Management of locally advanced breast cancer-perspectives and future directions

Clinical Outcomes of N3 Breast Cancer: A Real-World Study of a Single Institution and the US Surveillance, Epidemiology, and End Results (SEER) Database

Background

Although stage IIIC (any TN3M0) breast cancer is known to have a dismal prognosis, the clinical outcome of current standard management and the prognostic differences between N3a, N3b and N3c remain to be further investigated.

Material and Methods

Data from our center on pathologic N3 (pN3) (n=284) breast cancer and the US Surveillance, Epidemiology, and End Results (SEER) database on clinical N3 (cN3) (n=15,291) and M1 (n=23,623) breast cancer between January 2004 and December 2015 were systematically analyzed for clinicopathological characteristics and survival outcomes.

Results

In our institution, patients with pN3c had the worst survival, with 5-year OS and DFS rates of 52.4% and 41.5%, respectively. Patients with pN3b had a relatively good prognosis, with a 5-year OS rate of 75.3% vs 63.9% for the pN3a group (p=0.045). For DFS, the 5-year survival rate was 63.1% in the pN3b group compared with 40.3% in the pN3a group (p=0.030). In the US SEER database, patients with cN3c had the worst survival in the cN3 group, but the prognosis of cN3c was much better than that of M1. Similarly, patients with cN3b had a better prognosis compared with patients in other groups, with a 5-year OS rate of 68.9% vs 61.9% for the cN3a group (p<0.001) and a 5-year BCSS rate of 73.4% vs 67.1% for the cN3a group (p<0.001).

Conclusion

Breast cancer patients with N3c had the worst clinical outcomes, while the prognosis of N3b patients was better than that of N3a patients.

Reconstruction of the chest wall in locally advanced breast cancer with multi-disciplinary cooperation: a case report of mesh repair plus TRAM combined with DIEP chest wall reconstruction

Locally advanced breast cancer, which is defined as a malignant breast tumor that invades or adheres to the surrounding tissue, is characterized by the invasion of the chest wall and the skin surface by the tumor. Multiple lymph nodes are invaded and fuse into a mass, causing extensive axillary lymph node metastasis. However, locally advanced breast cancer does not exhibit distant metastasis. At present, in most hospitals in China and the rest of the world, this type of breast cancer is primarily managed through systematic and local treatments. However, a consensus concerning the optimal surgical method for chest wall reconstruction, which for many surgeons is a difficult and confusing procedure, has not been reached. In the past, many breast centers had used skin flap combined with hard mesh titanium alloy plate to repair the large chest wall defects. Although titanium alloy plate can maintain the stability of the chest wall, it may have a negative effect on the follow-up radiotherapy of breast cancer patients, which is a controversial method. In addition, titanium alloy mesh also has the risk of deformation and fracture. These factors will cause some hidden dangers to patient safety. According to the research, the soft mesh not only has the characteristics of satisfactory compatibility and robustness for maintaining the stability of chest wall, but also does not affect the postoperative radiotherapy of patients. Combined with the advantages of soft mesh, Our department treated a case of locally advanced breast cancer with chest wall invasion. Through cooperation between the breast surgery and thoracic surgery departments, a mesh repair plus transverse rectus abdominis myocutaneous (TRAM) combined with deep inferior epigastric perforator (DIEP) procedure was performed to remove the breast tumor and repair the large area of skin defect after surgery, and a relatively satisfactory therapeutic effect was achieved. In this case, we took two novel approaches: first, a 4-layer high-density polyethylene mesh was used to repair the defect; secondly, the inferior epigastric artery perforation was anastomosed with the thoracoacromial artery (end-to-end anastomosis) and the inferior epigastric vein perforation was anastomosed with the axillary vein (end-to-side anastomosis).

Neoadjuvant endocrine therapy in locally advanced estrogen or progesterone receptor-positive breast cancer: determining the optimal endocrine agent and treatment duration in postmenopausal women-a literature review and proposed guidelines

Introduction

For patients with locally advanced estrogen receptor or progesterone receptor-positive breast cancer, neoadjuvant endocrine therapy (NET) facilitates down-staging of the tumor and increased rates of breast-conserving surgery. However, NET remains under-utilized, and there are very limited clinical guidelines governing which therapeutic agent to use, or the optimal duration of treatment in postmenopausal women. This literature review aims to discuss the evidence surrounding (1) biomarkers for patient selection for NET, (2) the optimal neoadjuvant endocrine agent for postmenopausal women with locally advanced breast cancer, and (3) the optimal duration of NET. In addition, we make initial recommendations towards developing a clinical guideline for the prescribing of NET.

Method

A wide-ranging search of online electronic databases was conducted using a truncated PIC search strategy to identify articles that were relevant to these aims and revealed a number of key findings.

Results

Randomized trials have consistently demonstrated that aromatase inhibitors are more effective than tamoxifen, in terms of objective response rate and rate of BCS, and should be used as first-line NET. The three available aromatase inhibitors have so far been demonstrated to be biologically equivalent, with the choice of aromatase inhibitor not having been shown to affect clinical outcomes. There is increasing evidence for extending the duration of NET beyond 3 to 4 months, to at least 6 months or until maximal clinical response is achieved. While on-treatment levels of the proliferation marker Ki67 are predictive of long-term outcome, the choice of adjuvant therapy in patients who have received NET and then surgery is best guided by the preoperative endocrine prognostic index, or PEPI, which incorporates Ki67 with other clinical parameters.

Conclusion

This study reveals that in appropriately selected patients, NET can provide equivalent clinical benefit to neoadjuvant chemotherapy in the same cohort, if suitable treatments and durations are chosen. Our findings highlight the need for better defined biomarkers both for guiding patient selection and for measuring outcomes. Development of standard guidelines for the prescribing of NET has the potential to improve both clinical outcomes and quality of life in this patient cohort.

A priori prediction of tumour response to neoadjuvant chemotherapy in breast cancer patients using quantitative CT and machine learning

Response to Neoadjuvant chemotherapy (NAC) has demonstrated a high correlation to survival in locally advanced breast cancer (LABC) patients. An early prediction of responsiveness to NAC could facilitate treatment adjustments on an individual patient basis that would be expected to improve treatment outcomes and patient survival. This study investigated, for the first time, the efficacy of quantitative computed tomography (qCT) parametric imaging to characterize intra-tumour heterogeneity and its application in predicting tumour response to NAC in LABC patients. Textural analyses were performed on CT images acquired from 72 patients before the start of chemotherapy to determine quantitative features of intra-tumour heterogeneity. The best feature subset for response prediction was selected through a sequential feature selection with bootstrap 0.632 + area under the receiver operating characteristic (ROC) curve (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\mathrm{A}\mathrm{U}\mathrm{C}}_{0.632+}$$\end{document}AUC0.632+) as a performance criterion. Several classifiers were evaluated for response prediction using the selected feature subset. Amongst the applied classifiers an Adaboost decision tree provided the best results with cross-validated \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\mathrm{A}\mathrm{U}\mathrm{C}}_{0.632+}$$\end{document}AUC0.632+, accuracy, sensitivity and specificity of 0.89, 84%, 80% and 88%, respectively. The promising results obtained in this study demonstrate the potential of the proposed biomarkers to be used as predictors of LABC tumour response to NAC prior to the start of treatment.

Machine Learning-Based A Priori Chemotherapy Response Prediction in Breast Cancer Patients using Textural CT Biomarkers. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020;2020:1250-1253. [PMID: 33018214 DOI: 10.1109/embc44109.2020.9176099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Early prediction of cancer response to neoadjuvant chemotherapy (NAC) could permit personalized treatment adjustments for patients, which would improve treatment outcomes and patient survival. For the first time, the efficiency of quantitative computed tomography (qCT) textural and second derivative of textural (SDT) features were investigated and compared in this study. It was demonstrated that intra-tumour heterogeneity can be probed through these biomarkers and used as chemotherapy tumour response predictors in breast cancer patients prior to the start of treatment. These features were used to develop a machine learning approach which provided promising results with cross-validated AUC0.632+, accuracy, sensitivity and specificity of 0.86, 81%, 74% and 88%, respectively.Clinical Relevance- The results obtained in this study demonstrate the potential of textural CT biomarkers as response predictors of standard NAC before treatment initiation.

Quantitative Comparison of Prone and Supine PERCIST Measurements in Breast Cancer

Positron emission tomography (PET) is typically performed in the supine position. However, breast magnetic resonance imaging (MRI) is performed in prone, as this improves visibility of deep breast tissues. With the emergence of hybrid scanners that integrate molecular information from PET and functional information from MRI, it is of great interest to determine if the prognostic utility of prone PET is equivalent to supine. We compared PERCIST (PET Response Criteria in Solid Tumors) measurements between prone and supine FDG-PET in patients with breast cancer and the effect of orientation on predicting pathologic complete response (pCR). In total, 47 patients were enrolled and received up to 6 cycles of neoadjuvant therapy. Prone and supine FDG-PET were performed at baseline (t₀; n = 46), after cycle 1 (t₁; n = 1) or 2 (t₂; n = 10), or after all neoadjuvant therapy (t₃; n = 19). FDG uptake was quantified by maximum and peak standardized uptake value (SUV) with and without normalization to lean body mass; that is, SUV_max, SUV_peak, SUL_max, and SUL_peak. PERCIST measurements were performed for each paired baseline and post-treatment scan. Receiver operating characteristic analysis for the prediction of pCR was performed using logistic regression that included age and tumor size as covariates. SUV and SUL metrics were significantly different between orientation (P < .001), but were highly correlated (P > .98). Importantly, no differences were observed with the PERCIST measurements (P > .6). Overlapping 95% confidence intervals for the receiver operating characteristic analysis suggested no difference at predicting pCR. Therefore, prone and supine PERCIST in this data set were not statistically different.

Defining health-related quality of life in localized and advanced stages of breast cancer - the first step towards hereditary cancer genetic counseling

The important goal in breast cancer treatment is to improve patient quality of life. Due to the huge economic burden, it is necessary to estimate the health state utility values for different breast cancer stages accurately. A group of 114 women filled out the EuroQol-5D-3L questionnaire at two time points. The participants were divided into three groups, as follows: group 1 including healthy high-risk individuals; group 2 including patients with localized stage breast cancer; and group 3 including patients with advanced stage breast cancer. Results were expressed either as summary health state utility score or summary visual-analog score. The EuroQol utility index score and EuroQol visual-analog score were statistically significantly higher in the group of healthy high-risk individuals. The EuroQol visual-analog score was mostly correlated with the anxiety/depression and pain/discomfort quality of life dimensions. Health state utility values for different breast cancer stages are a necessary tool to perform economic analyses in breast cancer management decision making, due to its huge economic burden. Special attention should be paid to assessment of the psychosocial aspects of the disease, as well as pain management.

MicroRNA-4317 predicts the prognosis of breast cancer and inhibits tumor cell proliferation, migration, and invasion

Previous researches have indicated that miR-4317 was aberrantly expressed in several tumors. However, the potential role of miR-4317 in breast cancer is still unclear. The aim of this study was to investigate the potential role of miR-4317 in breast cancer. The relative expression levels of miR-4317 were detected in breast cancer tissues and cell lines using qRT-PCR analysis. The Kaplan-Meier survival curve and multivariate Cox regression analyses were used to investigate the prognostic significance of miR-4317 in breast cancer. CCK-8 and Transwell assays were performed to evaluate the effects of miR-4317 on cell proliferation, migration, and invasion. The results showed that miR-4317 expression was decreased in breast cancer tissues and cell lines. Downregulation of miR-4317 was significantly associated with lymph node metastasis, TNM stage, and poor prognosis. Overexpression of miR-4317 inhibited proliferation, migration, and invasion of breast cancer cells, while downregulation of miR-4317 exhibited the opposite effects. MYD88 may be a direct target of miR-4317. The results suggest miR-4317 may play a tumor suppressor role in breast cancer and inhibit proliferation, migration, and invasion of breast cancer cells by targeting MYD88. The findings provide novel evidence of miR-4317 as a potential prognostic biomarker and therapeutic target for breast cancer.

Predicting Response to Neoadjuvant Chemotherapy Using 18F FDG PET-CT in Patients with Locally Advanced Breast Cancer

OBJECTIVE

The study was aimed to find the utility of 18F FDG PET CT in assessing response to neoadjuvant chemotherapy (NACT) in female patients with locally advanced breast cancer (LABC).

METHODS

All willing women with biopsy proven LABC, following clinical evaluation underwent baseline 18F FDG PET CT along with mammosonograpy and contrast enhanced computerized chest radiography (CECT). The response was assessed clinically before each cycle of chemotherapy using RECIST criteria. Those who were progressing clinically were offered alternate chemotherapy or radiation or surgery. Clinical responders were re-evaluated with 18F FDG PET CT, mammosonogram and CT chest before surgery. The pathological response as assed with residual cancer burden score was used as gold standard.

RESULTS

Of the 30 women eligible, 26 women underwent repeat evaluation and surgery. The mean age was 49 years, 16 women were postmenopausal and 15 tumors were receptor positive. On final histopathology 15 % had completer response and 46 % were non responders. Using a cut off value of 50% of the baseline SUVmax, PET-CT had sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 64%, 75%, 75%, 65%, and 69%, respectively in differentiating pathological responders from non-responders.

CONCLUSION

18F FDG PET-CT predicted the response with greater accuracy than CT or clinical examination. Hence it can be used to identify non responders early in the course and alternate treatment can be offered to patients.

Clip and wire localization of locally advanced malignant breast masses in patients undergoing neoadjuvant chemotherapy and breast conservation therapy

Background

In locally advanced breast cancers, the use of preoperative systemic therapy has been shown to induce tumor response and to improve the local control rate after subsequent surgery and radiation therapy. The purpose of the study is to evaluate the accuracy of localization of breast malignant masses in patients who received neoadjuvant chemotherapy and will undergo conservative breast surgery by using clip and wire marker.

Results

Clip placement was done in 20/20 cases (100%). There was no mammographic evidence of clip migration or complication related to the clip insertion. Wire localization of tumor bed marked by radiopaque clip 1-day preoperative was done in 18/20 patient (90%), the other 2 patients, the masses were clinically palpable (10%). Accurate localization by wire was positive in 18/18 cases. Clip and wire retrieval were positive in all cases.

Conclusion

Clip markers can be used for tumor localization in breast cancer patients undergoing neoadjuvant chemotherapy without migration. Clips are tolerated and safe for the patient, easily visualized on imaging, do not interfere with treatment response, and are cost-effective. Also, serves as a guide for post-neoadjuvant chemotherapy localization when the tumor is not palpable.

I-SPY 2: a Neoadjuvant Adaptive Clinical Trial Designed to Improve Outcomes in High-Risk Breast Cancer

Purpose of Review

The I-SPY 2 trial is an adaptive clinical trial platform designed to improve outcomes in high-risk breast cancer patients by testing new drugs in the neoadjuvant setting. The intent of this review is to discuss background, study structure, innovation, and outcomes of the I-SPY 2 trial.

Recent Findings

I-SPY 2 evaluates new agents combined with standard therapy with pathologic complete response (pCR) as the primary endpoint. I-SPY-2 uses clinical biomarkers to classify breast cancer into 10 subtypes, with Bayesian adaptive randomization to allow individualized patient assignment to therapy arms to maximize treatment effects. A total of 7 drugs have graduated from I-SPY 2. Multiple new agents are currently in active enrollment in I-SPY 2.

Summary

I-SPY 2 uses an individualized approach in clinical trial design to improve high-risk breast cancer outcomes. The purpose of this review is to encourage further research and innovation in this area and bring more precise treatment options to breast cancer patients.

Monitoring Breast Cancer Response to Neoadjuvant Chemotherapy Using Ultrasound Strain Elastography

Strain elastography was used to monitor response to neoadjuvant chemotherapy (NAC) in 92 patients with biopsy-proven, locally advanced breast cancer. Strain elastography data were collected before, during, and after NAC. Relative changes in tumor strain ratio (SR) were calculated over time, and responder status was classified according to tumor size changes. Statistical analyses determined the significance of changes in SR over time and between response groups. Machine learning techniques, such as a naïve Bayes classifier, were used to evaluate the performance of the SR as a marker for Miller-Payne pathological endpoints. With pathological complete response (pCR) as an endpoint, a significant difference (P < .01) in the SR was observed between response groups as early as 2 weeks into NAC. Naïve Bayes classifiers predicted pCR with a sensitivity of 84%, specificity of 85%, and area under the curve of 81% at the preoperative scan. This study demonstrates that strain elastography may be predictive of NAC response in locally advanced breast cancer as early as 2 weeks into treatment, with high sensitivity and specificity, granting it the potential to be used for active monitoring of tumor response to chemotherapy.

Patterns of Care and Efficacy of Chemotherapy and Radiotherapy in Skin-Involved Breast Cancers of All Sizes

BACKGROUND

The management of small skin-involved (SI) invasive breast cancers is controversial because although they are considered unresectable, their prognosis is far better than their stage III classification. This study was undertaken to determine how SI lesions are treated in the United States and to discern the benefit of systemic therapy.

PATIENTS AND METHODS

Data of patients diagnosed with stage I-III breast cancer in the National Cancer Data Base between 2004 and 2011 were reviewed. Treatment patterns were examined and overall survival assessed.

RESULTS

A total of 3485 patients had SI and 456,287 patients had non-SI breast cancers. Chemotherapy was administered to 68.5% of SI and 45.9% of non-SI tumors (P < .001), including 77.2% of SI and 33% of non-SI tumors < 2 cm (P < .001). After adjusting for patient and tumor characteristics, SI patients were 19.4% more likely to receive chemotherapy than non-SI patients. Radiotherapy was provided to 61.1% of SI and 64.3% of non-SI tumors (P < .001), including 65.5% of SI and 66.5% non-SI tumors < 2 cm (P = .711). After adjusting for patient and tumor characteristics, SI patients were 76.6% more likely to receive radiotherapy than non-SI patients. Chemotherapy and radiotherapy provided an overall survival benefit for stage II and III SI and non-SI tumors.

CONCLUSION

Despite controversy regarding staging and prognosis of SI tumors, the majority of patients are provided systemic therapy and radiotherapy. Varied patterns of chemotherapy administration for SI tumors suggests that further treatment guidance and standardization are required, especially because chemotherapy and radiotherapy are equally efficacious in SI and non-SI tumors alike.

Exosomal miRNA profile as complementary tool in the diagnostic and prediction of treatment response in localized breast cancer under neoadjuvant chemotherapy

BACKGROUND

Breast cancer patients under neoadjuvant chemotherapy includes a heterogeneous group of patients who eventually develop distal disease, not detectable by current methods. We propose the use of exosomal miRNAs and circulating tumor cells as diagnostic and predictive biomarkers in these patients.

METHODS

Fifty-three breast cancer women initially diagnosed with localized breast cancer under neoadjuvant chemotherapy were prospectively enrolled in this study. However, six of them were later re-evaluated and diagnosed as metastatic breast cancer patients by PET-CT scan. Additionally, eight healthy donors were included. Circulating tumor cells and serum exosomal miRNAs were isolated from blood samples before and at the middle of neoadjuvant therapy and exosomal miRNA levels analyzed by qPCR.

RESULTS

Before neoadjuvant therapy, exosomal miRNA-21 and 105 expression levels were higher in metastatic versus non-metastatic patients and healthy donors. Likewise, higher levels of miRNA-222 were observed in basal-like (p = 0.037) and in luminal B versus luminal A (p = 0.0145) tumor subtypes. Exosomal miRNA-222 levels correlated with clinical and pathological variables such as progesterone receptor status (p = 0.017) and Ki67 (p = 0.05). During neoadjuvant treatment, exosomal miRNA-21 expression levels directly correlated with tumor size (p = 0.039) and inversely with Ki67 expression (p = 0.031). Finally, higher levels of exosomal miRNA-21, miRNA-222, and miRNA-155 were significantly associated with the presence of circulating tumor cells.

CONCLUSION

Liquid biopsies based on exosomal miRNAs and circulating tumor cells can be a complementary clinical tool for improving breast cancer diagnosis and prognosis.

Barriers in Latin America for the management of locally advanced breast cancer

Breast cancer (BC) is a highly prevalent malignancy in Latin American women, most cases being diagnosed at locally advanced or metastatic stages when options for cancer care are limited. Despite its label as a public health problem in the region, Latin American BC patients face several barriers in accessing standard of care treatment when compared with patients from developed countries. In this review, we analyse the landscape of the four main identified barriers in the region: i) high burden of locally advanced/advanced BC; ii) inadequate access to medical resources; iii) deficient access to specialised cancer care and iv) insufficient BC research in Latin America. Unfortunately, these barriers represent the main factors associated with the BC poor outcomes seen in the region. Targeted actions should be conducted independently by each country and as a region to overcome these limitations and create an enhanced model of BC care.

Molecular signature of response to preoperative radiotherapy in locally advanced breast cancer

Background

Radiation therapy is an indispensable part of various treatment modalities for breast cancer. Specifically, for non-inflammatory locally advanced breast cancer (LABC) patients, preoperative radiotherapy (pRT) is currently indicated as a second line therapy in the event of lack of response to neoadjuvant chemotherapy. Still approximately one third of patients fails to respond favourably to pRT. The aim of this study was to explore molecular mechanisms underlying differential response to radiotherapy (RT) to identify predictive biomarkers and potential targets for increasing radiosensitivity.

Methods

The study was based on a cohort of 134 LABC patients, treated at the Institute of Oncology and Radiology of Serbia (IORS) with pRT, without previous or concomitant systemic therapy. Baseline transcriptional profiles were established using Agilent 60 K microarray platform in a subset of 23 formalin-fixed paraffin-embedded (FFPE) LABC tumour samples of which 11 radiotherapy naïve and 3 post-radiotherapy samples passed quality control and were used for downstream analysis. Biological networks and signalling pathways underlying differential response to RT were identified using Ingenuity Pathways Analysis software. Predictive value of candidate genes in the preoperative setting was further validated by qRT-PCR in an independent subset of 60 LABC samples of which 42 had sufficient quality for data analysis, and in postoperative setting using microarray data from 344 node-negative breast cancer patients (Erasmus cohort, GSE2034 and GSE5327) treated either with surgery only (20%) or surgery with RT (80%).

Results

We identified 192 significantly differentially expressed genes (FDR < 0.10) between pRT-responsive and non-responsive tumours, related to regulation of cellular development, growth and proliferation, cell cycle control of chromosomal replication, glucose metabolism and NAD biosynthesis II route. APOA1, MAP3K4, and MMP14 genes were differentially expressed (FDR < 0.20) between pRT responders and non-responders in preoperative setting, while MAP3K4 was further validated as RT-specific predictive biomarker of distant metastasis free survival (HR = 2.54, [95%CI:1.42–4.55], p = 0.002) in the postoperative setting.

Conclusions

This study pinpoints MAP3K4 as a putative biomarker of response to RT in both preoperative and postoperative settings and a potential target for radiosensitising combination therapy, warranting further pre-clinical studies and prospective clinical validation.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-1129-4) contains supplementary material, which is available to authorized users.

Anti-breast-Cancer Activity Exerted by β-Sitosterol-d-glucoside from Sweet Potato via Upregulation of MicroRNA-10a and via the PI3K-Akt Signaling Pathway

Breast cancer (BC) is a prominent source of cancer mortality in women throughout the world. β-Sitosterol-d-glucoside (β-SDG), a newly isolated phytosterol from sweet potato, possibly displays potent anticancer activity. However, the probable anticancer mechanisms involved are still unclear. This study sought to study how β-SDG from sweet potato affects two BC cell lines (MCF7 and MDA-MB-231) and nude mice bearing MCF7-induced tumors. In addition, we assessed how β-SDG affects tumor suppressor miR-10a and PI3K-Akt signaling in BC cells. Cell viability and proliferation were determined via MTT and colony-formation assays, and apoptosis was quantified by Hoechst staining and flow cytometry. In addition, miR-10a expression and apoptosis-related protein levels were measured. Our study indicated that β-SDG exhibited cytotoxic activities on MCF7 and MDA-MB-231 cells via inducing apoptosis and activating caspase proteases in these cells. Furthermore, the experimental results in nude mice bearing MCF7-induced tumors demonstrated that oral β-SDG administration at medium (60 mg/kg) or high (120 mg/kg) doses was sufficient to substantially impair the growth of tumors and to decrease the levels of CEA, CA125, and CA153 by 64.71, 74.64, and 85.32%, respectively, relative to those of the controls ( P < 0.01). β-SDG was further found to regulate the expression of PI3K, p-Akt, Bcl-2-family members, and other factors involved in the PI3K-Akt-mediated mitochondrial signaling pathway via the tumor suppressor miR-10a. These findings indicated that β-SDG suppresses tumor growth by upregulating miR-10a expression and inactivating the PI3K-Akt signaling pathway. Furthermore, β-SDG could be developed as a potential therapeutic agent against MCF7-cell-related BC.

In Vitro Cytotoxic Activity of a Lactococcus lactis Antimicrobial Peptide Against Breast Cancer Cells

BACKGROUND

Nisin, an effective natural food preservative, is an antimicrobial peptide produced by Lactococcus lactis. Although it has been mainly studied and developed as a potential alternative for antibiotics, other pharmacological effects of the nisin including cytotoxic and anti-tumor activity have been attracted many attentions.

OBJECTIVES

Here, we aimed to evaluate in vitro cytotoxic activity of the nisin against breast cancer cells.

MATERIALS AND METHODS

The effect of temperature, pH, and chemical composition of the medium on the yield of nisin production was evaluated. As well, the anti-proliferative effect of nisin against a breast cancer cell line (i. e., MCF-7) and a non-cancerous cell line (i.e, HUVEC) was determined using MTT assay. Furthermore, the potential of the synergistic effect of the nisin on the doxorubicin cytotoxicity was evaluated.

RESULTS

The optimum culture condition for the nisin production by L. lactis was found to be MRS medium (pH 6.3) supplemented with the tryptone and incubation at 30 °C. MTT assay results indicate that nisin exhibits a high and selective cytotoxicity against MCF-7 cell line with IC50 value of 5 μM. Furthermore, a combination of nisin and doxorubicin at sub-inhibitory concentrations were more cytotoxic compared to either of drugs alone.

CONCLUSION

It could be suggested that nisin, either alone or in combination with other chemotherapeutic agents, could be a potential therapeutic for the breast cancer cells.

Distress Among Locally Advanced Breast Cancer Patients from Diagnosis to Follow-Up: A Critical Review of Literature

OBJECTIVE

This critical review used a systematic approach to explore the prevalence of distress among locally advanced breast cancer (LABC) patients along their treatment journey. This review explored the domains of distress (psychosocial, physical and/or practical) that are significant to this patient population and determined indications for psychosocial support throughout the patients' treatment.

METHODS

Electronic databases including CINAHL, EmBase, Medline PsycInfo, and gray literature were searched from the year 2000 to 2016, to produce relevant literature. A critical review was conducted on 73 articles meeting the inclusion and exclusion criteria. A narrative synopsis was used to summarize the findings under key themes.

RESULTS

The results indicate that 16/73 studies assessed for distress in all three domains of distress throughout the treatment course. A meta-analysis was not possible due to the methodological heterogeneity of the articles, the variation of assessment tools used, timing in which the assessments were done, and the different treatment modalities. Distress was prevalent from the time of diagnosis, through treatment, and into survivorship. Sexuality, body image, age, financial difficulty, family/social support, and informational needs were common themes that emerged among the LABC population in these studies.

CONCLUSIONS

Comprehensive assessments incorporating all three domains of distress with the appropriate tools will assist health care professionals throughout the complicated treatment trajectory of LABC patients in taking a more proactive approach in assisting patients' concerns and preventing undue or increase in psychological distress during or after active treatment. This will encourage effective patient-centered communication and supportive care referrals for a better patient experience.

The combined therapeutic effects of 131iodine-labeled multifunctional copper sulfide-loaded microspheres in treating breast cancer

Compared to conventional cancer treatment, combination therapy based on well-designed nanoscale platforms may offer an opportunity to eliminate tumors and reduce recurrence and metastasis. In this study, we prepared multifunctional microspheres loading 131I-labeled hollow copper sulfide nanoparticles and paclitaxel (131I-HCuSNPs-MS-PTX) for imaging and therapeutics of W256/B breast tumors in rats. 18F-fluordeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) imaging detected that the expansion of the tumor volume was delayed (P<0.05) following intra-tumoral (i.t.) injection with 131I-HCuSNPs-MS-PTX plus near-infrared (NIR) irradiation. The immunohistochemical analysis further confirmed the anti-tumor effect. The single photon emission computed tomography (SPECT)/photoacoustic imaging mediated by 131I-HCuSNPs-MS-PTX demonstrated that microspheres were mainly distributed in the tumors with a relatively low distribution in other organs. Our results revealed that 131I-HCuSNPs-MS-PTX offered combined photothermal, chemo- and radio-therapies, eliminating tumors at a relatively low dose, as well as allowing SPECT/CT and photoacoustic imaging monitoring of distribution of the injected agents non-invasively. The copper sulfide-loaded microspheres, 131I-HCuSNPs-MS-PTX, can serve as a versatile theranostic agent in an orthotopic breast cancer model.

Breast cancer complexity: implications of intratumoral heterogeneity in clinical management

Generation of intratumoral phenotypic and genetic heterogeneity has been attributed to clonal evolution and cancer stem cells that together give rise to a tumor with complex ecosystems. Each ecosystem contains various tumor cell subpopulations and stromal entities, which, depending upon their composition, can influence survival, therapy responses, and global growth of the tumor. Despite recent advances in breast cancer management, the disease has not been completely eradicated as tumors recur despite initial response to treatment. In this review, using data from clinically relevant breast cancer models, we show that the fates of tumor stem cells/progenitor cells in the individual tumor ecosystems comprising a tumor are predetermined to follow a limited (unipotent) and/or unlimited (multipotent) path of differentiation which create conditions for active generation and maintenance of heterogeneity. The resultant dynamic systems respond differently to treatments, thus disrupting the delicate stability maintained in the heterogeneous tumor. This raises the question whether it is better then to preserve stability by preventing takeover by otherwise dormant ecosystems in the tumor following therapy. The ultimate strategy for personalized therapy would require serial assessments of the patient's tumor for biomarker validation during the entire course of treatment that is combined with their three-dimensional mapping to the tumor architecture and landscape.

A phase 2 study of capecitabine and concomitant radiation in women with advanced breast cancer

PURPOSE

To examine the response rate of gross chemo-refractory breast cancer treated with concurrent capecitabine (CAP) and radiation therapy in a prospective Phase II study.

METHODS AND MATERIALS

Breast cancer patients with inoperable disease after chemotherapy, residual nodal disease after definitive surgical resection, unresectable chest wall or nodal recurrence after a prior mastectomy, or oligometastatic disease were eligible. Response by RECIST criteria was assessed after 45 Gy. Conversion to operable, locoregional control, and grade ≥3 toxicities were assessed. The first 9 patients received CAP 825 mg/m2 twice daily continuously. Because of toxicity, subsequent patients received CAP only on radiation days. Kaplan-Meier analysis was used to estimate overall survival (OS) and locoregional recurrence-free survival.

RESULTS

From 2009 to 2012, 32 patients were accrued; 26 received protocol-specified treatment. Median follow-up was 12.9 months (interquartile range, 7.10-42.9 months). Nineteen patients (73%) had partial or complete response. Fourteen patients (53.9%) experienced grade 3 non-dermatitis toxicity (7 of 9 continuous dosing). Three of four inoperable patients converted to operable. One-year actuarial OS in the treated cohort was 54%. The trial was stopped early after interim analysis suggested futility independent of response. Treatment was deemed futile (ie, conversion to operable but M1 disease immediately postoperatively) in 9 of 10 patients with triple-negative (TN) versus 6 of 16 with non-TN disease (P=.014). Median OS and 1-year locoregional recurrence-free survival among non-TN versus TN patients was 22.8 versus 5.1 months, and 63% versus 20% (P=.007).

CONCLUSIONS

Capecitabine can be safely administered on radiation days with careful clinical monitoring and was associated with encouraging response in this chemo-refractory cohort. However, patients with TN breast cancer had poor outcomes even when response was achieved. Further study in non-TN patients may be warranted.

Evaluation of the prognostic stage in the 8th edition of the American Joint Committee on Cancer in locally advanced breast cancer: An analysis based on SEER 18 database

BACKGROUND

The new "prognostic stage" in the 8th edition of the American Joint Committee on Cancer (AJCC) incorporated important biologic factors such as estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor-2 (HER2), histologic grade and TNM stage into one system. The objective of this study was to evaluate the "prognostic stage" in locally advanced breast cancer (LABC) based on the Surveillance, Epidemiology, and End Results (SEER) 18 database.

METHODS

10053 LABCs diagnosed between 2010 and 2013 were enrolled. TNM stage was based on AJCC 7th edition. Comparisons of biologic factor proportions among stage changes were performed using Pearson's chi-square test. Breast cancer-specific survival (BCSS) and overall survival (OS) were estimated using the Kaplan-Meier method and log rank testing with pairwise comparisons between different stages was conducted. Cox models were fitted to assess the independent prognostic factors.

RESULTS

The prognostic stage grouped LABC into six stages: IB-IIIC among which IB-IIIA had a relatively better survival. It reassigned 74% LABCs to a different tumor stage. 60.4% cases in grade III and 68.3% cases with triple negative breast cancer were upstaged while 57.1% cases with ER/PR dual positivity were down staged. It was an independent prognostic factor of LABC. There were statistically significant survival differences among stage IB-IIIA, IIIB and IIIC. Among each TNM stage, there were statistically significant survival differences among stage changes.

CONCLUSIONS

The prognostic stage provided accurate prognostic information for LABC compared with anatomic TNM stage. It will lead to accuracy in prognosis prediction and optimal treatment selection, and therefore, better outcomes.

Using a novel T-lymph node ratio model to evaluate the prognosis of nonmetastatic breast cancer patients who received preoperative radiotherapy followed by mastectomy: An observational study

We aimed to investigate the prognostic value of postpathological characters in nonmetastatic breast cancer (NMBC) patients who received preoperative radiotherapy (PRT) followed by mastectomy (MAST).We conducted retrospective analyses using the data collected from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute. Univariate and multivariate analyses were performed to identify prognostic factors. Disease-specific survival was calculated by the Kaplan-Meier curve and validated by log rank test. The discriminations of independent risk factors and staging systems were compared by the area under receiver operating characteristic curves (AUC) and validated by Harrell concordance index (bootstrapping algorithm). Akaike information criterion (AIC) was applied to compare the difference of model.One thousand three hundred fifty NMBC patients who had received PRT followed by MAST from 1988 to 2013 were included in the study. We found the metastatic lymph node ratio (mLNR) staging was a superior indicator than pN staging. Thus, we proposed a T-lymph node ratio (T-NR) staging system with simplified-T categories (T0-3 and T4) and the mLNR staging. The novel T-NR staging system provided larger AUC (P = .024, .008, respectively) and the smaller AIC (P < .001) value than American Joint Committee on Cancer staging system.The novel T-NR staging system performed more accurate survival prediction and better model fitness for NMBC patients who receive PRT followed by MAST, it may provide a wide applicability in clinical decision-making.

Comparison of breast-conserving surgery with mastectomy in locally advanced breast cancer after good response to neoadjuvant chemotherapy: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

The application of breast-conserving surgery (BCS) on patients with locally advanced breast cancer (LABC) with good response to neoadjuvant chemotherapy (NACT) still remains controversial. The objective in this study is to analyze the safety of BCS in the management of LABC in patients with good response to NACT.

METHODS

We searched the electronic databases of Medline (Pubmed) and Cochrane Library for reports on local recurrence (LR), regional recurrence (RR), distant recurrence (DR), 5-year disease-free survival (DFS) or 5-year overall survival (OS) in patients with LABC receiving BCS or mastectomy (MT) and with good response to NACT. Based on the research results, we conducted a meta-analysis using Review Manager 5.3.

RESULTS

Our study showed that 16 studies with a combined total of 3531 patients, of whom 1465 patients underwent BCS, whereas 2066 patients underwent MT. There was no significant heterogeneity among these studies (Q statistic: P = .88; I = 0%). Patients with good response to NACT showed no significant difference in LR and RR [odd ratio (OR) = 0.83; 95% confidence interval (CI): 0.60-1.15; P = .26; OR = 0.56; 95% CI: 0.33-0.93; P = .03], while we figured out a lower DR (OR = 0.51; 95% CI: 0.42-0.63; P < .01), a higher DFS (OR = 2.35; 95% CI: 1.84 to 3.01, P < .01) and a higher OS (OR = 2.12; 95% CI: 1.51 to 2.98, P < .01) in BCS compared with MT.

CONCLUSION

This meta-analysis concluded that BCS was a safe surgery for patients with LABC and had good response to NACT.

Weekly taxane-anthracycline combination regimen versus tri-weekly anthracycline-based regimen for the treatment of locally advanced breast cancer: a randomized controlled trial

Background

Extensive studies have confirmed the efficacy of taxanes in combination with anthracycline-based chemotherapy on breast cancer. However, few studies have assessed the efficacy of weekly taxane–anthracycline regimens on locally advanced breast cancer. This study was to compare the efficacy and safety of a weekly taxane–anthracycline regimen with those of tri-weekly anthracycline-based regimen in patients with locally advanced breast cancer.

Methods

Patients with locally advanced breast cancer were randomized to receive 4–6 cycles of neoadjuvant chemotherapy with tri-weekly 5-fluorouracil–epirubicin–cyclophosphamide (FEC) regimen or weekly paclitaxel–epirubicin (PE) regimen. The primary endpoint was the pathologic complete response (pCR) rate. Other endpoints included the clinical tumor response, breast-conserving surgery rate, and adverse events.

Results

Between March 2010 and September 2013, 293 patients were randomized to the FEC (n = 151) and PE (n = 142) arms. The overall clinical response rate was significantly higher in the PE arm than in the FEC arm (76.06% vs. 59.95%, P = 0.001). Consistently, the post-chemotherapy pathologic T and N stages were significantly lower in the PE arm than in the FEC arm (P < 0.001). However, the pCR rate was similar in the two arms (10.61% vs. 12.31%, P = 0.665). Overall, 36 (27.27%) patients in the FEC arm and 6 (35.28%) in the PE arm were qualified for breast-conserving surgery. Most adverse events were comparable in both arms, with more severe neutropenia in the PE arm than in the FEC arm (11.97% vs. 5.96%, P = 0.031).

Conclusions

In patients with locally advanced breast cancer, weekly PE was not superior to FEC in terms of pCR. However, weekly PE has a higher response rate and superior down-staging effects. On this account, the PE regimen may be considered an alternative option for locally advanced breast cancer. Long-term follow-up data are needed to confirm the efficacy of this regimen on locally advanced breast cancer.

Trial registration Chinese clinical trial registry, ChiCTR-TRC-10001043, September 21, 2014

Inflammatory breast cancer in the Netherlands; improved survival over the last decades

PURPOSE

Locally advanced breast cancer (LABC) includes inflammatory breast cancer (IBC) as well as non-inflammatory LABC (NI-LABC). The aim of this population-based study was to compare the tumour characteristics, treatment and relative survival of IBC and NI-LABC patients.

METHODS

Patients with either IBC (cT4d) or NI-LABC (cT4a-c) were identified from the nationwide Netherlands Cancer Registry from the period 1989-2015. In each group, patients are divided into three time periods in order to perform a trend analysis: 1989-1997, 1998-2006, and 2007-2015.

RESULTS

IBC comprised 1.1% and NI-LABC 4.6% of all diagnosed breast cancer patients. IBC patients showed more nodal metastases (77.8 vs. 69.7%, P < 0.001) and distant metastases (39.7 vs. 34.1%, P < 0.001). IBC tumours were more often triple negative (23.2 vs. 12.8%, P < 0.001) and poorly differentiated (69.8 vs. 53.8%, P < 0.001). Trimodality therapy (neoadjuvant chemotherapy, surgery and adjuvant radiotherapy) was more often applied over time in both groups (IBC: 23.7%-56.0%-68.6%; NI-LABC: 3.7%-25.9%-43.6%; P _trend < 0.001). In IBC patients, relative 5-year survival was significantly shorter than in patients with NI-LABC (30.2 vs. 45.1%, P < 0.001). The relative survival significantly improved for IBC from 17.2% (1989-1997) to 30.0 and 38.9% for the last two time periods (1998-2006: P < 0.001; 2007-2015: P < 0.001). In contrast, survival did not significantly improve in NI-LABC breast cancer: from 44.7% (1989-1997) to 44.0 and 48.4% (1998-2006: P = 0.483; 2007-2015: P = 0.091).

CONCLUSIONS

IBC has tumour characteristics that determine its aggressive biology compared to NI-LABC. Trimodality therapy was increasingly applied in both groups, but did not improve survival in NI-LABC. Although relative survival in IBC patients has improved during the last decades, it remains a disease with a dismal prognosis.

Is there a role for salvage radiotherapy in locally advanced breast cancer refractory to neoadjuvant chemotherapy?

INTRODUCTION

Locally advanced breast cancer (LABC) is a major problem, especially in developing countries. The standard treatment for LABC is neoadjuvant chemotherapy, with or without anti-Her2 therapy, followed by surgery, radiotherapy, and adjuvant systemic treatment if appropriate. However, there are few data in the literature addressing alternatives when neoadjuvant chemotherapy fails to reduce the tumour for surgery.

MATERIALS AND METHODS

We conducted a retrospective study including all patients who had non-metastatic LABC treated with neoadjuvant chemotherapy and who were not eligible for surgical resection; these patients were submitted to salvage radiotherapy (RTX) between January 2000 and December 2012 at the Brazilian National Cancer Institute.

RESULTS

Fifty-seven patients were included, with a median age of 51 (23-72) years. The most frequent clinical stages were IIIA and IIIB, corresponding to 19.3% and 70.2%, respectively; mean tumour size was 8.74 (3-18) cm, and 44 patients (77.2%) had nodal involvement. Chemotherapeutic regimens containing anthracyclines were prescribed to 98.2% of the patients. Fifteen patients (26.3%) received taxanes and anthracyclines. Radiation dose was 50 Gy divided into 25 fractions; 43 patients (75.4%) had their tumours downsized by RTX and underwent mastectomy. Overall survival (OS) was 38 (23-52) months. Patients who were submitted to surgery had an OS of 49 (28-70) months and those who were not eligible for mastectomy after radiotherapy had an OS of 18 (9-27) months.

CONCLUSION

This retrospective study confirms that RTX is an effective treatment to downsize LABC tumours with low or no response to chemotherapy, thereby enabling surgical resection which may improve overall patient outcome.

Targeted adjuvant therapy in breast cancer

INTRODUCTION

The potential of molecular targeted therapy to improve the clinical outcomes of patients with early-stage breast cancer (BC) as adjuvant therapy has been first demonstrated through endocrine treatment. The introduction of HER2 blockade, through the successful clinical development of trastuzumab, changed the natural history of HER2-positive BC subtype. Areas covered: There are ongoing efforts to augment further the use of targeted agents as adjuvant treatment in BC, hoping that early introduction of targeted therapy blocking key oncogenic drivers of micro-residual disease, will significantly improve clinical outcomes. In the present Review, we present data through extensive search of PubMed about the following targeted adjuvant therapeutic strategies in BC: i) HER2 blockade and ongoing efforts to further augment its efficacy for patients with HER2-positive disease, ii) angiogenesis inhibition, iii) PI3K-mTOR- AKT pathway inhibition, iv) CDK4/6 inhibition, v) PARP inhibition. Expert commentary: we provide insights about challenges and potential ways to overcome them, in terms of successful clinical development of targeted agents as adjuvant therapy for patients with BC. In particular, we emphasize the need to systematically assess minimal residual cancer burden as a way to increase the rates of successful clinical development of targeted agents in the adjuvant setting.

Primary surgical treatment of locally advanced breast cancer in low resource settings

•Optimum management of locally advanced breast cancer is multidisciplinary.•Neoadjuvant chemotherapy is mainstay of management.•Primary surgical treatment may be acceptable in selected patients.

Over-treatment in metastatic breast cancer

Metastatic breast cancer is an incurable disease and the main goals of treatment are prolongation of survival and preservation/improvement of quality of life. Thus the main philosophy of treatment should be to use the least toxic methods, as long as they provide sufficient disease control. In ER-positive tumours this can be in many cases achieved by endocrine therapy; in HER2-positive cancers efficacy of backbone therapy can be enhanced by an anti-HER2 agent. In patients requiring chemotherapy, consecutive single agent regimen provide disease control of a duration at least comparable to multidrug regimen, at a cost of significantly lower toxicity and are a preferred strategy in the majority of cases. Available data demonstrate, however, that aggressive chemotherapy is still overused in many metastatic breast cancer patients. The objective of this manuscript is to critically review available data on treatment choices and sequence in metastatic breast cancer across all breast cancer subtypes in relation to possible overtreatment, including therapies which are not recommended by current guidelines or not even approved. Our aim is to provide guidance on applying these data to clinical practice, but also to describe various, often non-scientific factors influencing therapeutic decisions in an aim to identify areas requiring educational and possibly political actions.

Phosphatidylserine-targeting antibodies augment the anti-tumorigenic activity of anti-PD-1 therapy by enhancing immune activation and downregulating pro-oncogenic factors induced by T-cell checkpoint inhibition in murine triple-negative breast cancers

Background

The purpose of this study was to investigate the potential of antibody-directed immunotherapy targeting the aminophospholipid phosphatidylserine, which promotes immunosuppression when exposed in the tumor microenvironment, alone and in combination with antibody treatment towards the T-cell checkpoint inhibitor PD-1 in breast carcinomas, including triple-negative breast cancers.

Methods

Immune-competent mice bearing syngeneic EMT-6 or E0771 tumors were subjected to treatments comprising of a phosphatidylserine-targeting and an anti-PD-1 antibody either as single or combinational treatments. Anti-tumor effects were determined by tumor growth inhibition and changes in overall survival accompanying each treatment. The generation of a tumor-specific immune response in animals undergoing complete tumor regression was assessed by secondary tumor cell challenge and splenocyte-produced IFNγ in the presence or absence of irradiated tumor cells. Changes in the presence of tumor-infiltrating lymphocytes were assessed by flow cytometry, while mRNA-based immune profiling was determined using NanoString PanCancer Immune Profiling Panel analysis.

Results

Treatment by a phosphatidylserine-targeting antibody inhibits in-vivo growth and significantly enhances the anti-tumor activity of antibody-mediated PD-1 therapy, including providing a distinct survival advantage over treatment by either single agent. Animals in which complete tumor regression occurred with combination treatments were resistant to secondary tumor challenge and presented heightened expression levels of splenocyte-produced IFNγ. Combinational treatment by a phosphatidylserine-targeting antibody with anti-PD-1 therapy increased the number of tumor-infiltrating lymphocytes more than that observed with single-arm therapies. Finally, immunoprofiling analysis revealed that the combination of anti-phosphatidylserine targeting antibody and anti-PD-1 therapy enhanced tumor-infiltrating lymphocytes, and increased expression of pro-immunosurveillance-associated cytokines while significantly decreasing expression of pro-tumorigenic cytokines that were induced by single anti-PD-1 therapy.

Conclusions

Our data suggest that antibody therapy targeting phosphatidylserine-associated immunosuppression, which has activity as a single agent, can significantly enhance immunotherapies targeting the PD-1 pathway in murine breast neoplasms, including triple-negative breast cancers.

Impact of Screening on Breast Cancer Mortality: The UK Program 20 Years On

BACKGROUND

With changes in diagnosis, treatment, and management of breast cancer since the mammography screening trials, there is a need to evaluate contemporary breast screening programs. A case-control study was set up to assess the current impact of attendance in the English Breast Screening Program on breast cancer mortality.

METHODS

Cancer registry cases who died from primary breast cancer ages 47 to 89 years in London in 2008 to 2009 (869 women) were matched to 1 or 2 general population controls (1,642 women) with no diagnosis of breast cancer at the time of the case's diagnosis, who were alive at the case's death. Cases and controls were matched for date of birth and screening area, and had been invited to breast screening at least once prior to the case's diagnosis. ORs were estimated using conditional logistic regression. Self-selection bias was addressed using contemporaneous attendance at the cervical screening program. Sensitivity analyses were undertaken to assess the likely effect of lead time bias.

RESULTS

Attendance at breast screening resulted in a breast cancer mortality reduction of 39% [OR, 0.61; 95% confidence interval (CI), 0.44-0.85] after self-selection correction. Attendance in the last 3 years prior to diagnosis resulted in a 60% mortality reduction (OR, 0.40; 95% CI, 0.31-0.51). Lead time bias effects were negligible.

CONCLUSION

Our results suggest that community breast screening programs provide their expected benefit in terms of reducing the risk of breast cancer death among women participating.

IMPACT

Mammography is an important tool for reducing breast cancer mortality and its impact could be increased by encouraging regular attendance.

Neoadjuvant endocrine therapy in breast cancer: current role and future perspectives

Luminal breast cancer, as defined by oestrogen and/or progesterone expression by immunohistochemistry, accounts for up to 75% of all breast cancers. In this population, endocrine therapy is likely to account for most of the gains obtained with the administration of adjuvant systemic treatment. The role of adjuvant chemotherapy in these patients remains debatable since it is known that only a small fraction of patients will derive meaningful benefit from this treatment whilst the majority will be exposed to significant and unnecessary chemotherapy-related toxicities, in particular the elderly and frail. Therefore, neoadjuvant endocrine therapy (NET) becomes an attractive option for selected patients with hormonal-receptor positive locally advanced breast cancer. In this review, we discuss the current role of NET and future perspectives in the field.

The in vitro immunogenic potential of caspase-3 proficient breast cancer cells with basal low immunogenicity is increased by hypofractionated irradiation

BACKGROUND

Radiotherapy is an integral part of breast cancer treatment. Immune activating properties of especially hypofractionated irradiation are in the spotlight of clinicians, besides the well-known effects of radiotherapy on cell cycle and the reduction of the clonogenic potential of tumor cells. Especially combination of radiotherapy with further immune stimulation induces immune-mediated anti-tumor responses. We therefore examined whether hypofractionated irradiation alone or in combination with hyperthermia as immune stimulants is capable of inducing breast cancer cells with immunogenic potential.

METHODS

Clonogenic assay, AnnexinA5-FITC/Propidium iodide assay and ELISA analyses of heat shock protein 70 and high mobility group box 1 protein were applied to characterize colony forming capability, cell death induction, cell death forms and release of danger signals by breast cancer cells in response to hypofractionated radiation (4x4Gy, 6x3Gy) alone and in combination with hyperthermia (41.5 °C for 1 h). Caspase-3 deficient, hormone receptor positive, p53 wild type MCF-7 and caspase-3 intact, hormone receptor negative, p53 mutated MDA-MB231 breast cancer cells, the latter in absence or presence of the pan-caspase inhibitor zVAD-fmk, were used. Supernatants of the treated tumor cells were analyzed for their potential to alter the surface expression of activation markers on human-monocyte-derived dendritic cells.

RESULTS

Irradiation reduced the clonogenicity of caspase deficient MCF-7 cells more than of MDA-B231 cells. In contrast, higher amounts of apoptotic and necrotic cells were induced in MDA-B231 cells after single irradiation with 4Gy, 10Gy, or 20Gy or after hypofractionated irradiation with 4x4Gy or 6x3Gy. MDA-B231 cells consecutively released higher amounts of Hsp70 and HMGB1 after hypofractionated irradiation. However, only the release of Hsp70 was further increased by hyperthermia. Both, apoptosis induction and release of the danger signals, was dependent on caspase-3. Only supernatants of MDA-B231 cells after hypofractionated irradiation resulted in slight changes of activation markers on dendritic cells; especially that of CD86 was upregulated and HT did not further impact on it.

CONCLUSIONS

Hypofractionated irradiation is the main stimulus for cell death induction and consecutive dendritic cell activation in caspase proficient breast cancer cells. For the assessment of radiosensitivity and immunological effects of radio- and immunotherapies the readout system is crucial.

Clinical usefulness and relevance of intermediate endpoints for cytotoxic neoadjuvant therapy

Intermediate endpoints are surrogate markers of treatment efficacy assessed earlier than the true outcome of interest. Tumor response after systemic neoadjuvant therapy is considered a suitable intermediate endpoint, especially for specific breast cancer subtypes. Response can be evaluated either after only 1 cycle of treatment by clinical evaluation or at the end of the planned neoadjuvant treatment by histomorphologic examination of all surgically removed tissues from the breast and regional nodes. Although several meta-analyses showed a lower risk of death among patients who attain a pathologic complete response (pCR) compared with patients with residual tumor in breast and/or lymph nodes after neoadjuvant therapy, a statistically significant linkage between increased pCR rate by a specific treatment and improvement of survival by the same treatment has not been demonstrated yet. Therefore, formal surrogacy of pCR is not established. Moreover, the better definition of pCR is still an open issue: a large pooled analysis demonstrated that patients who attained ypT0 ypN0 (no invasive or non-invasive residual cancer in breast and nodes) experienced longer DFS (p < 0.001) compared with patients who attained ypTis ypN0 (no invasive residual in breast and nodes irrespective of residual non-invasive disease). Nevertheless, the Food and Drug Administration (FDA) recently allowed using pCR as a surrogate endpoint for accelerated approval process. Several meta-analyses demonstrated the greatest prognostic value of pCR in more aggressive breast cancer subtypes (i.e. triple-negative, HER2-positive, or high grade breast cancer). Usefulness of an earlier intermediate endpoints was prospectively demonstrated in the GeparTrio trial in which patients showing an early response achieved 4-times more frequently a pCR than those without early response.