Study participation improves treatment strategies and individual patient care in participating centers

BACKGROUND

The ADEBAR study is a prospective multicenter Phase III trial to examine whether high-risk breast cancer patients > or =4 involved axillary lymph nodes) benefit from a sequential anthracycline-docetaxel regimen compared to standard chemotherapy with anthracyclines. With a median recruitment of 33 patients per month at 198 actively-recruiting centers, the ADEBAR study was the best recruiting study in Germany until the end of the trial.

MATERIALS AND METHODS

A standardized questionnaire was sent to all participating centers in order to determine the extent to which treatment strategies and patient care are affected by participation in the ADEBAR study. The questionnaire covered 5 areas of interest: previous inclusion of patients at the same tumor stage in other studies, the type of chemotherapy received by comparable patients previously outside the study, change in the intensity of medical care since participating in the ADEBAR study, the information gained through participation in the study and changes in the overall quality of medical care.

RESULTS

51.0% (n=98) of the questionnaires were returned, from which 3 were excluded from the analysis due to being incomplete. In the year preceding the ADEBAR study, 63.2% of participating centers had not entered their high-risk patients into a clinical trial. Before participating in the ADEBAR protocol, 44.2% of patients with the same indication had received inadequate therapy by today's standards, such as CMF, EC/CMF or 4x EC. 59.0% of the centers noted an increase in the intensity of patient care as a result of participation in the study, independent of the care provided purely because of the study. By being part of a research network, with a regular flow of information via newsletters, study meetings and the like, 80.0% noted an improvement in their professional knowledge in the field of breast cancer. Moreover, 31.6% of the centers reported an improvement in the overall quality of their patient care since the start of the trial.

CONCLUSION

The results of the survey demonstrate that both physicians and patients benefit from participation in clinical trials as this is associated with optimized decision-making as regards therapy and patient care.

FGFR4 Arg388 allele is associated with resistance to adjuvant therapy in primary breast cancer

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Background: Bange et al. recently found that a single-nucleotide polymorphism (SNP) at codon 388 of fibroblast growth factor receptor 4 (FGFR4) gene, causing a transmembrane domain missense mutation (Gly388Arg), is associated with outcome in node-positive breast cancer. Methods: This study addresses clinical relevance of this SNP, FGFR4 genotype, phenotype, and HER2 regarding patient outcome and influence of adjuvant systemic therapy in a substantial primary breast cancer collective (n=372; 1987–2002), median follow-up 94.5 months. Treatment was administered according to consensus recommendations at the time: 73 patients (all N0) received no adjuvant systemic therapy; 114 received adjuvant chemotherapy (87% CMF-based), 164 tamoxifen, 10 combined chemo-endocrine therapy, 11 unknown. 128 (36%) patients experienced disease recurrence, 104 (81%) distant relapses; 140 (38%) died. PCR-RFLP-analysis of germ-line polymorphism was performed in uninvolved lymph nodes; FGFR4 and HER2 expression were assessed immunohistochemically in tumor tissue arrays. Primary endpoint was DFS, since it best reflects impact of adjuvant systemic therapy. Results: In 51% of patients, homo- or heterozygous Arg388 allele was present. No correlation existed between FGFR4 genotype and expression or HER2 status. In N0 patients, FGFR4 genotype was not correlated with disease outcome. In N+ patients, however, FGFR4 Arg388 was significantly associated with poor DFS (p=0.02) and OS (p=0.04). Notably, this association seems to be attributable to relatively poor therapy response in Arg388 carriers, reflected in their significantly shorter DFS (p=0.02) and OS (p=0.045) among patients receiving adjuvant systemic therapy. It is also seen as a significant interaction term in a multivariate proportional hazards model with Arg388 carriers having only about half as much benefit from adjuvant systemic therapy as wild-type carriers. Conclusions: Our results show that the previously found association of FGFR4 Arg388 genotype with breast cancer progression is strongest in patients with adjuvant systemic therapy, particularly chemotherapy, and thus may reflect therapy resistance.

No significant financial relationships to disclose.

Breast self examination training and counseling as motivation strategies for breast awareness and participation in breast cancer screening programs

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Background: In Germany, the particpation rate in gynecologic cancer and the Bavarian breast cancer screening program is only about 30%. Therefore, the impact of counseling and raising confidence in breast self examination (BSE) by a structured BSE training on breast awareness, acceptance of screening offer, and participation rate was evaluated. For evaluation of the training quality, specified MammaCare data sheets and questionnaires were used. Method: Since 2003, 167 women (mean age 35 y; range 19–65 y; 61% ≥40 y) got intensive breast cancer counceling and were professionally trained in MammaCare BSE; 41% had positive breast cancer family history. In their beginner’s course, trainees got general BSE information, covering breast anatomy, breast symptoms, breast cancer screening and therapy. Participants practised BSE, after training on tactually accurate silicone breast models with simulated lumps in order to discriminate normal nodularity from lumps. After 3 months, the supervision sessions included BSE evaluation and - again - professional instruction. In a model exam false positive and negative findings were documented. In breast exams, performance technique and breast tissue coverage were assessed. At both initial sessions and after 12 months, questionnaires on BSE practice, experience, and compliance, cancer worry, acceptance and participation at cancer screening programs were evaluated. Results: Breast cancer worry, anxiety, and lack of information were the main reasons for program participation. Within 3 months after the base course, mean decrease of breast cancer worry was about 95%. Participation in gynecologic and breast cancer screening (≥40 y) more than doubled (94% and 86%). Even after 12 months, these numbers remain consistent. 80% of participants practice BSE monthly, and 46% reported changes in lifestyle regarding nutrition and obesity. Conclusions: Our approach emphasizes importance of self confidence and awareness for participation in cancer screening, also in women with breast cancer family history. Counseling, BSE re-evaluation and reinforcement are correlated with decreased breast cancer worry, a main barrier against participation in breast and gynecologic cancer screening.

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Influence of pattern of menopausal transition on the amount of trabecular bone loss. Results from a 6-year prospective longitudinal study

INTRODUCTION

Bone density is lower in postmenopausal than in premenopausal women. Recent findings have suggested that accelerated bone loss already begins before menopause. Despite numerous cross-sectional studies on menopause-related bone density, longitudinal data on perimenopausal bone density changes are scarce. This study sought to characterize the dynamics of changes leading to postmenopausal osteopenia and to possibly find the time point at which accelerated bone loss begins.

METHODS

We prospectively followed 34 pre-, peri- and early postmenopausal women without prior external hormone use, measuring their lumbar spine trabecular bone density with quantitative computer tomography at 0, 2 and 6 years. The analysis of the changes over time was done in a tri-parted fashion, since menopausal status changed variably for individual subjects: we grouped the participants according to their currently valid menopausal classification for prospective (baseline classification), interim (2 years) and retrospective (6-year classification) analysis.

RESULTS

Six different patterns of menopausal transition were identified in our sample. Bone loss in the groups not reaching postmenopause during 6 years of observation was >50% of the maximum bone loss observed during the study period. Invariably for all analyses, the perimenopausal phase with estrogen levels still adequate was associated with the greatest reduction of trabecular bone mineral density, reaching 6.3% loss annually in the lumbar spine. By comparison, the average rate of loss was slower in the early postmenopause; total bone loss differed by pattern of menopausal transition (one-way ANOVA p<0.05).

CONCLUSION

The presented data for the first time show the perimenopausal course of trabecular bone loss (as measured by QCT of the lumbar spine). Acceleration of bone loss during perimenopause reached half-maximal values of the total bone loss measured around menopause, despite adequate serum estradiol levels.

Diagnostik und Therapie maligner Ovarialtumoren 2005: Die Empfehlungen der Kommission Ovar der AGO

Recommendations for diagnosis and treatment of malignant ovarian tumors with regard to the most recent data were worked out in a consensus process and valued by level of evidence (LoE) and grade of recommendation (GoR) of the Canadian Task Force for Preventive Health Care by the members of the Kommission Ovar der Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) in June 2005. A short version of these guidelines is presented.

Das STEMMAT-Projekt als Teil der Gesundheitsinitiative BayernAktiv: Adulte Stammzellen aus Nabelschnur und -blut als Alternative zur embryonalen Stammzellforschung

Adult stem cells from umbilical cord and cord blood are an interesting alternative to embryonic stem cells because such research is commonly recognized as ethical undisputed and many aspects are still insufficiently investigated. In the context of the STEMMAT research project (STEM = Stem Cell and MAT = Material) different aspects of stem cells from umbilical cord and cord blood are investigated, to improve basic science understanding and potentially leading someday to a clinical application.

MR-guided intervention in women with a family history of breast cancer

OBJECTIVE

A study was undertaken to assess the clinical value of magnetic resonance (MR) imaging-guided interventions in women with a family history, but no personal history of breast cancer.

METHODS AND PATIENTS

Retrospective review was performed on 63 consecutive women who had a family history, but no personal history of breast cancer. A total of 97 lesions were referred for an MR-guided intervention. Standardized MR examinations (1.0 T, T1-weighted 3D FLASH, 0.15 mmolGd-DTPA/kg body weight, prone position) were performed using a dedicated system which allows vacuum assisted breast biopsy or wire localization.

RESULTS

Histologic findings in 87 procedures revealed 9 (10%) invasive carcinomas, 12 (14%) ductal carcinomas in situ, 2 atypical ductal hyperplasias (2.5%) and 2 atypical lobular hyperplasias (2.5%). Sixty-two (71%) benign histologic results are verified by an MR-guided intervention, retrospective correlation of imaging and histology and by subsequent follow-up. In ten lesions the indication dropped since the enhancing lesion was no longer visible. Absent enhancement was confirmed by short-term re-imaging of the noncompressed breast and by follow-up.

CONCLUSION

Malignancy was found in 24%, high-risk lesions in 5% of successfully performed MR-guided biopsy procedures. A 57% of MR-detected malignancies were ductal carcinoma in situ. In 10% of the lesions the intervention was not performed, since no enhancing lesion could be reproduced at the date of anticipated intervention. Such problems may be avoided if the initial MRI is performed in the appropriate phase of the menstrual cycle and without hormonal replacement therapy.

Privates Nabelschnurblutbanking reduziert nicht die Probenanzahl für wissenschaftliche Stammzellforschung

OBJECTIVE

Private umbilical cord blood (UCB) banking after delivery has increased over the last decade. For adult/somatic stem cell research UCB is an essential source of stem cells and researchers question if the number of UCB samples for research might be reduced by private banking.

METHODS

A survey among seven private blood banks in Germany and analysis and comparison of the number of UCB samples donated for research within the STEMMAT project with private blood banking were performed from 03/2003 to 06/2005 at the Frauenklinik (OB/GYN), Technical University Munich, Germany.

RESULTS

Within 27.5 months 1,551 UCB samples were collected for research purposes; the effective recruitment rate was higher than expectations at an effective 66.2 %. Private UCB banking [n = 24] was distributed among three cord blood banks [n = 16, 6 and 4]. The rate of private blood banking was 0.99 % for all deliveries, thus reducing the effective rate for research purpose by only 1.5 %.

CONCLUSION

Under the assumption of active and successful recruitment of scientific UCB samples, private blood banking does not significantly reduce this rate and therefore is a negligible rival in the competition for sufficient numbers of UCB samples for research.

Knochenstoffwechsel, Knochendichte und Östrogenspiegel in der Perimenopause: eine prospektive 2-Jahres-Untersuchung

Bone metabolism and trabecular bone density were studied prospectively in 69 pre-, peri- and early postmenopausal women. Markers of bone resorption (OC = osteocalcin, BAP = bonespecific alkalic phosphatase) and bone formation (PYD = pyridinolin, DPD = desoxypyridnolin, NTX = N-terminal telopeptide crosslinked collagen type I, CTX = C-terminal telopeptide crosslinked collagen type I) in serum and urine were followed over a course of two years with five points of examination (0, 3, 6, 12 and 24 months). Bone density was measured at 0 and 24 months. The results of 40 hormonally untreated women who completed all examinations were compared regarding menopausal status and changes over the 2-year-period. While baseline tracecular bone density was lowest in early postmenoapusal women, perimenopausal women showed greatest bone loss (- 10,6 %) during the two year study period. Bone metabolism markers were highest in the postmenopausal group. Perimenopause was associated with a gradual rise in OC, PYD and CTX. Perimenopausal women showed the highest serum estradiol at 0 and 12 months with values exceeding those of premenopausal women. Whether the increased perimenopausal bone loss could be related to the increase in anovulatory cycles during the perimenopausal transition is subject to ongoing investigation.