Survival of patients with metastatic breast cancer: twenty-year data from two SEER registries

Benefits, Harms, and Stakeholder Perspectives Regarding Opioid Therapy for Pain in Individuals With Metastatic Cancer: Protocol for a Descriptive Cohort Study

BACKGROUND

Opioids are a key component of pain management among patients with metastatic cancer pain. However, the evidence base available to guide opioid-related decision-making in individuals with advanced cancer is limited. Patients with advanced cancer or cancer that is unlikely to be cured frequently experience pain. Opioids are a key component of pain management among patients with metastatic cancer pain. Many individuals with advanced cancer are now living long enough to experience opioid-related harm. Emerging evidence from chronic noncancer pain literature suggests that longer-term opioid therapy may have limited benefits for pain and function, and opioid-related harms are also a major concern. However, whether these benefits and harms of opioids apply to patients with cancer-related pain is unknown.

OBJECTIVE

This manuscript outlines the protocol for the "Opioid Therapy for Pain in Individuals With Metastatic Cancer: The Benefits, Harms, and Stakeholder Perspectives (BEST) Study." The study aims to better understand opioid decision-making in patients with advanced cancer, along with opioid benefits and harms, through prospective examination of patients' pain experiences and opioid side effects and understanding the decision-making by patients, care partners, and clinicians.

METHODS

This is a multicenter, prospective cohort study that aims to enroll 630 patients with advanced cancer, 20 care partners, and 20 clinicians (670 total participants). Patient participants must have an advanced solid cancer diagnosis, defined by the American Cancer Society as cancer that is unlikely to be cured. We will recruit patient participants within 12 weeks after diagnosis so that we can understand opioid benefits, harms, and perspectives on opioid decision-making throughout the course of their advanced cancer (up to 2 years). We will also specifically elicit information regarding long-term opioid use (ie, opioids for ≥90 consecutive days) and exclude patients on long-term opioid therapy before an advanced cancer diagnosis. Lived-experience perspectives related to opioid use in those with advanced cancer will be captured by qualitative interviews with a subset of patients, clinicians, and care partners. Our data collection will be grounded in a behavioral decision research approach that will allow us to develop future interventions to inform opioid-related decision-making for patients with metastatic cancer.

RESULTS

Data collection began in October 2022 and is anticipated to end by November 2024.

CONCLUSIONS

Upon successful execution of our study protocol, we anticipate the development of a comprehensive evidence base on opioid therapy in individuals with advanced cancer guided by the behavioral decision research framework. The information gained from this study will be used to guide interventions to facilitate opioid decisions among patients, clinicians, and care partners. Given the limited evidence base about opioid therapy in people with cancer, we envision this study will have significant real-world implications for cancer-related pain management and opioid-related clinical decision-making.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54953.

Oncotype DX Breast Recurrence Score Distribution and Chemotherapy Benefit Among Women of Different Age Groups With HR-Positive, HER2-Negative, Node-Negative Breast Cancer in the SEER Database

Objective: To explore the distribution of Oncotype DX Breast Recurrence Score (RS), the proportion of receiving chemotherapy, and the relationship between RS and chemotherapy benefit according to detailed age groups in women with hormone receptor-positive, human epidermal growth factor receptor 2-negative, node-negative (HR+/HER2−/N0) breast cancer.

Methods: This was an extensive, comprehensive, population-based retrospective study. Data on individuals with breast cancer were obtained from the Surveillance, Epidemiology, and End Results (SEER) Program. The cohort was divided into five groups by age (≤ 35, 36–50, 51–65, 66–80, >80 years). RS distribution and chemotherapy proportion among different age groups were analyzed, and the overall survivals between patients receiving chemotherapy and those not/unknown were compared in each age group.

Results: The study cohort comprised 49,539 patients and the largest age group was 51–65 years. The percentage of patients with low-risk RS (0–10) increased with age, whereas those with intermediate-risk RS (11–25) decreased with age (except for the group of 36–50 years, which had the highest rate of intermediate-risk RS). The age group ≤35 years has the greatest rate of high-risk RS (26–100). The proportion of receiving chemotherapy decreased with age in all RS risk categories. Overall survival was benefited by chemotherapy only in the age group of 66–80 years with intermediate- and high-risk RS, and chemotherapy seemed to do more harm than good for patients older than 80 years.

Conclusions: In the present study, we identified the distribution of RS, the proportion of receiving chemotherapy, and the relationship between RS and chemotherapy benefit according to a detailed age grouping for women with HR+/HER2−/N0 breast cancer, which may help in making individualized clinical decisions.

Variation in Breast Cancer Subtype Incidence and Distribution by Race/Ethnicity in the United States From 2010 to 2015

IMPORTANCE

Breast cancer is the most commonly diagnosed cancer and the leading cause of death in women worldwide. Yet the racial/ethnic disparity in incidences and distributions of breast cancer remains largely unknown.

OBJECTIVE

To examine the racial/ethnic patterns associated with the incidence of the subtypes of breast cancer and distribution of patients across clinicopathological variables.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database, which collected data from 18 SEER cancer registries that identified patients with breast cancer in the US diagnosed between January 1, 2010, and December 31, 2015. The inclusion criteria were (1) female patients with primary unilateral breast cancer who underwent surgical treatment; (2) record of estrogen receptor, progesterone receptor, and ERBB2 status; (3) record of medical history and histological subtype of the specified tumor location; and (4) data on patient race/ethnicity, lateral tumor position, tumor size, tumor TNM stage, and number of tumors. Incidence and distribution rates were identified and compared for different molecular subtypes, histological grades, pathological patterns, T stages, TNM stages, and tumor sites of breast cancers for each racial/ethnic group. Patient race/ethnicity was classified as follows: non-Hispanic White, Hispanic White, Black, Asian/Pacific Islander, American Indian/Alaskan Native, and unknown. Data were analyzed from January 1, 2010, to December 31, 2015.

MAIN OUTCOMES AND MEASURES

Incidence rates of 4 molecular subtypes: hormone receptor (HR)-positive and ERBB2-negative, HR-positive and ERBB2-positive, HR-negative and ERBB2-positive, and triple-negative breast cancer (TNBC). Data on distribution by histological grades (grades 1-4 and unknown), pathological patterns, T stages, TNM stages, and tumor sites was also extracted. Annual age-standardized incidence rates and incidence rate ratios (IRRs) were calculated with 95% CIs. Race/ethnicity case-to-case odds ratios were estimated using polytomous regression.

RESULTS

A total of 239 211 women with breast cancer were analyzed (median [interquartile range]) age, 60 [50-69] years). The annual incidence rate of all breast cancers was 31.3 (95% CI, 31.2- 31.5) per 100 000 people in non-Hispanic White women (the reference group), which was higher compared with the incidence among Black women (IRR, 1.04; 95% CI, 1.02-1.05; P < .001). The incidence rates were also lower in Asian/Pacific Islander (IRR, 0.90; 95% CI, 0.89-0.92; P < .001), American Indian/Alaskan native (IRR, 0.82; 95% CI, 0.81-0.83; P < .001), and Hispanic White women (IRR, 0.79; 95% CI, 0.75-0.83; P < .001). In Black patients, the incidences of the HR-positive and ERBB2-positive (IRR, 1.12; 95% CI, 1.08-1.16; P < .001), HR-negative and ERBB2-positive (IRR, 1.46; 95% CI, 1.38-1.54; P < .001), and TNBC (IRR, 2.07; 95% CI, 2.01-2.14; P < .001) subtypes were higher than those in non-Hispanic White patients, but the incidence of the HR-positive and ERBB2-negative subtype in Black women was lower (IRR, 0.86; 95% CI, 0.84-0.87; P < .001). The incidences of histological grade 1 (IRR, 0.75; 95% CI, 0.73-0.78; P < .001) and grade 2 (IRR, 0.91; 95% CI, 0.89-0.93; P < .001) were lower in Asian/Pacific Islander vs non-Hispanic White patients. Non-Hispanic White patients had a higher proportion of lobular carcinoma (9.7% [n = 15 718]) and tubular adenocarcinoma (0.6% [n = 997]) than Black (7.2% [n = 1933]; 0.3% [n = 81]), Asian/Pacific Islander (5.7% [n = 1202]; 0.3% [n = 55]), Hispanic White (7.2% [n = 1985]; 0.3% [n = 88]), and American Indian/Alaskan Native patients (7.2% [n = 101]; 0.4% [n = 5]).

CONCLUSIONS AND RELEVANCE

This cohort study found notable disparities in incidences and proportions of different molecular subtypes, histological grades, pathological patterns, T stages, TNM stages, and tumor sites associated with race/ethnicity. The findings suggest that combining epidemiologic with genomic and molecular profiling data warrants further research.

Development and validation of a nomogram for predicting survival of advanced breast cancer patients in China

Background

There is a lack of prognostic models predicting the overall survival (OS) of advanced breast cancer (ABC) patients in China.

Methods

Data from the China National Cancer Center database that recorded 4039 patients diagnosed with breast cancer between 1987 and 2019 were extracted and a total of 2263 ABC participants were enrolled in this study, which were further randomized 3:1 and divided into training (n = 1706) and validation (n = 557) groups. The nomogram was built based on independent predictors identified by univariate and multivariate cox regression analyses. The discriminatory and predictive capacities of the nomogram were assessed by Harrell’s concordance index (C-index) and calibration plots.

Results

Univariate and multivariate analyses found that age, Eastern Cooperative Oncology Group (ECOG) score, T-stage, N-stage, tumor subtype, the presence of distant lymph node (DLN)/liver/brain metastasis, local therapy, efficacy of first-line therapy and metastatic-free interval (MFI) were significantly related to OS (all P < 0.05). These variables were incorporated into a nomogram to predict the 2-year and 3-year OS of ABC patients. The C-indexes of the nomogram were 0.700 (95% confidence interval [CI]: 0.683–0.717) for the training set and 0.686 (95% CI: 0.652–0.719) for the validation set. The calibration curves revealed satisfactory consistency between actual survival and nomogram prediction in both the internal and external validations. The nomogram was capable of stratifying patients into different risk cohorts.

Conclusions

We constructed and validated a nomogram that might serve as an efficient tool to provide prognostic prediction for ABC patients and guide the physicians to make personalized treatment decisions.

•

The nomogram might serve as an efficient tool to provide prognostic prediction for advanced breast cancer patients.

•

This model could identify low-risk patients who might benefit from aggressive local curative treatment of liver metastasis.

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The nomogram suggested that the low-risk triple-negative breast cancer patients demanded more intensive treatments.

•

External validation from other centers was needed.

Cost-effectiveness analysis of ribociclib versus palbociclib in the first-line treatment of HR+/HER2- advanced or metastatic breast cancer in Spain

PURPOSE

The aim of this study was to evaluate the cost-effectiveness of ribociclib compared to palbociclib, both in combination with letrozole, in the first-line treatment of postmenopausal women with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) advanced or metastatic breast cancer (ABC) from the perspective of the Spanish National Health System (NHS).

PATIENTS AND METHODS

Disease progression was simulated with a partitioned survival model developed from the parameterization and extrapolation of survival curves of postmenopausal women with HR+/HER2- ABC from clinical trials with ribociclib or palbociclib, both in combination with letrozole. The model was structured on the basis of three health states (progression-free, progressed disease, and death), with a 1-month cycle length and inclusion of subsequent treatments administered for disease progression, over a time horizon of 15 years. Clinical, economic, and quality of life parameters were drawn from clinical trials and the literature. The use of resources and clinical practice in the Spanish setting was validated by a panel of experts. The Spanish NHS perspective was adopted, taking into account exclusively direct health costs from 2017 expressed in Euros. Drug prices used were the reported ex-factory prices. Uncertainty of the parameters and robustness of the results were evaluated using deterministic and probabilistic sensitivity analyses (2,000 iterations).

RESULTS

This cost-effectiveness analysis showed a greater benefit (0.437 and 0.285 life-years gained [LYGs] and quality-adjusted life years [QALYs] gained, respectively) and a slightly higher cost (€439.86) for ribociclib+letrozole compared to palbociclib+letrozole. The resulting incremental cost-effectiveness and cost-utility ratios were €1,007.69 per LYG and €1,543.62 per QALY gained, respectively. The results of the multiple sensitivity analyses showed limited dispersion of the outcomes, thus corroborating their robustness.

CONCLUSION

From the NHS perspective, considering the most commonly established willingness-to-pay thresholds in the Spanish setting, ribociclib+letrozole would represent a cost-effective therapeutic option compared to palbociclib+letrozole in the first-line treatment of HR+/HER2- ABC in postmenopausal women.

Time trends of overall survival among metastatic breast cancer patients in the real-life ESME cohort

AIM

Real-life analysis of overall survival (OS) trends among metastatic breast cancer (MBC) patients may help define medical needs and evaluate the impact of public health investments. The present study aimed to evaluate the independent impact of the year of MBC diagnosis on OS in the Epidemio-Strategy-Medical-Economical (ESME)-MBC cohort.

METHODS

ESME-MBC (NCT03275311) is a French, national, multicentre, observational cohort including 16,702 consecutive newly diagnosed MBC patients (01 January 2008-31 December 2014). Of 16,680 eligible patients, 15,085 had full immunohistochemistry data, allowing classification as hormone receptor-positive and HER2-negative (HR+/HER2-, N = 9907), HER2-positive (HER2+, N = 2861) or triple-negative (HR-/HER2-, N = 2317) subcohorts. Multivariate analyses of OS were conducted among the full ESME cohort and subcohorts.

RESULTS

Median OS of the whole cohort was 37.22 months (95% confidence interval [CI], 36.3-38.04). Year of diagnosis was an independent predictor of OS (hazard ratio 0.98 [95% CI, 0.97-1.00], P = .01) together with age, subtype, disease-free interval, visceral metastases and number of organs involved. Median OS of HR+/HER2-, HER2+ and HR-/HER2- subcohorts was, respectively, 42.12 (95% CI, 40.90-43.10), 44.91 (95% CI, 42.51-47.90) and 14.52 (95% CI, 13.70-15.24) months. Year of diagnosis was a strong independent predictor of OS in HER2+ subcohort (hazard ratio 0.91 [95% CI, 0.88-0.94], P < .001), but not in HR+/HER2- nor HR-/HER2- subcohorts (hazard ratio 1.00 [95% CI, 0.98-1.01], P = .80 and 1.00 [95% CI, 0.97-1.02], P = .90, respectively).

CONCLUSIONS

The OS of MBC patients has slightly improved over the past decade. However, this effect is confined to HER2+ cases, highlighting the need of new strategies in the other subtypes.

The new TNM-based staging of breast cancer

This review describes the changes that have been implemented in the Tumor-Node-Metastasis (TNM)-based staging of breast cancers by the new, 8th editions of the relevant Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) publications. After giving a background for TNM being the common language of cancer staging and related activities like cancer treatment and registration, it summarizes not only the changes but reviews some highlights important for pathologists, and lists and comments on the differences between the publications and diagnostic practices based on them. A section is dedicated to the prognostic stages of breast carcinomas introduced in the AJCC Cancer Staging Manual, but not mentioned in the UICC TNM classification of malignant tumors. A few issues that are not appropriately covered by TNM according to the authors' view (e.g., multifocal tumors, larger lymph node metastases identified by molecular methods, the heterogeneous prognosis of M1-defined stage IV disease) close the review with the final thoughts raising the vision of a potential loss of the common staging language.

Willingness of Patients with Breast Cancer in the Adjuvant and Metastatic Setting to Use Electronic Surveys (ePRO) Depends on Sociodemographic Factors, Health-related Quality of Life, Disease Status and Computer Skills

Introduction: Because of the often unfavorable prognosis, particularly for patients with metastases, health-related quality of life is extremely important for breast cancer patients. In recent years, data on patient-relevant endpoints is being increasingly collected electronically; however, knowledge on the acceptance and practicability of, and barriers to, this form of data collection remains limited. Material and Methods: A questionnaire was completed by 96 patients to determine to what extent existing computer skills, disease status, health-related quality of life and sociodemographic factors affect patients' potential willingness to use electronics methods of data collection (ePRO). Results: 52 of 96 (55 %) patients reported a priori that they could envisage using ePRO. Patients who a priori preferred a paper-based survey (pPRO) tended to be older (ePRO 53 years vs. pPRO 62 years; p = 0.0014) and typically had lower levels of education (p = 0.0002), were in poorer health (p = 0.0327) and had fewer computer skills (p = 0.0003). Conclusion: Barriers to the prospective use of ePRO were identified in older patients and patients with a lower quality of life. Given the appropriate conditions with regard to age, education and current health status, opportunities to participate should be provided to encourage patients' willingness to take part and ensure the validity of survey results. Focusing on ease of use of ePRO applications and making applications more patient-oriented and straightforward appears to be the way forward.

Risk of treatment related death and febrile neutropaenia with first line palliative chemotherapy for de novo metastatic breast cancer in clinical practice in a middle resource country

BACKGROUND

The risk of febrile neutropaenia (FN) and treatment related death (TRD) with first line palliative chemotherapy for de novo metastatic breast cancer (MBC) remains unknown outside of a clinical trial setting despite its widespread usage. This study aimed to determine rates in a large cohort of patients treated in the University of Malaya Medical Centre (UMMC).

MATERIALS AND METHODS

Patients who were treated with first line palliative chemotherapy for de novo MBC from 2002-2011 in UMMC were identified from the UMMC Breast Cancer Registry. Information collected included patient demographics, histopathological features, treatment received, including the different chemotherapy regimens, and presence of FN and TRD. FN was defined as an oral temperature >38.5° or two consecutive readings of >38.0° for 2 hours and an absolute neutrophil count <0.5x109/L, or expected to fall below 0.5x109/L (de Naurois et al, 2010). TRD was defined as death occurring during or within 30 days of the last chemotherapy treatment, as a consequence of the chemotherapy treatment. Statistical analysis was performed using the SPSS version 18.0 software. Survival probabilities were estimated using the Kaplan-Meier method and differences in survival compared using log-rank test.

RESULTS

Between 1st January 2002 and 31st December 2011, 424 patients with MBC were treated in UMMC. A total of 186 out of 221 patients with de novo MBC who received first line palliative chemotherapy were analyzed. The mean age of patients in this study was 49.5 years (range 24 to 74 years). Biologically, ER status was negative in 54.4% of patients and Her-2 status was positive in 31.1%. A 5-flourouracil, epirubicin and cyclophosphamide (FEC) chemotherapy regimen was chosen for 86.6% of the cases. Most patients had multiple metastatic sites (58.6%). The main result of this study showed a FN rate of 5.9% and TRD rate of 3.2%. The median survival (MS) for the entire cohort was 19 months. For those with multiple metastatic sites, liver only, lung only, bone only and brain only metastatic sites, the MS was 18, 24, 19, 24 and 8 months respectively (p-value= 0.319).

CONCLUSIONS

In conclusion, we surmise that FEC is a safe regimen with acceptable FN and TRD rates for de novo MBC.

Metastatic breast cancer: prolongation of survival in routine care is restricted to hormone-receptor- and Her2-positive tumors

18,000 women die due to metastatic breast cancer in Germany per year. Median survival is 20–28 months after diagnosis. The question we wanted to answer was whether survival has improved in routine care? For this purpose we conducted a retrospective analysis of all patients with metastatic breast cancer who were treated between 06/1995-06/2013 in a community-based oncology group practice in Germany. 716 patients were analyzed with a median age of 61 (31–93). Localizations of metastases were distributed as follows: 47% visceral, 36% bone, 9% lymphatic, 4% CNS, 4% others. 79% were hormone-receptor-positive, 20% Her2-positive, 9% triple-negative. Median overall survival was 34 months (95% Confidence Interval: 31–37), median disease-specific survival 36.8 months and disease-specific survival after 5 years 34%. Survival was significantly correlated with localizations of metastases, number of metastasized organs, disease free survival since initial diagnosis, hormone-receptor status and age. Patients with hormone-receptor-positive tumors had a median overall survival of 37 months, Her2-positive patients of 34 months and triple-negative patients of 13 months. 86% of hormone-receptor-positive patients received antihormonal therapy. 81% of Her2-positive patients received anti-Her2 therapy. In summary, longer survival is strongly restricted to hormone receptor- and Her2-positive tumors most likely due to targeted therapies directed against the estrogen-receptor and Her2.

Predicting survival of de novo metastatic breast cancer in Asian women: systematic review and validation study

Background

In Asia, up to 25% of breast cancer patients present with distant metastases at diagnosis. Given the heterogeneous survival probabilities of de novo metastatic breast cancer, individual outcome prediction is challenging. The aim of the study is to identify existing prognostic models for patients with de novo metastatic breast cancer and validate them in Asia.

Materials and Methods

We performed a systematic review to identify prediction models for metastatic breast cancer. Models were validated in 642 women with de novo metastatic breast cancer registered between 2000 and 2010 in the Singapore Malaysia Hospital Based Breast Cancer Registry. Survival curves for low, intermediate and high-risk groups according to each prognostic score were compared by log-rank test and discrimination of the models was assessed by concordance statistic (C-statistic).

Results

We identified 16 prediction models, seven of which were for patients with brain metastases only. Performance status, estrogen receptor status, metastatic site(s) and disease-free interval were the most common predictors. We were able to validate nine prediction models. The capacity of the models to discriminate between poor and good survivors varied from poor to fair with C-statistics ranging from 0.50 (95% CI, 0.48–0.53) to 0.63 (95% CI, 0.60–0.66).

Conclusion

The discriminatory performance of existing prediction models for de novo metastatic breast cancer in Asia is modest. Development of an Asian-specific prediction model is needed to improve prognostication and guide decision making.

Application of ex vivo micro-computed tomography for assessment of in vivo fluorescence and plain radiographic imaging for monitoring bone metastases and osteolytic lesions

The intracardiac injection model is a commonly used in vivo model to test therapeutic response in bone metastases. However, few studies have critically compared the performance of different imaging methods in terms of sensitivity and quantitative assessment of osteolytic lesions. We performed in vivo optical and plain radiographic imaging of bone metastases followed by high-sensitivity ex vivo micro-computed tomography (micro-CT) imaging. This approach allowed for quantitative assessment of in vivo imaging techniques using fluorescence and plain radiography. Comparison of lesions detected in vivo by fluorescent optical imaging with ex vivo micro-CT revealed that the limited spatial resolution of fluorescent optical imaging may underestimate the number of bone metastases. Radiography was compared with micro-CT for the detection of osteolytic lesions. When using dichotomous yes/no grading, there was a 64% agreement in detection of osteolytic lesions. When subjective semiquantitative grading methods were used to assess the extent of osteolytic lesions, a positive association between the micro-CT grades and the square root of the radiography-based grades was observed (p < 0.05). Micro-CT also showed a significant association with fluorescent optical values; however, no such association was observed between lesion scores based on radiographs and those based on fluorescent imaging. The findings reveal an approximate two-fold sensitivity for micro-CT compared to plain radiography in the detection of osteolytic lesions. Significant associations between micro-CT-based osteolytic lesion grade and tumor growth characterized by increased fluorescent area document the value of these two techniques for the assessment of osteolytic bone metastases.

Obesity is an independent predictor of poor survival in metastatic breast cancer: retrospective analysis of a patient cohort whose treatment included high-dose chemotherapy and autologous stem cell support

The purpose of the study was to identify predictors of long-term survival in metastatic breast cancer (MBC). A cohort of 96 patients, who received high-dose chemotherapy with autologous stem cell support (HD-ASCT) as part of their treatment, was analyzed. Percent long-term survival at 10 years was 24.5% (CI 17.2-34.9%) when metastasis was diagnosed and 14.4% (CI 8.7-23.9%) when MBC was diagnosed. Survival was impacted significantly by body mass index (BMI). Median overall survival from initial diagnosis or from time of metastasis for patients with BMIs ≤30 and >30 (obese) was 7.1 (CI 4.4-8.7) and 3.2 years (2.41-6.75), respectively, or 3.2 or 2.3 years (all P = 0.02). Also, obesity was the only independent patient-related predictor of time to metastasis and of survival. While obesity is linked with poor outcomes in earlier stages of breast cancer, this has not been previously reported for MBC.

[Survival chances of Hungarian cancer patients in the National Cancer Registry]

The Hungarian National Cancer Registry (HNCR) was launched in August, 1999 by the National Cancer Institute. The main goal of HNCR is to determine the prevalence of different types of malignant cancers. A new method, period analysis was invented to determine survival chances of patients with malignant tumor. Based on period analysis we developed a new method by approximating survivals of Hungarian cancer patients with the help of Gompertz distribution. Our survival analysis was based on HNCR data of patients with cancer recognized between January 1, 2002 and December 31, 2005. These data are far enough from the time when HNCR started, thus they do not contain the initial errors, but also far enough from the present so their correction could be considered completed. In case of 21 malignant tumor locations for males and 23 ones for females we determined the parameters of the Gompertz distribution and based on the estimated parameters we estimated the expected survival probabilities for each specific tumor type and gender. In this study we have not used the TNM-based clinical stage or any other data of the patients contained by HNCR. Using the Gompertz model, the complete recovery of a cancer patient is always possible and the probability of recovery has a reliable estimate based on a short follow-up period only. We compared our results with five-year survival data of Canada, Italy, Norway and Finland and we did not find substantial differences. For both men and women, considering any specific location, the differences in survival among countries are much smaller than the difference between locations.

Epidermal growth factor receptor cooperates with signal transducer and activator of transcription 3 to induce epithelial-mesenchymal transition in cancer cells via up-regulation of TWIST gene expression

Aberrant epidermal growth factor receptor (EGFR) signaling is a major cause of tumor progression and metastasis; the underlying mechanisms, however, are not well understood. In particular, it remains elusive whether deregulated EGFR pathway is involved in epithelial-mesenchymal transition (EMT), an early event that occurs during metastasis of cancers of an epithelial origin. Here, we show that EGF induces EGFR-expressing cancer cells to undergo a transition from the epithelial to the spindle-like mesenchymal morphology. EGF reduced E-cadherin expression and increased that of mesenchymal proteins. In search of a downstream mediator that may account for EGF-induced EMT, we focused on transcription repressors of E-cadherin, TWIST, SLUG, and Snail and found that cancer cells express high levels of TWIST and that EGF enhances its expression. EGF significantly increases TWIST transcripts and protein in EGFR-expressing lines. Forced expression of EGFR reactivates TWIST expression in EGFR-null cells. TWIST expression is suppressed by EGFR and Janus-activated kinase (JAK)/signal transducer and activator of transcription 3 (STAT3) inhibitors, but not significantly by those targeting phosphoinositide-3 kinase and MEK/ERK. Furthermore, constitutively active STAT3 significantly activates the TWIST promoter, whereas the JAK/STAT3 inhibitor and dominant-negative STAT3 suppressed TWIST promoter. Deletion/mutation studies further show that a 26-bp promoter region contains putative STAT3 elements required for the EGF-responsiveness of the TWIST promoter. Chromatin immunoprecipitation assays further show that EGF induces binding of nuclear STAT3 to the TWIST promoter. Immunohistochemical analysis of 130 primary breast carcinomas indicates positive correlations between non-nuclear EGFR and TWIST and between phosphorylated STAT3 and TWIST. Together, we report here that EGF/EGFR signaling pathways induce cancer cell EMT via STAT3-mediated TWIST gene expression.

Quantitative exploration of possible reasons for the recent improvement in breast cancer survival

OBJECTIVE

Breast cancer mortality has been declining in many countries including Canada because of improvements in survival. This study attempts to explain observed trends in breast cancer survival with special attention given to the role of improvements in early detection and treatment.

METHODS

This study is based on 4,312 women diagnosed with primary invasive breast carcinoma treated in a Canadian breast center between 1976 and 2000 and followed to the end of 2001. Observed and relative survival rates were calculated. Multivariate relative survival regression models were used to assess trends in breast cancer survival over the study period.

RESULTS

The proportion of women with small tumors (< or = 10 mm) was higher in late 1990s, while that of women with regional involvement was lower compared to earlier periods. Adjuvant chemotherapy or endocrine therapy use increased steadily from 6.6% to 84.0% during the study period. Five-year relative survival rates ranged between 82.1% and 83.7% between 1976 and 1990, and increased thereafter to reach 87.6% in 1991-95, and 92.1% in 1996-2000. During the first five years after diagnosis, women diagnosed in 1991-95 and 1996-2000 experienced a reduction in breast cancer mortality of 28% (Relative Risk (RR)= 0.72; 95% CI: 0.59-0.89) and 49% (RR = 0.51; 95% CI: 0.39-0.68) respectively compared to women diagnosed in 1976-90. Improvement in breast cancer survival in 1990's could not be explained by characteristics of women, biology of the tumor, advancements in early detection and type of initial treatments.

CONCLUSION

A substantial increase in breast cancer survival was observed in the 1990s but the reasons for this improvement remain elusive. Better knowledge of these reasons could help not only to further reduce the burden related to breast cancer but also the burden related to other major cancer sites.

Calcium transport and signaling in the mammary gland: targets for breast cancer

The mammary gland is subjected to extensive calcium loads during lactation to support the requirements of milk calcium enrichment. Despite the indispensable nature of calcium homeostasis and signaling in regulating numerous biological functions, the mechanisms by which systemic calcium is transported into milk by the mammary gland are far from completely understood. Furthermore, the implications of calcium signaling in terms of regulating proliferation, differentiation and apoptosis in the breast are currently uncertain. Deregulation of calcium homeostasis and signaling is associated with mammary gland pathophysiology and as such, calcium transporters, channels and binding proteins represent potential drug targets for the treatment of breast cancer.

Quantitative target sizes for breast tumor detection prior to metastasis: a prerequisite to rational design of 4D scanners for breast screening

It is important to determine a breast cancer tumor target size for new screening equipment and molecular detection. Records of women aged 40-69 years diagnosed in 1988-1997 with a nonmetastasized, node-negative, or node-positive T1-stage breast cancer were abstracted from the Surveillance, Epidemiology, and End Results (SEER) public-use database. The linear, Gompertzian, lognormal, and power-exponential models of the effect of tumor size on breast cancer specific mortality were compared using corresponding transforms of size in multivariate Cox proportional hazard models. Criteria for comparison were the linearization of the size transforms and the Nagelkerke R2N index for the Cox models. Our results show that the assumption of a linear effect of tumor size was rejected by the linearity test (P=0.05). The Gompertzian, lognormal, and power-exponential transforms satisfied the test with P-values of 0.08, 0.29, and 0.14, respectively. The corresponding R2N were 0.08410, 0.08420, and 0.08414, respectively, showing a marginally best fit with the lognormal model, which was selected as a model for small tumors. The lognormal function with unadjusted crude death rates gave a lognormal-location parameter of 25 and shape parameter of 1.7, while the corresponding values in multivariate models were 18 and 2, respectively. The derivation of the lognormal model indicates tumor growth acceleration starting at 3 mm (unadjusted crude data) or 2 mm (multivariate model). The breast cancer tumor target size for screening equipment, whether by imaging or molecular detection, is therefore 2 mm.

Minimum follow-up time required for the estimation of statistical cure of cancer patients: verification using data from 42 cancer sites in the SEER database

Background

The present commonly used five-year survival rates are not adequate to represent the statistical cure. In the present study, we established the minimum number of years required for follow-up to estimate statistical cure rate, by using a lognormal distribution of the survival time of those who died of their cancer. We introduced the term, threshold year, the follow-up time for patients dying from the specific cancer covers most of the survival data, leaving less than 2.25% uncovered. This is close enough to cure from that specific cancer.

Methods

Data from the Surveillance, Epidemiology and End Results (SEER) database were tested if the survival times of cancer patients who died of their disease followed the lognormal distribution using a minimum chi-square method. Patients diagnosed from 1973–1992 in the registries of Connecticut and Detroit were chosen so that a maximum of 27 years was allowed for follow-up to 1999. A total of 49 specific organ sites were tested. The parameters of those lognormal distributions were found for each cancer site. The cancer-specific survival rates at the threshold years were compared with the longest available Kaplan-Meier survival estimates.

Results

The characteristics of the cancer-specific survival times of cancer patients who died of their disease from 42 cancer sites out of 49 sites were verified to follow different lognormal distributions. The threshold years validated for statistical cure varied for different cancer sites, from 2.6 years for pancreas cancer to 25.2 years for cancer of salivary gland. At the threshold year, the statistical cure rates estimated for 40 cancer sites were found to match the actuarial long-term survival rates estimated by the Kaplan-Meier method within six percentage points. For two cancer sites: breast and thyroid, the threshold years were so long that the cancer-specific survival rates could yet not be obtained because the SEER data do not provide sufficiently long follow-up.

Conclusion

The present study suggests a certain threshold year is required to wait before the statistical cure rate can be estimated for each cancer site. For some cancers, such as breast and thyroid, the 5- or 10-year survival rates inadequately reflect statistical cure rates, and highlight the need for long-term follow-up of these patients.

Long-term survival rates of laryngeal cancer patients treated by radiation and surgery, radiation alone, and surgery alone: studied by lognormal and Kaplan-Meier survival methods

Background

Validation of the use of the lognormal model for predicting long-term survival rates using short-term follow-up data.

Methods

907 cases of laryngeal cancer were treated from 1973–1977 by radiation and surgery (248), radiation alone (345), and surgery alone (314), in registries of Connecticut and Metropolitan Detroit of the SEER database, with known survival status up to 1999. Phase 1 of this study used the minimum chi-square test to assess the goodness of fit of the survival times of those who died with disease to a lognormal distribution. Phase 2 used the maximum likelihood method to estimate long-term survival rates using short-term follow-up data. In order to validate the lognormal model, the estimated long-term cancer-specific survival rates (CSSR) were compared with the values calculated by the Kaplan-Meier (KM) method using long-term data.

Results

The 25-year CSSR were predicted to be 72%, 68% and 65% for treatments by radiation and surgery, by radiation alone, and by surgery alone respectively, using short-term follow-up data by the lognormal model. Corresponding results calculated by the KM method were: 72+/-3%, 68+/-3% and 66+/-4% respectively.

Conclusions

The lognormal model was validated for the prediction of the long-term survival rates of laryngeal cancer patients treated by these different methods. The lognormal model may become a useful tool in research on outcomes.