Extended Indications for Skin Conserving of the Nipple Areola Complex during Subcutaneous Mastektomie

Background: Conventional breast cancer surgery in case of a non breast conserving procedure still includes the routine excision of the nipple areolar complex (NAC) optional followed by nipple reconstruction. Numerous authors consider multiple predictive factors to decide whether the Nipple Areola Complex (NAC) can be conserved or not during mastectomy. These are: tumour-nipple distance, tumour size, axillary lymph-node status and lymph vascular invasion. Thus only a very limited percentage of patients can keep their NAC.If the breast gland tissue and all galactophoric ducts can be separated completely from the NAC during subcutaneous mastectomy (SCM), conservation of the NAC is feasible even in large, central and retroareola tumours.Patients and methods: (www.clinicaltrials.com ID: NCT00641628) From July 2003 to Mai 2006 we performed 109 SCMs on 96 patients. 94 of these breasts showed indications for modified radical mastectomy (MRM) or ablatio simplex. 78 due to invasive carcinoma (MRM indication) and 16 of them had extensive ductal carcinoma in situ (DCIS), (indication for simple ablation). At least 33 of the breasts had malignancy underneath the skin within the areola margin (central located tumours). After dissection of the complete mammary gland tissue, the skin envelope with the areola is folded inside out an all galactophoric ducts and any subjacent tissue on the areola base are precisely dissected under the surgeons' visual control. Of this skin-closest retroareola tissue, frozen sections and HE-histopathologic examinations are requested to decide whether the NAC can be preserved or not.Results: We found the Need to dissect the NAC in 13 of 109 breasts (12%), altering the procedure to a skin sparing mastectomy (SSM). Necrosis of the NAC which had to be subjected to surgical intervention occurred in only one of the conserved 96. After a follow-up of 20-54, median 34 months no recurrence within the NAC was observed. One local recurrence on the thoracic wall and one axillary recurrence were detected. 2 of 96 patients developed distant metastases. One death was recorded. Occasionally, partial necrosis of the nipple occurred, leaving a depigmentation of the skin but maintaining a good or excellent cosmetic result in most cases. Necrosis of the NAC which had to be subjected to surgical intervention occurred in only one patient.Conclusion: SCM, including NAC conservation, may be performed according to MRM indications if an intraoperatively frozen section (and the corresponding HE-histopathology) of the NAC closest tissue is free of tumour. The remaining contraindications for SCM are: extensive tumour involvement of the skin, inflammatory breast cancer and clinical suspicious nipple.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3107.

Sequential Treatment with Epirubicin/Cyclophosphamide, Followed by Docetaxel Is Equieffective, but Less Toxic Than FEC120 in the Adjuvant Treatment of Breast Cancer Patients with Extensive Lymph Node Involvement: The German ADEBAR Phase III Study

Background: Based on meta-analytic evidence, taxane containing adjuvant chemotherapy has been established as standard treatment in node-positive breast cancer. However, in the MA-21 study, adriamycin-cyclophosphamide, followed by paclitaxel (AC-P) was significantly inferior to the gold standard of anthracycline treatment, FEC120 (Burnell, SABCS 2006). We prospectively compared a sequential epirubicin-docetaxel chemotherapy regimen to FEC120.Patients and Methods:The ADEBAR study was a multicenter phase III trial (n=1502) to evaluate whether breast cancer (BC) pts with > 3 axillary lymph node metastases benefit from a sequential anthracycline-docetaxel regimen (E90C–D: 4 cycles epirubicin [E] 90 mg/m2 plus cyclophosphamide [C] 600 mg/m2 q21 days followed by 4 cycles docetaxel [D] 100mg/m2 q21 days) compared to dose-intensive anthracycline-containing polychemotherapy (FE120C: 6 cycles E 60 mg/m² d 1+8, 5-FU 500mg/m² d 1+8 and C 75 mg/m² d 1-14, q4 weeks). The median follow-up time was 47 mts.(range 2-83 mts).Results:Treatment was stopped prematurely in 3.7% of the pts in the E90C–D arm and in 8.0% in the FE120C arm due to toxicity (p=0.0009). Antibiotic treatment was given in 10.4% (E90C–D) vs. 19.7% (FE120C), G-CSF support in 39.2% vs 61.4 % and erythropoietin stimulation in 8.7% vs. 20.0%, respectively (p<0.0001). Haematological toxicity (leucopenia, neutropenic fever, thrombocytopenia, anemia) was significantly higher in the FE120C-arm.At the time of the current analysis, 281 events of recurrence of breast cancer, were observed: 128 events in the FE120C group and 153 in the E90C–D group. The unadjusted hazard ratio (HR) was 0.88 (95 percent confidence interval, 0.694 to 1.115; p=0.2197, log-rank test). Overall survival in the two groups was not significantly different: (84 deaths with FE120C vs. 88 with E90C–D (HR 0.999, 0.738-1.352, p=0.99). Subgroup analyses, stratifying for tumor size, lymph node involvement, hormone receptor and HER2-neu status showed no significant difference between the two treatment arms.Conclusion:Different toxicity profiles given, hematological toxicity in the FE120C group was more severe than in the E90C–D.In contrast to AC-P in earlier studies, EC-Doc provides a feasible and effective alternative option to dose-intensified FEC with different saftey profile in this high risk breast cancer cohort.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 604.

Counseling and care: A Breast Cancer Awareness Training to improve participation and adherence to screening recommendations in women with a family history of breast cancer

1530

Background: BRCA1 or BRCA2 mutation carriers are at an increased lifetime risk to develop breast and ovarian cancer. In a substantial number of families with affected members the known susceptibility genes cannot be identified. According to the recommendations of the German Consortium for Hereditary Breast and Ovarian Cancer, women with a hereditary predisposition for breast cancer should participate at an intensified surveillance program (ISP) including genetic counseling, risk estimation, BSE, CBE, BreastUS, MX, and MRI. Nonadherence might be influenced by cancer worryness, anxiety, health beliefs, and a lack of information about screening benefits.The aim of this investigation was to evaluate the impact of an indivualized Breast Cancer Awareness Training to improve the participation and adherence towards an ISP. Methods: Since 2005, an at-risk sample of 46 non-participating women (mean age 29 y; range 19–43 y) got an intensive breast cancer awareness training, including structured BSE, specific information about regular follow-up, screening advice, and radiological diagnostic procedures. To establish invidualized counseling and training particular needs (e.g., reasons for non-adherence, health beliefs and behaviours), risk perception, anxiety, and sociodemographic factors were evaluated by interviews and self-report questionnaires. The control group consisted of 38 participants of the ISP. Results: Breast cancer worry, anxiety, and lack of information about the benefits of screening programs were the main reasons for non-adherence. Within 3 months after the base counseling participation rates in MX (>30J), BUS, MRI, and CBE reached 98%. The numbers remain consistent in a 2-year follow up. 80% of participants practice BSE monthly, and 46% reported changes in lifestyle regarding nutrition, obesity, and health beliefs. Conclusions: Our approach emphasizes importance of self confidence and awareness for participation at the ISP for women at high breast cancer risk. Individualized counseling, BSE, re-evaluation, and reinforcement sessions are correlated with changes in health beliefs and behaviours for enhancing participation and adherence in women with a family history of breast cancer.

No significant financial relationships to disclose.

Interim analysis of the multicenter phase II HEDON trial evaluating pathological response to pre-operative docetaxel and docetaxel+trastuzumab (T) in locally advanced breast cancer (BR) stratified by HER2-status

e11512

Background: Docetaxel is the most effective mono-substance in metastatic BC and highly effective in adjuvant chemotherapy. Early docetaxel-monotherapy data in primary systemic therapy (PST) showed a pCR of 18% (Amat et al; 2003), comparable with pCR-rates of standard PST combination chemotherapy. HEDON was conducted to evaluate efficacy of docetaxel ± T with regard to pCR (defined as absence of invasive and non-invasive BC in breast and lymph nodes) as primary endpoint; secondary endpoints were safety, breast conservation rate and 5-yr DFS. Additionally Trans-HEDON includes a translational research program to identify molecular RNA and methylation (DNA) based markers of response to docetaxel-monotherapy. Methods: From 2006 until 2008, the multicenter phase II HEDON trial fully recruited 93 pts, with therapy still ongoing; tumor stages: T2 (23), T3 (11), T4 (5); nodal status: N0 (16), N1–2 (23). Arm A: Docetaxel (100 mg/m2x6) in HER2-negative (n=60) and Arm B: Docetaxel (100 mg/m2x6) in combination with T (18x2mg/kg KG) preoperatively in HER2-overexpressed BC (n=33), followed by surgery and then by adjuvant epirubicin/cyclophosphamide (E90Cx4), radiotherapy if indicated, T for altogether one year, and endocrine therapy in ER+ and/or PgR+ BC. Pre-planned interim analysis (safety and efficacy) was performed after recruitment of 39 pts (Arm A 26, Arm B 13). Results: In Arm A, 7 pts. (26.9%) achieved pCR and 9 pts. (34.6%) pPR. In Arm B, 7 pts. (53.8%) achieved pCR and all 6 others (46.2%) pPR. Neutropenia occurred in 11 pts. (8 with grade 3). Moderate (25%) dose reduction was necessary in 13 pts., and 50% dose reduction in one patient. Conclusion: According to interim analysis of the HEDON trial, docetaxel-monotherapy of 6 cycles at 100mg/m2 q21 (plus T in HER2-positive BC) is an effective and safely administrable PST. There were no unexpected toxicities, and preliminary pCR rates in HER2-neg (26.9%) and HER2-pos (53.8%) pts. were comparable to those of combination chemotherapy. These interim results will be completed by final analysis on the full collective, with molecular predictors from TransHEDON hopefully identifying patients who derive extensive benefit.

[Table: see text]

Weekly versus 3-weekly docetaxel (D2) plus doxorubicin (D4) for first-line treatment of metastatic breast cancer (MBC)

1101

Background: We investigated the toxicity and efficacy of weekly applied docetaxel compared to its standard 3-weekly application in pts previously untreated with chemotherapy for MBC. Methods: In the D2 trial (>60 yrs or KPS 60–80%), pts were randomized to receive docetaxel either on a 3-weekly (75 mg/m2 q3w) or on a weekly schedule (30 mg/m2 d1, 8, 15 q4w). In the D4 study (<65 yrs or KPS 70–100%), pts received doxorubicin (50 mg/m2, d 1) in addition to docetaxel given either at q3w dose of 75 mg/m2 or at as 35 mg/m2 (days 1, 8, 15, q4w). Results: The primary endpoint (toxicity) was achieved in D2 and failed in D4. Both studies were terminated prematurely (D2 n = 102/162 D4 n = 85/242 pts). In the D2 study, leucopenia ≥grade 3 was significantly less frequent in the weekly arm (4.2% q1w versus 51.9% q3w, p < 0.0001). In the weekly versus 3-weekly arm ORR was 26.8% versus 46.9% (p = 0.08), TTP was 5.4 versus 6.3 months (p = 0.91), and OS was 22.7 versus 15.8 months (p = 0.24). In the D4 study, an unexpectedly low rate of leucopenia ≥grade 3 was observed in the 3-weekly arm (29.7% q3w versus 35.7% q1w, p = 0.21). In the weekly versus 3-weekly arm, ORR was 50.0% versus 55.0% (p = 0.82), TTP was 6.2 versus 10.3 months (p = 0.36), and OS was 20.5 versus 28.9 months (p = 0.98). Non-hematological toxicity ≥grade 3 was generally mild and comparable within the two schedules. Conclusions: The present data support the feasibility of both, the weekly and the 3-weekly regimen of docetaxel application either as a single-agent or in combination with doxorubicin. As expected, leucopenia seems avoidable in the weekly scheduled of single-agent docetaxel (D2), whereas a combined weekly schedule of docetaxel/doxorubicin as given in the D4 study failed to confirm an expected lower rate of leucopenia.

[Table: see text]

Prospective study comparing hospital costs and DRG reimbursement of inpatient treatment of febrile neutropenia during adjuvant anthracycline-based CTX for primary breast cancer

e11570

Background: Febrile neutropenia (FN) is an undesired effect of myelosuppressive chemotherapy (CTX). To date limited data on costs of FN management is available. We compared costs and reimbursement of FN in a study of BC patients during adjuvant anthracycline (AC)-based CTX. Methods: Prospective, observational, longitudinal study in primary BC patients, enrolled 1–12/2006 consecutively before start of CTX in a German university clinic. FN was defined as fever >38ºC + ANC <1x109/L. Clinical and resource use data + DRG reimbursement were analyzed from medical charts. Costs for inpatient therapy of FN were compared to DRG reimbursement and results are presented from provider's perspective. Results: Of all patients approached (n=61), n=54 signed informed consent (88.5%), n=2 withdraw (3.3%) and n=2 were excluded from evaluation because of non-AC-based CTX. Patients were on avg. 57.4 (32–74) years and otherwise healthy ECOG 1 (n=50; 100%). Tumor classification was T1 n=25, T2 n=19, ≥T3 n=5 and pTx n=1. Chemo regimen was either AC-based n=29 (58.0%) or AC+taxane-based n=21 (42.0%). 12 episodes of FN occurred (24.0%) in 11 patients, one patient had 2 episodes; n=11 were treated as inpatients, n=1 as outpatient. Hospital stay for inpatients was on avg. 5.4 days (4–8), 0.7 days below average according to G-DRG catalog. Mean cost per FN episode requiring hospital treatment was 1.827 €, SD ±795 € (95%CI: 1293, 2361). Basic hospital costs were 83%, drug treatment 9% and diagnostics 8% of total direct costs. DRG reimbursement for inpatient FN was 2.145 € per episode, thus cost covering for the provider. Avg. reimbursement rate/day was 417 € (253–665 €). Inadequately DRG coding (n=4) resulted in a loss of 1.069 €/case (-42.2%). Conclusions: Costs for FN treatment vary among patients and DRG reimbursement does not necessarily reflect providers’ costs. Main cost drivers are hospitalization, length of stay, diagnostics and antibiotics. Surprisingly, inpatient treatment of FN under current therapy regimen is cost covering if adequately coded. This prospective evaluation and calculation of provider's costs and reimbursement helps understanding the allocation of resources for rational and cost-covering therapy.

[Table: see text]

Impact of BRCA mutation status on the clinical phenotype and survival of hereditary breast cancer

Abstract #3091

Background : In a multidisciplinary program supported by the German Cancer Aid in 1996-2006 a total of 3.408 women with a family history for breast and/or ovarian cancer were genetically counselled and tested for BRCA-1 and BRCA-2 mutations.&#x2028; Methods: The mutations were detected using DHPLC and direct sequencing. The family history of breast and/or ovarian cancer was proven by collecting medical reports of family members. The statistical analysis was done using standard procedures (Kaplan-Meier-analysis, t-test, chi-square-test).&#x2028; Results: Among the women with breast cancer 566 showed a deleterious BRCA1 and 313 a BRCA2 mutation. Four women were found to have mutations in both genes and 2.525 were BRCA-1/2 negative. In accordance with the literature we found the phenotype “hormone receptor negative and grade 3” as well as the medullary subtype significantly more often in BRCA1 associated breast cancers (74% vs. 24%, 63% vs. 42% and 10% vs. 5%). The median age of onset was significantly lower in BRCA1 mutation carriers (38 yrs) compared to BRCA2 mutation carriers (45 yrs) and women tested negative for BRCA1 and BRCA2 mutations (46 yrs) as well as sporadic breast cancer cases within these families (52 yrs). The median age of the 4 women with mutations in both genes was even lower (median age 33.5 yrs). Although BRCA2 associated breast carcinomas presented in more advanced stages (N+ in 44%[118/257] compared to BRCA-1 positive in 31%[166/519], p&lt;0.01) there was no difference in overall survival between BRCA1 and BRCA2 mutation carriers. However, BRCA1 and BRCA2 negative cases showed a significantly better survival rate compared to the women with mutations (p&lt;0.0001). Women from families with early onset breast cancer (&lt;35 yrs) or bilateral breast cancer (&lt;40 yrs) had a significantly better survival (p&lt;0.0001) than women from families with a later age of onset.&#x2028; Conclusions: The BRCA mutation status has a significant impact on the clinical phenotype of hereditary breast cancer which is important for the clinical management, counselling and prevention.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3091.

Concentrations of plasminogen activator inhibitor type1 (PAI-I) and urokinase-type plasminogen aktivator (uPA) in primary breast cancer (BC) tissue and corresponding axillary lymph node metastasis

Abstract #2046

Background: Components of the plasminogen activator system play a key role in tumor invasion and metastasis. Tumor tissue levels of urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1 showed a strong prognostic impact in node-negative and node-positive primary BC. uPA/PAI-1 were the first novel prognostic factors in primary BC reaching the highest level of evidence for their clinical utility and they have recently been recommended by ASCO for clinical decision making.&#x2028; Material and Methods: For the first time, correlations between uPA and PAI-1 concentrations in 73 primary tumor tissues and corresponding axillary lymphnodes (ALN) in node-negative (pN0) and node-positive (pN+) BC (1991-98) and their prognostic impact on disease-free (DFS) and overall survival (OS) were evaluated.&#x2028; Results: Median follow-up was 56 months. Overall, PAI-I (p=0,014) and uPA concentrations (p&lt;0,001) were significantly higher in tumour tissue than in the corresponding ALN. There was no significant difference of PAI-1 in primary tumor tissue between pN0 and pN+ disease. In involved ALN (pN+), concentrations of PAI-1 but not of uPA, were significantly higher than in pN0 (p&lt;0.001). Moreover, patients with higher PAI-1 concentrations in the corresponding ALN than in their primary tumor had a significantly shorter DFS (p&lt;0,001) and OS (p=0.005).&#x2028; Discussion: Our clinical findings support the basic research data implicating uPA and PAI-1 as key proteolytic factors in metastasis-asociated processes such as adhesion, angiogenesis, invasion, proliferation and migration. For the first time, we are able to demonstrate that particularly PAI-1 seems to be involved in tumor metastasis in primary breast cancer with its concentrations being higher in involved ALN than in the primary tumor. Besides uPA/PAI-1 being validated and clinically useful prognostic factors, interference with the uPA/PAI-1 system thus promises to be an interesting therapeutic concept in BC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2046.

The benefit using an integrated electronic trial platform for a neoadjuvant therapy trial (HEDON) in primary breast cancer – results of an evaluation study

Abstract #3114

Background: At present, academic medical centers conducting investigator initiated trials (IIT) have the choice of relying on paper or going electronic regarding electronic data capture and data management solutions. Many of the electronic systems have originally been developed for requirements of the pharmaceutical industry and all of the currently available systems would thus be isolated in the existing IT setting of the medical centers.&#x2028; We here suggest an approach to integrate a data management system into existing hospital information systems (HIS) and to provide the end users (e.g. physicians, investigators, study nurses) with consolidated user interfaces and integrated systems.&#x2028; Methods: In 2005, a collaboration between the Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technical University of Munich and Siemens Medical Solutions was initiated as a pilot project.&#x2028; An integrated platform for clinical trials was developed and implemented to support the HEDON trial (Herceptin-Docetaxel-Neoadjuvant), an investigator initiated clinical phase II trial concerning primary systemic therapy of breast cancer. The HEDON trial started in February 2006 and will have recruited all of a total of 90 planned patients in the end of this year. In addition, a translational research trial (TransHEDON) evaluating therapy response markers is an essential component of the clinical trial.&#x2028; Using the integrated platform, clinical data as well as laboratory data are automatically populated from the HIS into the electronical study CRFs, after data confirmation by investigators or study nurses (depending on their defined role) using the validation buffer of the system. The existing PACS and HIS are made accessible from the platform which has special capabilities to greatly improve user interactions with all relevant systems. To quantify the benefit of such an integrated system, an integrated evaluation project was set up including the quantification time savings for all involved personnel. For a pre-defined time period, data capture and data management processes are performed paper based and electronically. This allows thorough and critical analysis of all involved processes&#x2028; Resukts; Errors that occur specially due to manually entering laboratory data can be dramatically minimized using such an electronical data capture system. Another important benefit is time savings. The data will be presented.&#x2028; Conclusion:This single-sign-on electronic platform for clinical trials has been validated in its whole and fulfils the regulatory requirements as specified by GCP or 21 CFR part 11 compliance for trials of the FDA. We consider this integrated system to be very helpful for implementation of clinical trials into a routine hospital setting.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3114.

[Human embryonic stem cell research in Germany. The scientific reviewing of applications for the import and use of human embryonic stem cells]

From July 2002 to May 2008, 36 applications for the import and use of human embryonic stem cells (hES) were reviewed by the German Central Ethics Committee for Stem Cell Research (ZES). A flood of applications anticipated by opponents to human embryonic stem cell research has not occurred since the enactment of the German Stem Cell Act in 2002. On the contrary, German hES cell research is below international average in terms of project numbers. The current restrictions for using hES cells in Germany might be causative for the opinion that this type of research is not considered to be very promising. This could hold true especially for research aiming at clinical applications. Consequently, potential research goals of premium importance, especially those of potential clinical relevance, could be seriously jeopardized.