Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Immune repertoire and responses to neoadjuvant TCHP therapy in HER2-positive breast cancer

Background

Despite the introduction of trastuzumab, pathologic complete response (pCR) is not attained in approximately 30-40% of Human epithelial growth factor receptor-2-positive breast cancer. Tumor-infiltrating lymphocytes (TIL) have been suggested as a predictive marker of treatment response, albeit not always effective. We investigated the relationship between trastuzumab, docetaxel, carboplatin, and pertuzumab (TCHP) treatment and immune repertoire as a treatment response predictor.

Design

In all, 35 cases were divided into two experimental groups: 10 and 25 cases in the preliminary and main experiments, respectively. In the preliminary experiment, the biopsy tissues before TCHP treatment and the surgical tissues after TCHP treatment were compared. In the main experiment, the biopsy tissues before TCHP treatment were compared according to the TCHP treatment response.

Methods

The T-cell repertoire for TRA, TRB, TRG, and TRD, and B-cell repertoire for immunoglobulin heavy, immunoglobulin kappa, and immunoglobulin lambda were evaluated. Whole transcriptome sequencing was also performed.

Results

In the preliminary experiment, the density and richness of the T-cell receptor (TCR) and B-cell receptor (BCR) repertoires decreased after treatment, regardless of TCHP response. In the main experiment, the Shannon's entropy index, density, and length of CDR3 of the TCR and BCR repertoires did not differ significantly in patients who did and did not achieve pCR. The pCR and non-pCR subgroups according to the level of TILs revealed that the non-pCR/lowTIL group had a higher proportion of low-frequency clones than the pCR/lowTIL group in TRA (non-pCR/lowTIL versus pCR/lowTIL, 0.01-0.1%, 63% versus 45.3%; <0.01%, 32.9% versus 51.8%, p < 0.001) and TRB (non-pCR/lowTIL versus pCR/lowTIL, 0.01-0.1%, 26.5% versus 14.7%; <0.01%, 72.0% versus 84.1%, p < 0.001).

Conclusions

The role of the diversity, richness, and density of the TCR and BCR repertoires as predictive markers for TCHP response was not identified. Compositions of low-frequency clones could be candidates for predictive factors of TCHP response; however, validation studies and further research are necessary.

Ki67 increase after core needle biopsy associated with worse disease outcome in HER2-negative breast cancer patients

Ki67 would change after core needle biopsy (CNB) in invasive breast cancer. However, whether Ki67 alteration (ΔKi67) influences disease outcomes remains unclear. Here we aim to evaluate the prognostic value of ΔKi67. Patients with paired CNB and open excision biopsy (OEB) samples between January 2009 and June 2016 were retrospectively analyzed. ΔKi67 was calculated as the absolute difference between Ki67 level in CNB and OEB samples, and the median value of 5% was adopted to category patients into high- and low ΔKi67 groups. Disease-free survival (DFS) and overall survival (OS) were compared between different ΔKi67 groups. Overall, 2173 invasive breast cancer patients were included. Median Ki67 was higher in OEB than CNB samples: 25.00% versus 20.00% (P < 0.001). Axillary nodal status, STI, histological grading, and molecular subtype were independently associated with ΔKi67 (P < 0.05). In the whole population, patients with low ΔKi67 showed superior 5-year DFS (89.6% vs 87.0%, P = 0.026), but similar OS (95.8% vs 94.3%, P = 0.118) compared to those with high ΔKi67. HER2 status at surgery was the only significant factor interacting with ΔKi67 on both DFS (P = 0.026) and OS (P = 0.007). For patients with HER2-negative disease, high ΔKi67 was associated with worse 5-year DFS (87.2% vs 91.2%, P = 0.004) as well as impaired 5-year OS (93.9% vs 96.8%, P = 0.010). ΔKi67 had no significant impact on survival of HER2-positive patients. Ki67 increase after CNB was significantly associated with worse disease outcomes in HER2-negative, but not in HER2-positive patients, which warrants further study.

Recent advances in cold atmospheric plasma (CAP) for breast cancer therapy

The serious problems of conventional breast cancer therapy strategies such as drug resistance, severe side effects, and lack of selectivity prompted the development of various cold atmospheric plasma (CAP) devices. Due to its advanced technology, CAP can produce a unique environment rich in reactive oxygen and nitrogen species (RONS), photons, charged ions, and an electric field, making it a promising revolutionary platform for cancer therapy. Despite substantial technological successes, CAP-based therapeutic systems are encounter with distinct limitations, including low control of the generated RONS, poor knowledge about its anticancer mechanisms, and challenges concerning designing, manufacturing, clinical translation, and commercialization, which must be resolved. The latest developments in CAP-based therapeutic systems for breast cancer treatment are discussed in this review. More significantly, the integration of CAP-based medicine approaches with other breast cancer therapies, including chemo- and nanotherapy is thoroughly addressed.

Multicentricity in Different Molecular Subtypes of Breast Cancer: A Cross-sectional Study in Isfahan

Background

Breast cancer is the most common cancer leading to death in women. Women with multicentric breast cancer were reported more likely to have poor prognosis. Here, we decided to study and compare the frequency distribution of multicentricity in different subtypes of breast cancer.

Materials and Methods

This is a cross-sectional study that was performed in 2019-20 on medical records and breast pathology reports of 250 patients who undergone mastectomy due to breast cancer. Demographic data of all patients including age, along with other medical data such as menstruation condition, breast cancer grade, multicentricity status, stage, and expression of estrogen receptor (ER), progesterone (PR), and human epidermal growth factor receptor 2 (HER2) receptors were collected from medical records. Samples were divided into four subtypes of Luminal B, Luminal A, HER2 expressing, and basal-like.

Results

The mean age of patients was 50.21 ± 11.15 years. Ninety-five patients (38%) had multicentricity and HER2 expressing (48.5%) and Luminal A (41.4%) were most common in patients with multicentricity. In addition, basal-like group presented with least multicentricity (13.5%) among the subtypes (P = 0.008). We also showed significant increased chances of multicentricity in Luminal B (odds ratio [OR] = 3.782) (P = 0.033), Luminal A (OR = 5.164) (P = 0.002), and HER2-expressing group (OR = 5.393) (P = 0.011).

Conclusions

Taken together, we showed significantly increased chances of multicentricity in patients with HER2-expression, Luminal A, and Luminal B groups compared to basal-like group or triple negative. These results were in line with most previous studies; however, we showed higher rates of multicentricity among our population compared to some previous reports.

Sialyl LewisX/A and Cytokeratin Crosstalk in Triple Negative Breast Cancer

Triple-negative breast cancer (TNBC) encompasses multiple entities and is generally highly aggressive and metastatic. We aimed to determine the clinical and biological relevance of Sialyl-Lewis X and A (sLe^X/A)-a fucosylated glycan involved in metastasis-in TNBC. Here, we studied tissues from 50 TNBC patients, transcripts from a TNBC dataset from The Cancer Genome Atlas (TCGA) database, and a primary breast cancer cell line. All 50 TNBC tissue samples analysed expressed sLe^X/A. Patients with high expression of sLe^X/A had 3 years less disease-free survival than patients with lower expression. In tissue, sLe^X/A negatively correlated with cytokeratins 5/6 (CK5/6, which was corroborated by the inverse correlation between fucosyltransferases and CK5/6 genes. Our observations were confirmed in vitro when inhibition of sLe^X/A remarkably increased expression of CK5/6, followed by a decreased proliferation and invasion capacity. Among the reported glycoproteins bearing sLe^X/A and based on the STRING tool, α6 integrin showed the highest interaction score with CK5/6. This is the first report on the sLe^X/A expression in TNBC, highlighting its association with lower disease-free survival and its inverse crosstalk with CK5/6 with α6 integrin as a mediator. All in all, sLe^X/A is critical for TNBC malignancy and a potential prognosis biomarker and therapeutic target.

Impact of Physical Rehabilitation on Bone Biomarkers in Non-Metastatic Breast Cancer Women: A Systematic Review and Meta-Analysis

Rehabilitation might improve bone health in breast cancer (BC) patients, but the effects on bone biomarkers are still debated. Thus, this meta-analysis of randomized controlled trials (RCTs) aims at characterizing the impact of rehabilitation on bone health biomarkers in BC survivors. On 2 May 2022, PubMed, Scopus, Web of Science, Cochrane, and PEDro were systematically searched for RCTs assessing bone biomarker modifications induced by physical exercise in BC survivors. The quality assessment was performed with the Jadad scale and the Cochrane risk-of-bias tool for randomized trials (RoBv.2). Trial registration number: CRD42022329766. Ten studies were included for a total of 873 patients. The meta-analysis showed overall significant mean difference percentage decrease in collagen type 1 cross-linked N-telopeptide (NTX) serum level [ES: -11.65 (-21.13, -2.17), p = 0.02)] and an increase in bone-specific alkaline phosphatase (BSAP) levels [ES: +6.09 (1.56, 10.62). According to the Jadad scale, eight RCTs were considered high-quality studies. Four studies showed a low overall risk of bias, according to RoBv.2. The significant effects of rehabilitation on bone biomarkers suggested a possible implication for a precision medicine approach targeting bone remodeling. Future research might clarify the role of bone biomarkers monitoring in rehabilitation management of cancer treatment induced bone-loss.

Comparing the performance of three modalities of breast cancer screening within a combined programme targeting at-risk women in Indonesia: An implementation study

ABSTRACTAlthough mammography is the gold standard for breast cancer screening, the World Health Organization recommends clinical breast examination (CBE) as the preferred early detection method in countries with limited resources. However, its effectiveness as a 'stand-alone' screening modality compared with other techniques remains unclear. Therefore, we evaluated a risk-based opportunistic breast cancer screening programme using three modalities. Between June and December 2018, we conducted a cross-sectional study in Yogyakarta, Indonesia, of women aged >40 years with at least one risk factor for breast cancer. Subjects underwent CBE, mammography, and ultrasonography. We calculated the proportion of breast lesions detected through each modality and compared their mass size. A total of 503 eligible subjects were screened. Five cases of potential malignant lesions were detected; pathological tests conducted for 4 of them confirmed breast cancer diagnoses. A combined assessment of mammography and ultrasonography examinations revealed 343 breast lesions (68.2%), whereas CBE screening detected only 76 breast lesions (15.1%). The mean lesion sizes detected by mammography or ultrasonography, but not through CBE, were significantly smaller (p-values of 0.037 and 0.007 for mammography and ultrasonography, respectively). In conclusion, mammography and ultrasonography produced higher detection rates for benign and malignant breast lesions compared with CBE.

Tumor-associated macrophages respond to chemotherapy by detrimental transcriptional reprogramming and suppressing stabilin-1 mediated clearance of EGF

Introduction

Tumor resistance to chemotherapy and metastatic relapse account for more than 90% of cancer specific mortality. Tumor-associated macrophages (TAMs) can process chemotherapeutic agents and impair their action. Little is known about the direct effects of chemotherapy on TAMs.

Methods

The effect of chemotherapeutic platinum agent cisplatin was assessed in the model system of human ex vivo TAMs. Whole-transcriptome sequencing for paired TAMs stimulated and not stimulated by cisplatin was analysed by NGS. Endocytic uptake of EGF was quantified by flow cytometry. Confocal microscopy was used to visualize stabilin-1-mediated internalization and endocytic trafficking of EGF in CHO cells expressing ectopically recombinant stabilin-1 and in stabilin-1+ TAMs. In cohort of patients with breast cancer, the effect of platinum therapy on the transcriptome of TAMs was validated, and differential expression of regulators of endocytosis was identified.

Results

Here we show that chemotherapeutic agent cisplatin can initiate detrimental transcriptional and functional programs in TAMs, without significant impairment of their viability. We focused on the clearance function of TAMs that controls composition of tumor microenvironment. For the first time we demonstrated that TAMs' scavenger receptor stabilin-1 is responsible for the clearance of epidermal growth factor (EGF), a potent stimulator of tumor growth. Cisplatin suppressed both overall and EGF-specific endocytosis in TAMs by bidirectional mode: suppression of positive regulators and stimulation of negative regulators of endocytosis, with strongest effect on synaptotagmin-11 (SYT11), confirmed in patients with breast cancer.

Conclusion

Our data demonstrate that synergistic action of cytostatic agents and innovative immunomodulators is required to overcome cancer therapy resistance.

The impact of age on outcomes of breast cancer in different hormone receptor and HER2 groups

OBJECTIVE

The aim of the current study was to explore the association between age and outcomes in breast cancer.

METHODS

Patients during 2010-2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and breast cancer-specific death (BCSD) were taken as endpoints. The restrict cubic spline graph (RCS) was used to explore the relationship between age and outcomes in patients, and the cumulative incidence of BCSD and non-BCSD was calculated using the Gray method. Age-specific gene expression profiles were studied using RNA sequence data from the Cancer Genome Atlas (TCGA) database to explore whether there were young age-related gene or gene sets.

RESULTS

A total of 142,755 patients with breast cancer were included. The hazard ratio (HR) of OS for Patients with stage I-III breast cancer was roughly stable before 53 years old and increased significantly after that, and the HR of BCSD for these patients showed a U-shaped distribution when plotted against age, with patients younger than 50 years and patients older than 70 years experiencing the worst survival. Further stratified analysis according to molecular subtype revealed that the U-shaped distribution of the HR of BCSD with was only found in the Hormone receptor-positive/HER2-negative (HoR+/HER2-) subgroup. The cumulative incidence plots showed that young age was associated with worse BCSD in the breast cancer patients with stage I-III and HoR+/HER2- subgroup. In stage IV breast cancer, there was a linearity of the relationship between poor OS and increasing age. We failed to find any differentially expressed age-specific genes between 20-40 years and 41-60 years groups in 258 patients with stage I-III and HoR+/HER2- subtype.

CONCLUSION

Young age could predict worse BCSD of patient with stage I-III and HoR+/HER2- breast cancer. The escalating therapy was recommended to young age breast cancer with stage I-III and HoR+/HER2- subtype.

Adjuvant chemotherapy is associated with an overall survival benefit regardless of age in ER+/HER2- breast cancer pts with 1-3 positive nodes and oncotype DX recurrence score 20 to 25: an NCDB analysis

Background

The RxPONDER trial found that among breast cancer patients with estrogen receptor positive (ER+) breast cancer, 1-3 positive axillary nodes, and a recurrence score of ≤25, only pre-menopausal women benefitted from adjuvant chemoendocrine therapy; postmenopausal women with similar characteristic did not benefit from adjuvant chemotherapy. We aimed to replicate the RxPonder trial using a larger patient cohort with real world data to determine whether a RS threshold existed where adjuvant chemotherapy was beneficial regardless of age.

Methods

The National Cancer Database (NCDB) was queried for women with ER+, human epidermal growth factor receptor 2 (HER2) negative breast cancer, 1-3 positive axillary nodes, and RS ≤25 who received endocrine (ET) only or chemo-endocrine therapy (CET). Cox regression interaction was explored between CET and age as a surrogate for menopausal status.

Results

The final analytic cohort included 28,427 eligible women: 7,487 (26.3%) received adjuvant CET and 20,940 (73.7%) ET. In the entire cohort, RS had a normal distribution, with a median score of 14. After correcting for demographic and clinical variables, a threshold effect was observed with RS >20 being associated with a significantly inferior overall survival (OS) (P value range: < 0.001-0.019). In women with RS of 20-25, CET was associated with a significant improvement in OS compared to ET alone, regardless of age (age <=50: HR = 0.334, P=0.002; age>50: HR=0.521, P=0.019).

Conclusion

Among women with ER+/HER2- breast cancer with 1-3 positive nodes, and a RS of 20-25-in contrast to the RxPONDER trial-we observed that CET was associated with an OS benefit in women regardless of age.

Neoadjuvant endocrine therapy in postmenopausal women with HR+/HER2- breast cancer

INTRODUCTION

While endocrine therapy is the standard-of-care adjuvant treatment for hormone receptor-positive (HR+) breast cancers, there is also extensive evidence for the role of pre-operative (or neoadjuvant) endocrine therapy (NET) in HR+ postmenopausal women.

AREAS COVERED

We conducted a thorough review of the published literature, to summarize the evidence to date, including studies of how NET compares to neoadjuvant chemotherapy, which NET agents are preferable, and the optimal duration of NET. We describe the importance of on-treatment assessment of response, the different predictors available (including Ki67, PEPI score, and molecular signatures) and the research opportunities the pre-operative setting offers. We also summarize recent combination trials and discuss how the COVID-19 pandemic led to increases in NET use for safe management of cases with deferred surgery and adjuvant treatments.

EXPERT OPINION

NET represents a safe and effective tool for the management of postmenopausal women with HR+/HER2- breast cancer, enabling disease downstaging and a wider range of surgical options. Aromatase inhibitors are the preferred NET, with evidence suggesting that longer regimens might yield optimal results. However, NET remains currently underutilised in many territories and institutions. Further validation of predictors for treatment response and benefit is needed to help standardise and fully exploit the potential of NET in the clinic.

Patient preferences for features of HER2-targeted treatment of advanced or metastatic breast cancer: a discrete-choice experiment study

BACKGROUND

We aimed to quantify patients' benefit-risk preferences for attributes associated with human epidermal growth factor receptor 2 (HER2)-targeted breast cancer treatments and estimate minimum acceptable benefits (MABs), denominated in additional months of progression-free survival (PFS), for given treatment-related adverse events (AEs).

METHODS

We conducted an online discrete-choice experiment (DCE) among patients with self-reported advanced/metastatic breast cancer in the United States, United Kingdom, and Japan (N = 302). In a series of nine DCE questions, respondents chose between two hypothetical treatment profiles created by an experimental design. Profiles were defined by six attributes with varying levels: PFS, nausea/vomiting, diarrhea, liver function problems, risk of heart failure, and risk of serious lung damage and infections. Data were analyzed using an error component random-parameters logit model.

RESULTS

Among the attributes, patients placed the most importance on a change in PFS from 5 to 26 months; change from no diarrhea to severe diarrhea was the least important. Avoiding a 15% risk of heart failure had the largest MAB (5.8 additional months of PFS), followed by avoiding a 15% risk of serious lung damage and infections (4.6 months), possible severe liver function problems (4.2 months), severe nausea/vomiting (3.7 months), and severe diarrhea (2.3 months) compared with having none of the AEs. The relative importance of 21 additional months of PFS (increasing from 5 to 26 months) increased for women with HER2-negative disease and those with children.

CONCLUSIONS

Patients valued PFS gain higher than the potential risk of AEs when deciding between hypothetical breast cancer treatments.

Role of DEK in carcinogenesis, diagnosis, prognosis, and therapeutic outcome of breast cancer: An evidence-based clinical review

Breast cancer is a significantly burdening women's cancer with limited diagnostic modalities. DEK is a novel biomarker overexpressed in breast cancers, currently exhaustively researched for its diagnosis and prognosis. Search for relevant meta-analyses, cohorts, and experimental studies in the last fifteen years was done in five large scientific databases. Non-English, non-full text articles or unrelated studies were excluded. Thirteen articles discussed the potential of DEK to estimate breast cancer characteristics, treatment outcomes, and prognosis. This proto-oncogene plays a role in breast carcinogenesis, increasing tumour proliferation and invasion, preventing apoptosis, and creating an immunodeficient tumour milieu with M2 tumour-associated macrophages. DEK is also associated with worse clinicopathological features and survival in breast cancer patients. Using a Kaplan-Meier plotter data analysis, DEK expression predicts worse overall survival (HR 1.24, 95%CI: 1.01-1.52, p = 0.039), comparable to other biomarkers. DEK is a promising novel biomarker requiring further research to determine its bedside applications.

Validation study of a nomogram for predicting probability of low risk of MammaPrint results in women with clinically high-risk breast cancer

BACKGROUND

MammaPrint (MMP) helps clinicians identify the ideal time for adjuvant treatment for patients with early HR+/HER2- breast cancer. We aimed to validate a nomogram designed to predict probability of low risk of MMP results and to evaluate the difference in survival outcome between two groups divided by nomogram score.

METHODS

In this retrospective cohort study, we evaluated 172 patients from Asan Medical Center, Seoul, Korea, who underwent breast cancer surgery and MMP during 2020-2021. First, we validated the nomogram by calculating the area under the curve (AUC) and using calibration. Additionally, with the data of 1,835 T1-3N0-1M0 HR+/HER2- patients from Asan Medical Center during 2010-2013, we compared the disease-free survival (DFS), overall survival (OS), and breast cancer-specific survival (BCSS) rates by Kaplan-Meier analysis between the two groups divided by nomogram total point (TP) of 183.

RESULTS

The AUC calculated by validation of 172 patients was 0.73 (95% confidence interval [CI], 0.66-0.81). The discrimination and calibration of the prediction model were satisfactory following additional validation of 1835 patients. The high-risk and low-risk groups had different 5-year OS (97.9% vs. 98.1%, p = 0.056), DFS (98.6% vs. 99.4%, p = 0.008), and BCSS rates (98.6% vs. 99.4%, p = 0.002).

CONCLUSION

For treatment decision-making among clinically high-risk patients with HR+/HER2- and node-positive disease, the nomogram showed satisfactory performance in predicting patients with low genomic risk. Survival outcome significantly differed between two groups divided by nomogram TP. More studies are needed to validate this model in international cohorts and large prospective cohorts from other institutions.

THOR is a targetable epigenetic biomarker with clinical implications in breast cancer

BACKGROUND

Breast cancer (BC) is the most frequently diagnosed cancer and a leading cause of death among women worldwide. Early BC is potentially curable, but the mortality rates still observed among BC patients demonstrate the urgent need of novel and more effective diagnostic and therapeutic options. Limitless self-renewal is a hallmark of cancer, governed by telomere maintenance. In around 95% of BC cases, this process is achieved by telomerase reactivation through upregulation of the human telomerase reverse transcriptase (hTERT). The hypermethylation of a specific region within the hTERT promoter, termed TERT hypermethylated oncological region (THOR) has been associated with increased hTERT expression in cancer. However, its biological role and clinical potential in BC have never been studied to the best of our knowledge. Therefore, we aimed to investigate the role of THOR as a biomarker and explore the functional impact of THOR methylation status in hTERT upregulation in BC.

RESULTS

THOR methylation status in BC was assessed by pyrosequencing on discovery and validation cohorts. We found that THOR is significantly hypermethylated in malignant breast tissue when compared to benign tissue (40.23% vs. 12.81%, P < 0.0001), differentiating malignant tumor from normal tissue from the earliest stage of disease. Using a reporter assay, the addition of unmethylated THOR significantly reduced luciferase activity by an average 1.8-fold when compared to the hTERT core promoter alone (P < 0.01). To further investigate its biological impact on hTERT transcription, targeted THOR demethylation was performed using novel technology based on CRISPR-dCas9 system and significant THOR demethylation was achieved. Cells previously demethylated on THOR region did not develop a histologic cancer phenotype in in vivo assays. Additional studies are required to validate these observations and to unravel the causality between THOR hypermethylation and hTERT upregulation in BC.

CONCLUSIONS

THOR hypermethylation is an important epigenetic mark in breast tumorigenesis, representing a promising biomarker and therapeutic target in BC. We revealed that THOR acts as a repressive regulatory element of hTERT and that its hypermethylation is a relevant mechanism for hTERT upregulation in BC.

Upregulation of the EGFR/MEK1/MAPK1/2 signaling axis as a mechanism of resistance to antiestrogen‑induced BimEL dependent apoptosis in ER+ breast cancer cells

The epidermal growth factor receptor (EGFR) is commonly upregulated in multiple cancer types, including breast cancer. In the present study, evidence is provided in support of the premise that upregulation of the EGFR/MEK1/MAPK1/2 signaling axis during antiestrogen treatment facilitates the escape of breast cancer cells from BimEL‑dependent apoptosis, conferring resistance to therapy. This conclusion is based on the findings that ectopic BimEL cDNA overexpression and confocal imaging studies confirm the pro‑apoptotic role of BimEL in ERα expressing breast cancer cells and that upregulated EGFR/MEK1/MAPK1/2 signaling blocks BimEL pro‑apoptotic action in an antiestrogen‑resistant breast cancer cell model. In addition, the present study identified a pro‑survival role for autophagy in antiestrogen resistance while EGFR inhibitor studies demonstrated that a significant percentage of antiestrogen‑resistant breast cancer cells survive EGFR targeting by pro‑survival autophagy. These pre‑clinical studies establish the possibility that targeting both the MEK1/MAPK1/2 signaling axis and pro‑survival autophagy may be required to eradicate breast cancer cell survival and prevent the development of antiestrogen resistance following hormone treatments. The present study uniquely identified EGFR upregulation as one of the mechanisms breast cancer cells utilize to evade the cytotoxic effects of antiestrogens mediated through BimEL‑dependent apoptosis.

Thermodynamic Sensitivity of Blood Plasma Components in Patients Afflicted with Skin, Breast and Pancreatic Forms of Cancer

According to the World Health Organization's 2018 Global Cancer Survey, cancer is the second leading cause of death. From this survey, the third most common is breast cancer, the fifth is melanoma malignum and pancreatic adenocarcinoma ranks twentieth. Undoubtedly, the early diagnosis and monitoring of these tumors and related research is important for aspects of patient care. The aim of our present review was to explain an impressive methodology that is deemed suitable in reference to studying blood sample deviations in the case of solid tumors. Essentially, we compared the heat denaturation responses of blood plasma components through differential scanning calorimetry (DSC). In the control, between five and seven separable components can be detected, in which the primary component was albumin, while in the case of tumorous patients, the peaks of immunoglobulins were dominant. Moreover, the shape of the plasma DSC curves changed with a shift in the higher temperature ranges; thus, their pattern can be used as a suitable marker of direct immunological responses. The further development of the analysis of DSC curves raises the possibility of the early diagnosis of a potential tumor, the monitoring of diseases, or testing the efficacy of the therapy from a single drop of blood.

Intraoperative electron radiotherapy in early invasive ductal breast cancer: 6-year median follow-up results of a prospective monocentric registry

Background

Intraoperative electron radiotherapy (IOERT) can be used to treat early breast cancer during the conservative surgery thus enabling shorter overall treatment times and reduced irradiation of organs at risk. We report on our first 996 patients enrolled prospectively in a registry trial.

Methods

At Jules Bordet Institute, from February 2010 onwards, patients underwent partial IOERT of the breast. Women with unifocal invasive ductal carcinoma, aged 40 years or older, with a clinical tumour size ≤ 20 mm and tumour-free sentinel lymph node (on frozen section and immunohistochemical analysis). A 21 Gy dose was prescribed on the 90% isodose line in the tumour bed with the energy of 6 to 12 MeV (Mobetron®-IntraOp Medical).

Results

Thirty-seven ipsilateral tumour relapses occurred. Sixteen of those were in the same breast quadrant. Sixty patients died, and among those, 12 deaths were due to breast cancer. With 71.9 months of median follow-up, the 5-year Kaplan–Meier estimate of local recurrence was 2.7%.

Conclusions

The rate of breast cancer local recurrence after IOERT is low and comparable to published results for IORT and APBI. IOERT is highly operator-dependent, and appropriate applicator sizing according to tumour size is critical. When used in a selected patient population, IOERT achieves a good balance between tumour control and late radiotherapy-mediated toxicity morbidity and mortality thanks to insignificant irradiation of organs at risk.

Innovative Approach for a Typology of Treatment Sequences in Early Stage HER2 Positive Breast Cancer Patients Treated With Trastuzumab in the French National Hospital Database

BACKGROUND

Our objective was to describe the hospital-based systemic treatment sequences in early stage HER2+ breast cancer patients treated with trastuzumab in France in 2016.

METHODS

This retrospective observational study was based on the national hospital discharge database (PMSI). Patients hospitalized for breast cancer in 2016 and administration of trastuzumab between 6 months prior and 1 year after surgery were included. The following treatments were identified: (1) trastuzumab ± chemotherapy; (2) chemotherapy alone; (3) q3w trastuzumab weekly chemotherapy. Hospital admissions for cardiac events before and after the surgery were investigated. An unsupervised machine learning technic called TAK (Time-sequence Analysis through K-clustering) was used to identify and visualize typical systemic treatment sequences.

RESULTS

Overall, 3531 patients were included: 2619 adjuvant cohort patients (74.2%) and 912 neoadjuvant cohort patients (25.8%). The mean age was 56.4 years (±12.3), 99.7% patients were female. Treatment initiation occurred within 6 weeks of the surgery in 58% and 92% of patients, and trastuzumab treatment lasted 12 months (±1 month) in 75% and 66% of patients in the adjuvant and neoadjuvant cohorts, respectively. Nevertheless, 12% and 22% of patients were treated with trastuzumab for <11 months in the adjuvant and neoadjuvant cohorts, respectively. There was not one standard sequence of treatments per cohort, but 4 and 3 typical treatment sequences in the adjuvant and the neoadjuvant cohorts, respectively, plus 2 treatment sequences with an early treatment withdrawal. The frequency of patients with ⩾1 hospital stay with a cardiac event was higher among patients with an early treatment withdrawal.

CONCLUSIONS

The treatment sequences of most patients were in line with the recommendations in force. The machine learning approach provided a telling visual display of the results, thereby allowing healthcare professionals, health authorities, patients, and care givers to see the whole picture of the hospital-administered drug strategies.

Nomogram for predicting overall survival in Chinese triple-negative breast cancer patients after surgery

BACKGROUND

There are few nomograms for the prognosis of Chinese patients with triple-negative breast cancer (TNBC).

AIM

To construct and validate a nomogram for overall survival (OS) of Chinese TNBC patients after surgery.

METHODS

This study used the data of SEER*stat 8.3.5 and selected Chinese patients with TNBC operated on between 2010 and 2015. Univariate and multivariate Cox proportional hazard regression models were used. The identified variables were integrated to form a predictive nomogram and risk stratification model; it was assessed with C-indexes and calibration curves.

RESULTS

The median and maximal OS of the 336 patients was 39 and 83 mo, respectively. The multivariate analysis showed that age (P = 0.043), marital status (P = 0.040), tumor localization (P = 0.030), grade (P = 0.035), T classification (P = 0.012), and N classification (P = 0.002) were independent prognostic factors. The six variables were combined to construct a 1-, 3- and 5-year OS nomogram. The C-indexes of the nomogram to predict OS were 0.766 and compared to the seventh edition staging system, which was higher (0.766 vs 0.707, P < 0.001). In order to categorize patients into different prognostic groups, a risk stratification model was created. There was a significant difference between the Kaplan-Meier curves of the entire cohort and each disease stage according to the nomogram.

CONCLUSION

The nomogram provided prognostic superiority over the traditional tumor, node and metastasis system. It could help clinicians make individual OS or risk predictions for Chinese TNBC patients after surgery.

Mammography radiomics features at diagnosis and progression-free survival among patients with breast cancer

BACKGROUND

The associations between mammographic radiomics and breast cancer clinical endpoints are unclear. We aimed to identify mammographic radiomics features associated with breast cancer prognosis.

METHODS

Nested from a large breast cancer cohort in our institution, we conducted an extreme case-control study consisting of 207 cases with any invasive disease-free survival (iDFS) endpoint <5 years and 207 molecular subtype-matched controls with >5-year iDFS. A total of 632 radiomics features in craniocaudal (CC) and mediolateral oblique (MLO) views were extracted from pre-treatment mammography. Logistic regression was used to identify iDFS-associated features with multiple testing corrections (Benjamini-Hochberg method). In a subsample with RNA-seq data (n = 96), gene set enrichment analysis was employed to identify pathways associated with lead features.

RESULTS

We identified 15 iDFS-associated features from CC-view yet none from MLO-view. S(1,-1)SumAverg and WavEnLL_s-6 were the lead ones and associated with favourable (OR 0.64, 95% CI 0.42-0.87, P = 0.01) and poor iDFS (OR 1.53, 95% CI 1.31-1.76, P = 0.01), respectively. Both features were associated with eight pathways (primarily involving cell cycle regulation) in tumour but not adjacent normal tissues.

CONCLUSION

Our findings suggest mammographic radiomics features are associated with breast cancer iDFS, potentially through pathways involving cell cycle regulation.

Systematic review and meta-analysis of C-reactive protein as a biomarker in breast cancer

Inflammation is an enabling characteristic of the hallmarks of cancer. There has therefore been increasing interest in the clinical value of circulating inflammatory biomarkers in cancer. In this review, we summarize results on C-reactive protein (CRP), alone or as part of the Glasgow Prognostic Score (GPS, composed of CRP and serum albumin), as a biomarker of prognosis or prediction and monitoring of therapeutic response in patients with breast cancer. A systematic literature search was performed in Medline and Embase from 1990 to August 2021. The association of serum CRP and overall survival and disease/progression-free survival was summarized in meta-analyses using a random effects model. The results from a total of 35 included studies (20,936 patients) were divided according to three identified patient settings (metastatic, non-metastatic, and general setting). Most of the studies examined prognostic utility. Several larger studies observed associations between high serum CRP and poor survival, but the meta-analyses suggested a limited value in a non-metastatic and general breast cancer setting (populations with unknown or varied disease stage). In metastatic patients, however, more consistent findings supported an association between serum CRP and prognosis (hazard ratio for overall survival: 1.87 (95% CI 1.31-2.67). Only five studies examined a role in prediction or monitoring of therapeutic response. One study reported a significant association between serum CRP levels and response to chemotherapy. Findings regarding serum CRP as a biomarker in breast cancer appear inconsistent, particularly in non-metastatic and general breast cancer, where the prognostic value could not be confirmed. In patients with metastatic breast cancer we suggest that high serum CRP is an indicator of poor prognosis. Too few studies assessed the role of serum CRP in prediction or monitoring of treatment response to allow conclusions.

Unmet Care Needs and Uncertainty in Patients Newly Diagnosed with Breast Cancer

Breast cancer is the most common cancer in women in the world. Statistics revealed the number of breast cancer patients less than 40 years of age increased over time. Clinical studies found there is a trend of yearly illness happening in younger patients, whose needs related to the illness are different from older patients. The purpose of this study was to explore the uncertainty and needs of patients in different age groups who were newly diagnosed with breast cancer. A descriptive cross-sectional survey study was adopted to recruit 128 patients. The Mishel’s Uncertainty in Illness Scale (MUIS, Chinese version) and the Cancer Needs Questionnaire (short-form, CNQ-SF) were used to collect data. The results revealed that a patient’s age and religion negatively correlated with illness uncertainty. A patient’s age, educational level, work or not, and children’s age correlated with needs for care. Age, illness uncertainty, and educational level were important predictors of the needs of care, with an explanatory power of 29.0%. In Conclusion, patients ≤40 years of age had greater illness uncertainty and needs for care than those who were >40 years of age. For younger patients newly diagnosed with cancer, medical professionals should take the initiative to provide detailed and complete information on breast cancer treatment plans, prognosis, and home self-care, which helps clarify the possible future treatments and results and further enables patients to acquire self-care skills and knowledge.

Identification and verification of a 4-gene signature predicting the overall survival of cervical cancer

Cervical cancer (CC) is one of the most common gynecological malignancies, ranking fourth in both incidence and mortality in women worldwide. Early screening and treatment are of great significance in reducing the incidence and mortality of CC. Due to the complex molecular mechanisms of tumor progression, the predictive power of traditional clinical information is limited. In this study, an effective molecular model is established to assess prognosis of patients with CC and guide clinical treatment so as to improve their survival rate. Three high quality datasets (GSE138080, GSE52904, GSE67522) of expression profiling were obtained from gene expression omnibus (GEO) database. Another mRNA expression and clinicopathological data of CC were obtained from The Cancer Genome Atlas (TCGA) dataset. The bioinformatic analyses such as univariate analysis, multivariate Cox proportional-hazards model (Cox) analysis and lasso regression analysis were conducted to select survival-related differentially expressed genes (DEGs) and further establish a prognostic gene signature. Moreover, the performance of prognostic gene signature was evaluated based on Kaplan-Meier curve and receiver operating characteristic (ROC) curve. Gene set enrichment analysis (GSEA) and tumor immunity analysis were carried out to elucidate the molecular mechanisms and immune relevance. A 4-gene signature comprising procollagen-lysine, 2-oxoglutarate 5-dioxygenase 2 (PLOD2), spondin1 (SPON1), secreted phosphoprotein 1 (SPP1), ribonuclease H2 subunit A (RNASEH2A) was established to predict overall survival (OS) of CC. The ROC curve indicated good performance of the 4-gene signature in predicting OS of CC based on the TCGA dataset. The 4-gene signature classified the patients into high-risk and low-risk groups with distinct OS rates of CC. Univariate analysis and multivariate Cox regression analysis revealed that the 4-gene signature was an independent factor affecting the prognosis of patients with CC. Our study developed a 4-gene signature capable of predicting the OS of CC. The findings may be beneficial to individualized clinical treatment and timely follow-up for patients with CC.

Loss of HER2 in breast cancer: biological mechanisms and technical pitfalls

Loss of HER2 in previously HER2-positive breast tumors is not rare, occurring in up to 50% of breast cancers; however, clinical research and practice underestimate this issue. Many studies have reported the loss of HER2 after neoadjuvant therapy and at metastatic relapse and identified clinicopathological variables more frequently associated with this event. Nevertheless, the biological mechanisms underlying HER2 loss are still poorly understood. HER2 downregulation, intratumoral heterogeneity, clonal selection, and true subtype switch have been suggested as potential causes of HER2 loss, but translational studies specifically investigating the biology behind HER2 loss are virtually absent. On the other side, technical pitfalls may justify HER2 loss in some of these samples. The best treatment strategy for patients with HER2 loss is currently unknown. Considering the prevalence of this phenomenon and its apparent correlation with worse outcomes, we believe that correlative studies specifically addressing HER2 loss are warranted.

Development and Validation of Ferroptosis-Related lncRNAs as Prognosis and Diagnosis Biomarkers for Breast Cancer

Breast cancer (BC) is one of the most common malignancies affecting women. Ferroptosis is a novel cancer treatment option. The present study is aimed to identify suitable ferroptosis-related lncRNAs to predict and diagnose BC. Differential expression and Cox regression analyses were used to screen suitable prognostic biomarkers and construct a suitable risk model. We identified four ferroptosis-related differentially expressed lncRNAs (FR-DELs) (LINC01152, AC004585.1, MAPT-IT1, and AC026401.3), which were independently correlated with the overall survival of BC patients. The area under the curve value of the prognostic model using those four biomarkers was over 0.60 in all three groups. The sensitivity and specificity of the diagnostic model using those four biomarkers were 86.89% and 86.73%, respectively. Our present study indicated that these four FR-DELs (LINC01152, AC004585.1, MAPT-IT1, and AC026401.3) could be prognostic biomarkers for BC, although clinical validation studies are required.

Cardiometabolic Consequences of Targeted Anticancer Therapies

ABSTRACT

Cardiometabolic disease (CMD) is the most common preventable cause of death in the world. A number of components are included in the spectrum of CMD, such as metabolic syndrome/obesity, hyperglycemia/diabetes, dyslipidemia, and hypertension, which are independently associated with cardiovascular disease risk. These conditions often occur together, and patients with cancer frequently undergo treatments that can generate or worsen CMD. This review highlights and presents mechanistic and epidemiological evidence regarding CMD in 4 categories of anticancer medications, namely, mTOR/PI3K-Akt inhibitors, multitargeted tyrosine kinase inhibitor, immune checkpoint inhibitor therapy, and endocrine therapy. Patients taking these medications need careful monitoring during therapy. There is a role for cardio-oncology and onco-primary care specialists in optimally managing patients at risk to mitigate CMD during treatment with these and other investigational anticancer medications.

Clinical significance of the neutrophil-to-lymphocyte ratio in oligometastatic breast cancer

Purpose

This study investigated the clinical impact of pretreatment neutrophil-to-lymphocyte ratio (NLR) on survival in patients with oligometastatic breast cancer.

Patients and methods

We collected data from 397 patients who underwent primary breast surgery from 2004 to 2015 and developed recurrence during the follow-up. We reviewed the images and clinical information and defined OMD according to the European Society for Medical Oncology advanced breast cancer guidelines. The NLR was calculated using pretreatment data of primary breast cancer. The cutoff value of the NLR was determined by receiver operating characteristic curve with Youden Index.

Results

Among 397 patients, 131 had OMD at recurrence. The low-NLR group included patients of significantly older age at primary cancer than those in the high-NLR group. A low NLR indicated a better overall survival (p = 0.023) after adjusting for relevant factors, including estrogen receptor status, surgical resection of metastatic disease, metastatic organ number, disease-free interval, and liver metastasis than did the high-NLR group. We developed prognostic models for OMD using six independent prognostic factors, including the NLR. The number of factors was associated with overall survival; patients with all six favorable factors showed a good overall survival of 90.9% at 8 years and those with four or more factors showed 70.4%.

Conclusions

The NLR was an independent prognostic factor for overall survival in OMD. The number of favorable prognostic factors was associated with overall survival. A prognostic model, including the NLR, will help identify patients with a favorable prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06726-w.

The prognostic importance of glucose-to-lymphocyte ratio and uric acid in metastatic breast cancer patients treated with Cdk 4/6 inhibitors

Aim: To demonstrate the prognostic importance of glucose-to-lymphocyte ratio (GLR) and uric acid (UA) in patients with metastatic breast cancer (MBC) receiving Cdk 4/6 inhibitors. Materials & methods: Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, GLR, UA and CA15-3 were analyzed to assess their prognostic value using Kaplan-Meier curves and Cox regression analysis in 101 patients with MBC, retrospectively. Results: Importantly, both progression-free survival and overall survival were shorter in the group with high neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), GLR and UA. In the multivariate analysis, GLR and UA levels were independent prognostic factors for both progression-free survival and overall survival. Conclusion: In patients with MBC, GLR and UA are independent factors that predict survival times.

Does the breast reconstruction method have an impact on time delay to adjuvant chemotherapy – A comparison between autologous and expander/implant breast reconstruction

Introduction

This study aims to analyze whether autologous breast reconstruction as compared to expander/implant reconstruction has a higher risk of postoperative wound healing problems (WHPs) and thus potentially delays chemotherapy start.

Methods

Between January 2012 and December 2019, a total of 64 women with NSME/SSME and autologous (Group1, n = 33) or expander/implant reconstruction (Group2, n = 31) and adjuvant chemotherapy were enrolled in this study conducted at Innsbruck Medical University Hospital. Immediate postoperative WHPs in each group were compared, and the time from operation to initiation of chemotherapy was analyzed. If the start of chemotherapy was postponed for more than six weeks postoperatively due to WHP, it was defined as delayed. Statistical analysis was performed with SPSS and Fisher's exact test.

Results

More postoperative WHP occurred in Group 1 than in Group 2 (51.6% vs. 9.7%, p < 0.001). Due to WHP, chemotherapy start was delayed for more than six weeks postoperatively in 30.3% of Group 1 patients and 3.2% of Group 2 patients. Only small differences in age (Group 1: 47±1 vs. Group 2: 46±2 years) and BMI (Group 1: 24.3 ± 0.6 vs. Group 2: 23.3 ± 0.7 kg/m²) were found.

Conclusion

Our study shows a far smaller risk for postoperative WHP and delay of chemotherapy start in the expander/implant group in comparison with the autologous group. In some selected patients with high urgency for adjuvant chemotherapy, a bridging operation by means of expander reconstruction prior to chemotherapy could be an oncologically safe pathway.

Influence of the external breast prosthesis on the postural control of women who underwent mastectomy: Cross-sectional study

Women after mastectomy may decide to either have a breast reconstruction or use an external breast prosthesis.

AIM

The aim of the presented research was to evaluate the influence of external breast prosthesis on postural stability in women after mastectomy.

METHODS AND PROCEDURES

In the study 52 women after unilateral mastectomy took part. The study consisted of 4 parts: 1) anthropometric measurements; 2) measurements of upper limb circumference; 3) assessment of weight-bearing (WB); and 4) posturographic tests (PT).

OUTCOMES AND RESULTS

Differences in the arm circumferences on the amputated (A) and non-amputated (NA) sides did not confirm the occurrence of lymphedema in limb on amputated side. The results of the WB between the A and NA body sides in both tested conditions, i.e., with open and closed eyes, showed no significant differences between the test with and without an external prosthesis. No statistically differences have been observed between posturometric parameters with and without breast prosthesis during both PT. In comparing the posturometric parameters between the PT with open and closed eyes, the sway path of the center of pressure was statistically significantly longer when eyes were closed in both conditions, i.e., with and without breast prosthesis.

CONCLUSION AND IMPLICATIONS

The finding show that 1) external breast prosthesis does not have a significant influence on the symmetry of loading on the A and NA body sides and on the postural stability of women after unilateral mastectomy and 2) exclusion visual control during PT increases postural instability in women after unilateral mastectomy.

Effectiveness of different types, delivery modes and extensiveness of exercise in patients with breast cancer receiving systemic treatment - A systematic review and meta-analysis

BACKGROUND

Effects of exercise in patients with breast cancer have been thoroughly investigated. The aim was to explore differences in effects regarding type, delivery mode and extensiveness (e.g. intensity; volume) of the interventions.

METHODS

We searched for randomised controlled trials including patients with breast cancer receiving systemic treatment, exercise-based interventions, and measures on patient reported- and objectively measured outcomes.

RESULTS

Exercise showed significant and moderate effects on the primary outcomes quality of life and physical function, Standardised Mean Difference: 0.52 (95 % CI 0.38-0.65) and 0.52 (95 % CI 0.38-0.66), respectively. Type of exercise had little influence on the effects, however combined aerobic- and resistance exercise seemed superior for increasing physical function, compared to aerobic or resistance exercise. Supervised interventions were superior to partly and unsupervised. Extensiveness of the intervention only influenced physical function.

CONCLUSIONS

Supervised interventions, more than type or extensiveness of interventions, seem to increase effects.

Comparative Efficacy and safety of new targeted therapies and immunotherapies for metastatic triple negative breast cancer: a network meta-analysis

BACKGROUND

No therapeutic targets in metastatic triple-negative breast cancer (TNBC) have been established and no effective therapies are available. Several therapies directed at novel targets and also immunotherapies have recently shown promising results in advanced or metastatic TNBC. We aimed to compare the efficacy and safety of these new regimens for advanced or metastatic TNBC (mTNBC).

METHODS

: The PubMed, Embase, and Cochrane Library electronic databases were searched for phase III randomized trials. We conducted a network meta-analysis to compare the efficacy and safety of new targeted and immunotherapy regimens. Trial quality was assessed using the GRADE method. The comparative outcomes were progression-free survival, overall survival, and G3-4 adverse drug events (ADEs).

RESULTS

Thirteen phase III randomized controlled trials were identified in the network meta-analysis. Olaparib significantly improved PFS in comparison with the pembrolizumab plus chemotherapy1, atezolizumab plus nab-paclitaxel and pembrolizumab regimens. Sacituzumab yielded a significant improvement in OS over immunotherapies, veliparib and chemotherapy alone, but no significantly superiority over pembrolizumab, olaparib and talazoparib. The risk of ≥grade 3 ADEs associated with olaparib was significantly lower than the risks associated with the other regimens.

CONCLUSION

For mTNBC, sacituzumab had a better effect on overall survival, with comparatively high risk of SAE, and olaparib improved progression-free survival with a lower risk of SAE, particularly in those patients with BRCA mutations.

Survival comparison between postoperative and preoperative radiotherapy for stage I-III non-inflammatory breast cancer

To compare the survival benefit between preoperative and postoperative radiotherapy for stage I-III non-inflammatory breast cancer patients, we conducted a retrospective cohort study using surveillance, epidemiology and end results databases. Our study recruited patients who had been diagnosed with stage I-III breast cancer and underwent surgery and radiotherapy. The overall survival was calculated by Kaplan-Meier method. Cox risk model was used to determine the impact of radiotherapy according to stage, molecular subtype and other risk factors. Propensity score matching was used to balance measurable confounding factors. Of all the 411,279 enrolled patients varying from 1975 to 2016, 1712 patients received preoperative radiotherapy, and 409,567 patients received postoperative radiotherapy. Compared with the postoperative radiotherapy group, the preoperative radiotherapy group showed significantly higher risks of overall mortality and breast cancer-specific mortality. Survival differences in treatment sequences were correlated with stage, molecular subtypes and other risk factors. According to the results of this study, preoperative radiotherapy did not show a survival advantage, and postoperative radiotherapy is still the primary treatment. However, preoperative radiotherapy also has some theoretical advantages, such as phase reduction and recurrence reduction. Therefore, it is still worthy of further exploration.

Conservative interventions and clinical outcome measures used in the perioperative rehabilitation of breast cancer patients undergoing mastectomy: a scoping review

BACKGROUND

Mastectomy is the first-line treatment approach for more than 90% of breast cancer patients. The numerous physical impairments associated with this surgical procedure negatively impact the patient's quality of life. To date, rehabilitation resources available for breast cancer patients undergoing mastectomy within the institutions affiliated to the Centre intégré universitaire de soins de santé et de services sociaux de la Mauricie-et-du-Centre-du-Québec (CIUSSS-MCQ) are lacking and do not always seem to reflect the particularities of breast cancer care pathways. The purpose of this review was to identify and describe the conservative interventions and the clinical outcome measures used in the perioperative physical rehabilitation of women with breast cancer who are awaiting or have undergone mastectomy. We also aimed to report on the barriers and facilitators to study participation and completion.

METHODS

MEDLINE, CINAHL, and the Cochrane Library were searched from inception to January 2021, and we updated the search on July 11, 2022. We included peer-reviewed English and French literature with quantitative designs, describing conservative interventions and clinical outcome measures used within rehabilitation programs designed for women who were awaiting or had undergone mastectomy. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data.

RESULTS

Of the 6080 articles identified, 57 met the inclusion criteria. Most interventions were multimodal, which combined exercise with patient education, manual therapy, and/or lymphatic drainage. The most frequently used objective measures of physical function were shoulder range of motion, muscle strength, and signs of lymphedema. In contrast, the primary patient-reported outcome measures were quality of life, shoulder function, and pain. Undergoing another breast surgery, death, and cancer recurrence were the most reported barriers to study completion.

CONCLUSION

This scoping review reports on the heterogeneity and wide range of conservative interventions and clinical outcome measures used in the physical rehabilitation of breast cancer patients who had undergone or were scheduled to undergo mastectomy. Tailoring interventions to breast cancer patients' needs and promoting outpatient rehabilitation interventions appear to be better suited to the particularities of breast cancer care pathways. Further research is needed to better identify barriers and facilitators to study participation and completion.

Deep Learning Mechanism for Predicting the Axillary Lymph Node Metastasis in Patients with Primary Breast Cancer

The second largest cause of mortality worldwide is breast cancer, and it mostly occurs in women. Early diagnosis has improved further treatments and reduced the level of mortality. A unique deep learning algorithm is presented for predicting breast cancer in its early stages. This method utilizes numerous layers to retrieve significantly greater amounts of information from the source inputs. It could perform automatic quantitative evaluation of complicated image properties in the medical field and give greater precision and reliability during the diagnosis. The dataset of axillary lymph nodes from the breast cancer patients was collected from Erasmus Medical Center. A total of 1050 images were studied from the 850 patients during the years 2018 to 2021. For the independent test, data samples were collected for 100 images from 95 patients at national cancer institute. The existence of axillary lymph nodes was confirmed by pathologic examination. The feed forward, radial basis function, and Kohonen self-organizing are the artificial neural networks (ANNs) which are used to train 84% of the Erasmus Medical Center dataset and test the remaining 16% of the independent dataset. The proposed model performance was determined in terms of accuracy (Ac), sensitivity (Sn), specificity (Sf), and the outcome of the receiver operating curve (Roc), which was compared to the other four radiologists' mechanism. The result of the study shows that the proposed mechanism achieves 95% sensitivity, 96% specificity, and 98% accuracy, which is higher than the radiologists' models (90% sensitivity, 92% specificity, and 94% accuracy). Deep learning algorithms could accurately predict the clinical negativity of axillary lymph node metastases by utilizing images of initial breast cancer patients. This method provides an earlier diagnostic technique for axillary lymph node metastases in patients with medically negative changes in axillary lymph nodes.

Impact of adjuvant chemotherapy on T1N0M0 breast cancer patients: a propensity score matching study based on SEER database and external cohort

BACKGROUND

There is no clear consensus on the benefits of adjuvant chemotherapy for tumor-node-metastasis (TNM) stage T1 (T1N0M0) breast cancer (BC). Our study investigated the effects of adjuvant chemotherapy on T1N0M0 BC patients.

METHODS

Seventy-five thousand one hundred thirty-nine patients diagnosed with T1N0M0 BC were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Multivariate Cox analyses were performed to investigate the effects of adjuvant chemotherapy on T1a, T1b, and T1cN0M0 BC, including various tumor grades, and four molecular subtypes. Propensity score matching (PSM) was used to eliminate confounding factors and further compare the results between adjuvant chemotherapy and no adjuvant chemotherapy. Additionally, 545 T1N0M0 BC patients treated at the Northern Jiangsu People's Hospital were included as an independent external validation cohort. Univariate and multivariate Cox analyses were used to confirm the effects of adjuvant chemotherapy in T1a, T1b, and T1cN0M0 BC. Survival curves for the different tumor grades and molecular subtypes were plotted using the Kaplan-Meier method.

RESULTS

Adjuvant chemotherapy demonstrated a statistically significant improvement in overall survival (OS) in T1b and T1c BC, but not in T1a BC. Within T1b BC, adjuvant chemotherapy was found to have effects on grade III, and hormone receptor + (HoR +)/human epidermal growth factor receptor 2 + (HER2 +), HoR-/HER2 + , and HoR-/HER2- molecular subtypes, respectively. Adjuvant chemotherapy was beneficial to OS for grade II/III and T1c BC. Identical results were obtained after PSM. We also obtained similar results with external validation cohort, except that adjuvant chemotherapy made a difference in grade II and T1b BC of the external validation dataset.

CONCLUSIONS

Partial T1N0M0 BC patients with grade III T1bN0M0, patients with tumor grade II and III T1cN0M0, and excluding those with HoR + /HER2- subtype tumors, could obtain OS benefits from adjuvant chemotherapy.

Validation of a prognostic scoring system for postmastectomy locoregional recurrence in breast cancer

Background

To date, it remains unclear which patients with breast cancer (BC) benefit from post-mastectomy radiotherapy (PMRT). Cheng et al. developed and validated a scoring system based on 4 prognostic factors for locoregional recurrence (LRR) to identify patients in need for PMRT. These factors include age, estrogen receptor status, lymphovascular status and number of affected axillary lymph nodes.

Purpose

To validate the scoring system for LRR in BC developed by Cheng et al. by using an independent BC database.

Methods and materials

We retrospectively identified 1989 BC cases, treated with mastectomy (ME) with or without PMRT at the University Hospitals Leuven between 2000 and 2007. The primary endpoint was 5-year locoregional control rate with and without PMRT, according to the LRR score.

Results

Median follow-up time was 11.4 years. After excluding patients with missing variables 1103 patients were classified using the LRR scoring system: 688 (62.38%) patients were at low risk of recurrence (LRR score 0–1), 335 (30.37%) patients were at intermediate risk of recurrence (LRR score 2–3) and 80 (7.25%) patients were at high risk of recurrence (LRR score ≥4). 5-year locoregional control rates with and without PMRT were 99.20% versus 99.21% (p = 0.43) in the low-risk group; 98.24% versus 85.74% (p < 0.0001) in the intermediate-risk group and 96.87% versus 85.71% (p = 0.10) in the high-risk group respectively.

Conclusion

Our validation of the LRR scoring system suggests it can be used to point out patients that would benefit from PMRT. We recommend further validation of this scoring system by other independent institutions before application in clinical practice.

•

Post-mastectomy radiotherapy.

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Scoring system by Cheng et al.

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Based on 4 factors.

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Age, estrogen receptor, lymphovascular status, affected axillary lymph nodes.

•

Intermediate and high-risk patients could benefit from post-mastectomy radiotherapy.

Node Positivity Among Sonographically Suspicious but FNA-Negative Axillary Nodes

BACKGROUND

Fine needle aspiration (FNA) of sonographically suspicious axillary lymph nodes is helpful to clinically stage patients and guide consideration of neoadjuvant therapy in breast cancer. However, data are limited for suspicious nodes that are FNA negative. Our goal is to compare the frequency of node positivity between patients with negative axillary ultrasound (AUSneg) versus suspicious AUS with negative FNA (FNAneg).

METHODS

With IRB approval, we identified all clinically node-negative (cN0) patients with invasive breast cancer treated with upfront surgery at our tertiary care center between 2016 and 2021. AUS is routinely performed with FNA of suspicious lymph node(s). We compared clinicopathologic characteristics and nodal positivity rates between AUSneg and FNAneg groups.

RESULTS

A total of 1580 cN0 patients with invasive breast cancer were analyzed, including 1240 AUSneg and 340 FNAneg patients. The FNAneg group was younger (median age 59.7 years versus 63.5 years, p < 0.001) and had higher clinical T (cT) category (29.1% versus 21.7% with cT2-cT4 disease, p = 0.005). Final axillary pathologic node positivity did not differ significantly between the AUSneg and FNAneg groups (16.5% versus 19.1%, p = 0.25). Among FNAneg patients, 58/340 (17.1%) had a clip placed, with retrieval confirmed in 28/58 (48.3%). Of the 28 retrieved clipped nodes, 27 were sentinel nodes. Final pathologic nodal status (pN+%) did not differ between patients in whom retrieval of the clipped node was confirmed versus not confirmed (28.6% versus 16.7%, p = 0.28).

CONCLUSIONS

Both patients with sonographically suspicious node(s) and negative FNA and patients with negative AUS have a similarly low chance of positive nodes. Additionally, routine targeted excision of FNA-negative clipped nodes is not warranted.

Economic evaluations of mammography to screen for breast cancer in low- and middle-income countries: A systematic review

Background

Low- and middle-income countries (LMICs) have limited resources compared to high-income countries (HICs). Therefore, it is critical that LMICs implement cost-effective strategies to reduce the burden of breast cancer. This study aimed to answer the question of whether mammography is a cost-effective breast cancer screening method in LMICs.

Methods

A systematic article search was conducted through Medline, Embase, Web of Science, and Econlit. Studies were included only if they conducted a full economic evaluation and focused on mammography screening in LMICs. Two reviewers screened through the title and abstract of each article and continued with full-text selection. Data were extracted and synthesized narratively. Quality assessment for each included study was conducted using the Consensus Health Economic Criteria (CHEC) extended checklist.

Results

This review identified 21 studies economically evaluating mammography as a breast cancer screening method in LMICs. Eighteen of these studies concluded that mammography screening was a cost-effective strategy. Most studies (71%) were conducted in upper-middle-income countries (Upper MICs). The quality of the studies varied from low to good. Important factors determining cost-effectiveness are the target age group (eg, 50-59 years), the screening interval (eg, biennial or triennial), as well as any combination with other breast cancer control strategies (eg, combination with treatment strategy for breast cancer patients).

Conclusions

Mammography screening appeared to be a cost-effective strategy in LMICs, particularly in Upper MICs. More studies conducted in lower-middle-income and low-income countries are needed to better understand the cost-effectiveness of mammography screening in these regions.

Electronic Health Interventions for Patients With Breast Cancer: Systematic Review and Meta-Analyses

PURPOSE

Ongoing supportive care using electronic health (eHealth) interventions has the potential to provide remote support and improve health outcomes for patients with breast cancer. This study aimed to evaluate the effectiveness of eHealth interventions on patient-reported outcomes (quality of life [QOL], self-efficacy, and mental or physical health) for patients during and after breast cancer treatment and patient-reported experience measures (acceptability and engagement).

METHODS

Systematic review with meta-analyses (random-effects model) of randomized controlled trials was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Nine databases were searched using a prespecified search strategy. Patient-directed eHealth interventions for adult patients during or after active breast cancer treatment measuring QOL, self-efficacy, and mental (depressive, anxiety, and distress symptoms) or physical (physical activity, nutrition, and fatigue) health outcomes were included. Data from eligible full-text articles were independently extracted by six observers.

RESULTS

Thirty-two unique studies (4,790 patients) were included. All were health self-management interventions, and most were multicomponent (videos, forums, and electronic reminder systems) websites. Meta-analyses revealed a significant effect of eHealth interventions on QOL (standardized mean difference [SMD], 0.20 [95% CI, 0.03 to 0.36]), self-efficacy (SMD, 0.45 [95% CI, 0.24 to 0.65]), distress (SMD, -0.41 [95% CI,-0.63 to -0.20]), and fatigue (SMD, -0.37 [95% CI, -0.61 to -0.13]). Twenty-five studies (78.1%) measured patient-reported experience measures. Acceptability (n = 9) was high, with high ratings for satisfaction (range, 71%-100%), usefulness (range, 71%-95%), and ease-of-use (range, 73%-92%). Engagement (n = 25) decreased over time, but disease-focused information and interactive support were most engaging.

CONCLUSION

eHealth interventions may provide an acceptable and effective strategy for improving QOL, distress, self-efficacy, and fatigue among patients with breast cancer.

A Novel Surrogate Nomogram Capable of Predicting OncotypeDX Recurrence Score©

Background: OncotypeDX Recurrence Score© (RS) is a commercially available 21-gene expression assay which estimates prognosis and guides chemoendocrine prescription in early-stage estrogen-receptor positive, human epidermal growth factor receptor-2-negative (ER+/HER2−) breast cancer. Limitations of RS testing include the cost and turnaround time of several weeks. Aim: Our aim is to develop a user-friendly surrogate nomogram capable of predicting RS. Methods: Multivariable linear regression analyses were performed to determine predictors of RS and RS > 25. Receiver operating characteristic analysis produced an area under the curve (AUC) for each model, with training and test sets were composed of 70.3% (n = 315) and 29.7% (n = 133). A dynamic, user-friendly nomogram was built to predict RS using R (version 4.0.3). Results: 448 consecutive patients who underwent RS testing were included (median age: 58 years). Using multivariable regression analyses, postmenopausal status (β-Coefficient: 0.25, 95% confidence intervals (CIs): 0.03−0.48, p = 0.028), grade 3 disease (β-Coefficient: 0.28, 95% CIs: 0.03−0.52, p = 0.026), and estrogen receptor (ER) score (β-Coefficient: −0.14, 95% CIs: −0.22−−0.06, p = 0.001) all independently predicted RS, with AUC of 0.719. Using multivariable regression analyses, grade 3 disease (odds ratio (OR): 5.67, 95% CIs: 1.32−40.00, p = 0.037), decreased ER score (OR: 1.33, 95% CIs: 1.02−1.66, p = 0.050) and decreased progesterone receptor score (OR: 1.16, 95% CIs: 1.06−1.25, p = 0.002) all independently predicted RS > 25, with AUC of 0.740 for the static and dynamic online nomogram model. Conclusions: This study designed and validated an online user-friendly nomogram from routinely available clinicopathological parameters capable of predicting outcomes of the 21-gene RS expression assay.

Delay in the initiation of adjuvant chemotherapy in patients with breast cancer with mastectomy with or without immediate breast reconstruction

BACKGROUND

Patients with breast cancer undergoing mastectomy should be offered the option of immediate breast reconstruction (IBR). The aim of this retrospective study was to assess whether there is a delay in the initiation of adjuvant chemotherapy in patients undergoing mastectomy with or without IBR.

METHOD

The study included patients aged 70 years or younger with clinically node-negative breast cancer who underwent unilateral mastectomy with IBR (IBR group) or mastectomy alone (no-IBR group) followed by adjuvant chemotherapy at the Helsinki University Hospital between January 2012 to July 2018.

RESULTS

A total of 645 patients were included; 186 in the IBR group and 459 in the no-IBR group. Sixty-six (35.5 per cent) patients in the IBR group and 102 (22.2 per cent) patients in the no-IBR group received their first chemotherapy cycle later than 6 weeks after surgery (P < 0.001). The respective numbers for later than 8 weeks were 17 (9.1 per cent) and 14 (3.1 per cent) (P = 0.001). Among all 645 patients, postoperative complications were a significant risk factor for a delay in the initiation of chemotherapy. Sixty-seven (39.9 per cent) patients with and 101 (21.2 per cent) patients without complications had a delay in chemotherapy (P < 0.001). The delay in chemotherapy was due to complications in 39 (59.1 per cent) in the IBR group and in 28 (27.5 per cent) in the no-IBR group (P < 0.001).

CONCLUSION

Patients undergoing mastectomy alone were more likely to receive adjuvant chemotherapy within 6 weeks after surgery compared with the IBR patients. IBR significantly increased the risk of postoperative complications in comparison with mastectomy alone. The complications, in turn, were a significant risk factor for delay in adjuvant chemotherapy.

Cancer Treatment-Induced Bone Loss: Role of Denosumab in Non-Metastatic Breast Cancer

Chemotherapeutic agents, endocrine therapy and radiotherapy used in the management of breast cancer are known to cause decreased bone mineral density, and thus, increased incidence of fractures. A majority (~60%) of the breast cancer patients in India are either estrogen (ER) or progesterone hormone receptor (PR) positive. Adjuvant treatment with aromatase inhibitors (AIs) is the treatment mainstay for hormone-sensitive disease in postmenopausal (PM) women, with reduced bone mineral density (BMD), which results in increased fracture rates. Zoledronic acid, alendronate, risedronate and denosumab have been the agents of choice for managing bone loss. Denosumab 60 mg is approved for gaining bone mass in women with breast cancer who are at high risk for fracture following adjuvant AI treatment. The phase III HALT-BC data indicate an improvement in BMD with denosumab and a 50% reduction in clinical fractures, with significant improvements seen at the lumbar spine, distal third of the radius, and total hip. Denosumab has several advantages over other bone modifying agents such as subcutaneous self-administration by the patient themselves, no requirement of hospitalization, no dose modifications in renal impairment, and low incidence of acute phase anaphylactic reactions. We review the available evidence of denosumab for managing bone loss in non-metastatic breast cancer patients.

Update on prognostic and predictive biomarkers of breast cancer

Breast cancer represents a heterogeneous group of human cancer at both histological and molecular levels. Estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) are the most commonly used biomarkers in clinical practice for making treatment plans for breast cancer patients by oncologists. Recently, PD-L1 testing plays an important role for immunotherapy for triple-negative breast cancer. With the increased understanding of the molecular characterization of breast cancer and the emergence of novel targeted therapies, more potential biomarkers are needed for the development of more personalized treatments. In this review, we summarized several main prognostic and predictive biomarkers in breast cancer at genomic, transcriptomic and proteomic levels, including hormone receptors, HER2, Ki67, multiple gene expression assays, PD-L1 testing, mismatch repair deficiency/microsatellite instability, tumor mutational burden, PIK3CA, ESR1 andNTRK and briefly introduced the roles of digital imaging analysis in breast biomarker evaluation.

Modern Breast Cancer Surgery 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

This text is based on the recommendations accepted by the 4th Hungarian Consensus Conference on Breast Cancer, modified on the basis of the international consultation and conference within the frames of the Central-Eastern European Academy of Oncology. The recommendations cover non-operative, intraoperative and postoperative diagnostics, determination of prognostic and predictive markers and the content of cytology and histology reports. Furthermore, they address some specific issues such as the current status of multigene molecular markers, the role of pathologists in clinical trials and prerequisites for their involvement, and some remarks about the future.