Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline

Real-world perioperative treatment patterns and economic burden of recurrence in early-stage HER2-negative breast cancer: a SEER-Medicare study

AIM

This study aimed to describe treatment patterns and quantify the economic impact of recurrence in early-stage human epidermal growth factor receptor 2 (HER2)-negative breast cancer (BC).

MATERIALS & METHODS

Medicare beneficiaries with stages I-III HER2-negative BC and lumpectomy or partial/total mastectomy were identified from SEER-Medicare data (2010-2019). Perioperative therapies were reported in the neoadjuvant and adjuvant setting. Locoregional recurrence and distant metastasis were identified using a claims-based algorithm developed with clinical input and consisting of a diagnosis-based and treatment-based indicator. All-cause and BC-related healthcare resource utilization (HRU) per-patient-month and monthly healthcare costs were estimated from the recurrence date for patients with recurrence and from an imputed index date for patients without recurrence using frequency matching. HRU and costs were compared between groups stratified by hormone receptor-positive (HR+) or triple negative BC (TNBC) using multivariable regression models.

RESULTS

Of 28,655 patients, 8.5% experienced recurrence, 90.4% had HR+ disease, and 5.6% received neoadjuvant therapy. Relative to patients without recurrence, patients with recurrence had more advanced disease (stage II/III: 73.7% vs. 34.0%) and higher-grade tumors (Grade 3/4: 40.6% vs. 18.0%) at diagnosis. Recurrence in HR+/HER2-negative BC and TNBC was associated with higher rates of all-cause hospitalizations (incidence rate ratio [IRR]: 2.84 and 3.65), emergency department (ED) visits (IRR: 1.75 and 2.00), and outpatient visits (IRR: 1.46 and 1.55; all p < 0.001). Similarly, recurrence was associated with higher rates of BC-related HRU, particularly for ED visits in HR+/HER2-negative BC (IRR: 4.24; p < 0.001) and hospitalizations in TNBC (IRR: 11.71; p < 0.001). Patients with HR+/HER2-negative BC and TNBC recurrence incurred higher monthly all-cause (cost difference [CD]: $3988 and $4651) and BC-related healthcare costs (CD: $3743 and $5819).

CONCLUSIONS

Our findings highlight the considerable economic burden of recurrence in early-stage HER2-negative BC and underscore the unmet need for optimization of therapies that reduce recurrence in this population.

Axillary Surgery for Patients With Residual Isolated Tumor Cells (ypN0i+) After Neoadjuvant Systemic Therapy for Early Breast Cancer

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Triglyceride-glucose index and triglyceride-glucose-body mass index as prognostic factors for early stage breast cancer patients receiving neoadjuvant chemotherapy

BACKGROUND

Insulin resistance (IR) is closely associated with the risk of breast cancer. The triglyceride-glucose (TyG) index and the triglyceride-glucose-body mass index (TyG-BMI) are considered surrogate indicators of IR; however, their prognostic value in breast cancer patients has not been discussed. The purpose of this study is not only to explore whether the TyG index and the TyG-BMI can predict the chemotherapy response and long-term prognosis of breast cancer patients receiving neoadjuvant chemotherapy (NACT) but also to investigate the possible mediating mechanism and to analyze the relationship between TyG-related enzyme expression and drug resistance and prognosis.

METHODS

From November 2011 to December 2018, a total of 335 breast cancer patients referred to Harbin Medical University Cancer Hospital who received NACT and surgery were registered in this retrospective study. The TyG index and TyG-BMI before the first chemotherapy were retrospectively calculated. Tissue samples of breast cancer patients were obtained from the Cancer Genome Atlas database, and the associations between the expression levels of the FBP1 and G6PD enzymes and the clinicopathological features and prognosis of breast cancer were analyzed.

RESULTS

In receiver operating characteristic analyses, the optimal cutoff values for the TyG and TyG-BMI were determined at 8.01 and 194.91, respectively. Low levels of the TyG and TyG-BMI were not associated with pathological complete response. In multivariate analysis, high TyG was an independent prognostic factor for shorter disease-free survival (DFS; HR = 2.402, P = 0.008) and overall survival (OS; HR = 3.206, P = 0.010). After adjustments for the age group, cT stage group, and cN stage group, the dose-response relationships between TyG, TyG-BMI, and survival outcomes showed a linear correlation by restricted cubic spline analyses. Lg-transformed BMI did not significantly (P > 0.05) mediate the recurrence, metastasis, and deaths associated with TyG. The expressions of two enzymes related to TyG, FBP1 and G6PD, were higher in breast cancer tissues than in the adjacent normal tissues and were associated with the TNM stage. Survival analysis shows that patients with high expressions of FBP1 and G6PD have a shorter OS.

CONCLUSION

This study suggests that the TyG index level before NACT is an independent prognostic factor for DFS and OS and can serve as a promising biomarker to predict the long-term prognosis of breast cancer patients undergoing NACT. Moreover, the TyG index and TyG-BMI show a linear correlation with DFS and OS. The effect of the TyG index on DFS and OS is not significantly mediated by lg-transformed BMI. Besides, FBP1 and G6PD are prognostic indicators for breast cancer patients and may serve as biomarkers for the clinical diagnosis and treatment of breast cancer.

Mass spectrometry-based analysis of eccrine sweat supports predictive, preventive and personalised medicine in a cohort of breast cancer patients in Austria

Objective

Metabolomics measurements of eccrine sweat may provide novel and relevant biomedical information to support predictive, preventive and personalised medicine (3PM). However, only limited data is available regarding metabolic alterations accompanying chemotherapy of breast cancer patients related to residual cancer burden (RCB) or therapy response. Here, we have applied Metabo-Tip, a non-invasive metabolomics assay based on the analysis of eccrine sweat from the fingertips, to investigate the feasibility of such an approach, especially with respect to drug monitoring, assessing lifestyle parameters and stratification of breast cancer patients.

Methods

Eccrine sweat samples were collected from breast cancer patients (n = 9) during the first cycle of neoadjuvant chemotherapy at four time points in this proof-of-concept study at a Tertiary University Hospital. Metabolites in eccrine sweat were analysed using mass spectrometry. Blood plasma samples from the same timepoints were also collected and analysed using a validated targeted metabolomics kit, in addition to proteomics and fatty acids/oxylipin analysis.

Results

A total of 247 exogenous small molecules and endogenous metabolites were identified in eccrine sweat of the breast cancer patients. Cyclophosphamide and ondansetron were successfully detected and monitored in eccrine sweat of individual patients and accurately reflected the administration schedule. The non-essential amino acids asparagine, serine and proline, as well as ornithine were significantly regulated in eccrine sweat and blood plasma over the therapy cycle. However, their distinct time-dependent profiles indicated compartment-specific distributions. Indeed, the metabolite composition of eccrine sweat seems to largely resemble the composition of the interstitial fluid. Plasma proteins and fatty acids/oxylipins were not affected by the first treatment cycle. Individual smoking habit was revealed by the simultaneous detection of nicotine and its primary metabolite cotinine in eccrine sweat. Stratification according to RCB revealed pronounced differences in the metabolic composition of eccrine sweat in these patients at baseline, e.g., essential amino acids, possibly due to the systemic contribution of breast cancer and its impact on metabolic turnover.

Conclusion

Mass spectrometry-based analysis of metabolites from eccrine sweat of breast cancer patients successfully qualified lifestyle parameters for risk assessment and allowed us to monitor drug treatment and systemic response to therapy. Moreover, eccrine sweat revealed a potentially predictive metabolic pattern stratifying patients by the extent of the metabolic activity of breast cancer tissue at baseline. Eccrine sweat is derived from the otherwise hardly accessible interstitial fluid and, thus, opens up a new dimension for biomonitoring of breast cancer in secondary and tertiary care. The simple sample collection without the need for trained personnel could also enable decentralised long-term biomonitoring to assess stable disease or disease progression. Eccrine sweat analysis may indeed significantly advance 3PM for the benefit of breast cancer patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-025-00396-6.

Influence of histopathological changes after neoadjuvant chemotherapy on the survival of breast cancer patients

INTRODUCTION

Neoadjuvant chemotherapy (NACT) is an established form of therapy for early breast cancer (BC). The aim of our study was to analyze histopathological parameters before and after receiving NACT and to determine the influence of these changes on prognosis of BC patients.

MATERIAL AND METHODS

We retrospectively analyzed data of patients with primary early BC, diagnosed between January 2012 and December 2019, and NACT, followed by primary surgery. Patients achieving pathological complete response (pCR) were excluded. For the outcome analysis, disease-free survival (DFS) and overall survival (OS) were defined.

RESULTS

A total of 237 tumors were analyzed in the study. The conversion rates of tumor grade, estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), Ki67 status, and BC subtype were 34.6 %, 3.4 %, 14.3 %, 4.6 %, 30.0 %, and 28.7 %, respectively. After a median follow-up of 58.03 months, we found an association between consistently negative ER/PR with the worst prognosis (DFS and OS) (ER p < 0.0001 for both; PR p = 0.0003, p = 0.0004, respectively). The conversion from Ki67 ≥14 % to <14 % led to an improved outcome compared to a constant Ki67 ≥14 % (DFS p = 0.003, OS p = 0.001). Tumor residuals with a non-triple-negative (nTN) subtype (TN → nTN) showed a better prognosis than those with TN subtype (nTN → TN) (DFS and OS p < 0.0001).

CONCLUSIONS

After NACT, tumor grade and Ki67 showed the highest conversion rates between primary biopsy and tumor residual. Depending on changes in ER, PR, Ki67, and subtype, we found significant differences in the prognosis of the patients.

Long-term outcomes of volume de-escalation for breast nodal irradiation

INTRODUCTION

NCCN recommendations suggest irradiating chest wall/breast only + regional node irradiation (RNI) of the undissected axillary levels for node-positive breast cancer (BC) patients. We retrospectively analyzed a cohort of node-positive BC patients who received adjuvant radiotherapy (RT) with a volume de-escalation at the level of axillary nodes.

MATERIAL AND METHODS

We conducted a retrospective analysis of node-positive BC patients treated with adjuvant RT administered following a conventional fractionation schedule using a 3D-conformal technique to the chest wall or breast and only the IV axillary level. The primary endpoint of the study was disease free survival (DFS). Secondary endpoints included loco-regional control (LRC), and Overall Survival (OS). Toxicity was documented according to the Radiation Therapy Oncology Group (RTOG) criteria.

RESULTS

A total cohort of 343 patients was analyzed. Loco-regional recurrence occurred in 100 (29.1%). The 5- and 10-year Kaplan-Meyer curves for DFS were 81.4% (95% CI: 79.3%-83.5%) and 60.9% (95% CI: 57.6%-64.5%), respectively. Multivariate Cox analysis confirmed that lymph node ratio (HR = 9.76, 95% CI: 3.12-30.53, p = 0.0001), Luminal B subtype (HR = 2.03, 95% CI: 1.26-3.29, p = 0.004), and triple-negative subtype (HR = 2.70, 95% CI: 1.22-5.99, p = 0.01) were significant predictors of poor DFS. Lymphedema in the ipsilateral arm was reported in 32 (9.3%) patients, primarily Grade 1 or 2.

CONCLUSIONS

Improved patients' selection and a broader use of systemic therapy could make de-escalation a feasible option. However, this approach should be avoided in patients with extensive nodal involvement, specific molecular subtypes, or comorbidities that prevent the use of chemotherapy.

Sequence of therapy impact on older women with comorbidities and triple-negative or HER2-positive breast cancer

We sought to determine whether sequencing of treatment impacted outcomes in older, comorbid patients. Using the National Cancer Database(2010-2017), 2911 patients >70 with a Charleson Deyo Comorbidity(CCDM) score of 2/3 and cT1c-3/N0-3/HER2 positive or triple-negative breast cancer treated with chemotherapy,surgery,or both were included. Chi-square tests evaluated differences between groups. Multivariable models evaluated associations between overall survival and treatment. Majority 87.4%(n = 2544) underwent surgery first and 36.0%(n = 917) received adjuvant chemotherapy while 77.9%(n = 286) of chemotherapy first patients underwent surgery. Receipt of both modalities was associated with the best survival followed by surgery alone then chemotherapy alone. Additional analysis demonstrated no survival difference between patients who underwent surgery(±systemic therapy) vs systemic therapy(±surgery) first. Although combined treatment offers the best survival, as a single modality, patients treated with surgery vs systemic therapy alone fare better. This information in conjunction with patient preferences on quality of life can be used in making shared decisions.

A predictive model for neoadjuvant therapy response in breast cancer

Neoadjuvant therapy is a standard treatment for breast cancer, but its effectiveness varies among patients. This highlights the importance of developing accurate predictive models. Our study uses metabolomics and machine learning to predict the response to neoadjuvant therapy in breast cancer patients.

OBJECTIVE

To develop and validate predictive models using machine learning and circulating metabolites for forecasting responses to neoadjuvant therapy among breast cancer patients, enhancing personalized treatment strategies.

METHODS

Based on pathological analysis after neoadjuvant chemotherapy and surgery, this retrospective study analyzed 30 young women breast cancer patients from a single institution, categorized as responders or non-responders. Utilizing liquid chromatography-tandem mass spectrometry, we investigated the plasma metabolome, explicitly targeting 40 metabolites, to identify relevant biomarkers linked to therapy response, using machine learning to generate a predictive model and validate the results.

RESULTS

Eighteen significant biomarkers were identified, including specific acylcarnitines and amino acids. The most effective predictive model demonstrated a remarkable accuracy of 90.7% and an Area Under the Curve (AUC) of 0.999 at 95% confidence, illustrating its potential utility as a web-based application for future patient management. This model's reliability underscores the significant role of circulating metabolites in predicting therapy outcomes.

CONCLUSION

Our study's findings highlight the crucial role of metabolomics in advancing personalized medicine for breast cancer treatment by effectively identifying metabolite biomarkers correlated with neoadjuvant therapy response. This approach signifies a critical step towards tailoring treatment plans based on individual metabolic profiles, ultimately improving patient outcomes in breast cancer care.

Hypomethylating agents as emerging therapeutics for triple-negative breast cancer

Triple-negative breast cancer (TNBC) is recognized as the most aggressive subtype of breast cancer. Epigenetic silencing, such as DNA methylation mediated by DNA methyltransferases (DNMTs) plays key roles in TNBC tumorigenesis. Hypomethylating agents (HMAs) such as azacitidine, decitabine, and guadecitabine are key inhibitors of DNMTs, and accumulating evidence has shown their immunogenicity properties. In this review, the efficacy and anti-tumor immune responses triggered by HMAs in TNBC are presented and discussed. Essentially, overexpression of DNMTs is associated with poor prognosis and reduced TNBC survival rates, and these effects are negated by HMAs. In particular, HMAs could reverse epigenetic silencing of tumor suppressor genes and enhance immune recognition of TNBC cells. Clinical trials of HMAs in TNBCs are limited but early-stage trials indicate that HMAs are safe and tolerable. More clinical studies are required to establish the effectiveness of HMAs against the disease, as supported by preclinical data substantiating their effectiveness especially guadecitabine. Future research should focus on optimizing dosing and exploring combinations with immunotherapies to maximize the potential of HMAs in TNBC treatment.

Triple-Negative Breast Cancer Systemic Treatment: Disruptive Early-Stage Developments for Overcoming Stagnation in the Advanced Pipeline

New breast cancer (BC) diagnoses will soon reach 2.5-3 million/year worldwide, with 15-25% of them being triple-negative breast cancer (TNBC), the most aggressive type, characterized for lacking the main pharmacological targets: estrogen and progesterone receptors (ERs and PRs), as well as HER2 overexpression. Therefore, chemotherapy remains the almost-unique systemic treatment for TNBC. However, some targeted therapies are recommended for use in combination with chemotherapy; namely, PARP inhibitors for BRCA-mutated TNBC, the immune checkpoint inhibitors pembrolizumab and atezolizumab, as well as the antibody-drug conjugates sacituzumab govitecan and trastuzumab deruxtecan, the latter for HER2low subtypes. Regardless of the limited benefits they provide, other treatments with similar mechanisms of action are being investigated in advanced clinical stages. Further, therapies that benefit other cancers, like PI3K/Akt/mTOR pathway and CDK4/6 inhibitors, are still being investigated for TNBC, although convincing results have not been obtained. Given this scenario, it might appear innovation for TNBC treatments has become stuck. However, the huge unmet medical need drives intense research into the biology of the disease. As a result, emerging disruptive therapies are being tested in early-stage trials, designed for novel targets and applying cutting-edge advances in immunotherapy and precision oncology.

Retesting of oestrogen receptor, progesterone receptor and HER2 status of invasive carcinoma of the breast after neoadjuvant chemotherapy

AIMS

There is no consensus on whether oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status should be assessed after neoadjuvant chemotherapy. This study assessed the frequency of changes in ER, PR and HER2 status after neoadjuvant chemotherapy.

METHODS AND RESULTS

Of 353 patients who had neoadjuvant chemotherapy and anti-HER2 treatment, receptors were assessed in 185 residual carcinomas. Eight per cent of carcinomas that were ER-negative in the core biopsy were ER-positive in the excision compared with 1.5% of controls. All were HER2-positive in the core biopsy and 23% were HER2-negative in the excision compared with 0% of controls. Controls were cases tested in the core biopsy and subsequent surgical resection with no neoadjuvant treatment. Of 589 patients who had neoadjuvant chemotherapy alone, receptors were assessed in 495 residual carcinomas. Six per cent of carcinomas that were ER-negative in the core biopsy were ER-positive in the excision (mainly ER-low positive) compared with 1.5% of controls. All were HER2-negative in the core biopsy and 6% were HER2-positive in the excision (mainly immunohistochemistry score 2+ and HER2 gene amplified) compared with 2% of controls.

CONCLUSIONS

Negative to positive changes in receptor status after neoadjuvant chemotherapy are infrequent and the positive result in the excision is often weakly positive. These results imply that repeat assessment after neoadjuvant chemotherapy and surgery could influence the subsequent treatment in a small proportion of patients.

TROPION-Breast04: a randomized phase III study of neoadjuvant datopotamab deruxtecan (Dato-DXd) plus durvalumab followed by adjuvant durvalumab versus standard of care in patients with treatment-naïve early-stage triple negative or HR-low/HER2- breast cancer

Background

Despite treatment advances for patients with early-stage triple-negative breast cancer (TNBC) and hormone receptor (HR)-low/human epidermal growth factor receptor 2-negative (HER2-) breast cancer, treatments that improve clinical outcomes while mitigating toxicity are needed. Datopotamab deruxtecan (Dato-DXd), a TROP2-directed antibody-drug conjugate consisting of a humanized IgG1 monoclonal antibody attached via a plasma-stable cleavable linker to a topoisomerase-I inhibitor payload, has shown efficacy alone or in combination with durvalumab, a selective, high-affinity anti-programmed cell death ligand 1 antibody, in early-phase clinical studies.

Objectives

The primary objective of TROPION-Breast04 is to evaluate the efficacy and safety of neoadjuvant Dato-DXd plus durvalumab followed by adjuvant durvalumab with or without chemotherapy versus standard of care in patients with previously untreated early-stage TNBC or HR-low/HER2- breast cancer.

Design

This is an ongoing, international, phase III, open-label, randomized controlled study.

Methods and analysis

Approximately 1728 patients (aged ⩾18 years) will be randomized 1:1 to eight cycles of neoadjuvant Dato-DXd (6 mg/kg intravenously (IV) every 3 weeks (Q3W)) plus durvalumab (1120 mg IV Q3W) followed by nine cycles of adjuvant durvalumab (1120 mg IV Q3W) with or without chemotherapy versus eight cycles of pembrolizumab (200 mg IV Q3W) plus chemotherapy followed by nine cycles of adjuvant pembrolizumab (200 mg IV Q3W) with or without chemotherapy. Dual primary endpoints are pathological complete response by blinded central review and event-free survival by investigator assessment. Secondary endpoints include overall survival (key), distant disease-free survival, patient-reported outcomes, and safety.

Ethics

The study is approved by independent ethics committees and/or institutional review boards at each study site. All patients will provide written informed consent.

Discussion

This study will evaluate the potential use of neoadjuvant Dato-DXd plus durvalumab followed by adjuvant durvalumab with or without chemotherapy versus standard of care in patients with previously untreated early-stage TNBC or HR-low/HER2- breast cancer. The findings of this trial could lead to promising treatment options for these patients.

Trial registration

ClinicalTrials.gov identifier: NCT06112379.

Habitat-Based Radiomics for Revealing Tumor Heterogeneity and Predicting Residual Cancer Burden Classification in Breast Cancer

PURPOSE

To investigate the feasibility of characterizing tumor heterogeneity in breast cancer ultrasound images using habitat analysis technology and establish a radiomics machine learning model for predicting response to neoadjuvant chemotherapy (NAC).

METHODS

Ultrasound images from patients with pathologically confirmed breast cancer who underwent neoadjuvant therapy at our institution between July 2021 and December 2023 were retrospectively reviewed. Initially, the region of interest was delineated and segmented into multiple habitat areas using local feature delineation and cluster analysis techniques. Subsequently, radiomics features were extracted from each habitat area to construct 3 machine learning models. Finally, the model's efficacy was assessed through operating characteristic (ROC) curve analysis, decision curve analysis (DCA), and calibration curve evaluation.

RESULTS

A total of 945 patients were enrolled, with 333 demonstrating a favorable response to NAC and 612 exhibiting an unfavorable response to NAC. Through the application of habitat analysis techniques, 3 distinct habitat regions within the tumor were identified. Subsequently, a predictive model was developed by incorporating 19 radiomics features, and all 3 machine learning models demonstrated excellent performance in predicting treatment outcomes. Notably, extreme gradient boosting (XGBoost) exhibited superior performance with an area under the curve (AUC) of 0.872 in the training cohort and 0.740 in the testing cohort. Additionally, DCA and calibration curves were employed for further evaluation.

CONCLUSIONS

The habitat analysis technique effectively distinguishes distinct biological subregions of breast cancer, while the established radiomics machine learning model predicts NAC response by forecasting residual cancer burden (RCB) classification.

Genetic Alterations, Therapy Response, and Survival Among Patients With Triple-Negative Breast Cancer: A Secondary Analysis of a Randomized Clinical Trial

Importance

Subgroup definitions for possible deescalation of neoadjuvant cancer treatment are urgently needed in clinical practice.

Objective

To investigate the effect of BRCA1 and/or BRCA2 tumor pathogenic variants (tPVs) by comparing 2 deescalated neoadjuvant regimens (nab-paclitaxel plus either carboplatin or gemcitabine) on pathologic complete response (pCR), invasive disease-free survival (IDFS), and overall survival (OS) of patients with early-stage triple-negative breast cancer (TNBC).

Design, Setting, and Participants

This was a preplanned secondary analysis of a phase 2 prospective randomized clinical trial (ADAPT-TN) conducted by the West German Study Group (WSG) at 45 sites in Germany between June 2013 and February 2015. The trial enrolled patients with noninflammatory early-stage TNBC (clinical tumor size ≥1 cm; estrogen receptor and progesterone receptor expression <1%; and ERBB2 negative). DNA samples from pretreatment biopsies were obtained. Genetic analysis was performed between January 2018 and March 2020. Final data analyses took place in September 2023.

Exposure

Patients were randomized to 12 weeks of treatment with nab-paclitaxel plus either carboplatin or gemcitabine; omission of otherwise mandatory anthracycline-containing chemotherapy was allowed in the case of pCR. tPVs in 20 cancer-associated genes, including BRCA1 and BRCA2, were analyzed using a customized gene panel.

Main Outcomes and Measures

The prevalence of BRCA1 and/or BRCA2 tPVs and their effect on pCR rate, IDFS, and OS were evaluated using logistic and Cox proportional hazards regression.

Results

Of the 307 patients with DNA samples from pretreatment biopsies available, tumor next-generation sequencing analyses were successful for 266 patients. The 266 patients included in this analysis were female, with a median age of 51 years (range, 26-76 years). A total of 162 patients (60.9%) had a clinical tumor size of 2 cm or greater, and 70 (26.3%) had clinical node-positive disease. BRCA1 and/or BRCA2 tPVs were detected in 42 patients (15.8%). The highest pCR rate among patients with BRCA1 and/or BRCA2 tPVs was seen in the nab-paclitaxel plus carboplatin group (9 of 14 patients [64.3%]) compared with the nab-paclitaxel plus gemcitabine group (10 of 28 [35.7%]) (odds ratio, 3.24 [95% CI, 0.85-12.36]; P = .08); the highest numeric 5-year IDFS and OS rates (84.4% and 92.9%, respectively) were seen in the nab-paclitaxel plus carboplatin group.

Conclusions and Relevance

In this secondary analysis of the WSG-ADAPT-TN randomized clinical trial on tPVs, deescalated nab-paclitaxel plus carboplatin was superior to nab-paclitaxel plus gemcitabine, particularly in patients with BRCA1 and/or BRCA2 tPVs. These findings suggest that BRCA1 and/or BRCA2 tPV status could be a candidate marker for a deescalation strategy in early-stage TNBC; however, prospective validation of survival outcomes in larger cohorts with differentiation between germline and somatic pathogenic variants is necessary.

Trial Registration

ClinicalTrials.gov Identifier: NCT01815242.

Health-Related Quality of Life and Disease Acceptance Among Women with Breast Cancer Pre- and Post-Neoadjuvant Chemotherapy

Background/Objective: The study aimed to evaluate disease acceptance and quality of life in women with breast cancer before and after receiving neoadjuvant chemotherapy. Methods: The study included 211 women diagnosed with breast cancer who underwent neoadjuvant treatment. The following measures were utilized: the EORTC QLQ-C30 and QLQ-BR23 modules for quality of life assessment, the Acceptance of Illness Scale (AIS) questionnaire for evaluating disease acceptance, and a proprietary questionnaire. Assessments were conducted one week before the first chemotherapy session and three weeks after completing the chemotherapy. Statistical analysis was performed using STATISTICA v. 13. Results: The respondents exhibited an average acceptance of their disease, both before (28.2 pts) and after chemotherapy (25.5 pts). A decline in disease acceptance was observed in nearly 59.2% of the patients following chemotherapy. Higher levels of disease acceptance were associated with a better quality of life. The quality of life for the studied women decreased after neoadjuvant chemotherapy, particularly in the following areas: physical functioning (p = 0.0000), social functioning (p = 0.0000), body image assessment (p = 0.0000), sexual satisfaction (p = 0.0000), nausea and vomiting (p = 0.0000), fatigue (p = 0.0000), loss of appetite (p = 0.0000), insomnia (p = 0.0000), pain (p = 0.0000), hair loss (p = 0.0000), and side effects of systemic treatment (p = 0.0000). Conclusions: Post-neoadjuvant chemotherapy, a decline in disease acceptance and quality of life was observed among women with breast cancer in comparison with their pre-treatment status. Higher levels of disease acceptance were associated with a better quality of life. These findings may facilitate the creation of a more tailored care approach for women during and after chemotherapy.

Neoadjuvant nivolumab and chemotherapy in early estrogen receptor-positive breast cancer: a randomized phase 3 trial

Patients with estrogen receptor-positive (ER+), human epidermal growth factor receptor 2-negative (HER2-) primary breast cancer (BC) have low pathological complete response (pCR) rates with neoadjuvant chemotherapy. A subset of ER+/HER2- BC contains dense lymphocytic infiltration. We hypothesized that addition of an anti-programmed death 1 agent may increase pCR rates in this BC subtype. We conducted a randomized, multicenter, double-blind phase 3 trial to investigate the benefit of adding nivolumab to neoadjuvant chemotherapy in patients with newly diagnosed, high-risk, grade 3 or 2 (ER 1 to ≤10%) ER+/HER2- primary BC. In total, 510 patients were randomized to receive anthracycline and taxane-based chemotherapy with either intravenous nivolumab or placebo. The primary endpoint of pCR was significantly higher in the nivolumab arm compared with placebo (24.5% versus 13.8%; P = 0.0021), with greater benefit observed in patients with programmed death ligand 1-positive tumors (VENTANA SP142 ≥1%: 44.3% versus 20.2% respectively). There were no new safety signals identified. Of the five deaths that occurred in the nivolumab arm, two were related to study drug toxicity; no deaths occurred in the placebo arm. Adding nivolumab to neoadjuvant chemotherapy significantly increased pCR rates in high-risk, early-stage ER+/HER2- BC, particularly among patients with higher stromal tumor-infiltrating lymphocyte levels or programmed death ligand 1 expression, suggesting a new treatment paradigm that emphasizes the role of immunotherapy and T cell immunosurveillance in luminal disease. Clinical trials.gov identifier: NCT04109066.

Predicting progression in triple-negative breast cancer patients undergoing neoadjuvant chemotherapy: Insights from peritumoral radiomics

OBJECTIVE

To investigate whether radiomic features obtained from the intratumoral and peritumoral regions of pretreatment magnetic resonance imaging (MRI) can predict progression in patients with triple-negative breast cancer (TNBC) undergoing neoadjuvant chemotherapy (NAC) in comparison with the previously determined clinical score.

METHODS

This single-center retrospective study evaluated 224 women with TNBC who underwent NAC between 2010 and 2019. Women were randomly allocated to the training set (n = 169) for model development and the test set (n = 55) for model validation. The clinical score consisted of the histologic type, Ki-67 index, and degree of edema on T2-weighted imaging. Intratumoral and peritumoral radiomic features were extracted from T2-weighted images and the first- and last-phase images of dynamic contrast-enhanced MRI. The radiomics model was built using only radiomic features, whereas the combined model incorporated the clinical score along with radiomic features. The area under the receiver operating characteristic curve (AUC) was used to assess performance.

RESULTS

Progression occurred in 18 and five patients in the training and test sets, respectively. The radiomics model selected three radiomic features (two peritumoral and one intratumoral), while the combined model selected the clinical score and five radiomic features (four peritumoral and one intratumoral). Among the total radiomic features, Inverse Difference Normalized of the peritumoral region of the T2-weighted images, reflective of peritumoral heterogeneity, demonstrated the highest level of association with tumor progression. In the test set, the AUC values of the radiomics-only model, the combined model, and the clinical score were 0.592, 0.764, and 0.720, respectively. Compared to the clinical score, the radiomics-only model (0.720 vs. 0.592, p = 0.468) and the combined model (0.720 vs. 0.764, p = 0.553) did not show superior performance.

CONCLUSION

The radiomics features were not superior in predicting the progression of TNBC compared to the clinical score, although the peritumoral heterogeneity on T2-weighted images showed a potential.

The role of body composition in neurological and hematologic toxicity in a retrospective analysis of 120 breast cancer patients undergoing neoadjuvant chemotherapy: the COMBOTOX study

PURPOSE

Neoadjuvant chemotherapy (NAC) has a well-established role in locally advanced or chemoresponsive breast cancers (BC). Chemotherapic regimens are effective when patients receive the optimal doses. Toxicities are common in overweight/obese patients but may occur also in normal weight counterparts. This leads to delays, reductions, or discontinuation of treatment, with impact on outcomes. Current dosing is based on body weight and predicted Body Surface Area (BSA). These parameters do not take into consideration the individual variations of fat mass (FM) and fat-free mass (FFM) that affect pharmacokinetics. Assessment of body composition (BoCo), rather than Body Mass Index (BMI), could help to better plan chemotherapy and reduce drug-related toxicities. Our aim was to analyze the correlations between body weight, anthropometric measures, BoCO, and toxicities related to NAC in non-metastatic BC patients.

METHODS

This is a retrospective observational cohort study that includes 120 consecutive BC patients undergoing NAC, enrolled between May 2018 and December 2020. All patients received an evaluation of anthropometric parameters (height, weight, waist and hip circumference, BMI) and an assessment of BoCo using Segmental Multi-Frequency-Bioelectrical Impedance Analysis.

RESULTS

A logistic regression models confirmed that a higher FM was associated with a higher rate of neurological and hematologic toxicities in protocols containing Platinum. Moreover, patients with a low FFM% have a higher risk for hematologic toxicity in protocols containing Platinum.

CONCLUSION

A routine assessment of BoCo, in addition to evaluation of anthropometric measures and BMI, could allow to personalize chemotherapy doses, in order to reduce chemotherapy-related toxicities.

Evaluating Operative Times for Intraoperative Conversion of Axillary Node Biopsy to Axillary Lymph Node Dissection with Immediate Lymphatic Reconstruction

BACKGROUND

 Lymphedema can occur in patients undergoing axillary lymph node dissection (ALND) and radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed to decrease the risk of lymphedema in patients after ALND. Some patients who ultimately require ALND are candidates for attempted sentinel lymph node biopsy (SLNB) or targeted axillary excision. In those scenarios, ALND can be performed (1) immediately if frozen sections are positive or (2) as a second operation following permanent pathology. The purpose of this study is to evaluate immediate ALND/ILR following positive intraoperative frozen sections to guide surgical decision-making and operative planning.

METHODS

 A single-center retrospective review was performed (2019-2022) for breast cancer patients undergoing axillary node surgery with breast reconstruction. Patients were divided into two groups: immediate conversion to ALND/ILR (Group 1) and no immediate conversion to ALND (Group 2). Demographic data and operative time were recorded.

RESULTS

 There were 148 patients who underwent mastectomy, tissue expander (TE) reconstruction, and axillary node surgery. Group 1 included 30 patients who had mastectomy, sentinel node/targeted node biopsy, TE reconstruction, and intraoperative conversion to immediate ALND/ILR. Group 2 had 118 patients who underwent mastectomy with TE reconstruction and SLNB with no ALND or ILR. Operative time for bilateral surgery was 303.1 ± 63.2 minutes in Group 1 compared with 222.6 ± 52.2 minutes in Group 2 (p = 0.001). Operative time in Group 1 patients undergoing unilateral surgery was 252.3 ± 71.6 minutes compared with 171.3 ± 43.2 minutes in Group 2 (p = 0.001).

CONCLUSION

 Intraoperative frozen section of sentinel/targeted nodes extended operative time by approximately 80 minutes in patients undergoing mastectomy with breast reconstruction and conversion of SLNB to ALND/ILR. Intraoperative conversion to ALND adds unpredictability to the operation as well as additional potentially unaccounted operative time. However, staging ALND requires an additional operation.

Assessment of quality of life, pain, depression, and body-image in breast cancer patients in neoadjuvant therapy

Breast cancer is the leading cancer type among women globally, and its chemotherapy often results in multiple side effects, compromising the patient's quality of life. Our study aimed to analyze the impact of neoadjuvant chemotherapy on the quality of life in Brazilian women with breast cancer within the public health system. This research was a one-year, observational, longitudinal study, conducted at a charitable health facility, examining the effect of neoadjuvant chemotherapy on these women's quality of life. Sociodemographic and clinical data were extracted from medical records. Quality of life parameters were gauged using Portuguese-validated questionnaires: EORTC.QLQ - C30 version 3.0, EORTC.BR-23, Body Image Scale (BIS), BPI-SF pain scale, and Beck Depression Inventory (BDI). These tools were utilized at three intervals: before the start of systemic treatment, after three months (before initiating paclitaxel), and upon concluding neoadjuvant therapy. Qualitative variables were tested for normality using the Kolmogorov-Smirnov test. As the continuous variables referring to the questionnaires did not show normal distribution, non-parametric tests were used: Friedman tests for paired pairs, and Wilcoxon and Mann-Whitney tests for multiple comparisons. In all tests, the significance level adopted was 5%. The software used for the analysis was SPSS. Our findings revealed a decline in quality of life, observing deterioration in the role, social, and cognitive functioning domains. Additionally, symptoms like fatigue, hyporexia, constipation, and diarrhea became more pronounced during the treatment. The presence of minimal depressive symptoms, associated with systemic therapy side effects also contributed to this worsening. Notably, there were no improvements in any quality of life-related parameters, and no discernible differences were observed in pain levels or body image across the evaluated periods.

Association between mammographic breast density and outcome in patients with unilateral invasive breast cancer receiving neoadjuvant chemotherapy

PURPOSE

To analyze the relationship between mammographic breast density and tumor response and outcome at follow-up, in terms of overall survival (OS) and disease-free survival (DFS), in patients with unilateral invasive breast cancer receiving neoadjuvant chemotherapy (NACT).

METHODS

A total of 228 women (mean age, 47.6 years ± 10 [SD]; range: 24-74 years) with invasive breast cancer who underwent NACT were included in this observational retrospective study. Clinical, radiological and histopatological data were retrieved. Categorization of breast density was performed by two radiologists in consensus on mammography acquired at the time of diagnosis according to BI-RADS categories. Association between density categories and tumor response was analyzed in the overall population and in subgroups defined by menopausal status, tumor phenotype and stage at diagnosis. Kaplan-Meier (KM) curves were used to estimate the OS and DFS probabilities. Subgroup analyses based on menopausal status and tumor phenotype were performed.

RESULTS

A total of 30 patients (13.2%) achieved pathological complete response (pCR). No association between density categories and pCR was found (P = 0.973), even at subgroups analysis. The median follow-up time was 92 months. Patients with dense breast showed the longest DFS (P = 0.0094), results confirmed in premenopausal patients (P = 0.0024) and in triple negative breast cancers (P = 0.0292). Density category did not show a statistically significant association with OS.

CONCLUSION

Breast cancer patients receiving NACT with extremely dense breasts showed better DFS. No evidence of breast density as a predictive marker for complete pathological response or as a prognostic factor in terms of OS was found.

Prognostic Value of MRI Assessment of Residual Peritumoral Edema in Breast Cancer Treated With Neoadjuvant Chemotherapy

BACKGROUND

Peritumoral edema (PE) identified on T2-weighted breast MRI is a factor for poor prognosis in breast cancer.

PURPOSE

To assess the prognostic value of residual PE (rPE) in patients with PE positive breast cancer prior to neoadjuvant chemotherapy (NACT) who subsequently underwent curative surgery.

STUDY TYPE

Retrospective.

POPULATION

In total, 128 patients with nonmetastatic invasive breast cancer who underwent breast MRI before and after NACT.

FIELD STRENGTH/SEQUENCE

Axial precontrast 2D fast spin echo T2W fat-suppressed sequence. Axial dynamic 3D gradient echo T1W fat-suppressed sequence.

ASSESSMENT

PE was diagnosed when a signal intensity as high as water was detected surrounding the tumor on a T2-weighted breast MRI. PE was qualitatively evaluated by three readers with more than 20 years of experience in interpreting breast field imaging findings. Residual cancer burden (RCB) were assessed post-NACT. Recurrence-free survival (RFS) and overall survival (OS) were evaluated as the endpoints of this study.

STATISTICAL TESTS

Chi-square test; Kaplan-Meier method, log-rank test, and Cox proportional hazard model. A P-value <0.05 was considered statistically significant.

RESULTS

Pre-PE was observed in 64 out of 128 patients. Of these, rPE was observed in 21. In the log-rank test, breast cancer with rPE had significantly worse RFS and OS than that without rPE. Cox proportional hazard analysis identified rPE as a significant prognostic factor for recurrence (hazard ratio, 11.6; 95% confidence interval [CI], 3.05-43.8) and death (hazard ratio, 17.8; 95% CI, 3.30-96.3). Breast cancer with rPE had significant worse RFS and OS than that without rPE in RCB class II, and significant worse OS in pathological complete response, class I and class II in the log-rank test.

DATA CONCLUSION

rPE on a T2-weighted breast MRI was a significant factor for breast cancer recurrence and death in patients with pre-PE-positive breast cancer treated with NACT.

LEVEL OF EVIDENCE: 3

TECHNICAL EFFICACY

Stage 2.

The kinetic parameters of dynamic contrast-enhanced MRI with ultrafast imaging in breast cancer patients receiving neoadjuvant chemotherapy: Prediction of pathologic complete response and correlation with histologic microvessel density

Early prediction of pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer patients can help forecast prognosis and guide decisions on adjuvant therapy. This study aimed to determine whether the kinetic parameters of dynamic contrast-enhanced MRI (DCE-MRI) with ultrafast imaging can predict pCR following NAC in breast cancer patients and whether these parameters are correlated with histologic microvessel density (MVD). In this retrospective study, 61 breast cancer patients who underwent NAC and surgery between August 2020 and 2022 were analyzed. Ultrafast and conventional DCE-MRI features, along with pathologic results, were compared between the pCR and non-pCR groups. Regression analysis was conducted to identify predictive factors for pCR. Additionally, MRI kinetic parameters were correlated with histologic MVD. Of the 61 patients, 17 (27.9%) achieved pCR. The pCR group exhibited a larger delayed washout component (P = .002) and a smaller angiovolume (P = .02) compared to the non-pCR group; however, these factors lost significance when accounting for tumor size, lymph node status, and molecular subtypes. In a subgroup analysis based on molecular subtype, a low initial enhancement value (≤362.5%) and angiovolume (≤10.3 cc) predicted pCR in human epidermal growth factor receptor 2-enriched breast cancer, with an area under the curve of 0.833. The maximum slope on ultrafast MRI was higher in the high MVD group compared to the low MVD group (P = .049). Human epidermal growth factor receptor 2-enriched breast cancer with low vascularity on DCE-MRI is more likely to achieve pCR, although MRI kinetic parameters were not independent predictors of pCR in all breast cancer subtypes. The maximum slope on ultrafast MRI was the only kinetic parameter that correlated with histologic MVD. Larger studies focused on molecular subtypes are warranted.

Omega-3 fatty acids: molecular weapons against chemoresistance in breast cancer

Breast cancer is the most commonly diagnosed type of cancer and the leading cause of cancer-related death in women worldwide. Highly targeted therapies have been developed for different subtypes of breast cancer, including hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, triple-negative breast cancer (TNBC) and metastatic breast cancer disease are primarily treated with chemotherapy, which improves disease-free and overall survival, but does not offer a curative solution for these aggressive forms of breast cancer. Moreover, the development of chemoresistance is a major cause of therapeutic failure in this neoplasia, leading to disease relapse and patient death. In addition, chemotherapy's adverse side effects may substantially worsen health-related quality of life. Therefore, to improve the outcome of patients with breast cancer who are undergoing chemotherapy, several therapeutic options are under investigation, including the combination of chemotherapeutic drugs with natural compounds. Omega-3 (ω-3) polyunsaturated fatty acids (PUFAs), including docosahexaenoic and eicosapentaenoic acids, have drawn attention for their antitumoral properties and their preventive activities against chemotherapy-induced toxicities in breast cancer. A literature review was conducted on PubMed using keywords related to breast cancer, omega-3, chemoresistance, and chemotherapy. This review aims to provide an overview of the molecular mechanisms driving breast cancer chemoresistance, focusing on the role of ω-3 PUFAs in these recognized cellular paths and presenting current findings on the effects of ω-3 PUFAs combined with chemotherapeutic drugs in breast cancer management.

A deep learning approach for early prediction of breast cancer neoadjuvant chemotherapy response on multistage bimodal ultrasound images

Neoadjuvant chemotherapy (NAC) is a systemic and systematic chemotherapy regimen for breast cancer patients before surgery. However, NAC is not effective for everyone, and the process is excruciating. Therefore, accurate early prediction of the efficacy of NAC is essential for the clinical diagnosis and treatment of patients. In this study, a novel convolutional neural network model with bimodal layer-wise feature fusion module (BLFFM) and temporal hybrid attention module (THAM) is proposed, which uses multistage bimodal ultrasound images as input for early prediction of the efficacy of neoadjuvant chemotherapy in locally advanced breast cancer (LABC) patients. The BLFFM can effectively mine the highly complex correlation and complementary feature information between gray-scale ultrasound (GUS) and color Doppler blood flow imaging (CDFI). The THAM is able to focus on key features of lesion progression before and after one cycle of NAC. The GUS and CDFI videos of 101 patients collected from cooperative medical institutions were preprocessed to obtain 3000 sets of multistage bimodal ultrasound image combinations for experiments. The experimental results show that the proposed model is effective and outperforms the compared models. The code will be published on the https://github.com/jinzhuwei/BLTA-CNN .

Relationship between androgen receptor and androgen receptor-related protein expression in breast cancers focusing on morphologically identified carcinoma with apocrine differentiation

Breast cancer (BC) is classified based on the expression of histopathological markers, namely, estrogen receptor (ER), progesterone receptor (PgR), and human epidermal growth factor receptor 2 (HER2). Carcinomas with apocrine differentiation (CAD) are classified based on morphology. Androgen receptor (AR) is highly expressed in CAD; however, no study has comprehensively examined AR-related proteins in CAD. Therefore, we examined the expression of AR-related proteins and AR, compared protein expression patterns between morphologically identified CAD and other BC subtypes, and investigated CAD characteristics. We performed immunohistochemistry for AR and various AR-related proteins in 66 invasive ductal carcinoma (32 ER+/PgR+/HER2-, 8 ER+/PgR+/HER2+, 12 ER-/PgR-/HER2+, and 14 ER-/PgR-/HER2- [triple-negative breast cancer)), 21 invasive lobular carcinoma, and 27 CAD cases. In the CAD group, all cases were AR-positive; some AR-related proteins were highly expressed. Nuclear phosphorylated-mammalian target of rapamycin was highly expressed in CAD cases compared with that in other BC groups, with a 33.3% sensitivity and 97.7% specificity. AR-expressing CAD cases exhibited high expression of other AR-related proteins. Specifically, the combination of AR+, GCDFP15+, and ER - or AR+, FOXA1+, and ER - may be useful for the diagnosis and treatment of AR-positive BC and CAD. These results may assist in androgen-related molecular targeted therapy research.

PD-1/PD-L1 Inhibitors Increase Pathological Complete Response in Locally Advanced Gastric Cancer: A Meta-analysis and Trial Sequential Analysis

BACKGROUND AND OBJECTIVE

Gastric cancer (GC) remains a leading cause of morbidity and mortality worldwide. The current standard of care involves neoadjuvant chemotherapy (NACT) followed by radical gastrectomy. This study aims to evaluate the efficacy of neoadjuvant therapy with PD-1/PD-L1 inhibitors in comparison to chemotherapy alone for patients with locally advanced gastric cancer (LAGC).

METHODS

We conducted a systematic search of PubMed, Web of Science, and Embase to identify studies examining the addition of PD-1/PD-L1 inhibitors to neoadjuvant therapy for LAGC. Odds ratios (OR) were calculated for binary outcomes, such as pathological complete response (pCR), with corresponding 95% confidence intervals (CI).

RESULTS

Seven studies were included, encompassing a total of 1772 patients. Baseline median age ranged from 31 to 75 years. Most patients had an ECOG performance status score of 0 (942 patients), while 294 had an ECOG score of 1. The estimated pCR (OR 5.94, 95% CI 3.98-8.87; p < 0.000001) significantly favored the PD-1/PD-L1 inhibitors combined with chemotherapy over chemotherapy alone. Additionally, the incidence of certain adverse events increased significantly in the intervention group, including any-grade hypothyroidism (OR 4.55, 95% CI 2.27-9.10; p = 0.000019) and rash (OR 1.74, 95% CI 1.10-2.76; p = 0.017). Conversely, the control group showed a statistically significant lower incidence of grade ≥ 3 fatigue (OR 2.80, 95% CI 1.15-6.85; p = 0.024) compared to the intervention group.

CONCLUSION

This systematic review and meta-analysis indicate that the addition of PD-1/PD-L1 inhibitors to neoadjuvant chemotherapy is associated with a higher pathological complete response rate compared to chemotherapy alone in patients with locally advanced gastric cancer.

Exploring the heterogeneity of HER2 gene status and expression in non-positive breast cancer patients: insights from immunohistochemistry and fluorescence in situ hybridization

Breast cancer became the most prevalent malignancy among women, and HER2 expression status is critical for treatment decisions. With the emergence of ADC drugs, HER2 low-expressing patients who previously did not respond well to traditional anti-HER2 therapies may now benefit. In this study, immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) were applied to assess HER2 expression in 349 patients with HER2-non-positive breast cancer. Our analysis revealed that HER2-low tumors exhibited fewer grade III tumors (39.74% and 55.65%, respectively, P = 0.005) and higher positivity for estrogen receptor (ER, 88.89% vs. 61.74%, P < 0.001) and progesterone receptor (PR, 84.62% vs. 57.39%, P < 0.001) compared to HER2-ZERO tumors. Of the 349 cases, IHC was ultimately evaluated in 327, the antibodies demonstrated only 64.22% (95% CI: 58.76-69.42%) agreement between clone 4B5 and clone EP3. Pathologist 1, who had more extensive working experience, demonstrated higher consistency (94.19%) with the gold standard when using clone EP3, compared to Pathologist 2 (74.31%). FISH analysis revealed significant differences in HER2/CEP17 ratio and average HER2 copy numbers between HER2-ZERO and HER2-low tumors, but no clear cut-off value could be identified. Notably, HER2/CEP17 ratio mostly between 1 and 2, with HER2-ZERO tumors primarily ≤ 1.4, and average HER2 copy numbers were mostly ≥ 2 and < 4, with HER2-ZERO tumors primarily ≤ 2.5. Despite distinct clinicopathological features, FISH remains inadequate for distinguishing HER2-low from HER2-ZERO expression. Further studies are needed to improve HER2 assessment in this challenging subset of patients.

Strategies to enhance management of HER2-positive breast cancer in the elderly: an expert consensus perspective

Therapeutic decision-making for older patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer highlights the importance of a comprehensive geriatric assessment (CGA). This assessment considers the functional status, comorbidities, and relevant conditions of the patient, and allows for an estimation of life expectancy, but it does not facilitate individualized treatment plans. There are also other challenges to consider related to the cardiac toxicity of the treatments and the under-representation of older patients in clinical trials. The Oncogeriatrics Section of the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica, SEOM), the Spanish Group for Breast Cancer Research (Grupo Español de Investigación en Cáncer de Mama, GEICAM) and the Spanish Group of Study, Treatment and other Experimental Strategies in Solid Tumours (Grupo Español de Estudio, Tratamiento y otras Estrategias Experimentales en Tumores Sólidos, SOLTI) have gathered an expert committee to evaluate the scientific evidence on the management of older patients with HER2-positive breast cancer and to establish recommendations based on a comprehensive review of the existing literature. These recommendations underscore the importance of individualizing treatment plans based on the patient's physical status and tolerability to maximize efficacy while minimizing toxicity. Emphasis is placed on adapting neoadjuvant and adjuvant therapies according to geriatric assessment and specific patient needs. A careful selection of treatment schedules for advanced stages is needed to improve survival and quality of life, assuming that scientific evidence in this age group is limited.

Preliminary experience and learning curve of endoscopic nipple-areolar-complex sparing total mastectomy: A single-center retrospective study

BACKGROUND

In this study, the preliminary experience of endoscopic nipple-areolar-complex (NAC) sparing total mastectomy were analyzed and reported.

METHODS

The medical records of the patients who underwent Endoscopic NAC sparing total mastectomy from November 2019 to June 2022 in a single institute were collected and analyzed. The medical records of their clinicopathologic characteristics, perioperative parameters, postoperative complications, oncologic results were collected retrospectively. The learning curve was evaluated using univariable and multivariable analyses and analyzed using the CUSUM method.

RESULTS

A total of 56 surgeries from 53 patients were analyzed. The mean total operation time was 272.50±66.74 minutes while mean oncologic mastectomy was 155.61±43.21 minutes. The mean postoperative hospital days were 9.85±4.70 days. In CUSUM analysis, the cases needed to decrease operation time were 10th. The overall complication rate related to implant was 15.09%. There were one locoregional recurrence patient and one distant metastasis and mortality patient observed during median follow-up of 19.12±12.01 months.

CONCLUSION

According to our preliminary study, endoscopic NAC sparing total mastectomy is a safe procedure, and the operation time can be reduced with accumulated surgical experience.

Distinct mRNA expression profiles and miRNA regulators of the PI3K/AKT/mTOR pathway in breast cancer: insights into tumor progression and therapeutic targets

Background

Breast cancer remains a leading cause of mortality among women, driven by the molecular complexity of its various subtypes. This study aimed to investigate the differential expression of genes and miRNAs involved in the PI3K/AKT/mTOR signaling pathway, a critical regulator of cancer progression.

Methods

We analyzed tumor tissues from five breast cancer subtypes-luminal A, luminal B HER2-negative, luminal B HER2-positive, HER2-positive, and triple-negative breast cancer (TNBC)-and compared them with non-cancerous tissues. Microarray and qRT-PCR techniques were employed to profile mRNAs and miRNAs, while bioinformatic tools predicted miRNA-mRNA interactions. Statistical analysis was performed with a statistical significance threshold (p) < 0.05.

Results

We identified several upregulated genes across all subtypes, with TNBC and HER2-positive cancers showing the most significant changes. Key genes such as COL1A1, COL4A1, PIK3CA, PIK3R1, and mTOR were found to be overexpressed, correlating with increased cancer aggressiveness. miRNA analysis revealed that miR-190a-3p, miR-4729, and miR-19a-3p potentially regulate these genes, influencing the PI3K/AKT/mTOR pathway. For instance, reduced expression of miR-190a-3p may contribute to the overexpression of PIK3CA and other pathway components, enhancing metastatic potential.

Conclusion

Our findings suggest that the PI3K/AKT/mTOR pathway and its miRNA regulators play crucial roles in breast cancer progression, particularly in aggressive subtypes like TNBC. The identified miRNAs and mRNAs hold potential as biomarkers for diagnosis and treatment, but further validation in functional studies is required. This study provides a foundation for targeted therapies aimed at modulating this critical pathway to improve breast cancer outcomes.

Neoadjuvant Chemotherapy for T3 Tumors in the Era of Precision Medicine-Biology Is Still King

Clinical T3 (cT3) breast cancer (BC) presents a challenge for achieving cosmetically acceptable breast conservation, and neoadjuvant chemotherapy (NAC) is commonly used for cytoreduction in these high-risk cancers. MammaPrint® risk-of-recurrence and BluePrint® molecular subtyping genomic signatures have demonstrated high accuracy in predicting chemotherapy benefits. Here, we examined the utility of MammaPrint/BluePrint for predicting pathological Complete Response (pCR) rates to NAC among 404 patients diagnosed with cT3 early-stage BC. The association of genomic subtype and clinical features with the likelihood of pCR was evaluated by multivariate logistic regression. Differences in pCR rates between genomic risk categories were evaluated by a two-sided proportional z-test and stratified by nodal status. MammaPrint/BluePrint subtyping was associated with significantly higher odds ratios (ORs) for pCR in MammaPrint High-Risk/BluePrint Basal-Type (OR = 3.06, 95% CI: 1.15-8.19, p = 0.025) and HER2-Type (OR = 6.27, 95% CI: 2.19-19.38, p = 0.001) compared to BluePrint Luminal-Type. Of the 209 patients with hormone receptor-positive, HER2-negative disease, 6.7% achieved pCR, and MammaPrint High-Risk was associated with a significantly higher pCR rate (9.3%) compared to MammaPrint Low-Risk cancers (0%), regardless of nodal involvement (p = 0.036). These data show that for patients with MammaPrint Low-Risk, cT3 tumors are less likely to have clinically impactful cytoreduction from NAC, regardless of nodal involvement.

Harnessing Artificial Intelligence to Enhance Global Breast Cancer Care: A Scoping Review of Applications, Outcomes, and Challenges

BACKGROUND

In recent years, Artificial Intelligence (AI) has shown transformative potential in advancing breast cancer care globally. This scoping review seeks to provide a comprehensive overview of AI applications in breast cancer care, examining how they could reshape diagnosis, treatment, and management on a worldwide scale and discussing both the benefits and challenges associated with their adoption.

METHODS

In accordance with PRISMA-ScR and ensuing guidelines on scoping reviews, PubMed, Web of Science, Cochrane Library, and Embase were systematically searched from inception to end of May 2024. Keywords included "Artificial Intelligence" and "Breast Cancer". Original studies were included based on their focus on AI applications in breast cancer care and narrative synthesis was employed for data extraction and interpretation, with the findings organized into coherent themes.

RESULTS

Finally, 84 articles were included. The majority were conducted in developed countries (n = 54). The majority of publications were in the last 10 years (n = 83). The six main themes for AI applications were AI for breast cancer screening (n = 32), AI for image detection of nodal status (n = 7), AI-assisted histopathology (n = 8), AI in assessing post-neoadjuvant chemotherapy (NACT) response (n = 23), AI in breast cancer margin assessment (n = 5), and AI as a clinical decision support tool (n = 9). AI has been used as clinical decision support tools to augment treatment decisions for breast cancer and in multidisciplinary tumor board settings. Overall, AI applications demonstrated improved accuracy and efficiency; however, most articles did not report patient-centric clinical outcomes.

CONCLUSIONS

AI applications in breast cancer care show promise in enhancing diagnostic accuracy and treatment planning. However, persistent challenges in AI adoption, such as data quality, algorithm transparency, and resource disparities, must be addressed to advance the field.

Adjuvant taxane-based chemotherapy treatment in older patients with early breast cancer: A pooled analysis of five phase III trials from the Hellenic Oncology Research Group

INTRODUCTION

The use of taxanes in the adjuvant setting of early breast cancer (BC) confers survival benefits, however, their role in older patients merits further study. This retrospective pooled analysis of randomized controlled trials conducted by the Hellenic Oncology Research Group (HORG) aims to assess the efficacy and safety of taxane-based adjuvant chemotherapy in older women with BC.

MATERIALS AND METHODS

Five phase III trials containing a taxane, conducted by HORG between 1995 and 2013, were included in a patient-data pooled analysis. The primary endpoint was disease-free survival (DFS) at three years, whereas secondary outcomes included overall survival (OS) at five years and toxicity.

RESULTS

A total of 3,026 randomized patients, of whom 701 (23 %) were ≥ 65 years old (median age 69 years; range 65-80), were included in the analysis. No statistically significant heterogeneity in survival was observed between older and younger patients. Within the cohort of older patients, taxane-based regimens were superior to 5-fluorouracil, epirubicin, and cyclophosphamide (FE75C) regimen in terms of three-year DFS (92.02 % vs 77.17 %; p < 0.001) and five-year OS (94.38 % vs 72.64 %; p < 0.001), respectively. A higher number of older patients discontinued treatment compared to younger patients (5.7 % vs 2.9 %; p < 0.001), mainly due to toxicity (3.4 % vs 1.8 %; p = 0.01). The incidence of grade 3-4 neutropenia (35.4 % vs 29.8 %; p = 0.006) and thrombocytopenia (0.8 % vs 0.3 %; p = 0.049) was higher for patients aged ≥65 years compared to those aged <65 years; however, there was no difference in terms of febrile neutropenia and non-hematologic toxicity.

DISCUSSION

Taxane-based adjuvant chemotherapy offers significant survival benefits in older patients with BC, similar to younger patients, yet with increased toxicity.

A Comprehensive Analysis of Neoadjuvant Chemotherapy in Breast Cancer: Adverse Events, Clinical Response Rates, and Surgical and Pathological Outcomes-Bozyaka Experience

Objectives: To evaluate the neoadjuvant chemotherapy (NACTx) process in breast cancer (BC), its significant treatment-related adverse events (trAEs), tumor clinical response rates, and surgical and pathological outcomes, and to analyze factors influencing cavity shaving and axillary lymph node dissection (ALND) following sentinel lymph node biopsy (SLNB). Methods: A comprehensive retrospective study was conducted at a single center on patients who received NACTx for BC between 2015 and 2021. Results: Medical records of 242 patients were reviewed. Approximately one-fifth encountered grade ≥ 3 trAEs (21.5%), leading 3.3% to discontinue chemotherapy. Anthracycline cardiotoxicity (2.2%) caused one death (mortality rate = 0.4%). For clinical response and surgical and pathological outcomes, 229 patients were eligible. Clinical progression occurred in 3.9% of the patients (14% in triple-negative BC, p = 0.004). Breast-conserving surgery (BCS) was performed in 55% of the patients. There was no significant difference between the type of breast surgery (BCS vs. mastectomy) and molecular subtype, histology, tumor size, or tumor's pathological response degree. Cavity shaving was required in one-fifth of the patients who underwent BCS (n = 134) due to an invasive tumor at the surgical margin (SM). Tumor histology (invasive ductal vs. invasive lobular carcinoma; OR: 4.962, 95% CI 1.007-24.441, p = 0.049) and tumor SUVMax value (OR: 0.866, 95% CI 0.755-0.993, p = 0.039) had significant independent efficacy on SM positivity. Initially, 75% underwent SLNB, but nearly half of them needed ALND. ALND rates were significantly higher in the luminal A and LB-HER2(-) groups (87% vs. 69%) than in the HER2(+) and TN groups (43% to 50%) (p = 0.001). All luminal A patients and those with lobular histology required ALND after SLNB, but no patients in the HER2-enriched group required ALND. ER positivity and higher PR expression levels were associated with an increased need for ALND after SLNB, whereas HER2 positivity and higher SUVMax values of LN(s) were associated with a significantly reduced need for ALND. About 27% of the patients achieved overall pCR. No pCR was achieved in the LA group. Conclusions: The BC NACTx process requires close monitoring due to severe AEs and disease progression. NACTx decisions must be made on experienced multidisciplinary tumor boards, considering tumor characteristics and expected targets.

Effect of different intraoperative blood pressure regulation levels on postoperative myocardial injury in patients undergoing radical mastectomy for breast cancer after receiving neoadjuvant chemotherapy: a study protocol for a randomised controlled trial

INTRODUCTION

For patients with breast cancer receiving preoperative neoadjuvant chemotherapy with anthracyclines, there is an increased risk of postoperative myocardial injury due to the cardiotoxicity of the chemotherapeutic agents. The optimal intraoperative blood pressure regulation regimen for these patients is unclear. This study is being conducted to determine whether targeting mean arterial pressure (MAP) to 100%-120% of the patient's baseline blood pressure reduces the incidence of myocardial injury after non-cardiac surgery (MINS) compared with targeting MAP to 80%-100%. MINS is defined as elevated cardiac troponin levels within 30 days after non-cardiac surgery with or without clinical and electrocardiographic signs of cardiac ischaemia.

METHODS AND ANALYSIS

The study is a single-centre, single-blind, prospective randomised controlled trial. It is expected to enrol 166 subjects receiving neoadjuvant chemotherapy with anthracyclines, between the ages of 40 and 75 years, scheduled for radical mastectomy. Participants will be randomised 1:1 to a lower-level group:intraoperative MAP control at 80%-100% of baseline values or a higher-level group:intraoperative MAP control at 100%-120% of baseline values. The primary outcome is defined by the incidence of MINS at 6-8 hours, 24 hours and 48 hours postoperatively. The secondary outcomes are heart-type free fatty acid-binding protein values at 1-2 hours, 6-8 hours and 24 hours postoperatively; the incidence of acute kidney injury within 48 hours postoperatively; the Quality of Recovery-15 score at 24 hours, 48 hours postoperatively; post-anaesthesia care unit length of stay; other postoperative cardiovascular complications; the number of times rescue analgesia and antiemetics are required; the time to first ambulation and length of postoperative hospitalisation.

ETHICS AND DISSEMINATION

This study involves the participation of human subjects and has received approval from the Clinical Trial Ethics Committee at The Affiliated Lianyungang Hospital of Xuzhou Medical University (approval number: KY-20230915001). Study results will be presented at scientific meetings and in scientific publications.

TRIAL REGISTRATION NUMBER

ChiCTR2300077675.

The optimal neoadjuvant treatment strategy for HR+/HER2 + breast cancer: a network meta-analysis

The efficacy of neoadjuvant therapy varies significantly with hormone receptor (HR) status for patients with human epidermal growth factor receptor 2 (HER2) positive breast cancer (BC). Despite extensive research on HER2 + BC, the optimal neoadjuvant strategy for HR+/HER2 + BC remains inconclusive. This study aimed to identify the optimal neoadjuvant regimen for HR+/HER2 + BC treatment. We conducted a systematic search for trials comparing neoadjuvant regimens for HR+/HER2 + BC and a network meta-analysis. Odds ratios for pathological complete response (pCR) and hazard ratios for event-free survival (EFS) were calculated. Treatment regimens were ranked using the surface under the cumulative ranking curve. 20 trials with 2809 patients were included. In pCR analysis, three neoadjuvant regimens sequentially ranked at the top, namely those comprising T-DM1, pertuzumab with trastuzumab, and tyrosine kinase inhibitor with trastuzumab, demonstrating significantly higher pCR rates than monotherapies. In EFS analysis, pertuzumab with trastuzumab ranked the first while T-DM1 containing regimen ranked the last. Anthracycline-free regimens showed a marginally higher pCR rate than anthracycline-containing regimens, while carboplatin-containing regimens demonstrated a numerically higher pCR rate than carboplatin-free regimens. Significant heterogeneity was observed in endocrine therapy analysis, which may be caused by different strategies for incorporating endocrine therapy. In conclusion, trastuzumab plus pertuzumab stands out as the optimal neoadjuvant HER2-targeting regimen for HR+/HER2 + BC Furthermore, anthracycline-free carboplatin-containing chemotherapy emerges as a promising combination treatment. Further investigation is required to clarify the role of endocrine therapy in HR+/HER2 + BC to guide its clinical application.

The Impact of Traditional Chinese Medicine Kidney-Tonifying Methods on Osteoporosis or Bone Loss in HR+ Breast Cancer Patients Following Endocrine Therapy

OBJECTIVE

This study aims to systematically assess the therapeutic effects of Traditional Chinese Medicine (TCM) kidney-tonifying methods on osteoporosis in HR+ breast cancer patients after endocrine therapy, and to explore their clinical application value.

METHODS

This systematic review and meta-analysis adhered to the PRISMA guidelines and aimed to evaluate the impact of TCM kidney-tonifying methods on osteoporosis in HR+ breast cancer patients after endocrine therapy. Literature searches were conducted through October 2024 in databases including CBM, CNKI, Wanfang Data, PubMed, Web of Science, Cochrane Central, VIP, and renowned TCM databases such as TCM Online. Randomized controlled trials reporting lumbar spine bone density, femoral neck bone density, osteocalcin levels, pain VAS scores, and drug safety were included. The Cochrane tool was used for quality assessment, and meta-analysis was performed using RevMan 5.3 and Stata software.

RESULTS

This meta-analysis included 25 studies, covering 1795 patients. The combined results showed significant improvements in lumbar spine bone density (SMD = 0.98, 95 % CI: 0.52-1.44, P < 0.0001), femoral neck bone density (SMD = 0.73, 95 % CI: 0.35-1.10, P = 0.0001), and osteocalcin levels (SMD = 1.23, 95 % CI: 0.52-1.93, P = 0.0007) in patients treated with TCM kidney-tonifying methods compared to those in the control group. There was also a significant reduction in pain VAS scores (SMD = -1.14, 95 % CI:1.55 to -0.72, P < 0.00001). The safety data indicated no significant adverse reactions associated with the treatment.

CONCLUSION

TCM kidney-tonifying methods can significantly improve osteoporosis symptoms post-endocrine therapy in HR+ breast cancer patients, enhance bone density, and effectively reduce pain, demonstrating good safety and potential clinical value. Future research should further validate these findings through large-scale, multi-center randomized controlled trials to optimize treatment strategies.

Assessment of Tumor Response to Neoadjuvant Chemotherapy in Breast Cancer Using MRI and 18F-FDG PET/CT

Objective

Neoadjuvant chemotherapy (NACT) has been the primary treatment method for patients with local advanced breast cancer. A pathological complete response (pCR) to therapy correlates with better overall disease prognosis. Magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT) have been widely used to monitor the response to NACT in breast cancer. The aim of this study was to assess tumor response to NACT by MRI and PET/CT, to determine which imaging modality is more accurate in detecting tumor response post NACT in breast cancer.

Materials and Methods

A retrospective review of our database revealed 34 women with breast cancer that had MRI and PET/CT performed prior to and after NACT, followed by definitive surgery. For response assessment, we calculated the difference in maximum diameter of the tumor in MRI and difference in standard uptake values in PET/CT. The correspondence rate between the imaging modalities and pCR were calculated. For the prediction of pCR, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy where analyzed.

Results

The assessment of tumor response to NACT showed 11 cases with pCR (32%), 15 pathological partial response (44%) and eight pathological no response (24%). The correspondence rate between MRI and pathological response was 50% (17/34), compared to 65% (22/34) for PET/CT. For prediction of pCR, MRI showed higher specificity compared to PET/CT (78.2% vs. 73.9%, p = 0.024), while the accuracy of PET/CT was significantly higher (79.4% vs. 70.5%, p = 0.004). PET/CT also had a higher NPV compared to MRI (94.4% vs. 78.2%, p = 0.002). There were no differences in terms of sensitivity and PPV between MRI and PET/CT.

Conclusion

Compared to MRI, PET/CT was more likely to correlate with the pathological response after NACT. For the prediction of pCR, PET/CT proved to be a more accurate imaging modality to monitor response after NACT than MRI.

Neoadjuvant atezolizumab in combination with dual HER2 blockade plus epirubicin in women with early HER2-positive breast cancer: the randomized phase 2 ABCSG-52/ATHENE trial

The role of anthracyclines in the treatment of early breast cancer (EBC) is increasingly being challenged, especially in de-escalation strategies. However, owing to their immunogenic effects, anthracyclines are promising combination partners with immunotherapies. In the randomized phase 2 trial ABCSG-52 (EudraCT no. 2019-002364-27), we investigated epirubicin plus immunotherapy in women with human epidermal growth factor receptor 2 (HER2)-positive EBC. A total of 58 patients were randomized 1:1 to two cycles of a chemotherapy-free induction phase (part 1) of dual HER2 blockade with trastuzumab and pertuzumab (TP) plus the anti-programmed death ligand 1 antibody atezolizumab (TP-A) or TP alone. Thereafter, all patients received four cycles of TP-A in combination with epirubicin (part 2). The primary endpoint, pathological complete response (pCR), was met in 35 patients (60.3%; 95% confidence interval (CI) 47.5% to 71.9%), 19 patients (65.5%) in the TP-A group and 16 patients (55.2%) in the TP group. The residual cancer burden 0/I rate and objective response rate (secondary endpoints) in all patients with evaluable data were 80.0% (n = 44/55; 95% CI 67.6% to 88.4%) and 89.3% (n = 50/56; 95% CI 78.5% to 95.0%), respectively. Grade ≥3 adverse events were reported in 17 patients (29.3%). Based on our findings, we conclude that a neoadjuvant chemotherapy de-escalation immunotherapy regimen with trastuzumab, pertuzumab, atezolizumab and epirubicin is effective and safe in patients with HER2-positive EBC.

Contemporary trends in utilization of metastasectomy in the era of targeted and immunotherapies

BACKGROUND

Metastasectomy is a useful adjunct in the management of metastatic cancer. Widespread adoption of novel targeted and immunotherapies has improved the survival profiles of multiple malignancies, which has potentially altered the role of metastasectomy. This study aimed to characterize trends in metastasectomy across five primary cancers eligible for these therapies.

METHODS

The National Inpatient Sample was used to identify patients who underwent metastasectomy in the United States (2016-2021). Patients with procedure codes for resection of the lung, liver, adrenal gland, brain, or small bowel and concurrent diagnosis codes for secondary malignant neoplasm of that site were included. Subjects were subcategorized by primary malignancy: colorectal cancer, lung cancer, breast cancer, melanoma, or renal cancer. Sample weights were used to produce national estimates, which were incidence adjusted by primary malignancy. Trends in utilization were calculated with average annual percent change (AAPC) and linear regression coefficients.

RESULTS

Colorectal cancer was the most frequent indication for metastasectomy (n = 57,644 cases), followed by lung cancer (n = 55,090 cases), breast cancer (n = 12,616 cases), renal cancer (n = 8427 cases), and melanoma (n = 5658 cases). Utilization of metastasectomy increased over the study period for breast cancer (AAPC, +10.6%; p = .013) and melanoma (AAPC, +8.3%; p = .040) but did not change for lung cancer (AAPC, -1.6%; p = .26), colorectal cancer (AAPC, +0.3%; p = .83), or renal cancer (AAPC, +2.3%; p = .36).

CONCLUSIONS

Between 2016 and 2021, utilization of metastasectomy increased significantly for melanoma and breast cancer. The role of metastasectomy will likely continue to develop as new treatment protocols improve survival profiles for patients with metastatic disease.

Survival outcomes of neoadjuvant versus adjuvant therapy in patients with T1c, node-negative, human epidermal growth factor receptor 2-positive breast cancer: A Surveillance, Epidemiology, and End Results population-based study

BACKGROUND

Persistent debates exist regarding the superiority of neoadjuvant therapy (NAT) over adjuvant therapy (AT) for patients with T1c, node-negative, human epidermal growth factor receptor 2-positive (HER2+) breast cancer, and relevant guidelines for these patients are lacking.

METHODS

Data on patients with T1cN0M0-stage HER2+ breast cancer who received chemotherapy and surgery were extracted from 2010 to 2020 from the Surveillance, Epidemiology, and End Results database. Propensity score matching (PSM) was used to create well-balanced cohorts for the NAT and AT groups. Kaplan-Meier (KM) analysis and Cox proportional hazards models were used to assess the differences between NAT and AT in terms of overall survival (OS) and breast cancer-specific survival (BCSS). Additionally, logistic regression models were used to explore factors associated with response to NAT.

RESULTS

After PSM, 2140 patient pairs were successfully matched, which achieved a balanced distribution between the NAT and AT groups. KM curves revealed similar OS and BCSS between patients receiving NAT and those undergoing AT. A multivariate Cox model identified achieving pathological complete response (pCR) after NAT, compared with AT, as a protective prognostic factor for OS (hazard ratio, 0.52; 95% CI, 0.35-0.77; p < .001) and BCSS (hazard ratio, 0.60; 95% CI, 0.37-0.98; p = .041). A logistic regression model revealed that White race and hormone receptor-negative status independently predicted pCR.

CONCLUSIONS

For patients with T1cN0M0-stage HER2+ breast cancer, NAT demonstrated comparable OS and BCSS to AT. Patients who achieved pCR after NAT exhibited significantly better survival outcomes compared with those who received AT.

Optimizing Postneoadjuvant Treatment of Residual Breast Cancer With Adjuvant Bevacizumab Alone, With Metronomic or Standard-Dose Chemotherapy: A Combined Analysis of DFCI 05-055 and DFCI 09-134/TBCRC 012/ABCDE Clinical Trials

BACKGROUND

Breast cancer patients with residual disease after neoadjuvant therapy have increased risk of recurrence. Novel therapies to decrease this risk are urgently needed.

METHODS

Two clinical trials (05-055 and 09-134) offered adjuvant bevacizumab-based therapy to stage I-III breast cancer patients with residual disease after neoadjuvant chemotherapy. Study 05-055 evaluated four treatment regimens: bevacizumab (cohort A); bevacizumab with metronomic cyclophosphamide and methotrexate (CM) (cohort B); and bevacizumab with body surface area-dosed capecitabine (cohorts C); or flat-dosed capecitabine (cohort D). The primary endpoint was feasibility and tolerability. In 09-134, patients were randomized to bevacizumab with or without CM; the primary endpoint was recurrence-free survival (RFS). Study 09-134 closed prematurely for lack of accrual. A pooled survival analysis with participants from 05-055 and 09-134 was conducted.

RESULTS

Among 213 total patients (05-055, n = 163; 09-134, n = 50), the most common adverse events (AEs) of any grade were headache (49.3%) and fatigue (57.3%). Grade 3-4 AEs were highest in cohorts C (71.4%) and D (72.5%). The 36-month RFS was 58.0% with bevacizumab monotherapy, 62.3% with bevacizumab plus CM, and 72.7%-75.0% with bevacizumab plus capecitabine (depending on schedule). Treatment with capecitabine was independently associated with improved RFS in triple-negative breast cancer (TNBC) (HR: 0.47; 95% CI, 0.23-0.96).

CONCLUSION

This pooled analysis demonstrates that postneoadjuvant bevacizumab plus capecitabine may be associated with improved RFS, especially in TNBC. Each regimen carries moderate toxicity, and despite these treatments, patients with residual disease after neoadjuvant therapy still experience high rates of recurrence, indicating that new strategies are warranted.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, NCT00121134 (DFCI Protocol Number: 05-055); NCT00925652 (DFCI Protocol Number: 09-134).

Personalized multifactorial risk assessment in neoadjuvant-treated breast carcinoma

PURPOSE

Due to biological heterogeneity of breast carcinoma, predicting the individual response to neoadjuvant treatment (NAT) is complex. Consequently, there are no comprehensive, generally accepted practices to guide post-treatment follow-up. We present clinical and histopathological criteria to advance the prediction of disease outcome in NA-treated breast cancer.

METHODS

A retrospective consecutive cohort of 257 NA-treated Finnish breast cancer patients with up to 13-year follow-up and the corresponding tissue samples of pre- and post-NAT breast and metastatic specimen were evaluated for prognostic impacts. All relevant clinical and biomarker characteristics potentially correlated with tumor response to NAT, course of disease, or outcome of breast cancer were included in the statistical analyses.

RESULTS

The results highlight the intensified characterization of distinguished prognostic factors and previously overlooked histological features, e.g., mitotic and apoptotic activity. Particularly, decreased PR indicated 3.8-fold (CI 1.9-7.4, p = 0.0001) mortality risk, and a > 10.5-year shorter survival for the majority, > 75% of patients (Q1). Clinically applicable prognostic factors both preceding and following NAT were identified and compiled into heat maps to quantify mortality and recurrence risks. Combinations of risk factors for aggressive disease were exemplified as an interactive tool (bcnatreccalc.utu.fi) to illustrate the spectrum of disease outcomes.

CONCLUSION

The results emphasize the value of comprehensive evaluation of conventional patient and biomarker characteristics, especially concerning re-assessment of biomarkers, risk-adapted surveillance, and personalized treatment strategies. Future personalized NA-treatment strategies might benefit from models combining risk-adapted surveillance data and post-NAT re-assessed biomarkers.

Dynamic ultrasound-based modeling predictive of response to neoadjuvant chemotherapy in patients with early breast cancer

Early prediction of patient responses to neoadjuvant chemotherapy (NACT) is essential for the precision treatment of early breast cancer (EBC). Therefore, this study aims to noninvasively and early predict pathological complete response (pCR). We used dynamic ultrasound (US) imaging changes acquired during NACT, along with clinicopathological features, to create a nomogram and construct a machine learning model. This retrospective study included 304 EBC patients recruited from multiple centers. All enrollees had completed NACT regimens, and underwent US examinations at baseline and at each NACT cycle. We subsequently determined that percentage reduction of tumor maximum diameter from baseline to third cycle of NACT serves to independent predictor for pCR, enabling creation of a nomogram ([Formula: see text]). Our predictive accuracy further improved ([Formula: see text]) by combining dynamic US data and clinicopathological features in a machine learning model. Such models may offer a means of accurately predicting NACT responses in this setting, helping to individualize patient therapy. Our study may provide additional insights into the US-based response prediction by focusing on the dynamic changes of the tumor in the early and full NACT cycle.

A Real-World Comparison Between Adjuvant Docetaxel with Cyclophosphamide (TC) and Anthracycline-Taxane Chemotherapy in Early HER-2 Negative Breast Cancer

BACKGROUND

Anthracycline-taxane chemotherapy is the gold standard in high-risk breast cancer (BC), despite the potential risk of congestive heart failure (CHF). A suitable alternative for anthracycline-sparing chemotherapy is through the combination of docetaxel and cyclophosphamide (TC).

METHODS

Through a retrospective study of stage I-III HER2-negative BC, using administrative databases, we analyzed a total of 10,634 women treated with adjuvant chemotherapy in Ontario, Canada, between 2009 and 2017. We compared TC versus standardized anthracycline-taxane chemotherapies (ACT and FEC-D). We investigated the overall survival (OS), and explored the incidence of CHF, emergency department (ED) visits and febrile neutropenia.

RESULTS

With a median follow-up of 5.5 years, the 5-year analysis showed an increased OS in patients treated with TC, versus those treated with ACT, HR 0.77 (0.63-0.95, p = 0.015). Among ER+ BC, there was an increased OS in patients treated with ACT and FEC-D, versus those treated with TC, HR 0.70 (0.52-0.95, p = 0.021) and HR 0.71 (0.56-0.91, p = 0.007), respectively. There were no substantial differences in CHF, between TC and anthracycline-based treatments. Patients treated with TC and FEC-D had more ED visits, compared to those treated with ACT.

CONCLUSION

Our study shows that anthracycline-taxane regimens were the most commonly prescribed adjuvant chemotherapy options in HER2-negative BC. Women who received ACT had the lowest OS, likely due to their unfavorable pathology.

Apoptotic and Molecular Mechanisms of Carthamidin in Breast Cancer Therapy: An Integrated In Vitro and In Silico Study

The current study examines the anticancer properties of the chemical carthamidin in breast cancer through in-vitro and in silico analysis. This study's results demonstrated that carthamidin strongly inhibited the proliferation of MCF 7 cells in vitro, as evidenced by an IC50 value of 128.65 µg/mL at 24 h, determined using the MTT test. Laser confocal microscopy utilizing AO/EB labeling validated apoptotic effects through upregulating pro-apoptotic cell markers. At the same time, the ROS assay demonstrated elevated ROS production in the treated cells. LDH leakage was corroborated by leakage analysis, revealing high LDH levels at 100 µg/mL. The cellular growth parameters were subsequently examined via flow cytometry, showing that the cell cycle was halted in the G0/G1 phase, with 82.9% of the cells residing there. The molecular docking research demonstrated that carthamidin displayed a significant binding affinity with Notch receptors - NOTCH 1-4 and p53, with binding scores ranging from - 5.027 to - 7.402 kcal/mol. The results suggest that carthamidin has therapeutic potential in inducing apoptosis and impairing cancer cells, warranting further investigation in breast cancer treatments.

Establishment and clinical application of a prognostic index for inflammatory status in triple-negative breast cancer patients undergoing neoadjuvant therapy using machine learning

OBJECTIVE

This study aims to establish a new prognostic index using machine learning models to predict the clinical outcomes of triple-negative breast cancer (TNBC) patients receiving neoadjuvant therapy.

METHODS

In this study, we collected data from the electronic medical records system of Harbin Medical University Cancer Hospital to establish a training set of 501 breast cancer patients who received neoadjuvant therapy from January 2017 to December 2021. Additionally, we collected data from Harbin Medical University Affiliated Cancer Hospital, Harbin Medical University Affiliated Second Hospital, and Harbin Medical University Affiliated Sixth Hospital to establish a validation set of 1533 patients during the same period. All patients underwent blood tests, and the following inflammatory and immune indices were calculated for each patient: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammatory index (SII), systemic inflammatory response index (SIRI), and advanced lung cancer inflammation index (ALI). The observed outcomes included Disease-free survival (DFS) and overall survival (OS). Survival analysis was performed using Kaplan‒Meier survival curves, Cox survival analysis, propensity score matching analysis (PSM), and a nomogram to comprehensively investigate the impact of inflammatory status on patient survival.

RESULTS

The training set comprised 501 patients with a mean age of 48.63 (9.41) years, while the validation set comprised 1533 patients with a mean age of 49.01 (9.51) years. The formula for ANLR established through Lasso regression analysis on the training set is: ANLR index = NLR - 0.04 × ALB (g/L). In both the training and validation sets, ANLR was significantly associated with patient DFS and OS (all P < 0.05). Additionally, ANLR was found to be an independent prognostic factor in this study. PSM analysis further confirmed its significant correlation with patient DFS and OS (76 cases vs. 76 cases, χ2 = 2.179, P = 0.001 and χ2 = 2.063, P = 0.002). The nomogram containing ANLR also demonstrated high prognostic value. The C-index for the nomogram in the training set was 0.742 (0.619-0.886) for DFS and 0.758 (0.607-0.821) for OS, while in the validation set, the C-index was 0.733 (0.655-0.791) for DFS and 0.714 (0.634-0.800) for OS.

CONCLUSION

ANLR was associated with the prognosis of TNBC patients receiving neoadjuvant therapy and could identify high-risk postoperative patients.

Does T1c-2N0-1M0 triple negative breast cancer derive a benefit from neoadjuvant chemotherapy?

OBJECTIVES

Although neoadjuvant chemotherapy (NCT) is a standard approach for operable triple negative breast cancer (TNBC), the potential risks brought by it should also be noticed. Is the expanding indication of NCT to T1cN0M0 population appropriate? We conducted an investigation to compare the long-term survival of small tumor TNBC between NCT and adjuvant chemotherapy (ACT).

METHODS

For this propensity-matched analysis, we used data from Surveillance, Epidemiology, and End Results (SEER) database. We enrolled 1183 cases with NCT and 2550 cases with ACT who are AJCC clinical T1c-T2 N0-N1, diagnosed with invasive triple-negative breast cancer, from 2016 to 2017. The propensity score matching was utilized to minimize baseline characteristics bias. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated by the Cox proportional hazard regression model.

RESULTS

Compared with patients receiving ACT, patients with NCT in this study presented a higher proportion of younger age, T2 stage, N1 stage, and underwent more mastectomy. Multivariate analysis in matched patients showed that NCT had no significant survival benefit compared with ACT in T1c-2N0-1M0 TNBC patients. Stratified analyses by T stage and N stage demonstrated NCT mainly presented a survival advantage in patients with N1 stage. Further investigation found that NCT didn't improve BCSS (HR, 0.472; 95% CI 0.135-1.647; P = 0.239) and OS (HR, 0.392; 95% CI 0.147-1.047; P = 0.062) for patients with T1cN0M0 TNBC; however, it was associated with improved OS (HR, 1.951; 95% CI 1.003-3.797; P = 0.049) only for patients with T2N1M0 TNBC.

CONCLUSIONS

In this study, we did not find any profit brought by NCT in the stage I and stage IIa cohorts, but even more unfavorable outcomes appeared in the T1cN0M0 cohort. Therefore, whether the candidates of NCT should be extended to T1cN0M0 still need to be cautious.