resectable, locally advanced esophageal cancer received neoadjuvant cisplatin 60 mg/m(2) (days 1 and 22), paclitaxel 60 mg/m(2) (days 1, 8, 15, and 22), and 45 Gy hyperfractionated radiotherapy for 3 weeks followed by transhiatal esophagectomy. TM 20 mg PO QD was started 4 weeks post-op, and continued for 2 years to maintain the ceruloplasmin level between 5 and 15 mg/dl. Results Sixty-nine patients were enrolled (median age, 60 years). Sixty-six patients underwent surgery and 61 patients had a complete resection. Histologic complete response rate was 10 %. Twenty-one patients did not receive TM (metastases noted in the peri-operative period, prolonged post-operative recovery time, or patient refusal). Forty-eight patients started TM; 14 completed 24 months of treatment, 11 completed 10-18 months, 15 completed 2-8 months, and 8 completed ≤1 month. Twenty-seven patients had disease recurrence. With a median follow-up of 55 months, 25 patients were alive without disease, 1 was alive with disease, and 43 have died. Three-year recurrence-free survival was 44 % (95 % CI, 32-55 %) and the three-year overall survival was 45 % (95 % CI 33-56 %). Conclusions TM is an antiangiogenic agent that is well tolerated in the adjuvant setting. Disease-free survival and overall survival are promising when compared to historical controls treated at our institution with a similar regimen that did not include TM. However, the challenges associated with prolonged administration limit further investigation.

Individual and family characteristics associated with BRCA1/2 genetic testing in high-risk families

BACKGROUND

Little is known about family members' interrelated decisions to seek genetic testing for breast cancer susceptibility.

METHODS

The specific aims of this cross-sectional, descriptive, cohort study were (i) to examine whether individual and family characteristics have a direct effect on women's decisions to use genetic testing for hereditary susceptibility to breast cancer and (ii) to explore whether family characteristics moderate the relationships between individual characteristics and the decision to use genetic testing. Participants were women (>18 years old) who (i) received genetic testing for hereditary breast cancer and who agreed to invite one of their female relatives into the study and (ii) female relatives who had NOT obtained genetic testing and were identified by pedigree analysis as having >10% chances of hereditary susceptibility to breast cancer.

RESULTS

The final sample consisted of 168 English-speaking, family dyads who completed self-administered, mailed surveys with validated instruments. Multivariate conditional logistic regression analyses showed that the proposed model explained 62% of the variance in genetic testing. The factors most significantly associated with genetic testing were having a personal history of cancer; perceiving genetic testing to have more benefits than barriers; having greater family hardiness; and perceiving fewer negative consequences associated with a breast cancer diagnosis. No significant interaction effects were observed.

CONCLUSIONS

Findings suggest that both individual and family characteristics are associated with the decision to obtain genetic testing for hereditary breast cancer; hence, there is a need for interventions that foster a supportive family environment for patients and their high-risk relatives.

RhoC impacts the metastatic potential and abundance of breast cancer stem cells

Cancer stem cells (CSCs) have been shown to promote tumorigenesis of many tumor types, including breast, although their relevance to cancer metastasis remains unclear. While subpopulations of CSCs required for metastasis have been identified, to date there are no known molecular regulators of breast CSC (BCSC) metastasis. Here we identify RhoC GTPase as an important regulator of BCSC metastasis, and present evidence suggesting that RhoC also modulates the frequency of BCSCs within a population. Using an orthotopic xenograft model of spontaneous metastasis we discover that RhoC is both necessary and sufficient to promote SUM149 and MCF-10A BCSC metastasis–often independent from primary tumor formation–and can even induce metastasis of non-BCSCs within these cell lines. The relationship between RhoC and BCSCs persists in breast cancer patients, as expression of RhoC and the BCSC marker ALDH1 are highly correlated in clinical specimens. These results suggest new avenues to combating the deadliest cells driving the most lethal stage of breast cancer progression.

Clinical profile, BRCA2 expression, and the androgen receptor CAG repeat region in Egyptian and Moroccan male breast cancer patients

INTRODUCTION

Male breast cancer (MBC) is a rare disease. Rates of MBC in Northern Africa vary by region. The age-standardized incidence for MBC is higher in Morocco than in Egypt, and the Egyptian rate is similar to the U.S of approximately 1/10(5)This study aimed at investigating the clinical and molecular characteristics of MBC in Egypt and Morocco.

METHODS

This case-case study included 211 cases from Egypt and 132 from Morocco. Tumor tissues were available for 47 Egyptian and 18 Moroccan patients. Medical record information was abstracted for patients' demographics, medical history, and treatment. BRCA2 protein expression status was examined in Egyptian and Moroccan tumors. Androgen receptor CAG repeat length was analyzed using the tissue samples in Egyptian MBC tumors and controls. Limited amount of tissues from Morocco did not allow for the analysis of CAG repeats.

RESULTS

Egyptian MBC patients had a significantly lower age at diagnosis (Egypt: 57.5 ± 15.1, Morocco: 63.9 ± 14.4, P=0.0002) and a higher prevalence of liver cirrhosis (Egypt: 28.0%, Morocco: 0.8%, P=< 0.0001). MBC patients also had higher tumor grades [I (0.9%), II (81.0%), III (18.1%)] in Egypt vs. [I (10.7%), II (81.0%), III (8.3%)] in Morocco (P=0.0017). The clinical and molecular characteristics of the groups from the 2 countries did not significantly differ. There was no significant difference with respect to BRCA2 expression amongst countries (Egypt: 28.9% non-wild type, Morocco: 27.8% non-wild type, P=0.9297) or CAG lengths amongst BRCA2 expression types in Egyptians (Wild type: 54.6% with CAG repeat lengths of 20+, Non-wild type: 50% with CAG repeat lengths of 20+, P=0.7947).

CONCLUSIONS

Differences in MBC between Egypt and Morocco are more likely due to differences in other risk factors such as consanguinity and use of xenoestrogenic pesticides.

Traditional herbalists and cancer management in Kumasi, Ghana

Cancer incidence rates are increasing in sub-Saharan Africa where traditional medical practitioners (TMPs) are involved in cancer management. Little is known about the specific role that TMPs play in cancer management in Ghana; we hypothesize that an understanding of the practices of TMPs with regard to cancer patients would help to enhance literacy about cancer amongst TMPs and would contribute to the diagnosis of cancer at earlier stages, by avoiding the detrimental delays while enlisting their help in certain activities that enhance cancer care. To elucidate the nature of the involvement of TMPs in cancer management, we conducted semi-structured interviews with 42 TMPs who practice in Kumasi, Ghana. The interviews elicited information about their knowledge and practices regarding cancer management and interactions with local hospitals. The results showed that TMPs tended to identify cancers as diseases of visible masses, fungating lesions, ulceration, and bleeding reflecting the advanced stages and types of cancers they usually encounter. TMPs identified certain causes of cancer and believed that they can treat and prevent cancer. These results indicate that TMPs are significant health service delivery resources in Ghana for patients potentially affected with cancer. Our work suggests that dedicated efforts to further integrate TMPs into the overall health care system would be beneficial to patients. Future research should examine the role of cancer education and training programs for TMPs to enhance their knowledge, strengthen their ability to complement allopathic practitioners, and increase early detection and treatment efforts through appropriate and timely referrals.

Abstract 5511: Cancer care-seeking patterns in Kumasi, Ghana

Background and Objective: Data from each of the 32 sentinel hospitals within the 10 regions of Ghana indicate that cancer is among the top ten causes of death in the country and it also appears to be on the rise. Barriers that delay detection and treatment of cancer compound the untoward consequences of this rising incidence. Over 80% of cancer patients at Komfo Anokye Teaching Hospital (KATH) in Kumasi present to the hospital in Stage III or later, and data indicate that even those relatively rare patients who are identified through detection and screening in Ghana still present late to the hospital. Thus, understanding and addressing the causes of delayed or dropped treatment appears to be important steps that will guide policies for early detection and treatment. We conducted this study to identify the care-seeking and referral patterns of cancer patients before arriving at and within KATH to reach specialized cancer treatment. Methods: Semi-structured interviews with cancer patients were conducted between June-July 2011 at the Oncology Directorate at KATH, which is one of Ghana's two National Centers for Radiotherapy and Nuclear Medicine. Patients were asked about their care-seeking patterns from the beginning of their symptoms until their arrival at the Oncology Directorate, and about the barriers they faced during their care-seeking process. Abstraction of relevant clinical data from patient medical records was done to complement and validate data from the interviews. Preliminary Results: We attempted 224 interviews, with a final eligible sample size of 216 completed interviews. Over 56% of those interviewed were new patients first seen in the Oncology Directorate in 2011. Nearly 78% of the patients were females, consistent with the gender distribution of the Directorate. The most common cancers in our sample were: cervical and uterine (32.71%), breast (27.10%), head and neck (16.36%) and prostate (4.67%), approximately reflecting the different tumor types diagnosed in the Directorate overall. Patients interviewed came from all ten regions of Ghana, with 65.7% from the Ashanti region in which KATH is located. Patients reported visiting an average of 2 facilities before arriving at KATH, with an average time between initial symptoms and the first point of care being 4 months and a range of less than one month to over 6.5 years. Conclusions: Preliminary results suggest that the care-seeking patterns of cancer patients in Ghana might differ from what is commonly believed, with approximately 7% of the respondents reporting that they visited the facility of a traditional healer, herbalist or faith healer. Moreover, system-related delays may play a larger role in delayed care compared to patient-related delays. Further analysis from this study are ongoing and will help identify factors that impact the delay between the onset of cancer symptoms and presentation to treatment facilities and also factors that are amenable to modification within the Ghanaian health system.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5511. doi:1538-7445.AM2012-5511

Abstract 72: Amino terminus of SEPT9_i1 impacts cellular localization: Implications for mammary tumorigenesis

Septins were first discovered in Saccharomyces cerevisiae as proteins essential for faithful cell division. They are highly conserved and found in all eukaryotes with the exception of plants. One septin, SEPT9, was cloned from a region of allelic imbalance in breast and ovarian cancers on chromosome 17q25. Further analysis showed that SEPT9 encoded multiple protein isoforms. Retroviral expression of one isoform, SEPT9_i1, promoted oncogenic phenotypes including, increased cell proliferation, invasion, motility, and genomic instability in mammary epithelial cells. In addition, abnormal nuclear localization of SEPT9_i1 was observed. SEPT9_i1 is highly expressed in many cancers including, breast, ovarian, prostate, and head and neck. SEPT9_i1 differs from other SEPT9 isoforms by 25 unique amino acids at the N terminus. SEPT9_i3, which lacks these 25 amino acids, does not exhibit the same pro-oncogenic phenotypes associated with SEPT9_i1. The goal of this study is to determine the functional relevance of these amino acids with respect to cellular localization as well as phenotypes related to mammary tumorigenesis and metastasis. First, bioinformatic analysis revealed a bipartite nuclear localization signal within the 25 unique amino acids but no other recognized functional domains. To determine the effects of these 25 amino acids on nuclear localization, FLAG-tagged deletion (ΔN)-SEPT9_i1, full-length (FL) -SEPT9_i1, and empty vector control constructs were transiently transfected into two immortalized human mammary epithelial cell lines, HME and MCF-10a. Immunofluorescence analyses of FL-SEPT9_i1 and ΔN-SEPT9_i1 localization revealed a dramatic decrease in the amount of SEPT9_i1 localized to the nucleus in the ΔN-SEPT9_i1 versus FL- SEPT9_i1 lines. Stably expressing FL-SEPT9_i1 and ΔN-SEPT9_i1 HS578t cell lines were also generated using nucleofection for examination of the effects of ΔN-SEPT9_i1 on cellular phenotypes including cell proliferation, cell motility and invasion. We present data indicating that the deletion of the N terminal 25 amino acids decreases cell motility and invasion as compared to SEPT9_i1 in HS578t cells. In addition, we show increased cell proliferation in cells expressing ΔN-SEPT9_i1 as compared to both EV and SEPT9_i1. To date our results implicate an oncogenic role for high SEPT9_i1 in mammary tumorigenesis where the unique 25 amino acids of SEPT9_i1 may impact tumorigenesis. Further investigation could provide valuable insight into developing targeted chemotherapeutic agents.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 72. doi:1538-7445.AM2012-72

Abstract 5164: Using metabolomic flux to uncover new targets for the modulation of breast cancer metastasis

Inflammatory breast cancer (IBC) is the most deadly breast cancer because of its ability to rapidly metastasize, often before the primary lesion is detected. To better understand what drives this highly aggressive form of cancer, we studied central carbon metabolism in IBC. The Warburg effect, which is characterized by high rates of glucose uptake and glycolysis even under aerobic conditions, occurs in most cancer cells and plays an important role in the tumorigenic capacity of breast cancer. Specifically, we examined metabolic changes that occur when breast cancer cells switch from a proliferating phenotype to a highly motile phenotype. In primary tumor formation rapid proliferation is crucial, while in metastasis motility to new sites is critical. We hypothesize that alterations in the regulation of metabolic pathways leads to the direction of energy from proliferation to motility, and that this change is important in the progression of breast cancer towards metastases. Understanding if a coincident metabolic shift occurs when malignant cells switch from a proliferative to a more aggressive motile form may help identify new therapeutics for highly aggressive breast cancers. For our studies, we are using “normal-like” MCF-10A breast cells, which proliferate quickly and move slower than cancer cells, and two highly metastatic breast cancer cell lines (MDA-MB-231 and the IBC-derived line SUM 149), which have the ability to move quickly and proliferate relatively slowly. Using these cell lines as a model, we have examined metabolic changes as cancer progresses. We are conducting targeted metabolomic studies to determine relative concentrations of metabolites in the glycolysis, tricarboxylic acid (TCA) cycle, and mevalonate pathway. In addition, we are using 13C-labeled pyruvate and glucose to measure the transient and steady state flux through these metabolic pathways. Our preliminary results indicate interesting and unexpected changes in both the transient and steady state metabolic fluxes across the different cell lines. In addition, the metabolic flux through the TCA cycle is very active in the metastatic cancer cells despite an increase in glycolysis. In agreement with flux studies of other cancer cell lines, our results suggest that the cancer cells are likely using intermediates from the TCA cycle to generate nucleotides and fatty acids needed for replication. The results from this work, once validated, can be used to identify new therapeutic metabolic targets to modulate breast cancer metastasis.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5164. doi:1538-7445.AM2012-5164