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Tvedskov TF, Szulkin R, Alkner S, Andersson Y, Bergkvist L, Frisell J, Gentilini OD, Kontos M, Kühn T, Lundstedt D, Offersen BV, Bagge RO, Reimer T, Sund M, Rydén L, Christiansen P, de Boniface J. Axillary clearance and chemotherapy rates in ER+HER2- breast cancer: secondary analysis of the SENOMAC trial. THE LANCET REGIONAL HEALTH. EUROPE 2024; 47:101083. [PMID: 39386258 PMCID: PMC11460525 DOI: 10.1016/j.lanepe.2024.101083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 09/10/2024] [Accepted: 09/10/2024] [Indexed: 10/12/2024]
Abstract
Background Randomized trials have shown that axillary clearance (AC) can safely be omitted in patients with sentinel lymph node-positive breast cancer. At the same time, de-escalation of chemotherapy in postmenopausal patients with ER+HER2- breast cancer may depend on detailed axillary nodal stage. The aim of this pre-specified secondary analysis of the SENOMAC trial was to investigate whether the choice of axillary staging affected the proportion of patients receiving adjuvant chemotherapy, and recurrence-free survival (RFS). Methods Proportion receiving adjuvant chemotherapy was calculated according to AC or sentinel lymph node biopsy (SLNB) only, menopausal status, and region of inclusion, for 2168 patients with clinically node-negative ER+HER2- breast cancer and 1-2 sentinel lymph node macrometastases included in the SENOMAC trial. Findings In premenopausal patients, 514 out of 615 patients (83.6%) received adjuvant chemotherapy with no significant difference between randomization arms. In postmenopausal patients, the proportion receiving chemotherapy varied considerably by region and country (36.0-82.4%). In Denmark, where 194 out of 539 postmenopausal patients (36.0%) received adjuvant chemotherapy, rates differed significantly between the AC and the SLNB only arm (41.3% vs 31.4%, p = 0.019). After a median follow-up of 44.88 months for Danish postmenopausal patients, no significant difference was seen in 5-year RFS, which was 91% (85.6%-96.6%) for the SLNB only and 90.9% (86.3%-95.6%) for the AC arm (p = 0.42). Interpretation When omitting axillary clearance, and thus reducing the risk of long-term arm morbidity, potential under-treatment of postmenopausal patients with ER+HER2- breast cancer may require the development of new predictive and imaging tools. Funding Swedish Research Council, Swedish Cancer Society, Nordic Cancer Union, Swedish Breast Cancer Association.
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Affiliation(s)
- Tove Filtenborg Tvedskov
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Breast Surgery, Gentofte Hospital, Gentofte, Denmark
| | - Robert Szulkin
- Cytel Inc., Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sara Alkner
- Department of Oncology, Faculty of Medicine, Institution of Clinical Sciences Lund, Lund University, Lund, Sweden
- Skåne University Hospital, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Yvette Andersson
- Department of Surgery, Vastmanland Hospital Vasteras, Vasteras, Sweden
- Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Leif Bergkvist
- Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Jan Frisell
- Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Oreste Davide Gentilini
- Breast Surgery, IRCCS Ospedale San Raffaele, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
| | - Michalis Kontos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Kühn
- Die Filderklinik, Breast Center, Filderstadt, Germany
- Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Oncology at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Birgitte Vrou Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
- Department of Experimental Clinical Oncology, Danish Center for Particle Therapy, Aarhus, Denmark
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Surgery at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Malin Sund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Finland
- Department of Diagnostics and Intervention/ Surgery, Umeå University, Sweden
| | - Lisa Rydén
- Department of Oncology and Surgery, Faculty of Medicine, Institution of Clinical Sciences Lund, Lund University, Lund, Sweden
- Skåne University Hospital Lund, Department of Gastroenterology and Surgery, Malmö, Sweden
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St. Göran's Hospital, Stockholm, Sweden
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2
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Wang Z, Lu Y, Han M, Li A, Ruan M, Tong Y, Yang C, Zhang X, Zhu C, Wang C, Shen K, Dong L, Chen X. Association between homologous recombination deficiency status and carboplatin treatment response in early triple-negative breast cancer. Breast Cancer Res Treat 2024; 208:429-440. [PMID: 39048852 PMCID: PMC11457550 DOI: 10.1007/s10549-024-07436-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/10/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND The aim of this study was to assess homologous recombination deficiency (HRD) status and its correlation with carboplatin treatment response in early triple-negative breast cancer (TNBC) patients. METHODS Tumor tissues from 225 consecutive TNBC patients were evaluated with an HRD panel and homologous recombination-related (HRR) gene expression data. HRD positivity was defined as a high HRD score and/or BRCA1/2 pathogenic or likely pathogenic mutation. Clinicopathological factors, neoadjuvant treatment response, and prognosis were analyzed with respect to HRD status in these TNBC patients. RESULTS HRD positivity was found in 53.3% of patients and was significantly related to high Ki67 levels (P = 0.001). In patients who received neoadjuvant chemotherapy, HRD positivity (P = 0.005) or a high HRD score (P = 0.003) was significantly associated with a greater pathological complete response (pCR) rate, especially in those treated with carboplatin-containing neoadjuvant regimens (HRD positivity vs. negativity: 50.00% vs. 17.65%, P = 0.040). HRD positivity was associated with favorable distant metastasis-free survival (hazard ratio HR 0.49, 95% confidence interval CI 0.26-0.90, P = 0.022) and overall survival (HR 0.45, 95% CI 0.20-0.99, P = 0.049), irrespective of carboplatin treatment. CONCLUSION TNBC patients with high HRDs had high Ki67 levels and BRCA mutations. HRD-positive TNBC patients treated with carboplatin had a higher pCR rate. Patients with HRD positivity had a better prognosis, irrespective of carboplatin treatment, warranting further evaluation.
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Affiliation(s)
- Zheng Wang
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yujie Lu
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Mengyuan Han
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Anqi Li
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Miao Ruan
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yiwei Tong
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Cuiyan Yang
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Xiaotian Zhang
- Department of Translational Oncology, Amoy Diagnostics Co., Ltd., Xiamen, 361026, China
| | - Changbin Zhu
- Department of Translational Oncology, Amoy Diagnostics Co., Ltd., Xiamen, 361026, China
| | - Chaofu Wang
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Kunwei Shen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Lei Dong
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Xiaosong Chen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
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3
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Nader-Marta G, Singer C, Hlauschek D, DeMichele A, Tarantino P, de Azambuja E, Pfeiler G, Martin M, Balko JM, Nowecki Z, Balic M, Brufsky AM, Chan A, Morris PG, Haddad T, Loibl S, Liu Y, Soelkner L, Fesl C, Mayer EL, Gnant M. Clinical characterization, prognostic, and predictive values of HER2-low in patients with early breast cancer in the PALLAS trial (ABCSG-42/AFT-05/BIG-14-13/PrE0109). Breast Cancer Res 2024; 26:140. [PMID: 39375745 PMCID: PMC11459983 DOI: 10.1186/s13058-024-01899-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 10/01/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND Bidirectional crosstalk between HER2 and estrogen receptor (ER) pathways may influence outcomes and the efficacy of endocrine therapy (ET). Low HER2 expression levels (HER2-low) have emerged as a predictive biomarker in patients with breast cancer (BC). METHODS PALLAS is an open, international, phase 3 study evaluating the addition of palbociclib for 2 years to adjuvant ET in patients with stage II-III ER-positive/HER2-negative BC. To assess the impact of HER2 expression on patient outcomes in the phase III PALLAS trial, we analyzed (1) the association between rate of HER2-low with demographic and clinicopathological parameters, (2) the prognostic value of HER2-low status on invasive disease-free survival (iDFS), distant relapse-free survival (DRFS), and overall survival (OS) and (3) HER2 expression's value as a predictive biomarker of response to palbociclib. HER2-low was defined as HER2 immunohistochemistry (IHC) 1 + or IHC 2 + with negative in situ hybridization (ISH). All pathologic evaluation was performed locally. Prognostic and predictive power of HER2 were assessed with Cox models. RESULTS From the original PALLAS intention-to-treat population (N = 5753), 5304 patients (92.2%) were included in this analysis. Among these, 2254 patients (42.5%) were classified as having HER2 IHC 0 (HER2-0), and 3050 (57.5%) as having HER2-low disease (1838 with IHC 1 + and 1212 with IHC 2 +). Median follow-up was 59.8 months. HER2-low prevalence varied significantly across 21 participating countries (range 16.7% to 75.6%; p < 0.001) and was more frequent in patients enrolled in North America (63.1%) than in Europe (53.4%) or other regions (53.4%) (p < 0.001). HER2 status was not significantly associated with iDFS in a multivariable Cox model (hazard ratio 0.93, 95% confidence interval 0.81 - 1.06). No significant interaction was observed between treatment arm and HER2 status for iDFS (p = 0.43). Similar results were obtained for DRFS and OS. CONCLUSIONS In this large, prospective, global patient cohort, no differences were observed in clinical parameters, prognosis, or differential benefit from palbociclib between HER2-0 and HER2-low tumors. Significant geographic variability was observed in the prevalence of HER2-low status, suggesting a high degree of variation in pathologic assessment of HER2 expression without impact on outcomes.
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Affiliation(s)
- Guilherme Nader-Marta
- Institut Jules Bordet, Academic Trials Promoting Team (ATPT), Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium.
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Christian Singer
- Department of Obstetrics and Gynaecology and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Dominik Hlauschek
- Austrian Breast and Colorectal Cancer Study Group (ABCSG), Vienna, Austria
| | - Angela DeMichele
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Paolo Tarantino
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Evandro de Azambuja
- Institut Jules Bordet, Academic Trials Promoting Team (ATPT), Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Georg Pfeiler
- Department of Obstetrics and Gynaecology and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Miguel Martin
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Justin M Balko
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zbigniew Nowecki
- The Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Marija Balic
- Division of Oncology, Department of Internal Medicine, Medical University Graz, Graz, Austria
- University of Pittsburgh Hillman Cancer Center, Magee-Women's Hospital, Pittsburgh, PA, USA
| | - Adam M Brufsky
- University of Pittsburgh Hillman Cancer Center, Magee-Women's Hospital, Pittsburgh, PA, USA
| | - Arlene Chan
- Breast Cancer Research Centre-WA & Curtin University, Perth, Australia
| | - Patrick G Morris
- Cancer Trials Ireland, Dublin, Ireland
- Beaumont RCSI Cancer Centre, Dublin, Ireland
| | - Tufia Haddad
- Mayo Clinic Comprehensive Cancer Center, Rochester, MN, USA
| | - Sibylle Loibl
- German Breast Group, Prof. (Apl), Goethe University Frankfurt, Frankfurt am Main, Germany
- Clinical Consultant Centre for Haematology and Oncology/Bethanien, Frankfurt, Germany
| | - Yuan Liu
- Translational Oncology Global Product Development Pfizer Inc, San Diego, CA, USA
| | - Lidija Soelkner
- Austrian Breast and Colorectal Cancer Study Group (ABCSG), Vienna, Austria
| | - Christian Fesl
- Austrian Breast and Colorectal Cancer Study Group (ABCSG), Vienna, Austria
| | - Erica L Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Michael Gnant
- Austrian Breast and Colorectal Cancer Study Group (ABCSG), Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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4
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Skarping I, Bendahl PO, Szulkin R, Alkner S, Andersson Y, Bergkvist L, Christiansen P, Filtenborg Tvedskov T, Frisell J, Gentilini OD, Kontos M, Kühn T, Lundstedt D, Vrou Offersen B, Olofsson Bagge R, Reimer T, Sund M, Rydén L, de Boniface J. Prediction of High Nodal Burden in Patients With Sentinel Node-Positive Luminal ERBB2-Negative Breast Cancer. JAMA Surg 2024:2824187. [PMID: 39320882 PMCID: PMC11425194 DOI: 10.1001/jamasurg.2024.3944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
Importance In patients with clinically node-negative (cN0) breast cancer and 1 or 2 sentinel lymph node (SLN) macrometastases, omitting completion axillary lymph node dissection (CALND) is standard. High nodal burden (≥4 axillary nodal metastases) is an indication for intensified treatment in luminal breast cancer; hence, abstaining from CALND may result in undertreatment. Objective To develop a prediction model for high nodal burden in luminal ERBB2-negative breast cancer (all histologic types and lobular breast cancer separately) without CALND. Design, Setting, and Participants The prospective Sentinel Node Biopsy in Breast Cancer: Omission of Axillary Clearance After Macrometastases (SENOMAC) trial randomized patients 1:1 to CALND or its omission from January 2015 to December 2021 among adult patients with cN0 T1-T3 breast cancer and 1 or 2 SLN macrometastases across 5 European countries. The cohort was randomly split into training (80%) and test (20%) sets, with equal proportions of high nodal burden. Prediction models were developed by multivariable logistic regression in the complete luminal ERBB2-negative cohort and a lobular breast cancer subgroup. Nomograms were constructed. The present diagnostic/prognostic study presents the results of a prespecified secondary analysis of the SENOMAC trial. Herein, only patients with luminal ERBB2-negative tumors assigned to CALND were selected. Data analysis for this article took place from June 2023 to April 2024. Exposure Predictors of high nodal burden. Main Outcomes and Measures High nodal burden was defined as ≥4 axillary nodal metastases. The luminal prediction model was evaluated regarding discrimination and calibration. Results Of 1010 patients (median [range] age, 61 [34-90] years; 1006 [99.6%] female and 4 [0.4%] male), 138 (13.7%) had a high nodal burden and 212 (21.0%) had lobular breast cancer. The model in the training set (n = 804) included number of SLN macrometastases, presence of SLN micrometastases, SLN ratio, presence of SLN extracapsular extension, and tumor size (not included in lobular subgroup). Upon validation in the test set (n = 201), the area under the receiver operating characteristic curve (AUC) was 0.74 (95% CI, 0.62-0.85) and the calibration was satisfactory. At a sensitivity threshold of ≥80%, all but 5 low-risk patients were correctly classified corresponding to a negative predictive value of 94%. The prediction model for the lobular subgroup reached an AUC of 0.74 (95% CI, 0.66-0.83). Conclusions and Relevance The predictive models and nomograms may facilitate systemic treatment decisions without exposing patients to the risk of arm morbidity due to CALND. External validation is needed. Trial Registration ClinicalTrials.gov Identifier: NCT02240472.
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Affiliation(s)
- Ida Skarping
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Clinical Physiology and Nuclear Medicine, Skane University Hospital, Lund, Sweden
| | - Pär-Ola Bendahl
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Robert Szulkin
- Cytel Inc, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
| | - Sara Alkner
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Yvette Andersson
- Department of Surgery, Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Västmanland Hospital Västerås, Sweden
| | - Leif Bergkvist
- Centre for Clinical Research Uppsala University, Västmanland Hospital Västerås, Sweden
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hosoital, Denmark
| | - Tove Filtenborg Tvedskov
- Department of Breast Surgery, Gentofte Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Oreste D Gentilini
- Università Vita-Salute San Raffaele, Milano, Italy
- IRCCS Ospedale San Raffaele, Milano, Italy
| | - Michalis Kontos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Thorsten Kühn
- Interdisciplinary Breast Center, University of Ulm, Ulm, Germany
- Breast Center Die Filderklinik, Filderstadt, Germany
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Aarhus University, Faculty of Health, Aarhus, Denmark
| | - Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Malin Sund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Diagnostics and Intervention/Surgery, Umeå University, Umeå, Sweden
| | - Lisa Rydén
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Surgery and Gastroenterology, Skane University Hospital, Lund, Sweden
| | - Jana de Boniface
- Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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5
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Agostinetto E, Bruzzone M, Hamy AS, Kim HJ, Chiodi C, Bernstein-Molho R, Linn S, Pogoda K, Carrasco E, Derouane F, Bajpai J, Nader-Marta G, Lopetegui-Lia N, Partridge AH, Cortesi L, Rousset-Jablonski C, Giugliano F, Renaud T, Ferrari A, Paluch-Shimon S, Fruscio R, Cui W, Wong SM, Vernieri C, Ruddy KJ, Dieci MV, Matikas A, Rozenblit M, Aguilar Y Mendez D, De Marchis L, Borea R, Puglisi F, Pistelli M, Kufel-Grabowska J, Di Rocco R, Mariamidze E, Atzori F, Kourie HR, Popovic L, de Azambuja E, Blondeaux E, Lambertini M. Characteristics and clinical outcomes of breast cancer in young BRCA carriers according to tumor histology. ESMO Open 2024; 9:103714. [PMID: 39288653 PMCID: PMC11421331 DOI: 10.1016/j.esmoop.2024.103714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/11/2024] [Accepted: 08/19/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND Young women with breast cancer (BC) have an increased chance of carrying germline BRCA pathogenic variants (PVs). Limited data exist on the prognostic impact of tumor histology (i.e. ductal versus lobular) in hereditary breast cancer. METHODS This multicenter retrospective cohort study included women aged ≤40 years with early-stage breast cancer diagnosed between January 2000 and December 2020 and known to carry germline PVs in BRCA1/2. Histology was locally assessed in each center. The Kaplan-Meier method and Cox regression analysis were used to assess disease-free survival and overall survival. RESULTS Of 4628 patients included from 78 centers worldwide, 3969 (86%) had pure ductal, 135 (3%) pure lobular, and 524 (11%) other histologies. Compared with ductal tumors, lobular tumors were more often grade 1/2 (57.7% versus 22.1%), stage III (29.6% versus 18.5%), and luminal A-like (42.2% versus 12.2%). Lobular tumors were more often associated with BRCA2 PVs (71.1% BRCA2), while ductal tumors were more often associated with BRCA1 PVs (65.7% BRCA1). Patients with lobular tumors more often had mastectomy (68.9% versus 58.3%), and less often received chemotherapy (83.7% versus 92.9%). With a median follow-up of 7.8 years, no significant differences were observed in disease-free survival (adjusted hazard ratio 1.01, 95% confidence interval 0.74-1.37) or overall survival (hazard ratio 0.96, 95% confidence interval 0.62-1.50) between patients with ductal versus lobular tumors. No significant survival differences were observed according to specific BRCA gene, breast cancer subtype, or body mass index. CONCLUSIONS In this large global cohort of young BRCA carriers with breast cancer, the incidence of pure lobular histology was low and associated with higher disease stage at diagnosis, luminal-like disease and BRCA2 PVs. Histology did not appear to impact prognosis.
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Affiliation(s)
- E Agostinetto
- Academic Trials Promoting Team, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium.
| | - M Bruzzone
- U.O. Epidemiologia Clinica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - A-S Hamy
- Department of Medical Oncology, Universite Paris Cité, Institut Curie, Paris, France
| | - H J Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - C Chiodi
- Cancer Survivorship Program - Molecular Predictors and New Targets in Oncology, INSERM Unit 981, Gustave Roussy, Villejuif, France
| | - R Bernstein-Molho
- Susanne Levy Gertner Oncogenetics Unit, The Danek Gertner Institute of Human Genetics, Chaim Sheba Medical Center Affiliated to Tel Aviv University, Tel Hashomer, Israel
| | - S Linn
- Department of Molecular Pathology, Netherlands Cancer Institute (NKI), Amsterdam, The Netherlands
| | - K Pogoda
- Department of Breast Cancer and Reconstructive Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - E Carrasco
- Hereditary Cancer Genetics Unit, Medical Oncology Department, Vall d´Hebron University Hospital, Vall d´Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - F Derouane
- Department of General Medical Oncology and Multidisciplinary Breast Center, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - J Bajpai
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - G Nader-Marta
- Academic Trials Promoting Team, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - N Lopetegui-Lia
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland
| | - A H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - L Cortesi
- Department of Oncology and Haematology, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - C Rousset-Jablonski
- Department of Surgery, Leon Berard Cancer Center, Lyon; Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron; Unité INSERM U1290 RESHAPE, Lyon
| | - F Giugliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - T Renaud
- Cancer Genetics Unit, Bergonie Institute, Bordeaux, France
| | - A Ferrari
- Hereditary Breast and Ovarian Cancer (HBOC) Unit and General Surgery 3 - Senology, Surgical Department, Fondazione IRCCS Policlinico San Matteo, Pavia; University of Pavia, Pavia, Italy
| | - S Paluch-Shimon
- Breast Oncology Unit, Sharett Institute of Oncology, Hadassah University Hospital, Jerusalem; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - R Fruscio
- UO Gynecology, Fondazione IRCCS San Gerardo, Monza; Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - W Cui
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria; Department of Medical Oncology, Peter MacCallum Cancer Center, Melbourne, Australia
| | - S M Wong
- Stroll Cancer Prevention Centre, Jewish General Hospital, Montreal; McGill University Medical School, Montreal, Canada
| | - C Vernieri
- Medical Oncology Department, Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan; Oncology and Hematology-Oncology Department, University of Milan, Milan, Italy
| | - K J Ruddy
- Department of Oncology, Mayo Clinic College of Medicine, Rochester, USA
| | - M V Dieci
- Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padua; Oncologia 2, Istituto Oncologico Veneto IOV-IRCCS, Padua, Italy
| | - A Matikas
- Department of Oncology/Pathology, Karolinska Institute, Stockholm; Breast Center, Karolinska University Hospital, Stockholm, Sweden
| | - M Rozenblit
- Yale University, Medical Oncology, New Haven, USA
| | - D Aguilar Y Mendez
- Tecnologico de Monterrey, Breast Cancer Center, Hospital Zambrano Hellion - TecSalud, Monterrey, Mexico
| | - L De Marchis
- Division of Medical Oncology, Department of Radiological, Oncological and Pathological Sciences, 'La Sapienza' University of Rome, Rome; Oncology Unit, Umberto 1 University Hospital, Rome
| | - R Borea
- Medical Oncology Department, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa; Department of Internal Medicine and Medical Specialties (DIMI), School of Medicine, University of Genova, Genoa
| | - F Puglisi
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano; Department of Medicine, University of Udine, Udine
| | - M Pistelli
- Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | | | - R Di Rocco
- Department of Medical Oncology, Azienda USL Toscana Sud Est - Misericordia Hospital, Grosseto, Italy
| | - E Mariamidze
- Medical Oncology Department, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa; Department of Oncology and Hematology, Todua Clinic, Tbilisi, Georgia
| | - F Atzori
- Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - H R Kourie
- Saint Joseph University of Beirut, Beirut, Lebanon
| | - L Popovic
- Oncology Institute of Vojvodina - Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - E de Azambuja
- Academic Trials Promoting Team, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - E Blondeaux
- U.O. Epidemiologia Clinica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - M Lambertini
- Medical Oncology Department, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa; Department of Internal Medicine and Medical Specialties (DIMI), School of Medicine, University of Genova, Genoa
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6
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Ballé JK, Vetter M, Kenea TW, Eber-Schulz P, Reibold C, Ziegenhorn HV, Stückrath K, Wickenhauser C, Addissie A, Santos P, Kantelhardt EJ, Getachew S, Bauer M. PAM50 breast cancer subtypes and survival of patients in rural Ethiopia without adjuvant treatment: a prospective observational study. BMC Cancer 2024; 24:1127. [PMID: 39256703 PMCID: PMC11385137 DOI: 10.1186/s12885-024-12867-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 08/27/2024] [Indexed: 09/12/2024] Open
Abstract
PURPOSE Survival rates of breast cancer (BC) patients are particularly low in rural regions in sub-Saharan Africa (SSA) which is due to limited access to therapy. In recent years, gene expression profiling (GEP) of BC showed a strong prognostic value in patients with local tumour surgery and (neo)adjuvant treatment. The aim of this study was to evaluate the impact of intrinsic subtypes on survival of patients in rural Ethiopia without any (neo)adjuvant therapy. METHODS In total, 113 female patients from Aira Hospital with histologically proven BC and treated only with surgery were included in this study. All samples were analysed by immunohistochemistry (IHC) for estrogen receptor, progesterone receptor, HER2 and Ki67, as well as RNA-expression analysis for PAM50 subtyping. RESULTS A positive hormone receptor status was found in 69.0% of the tumours and intrinsic subtyping demonstrated Luminal B to be the most common subtype (34.5%). Follow-up data was available for 79 of 113 patients. Two-year overall survival (OS) was 57.3% and a considerably worse OS was observed in patients with Basal-like BC compared to Luminal A BC. Moreover, advanced tumours showed an increased risk of mortality. CONCLUSION The OS was very low in the patient cohort that received no (neo)adjuvant treatment. Immunohistochemistry and GEP confirmed endocrine-sensitive tumours in more than half of the patients, with a large proportion of Luminal B, HER2-enriched and Basal-like tumours so that adjuvant chemotherapy should be recommended.
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Affiliation(s)
- Judith Katharina Ballé
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Martina Vetter
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | | | - Pia Eber-Schulz
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Christian Reibold
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Hannes-Viktor Ziegenhorn
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Department of Anesthesiology and Critical Care Medicine, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Kathrin Stückrath
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Claudia Wickenhauser
- Institute of Pathology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Adamu Addissie
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Pablo Santos
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Eva Johanna Kantelhardt
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Sefonias Getachew
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Marcus Bauer
- Global Health Working Group, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
- Institute of Pathology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
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7
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Rodin D, Glicksman RM, Hepel JT, Huber K, Kirova Y, Loap P, Rakovitch E. Early-Stage Breast Cancer: A Critical Review of Current and Emerging Practice. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03293-0. [PMID: 39237044 DOI: 10.1016/j.ijrobp.2024.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/05/2024] [Accepted: 08/09/2024] [Indexed: 09/07/2024]
Abstract
Breast-conserving surgery followed by adjuvant radiation to reduce the risk of ipsilateral breast tumor recurrence is the mainstay of treatment for early-stage breast cancer (ESBC). However, improved understanding of the heterogeneity of the clinical and molecular characteristics of ESBC has led to greater efforts to personalize approaches to treatment. Furthermore, advances in the understanding of the radiobiology of breast cancer have led to several practice-changing trials on the effectiveness and tolerability of moderate and ultrahypofractionated radiation. Here, we review the recent evidence and ongoing research in the radiotherapeutic management of ESBC, including the use of boost for high-risk disease and opportunities for accelerated fractionation, partial breast irradiation, and radiation omission for low-risk disease. We also discuss how molecular profiling can inform decision-making and new opportunities for primary radiation therapy and reirradiation.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada.
| | - Rachel M Glicksman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jaroslaw T Hepel
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island
| | - Kathryn Huber
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Tufts University, Boston, Massachusetts
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Eileen Rakovitch
- Department of Radiation Oncology, University of Toronto, Ontario, Canada; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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8
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Huang X, Wu L, Liu Y, Xu Z, Liu C, Liu Z, Liang C. Development and validation of machine learning models for predicting HER2-zero and HER2-low breast cancers. Br J Radiol 2024; 97:1568-1576. [PMID: 38991838 PMCID: PMC11332671 DOI: 10.1093/bjr/tqae124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/03/2024] [Accepted: 06/23/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVES To develop and validate machine learning models for human epidermal growth factor receptor 2 (HER2)-zero and HER2-low using MRI features pre-neoadjuvant therapy (NAT). METHODS Five hundred and sixteen breast cancer patients post-NAT surgery were randomly divided into training (n = 362) and internal validation sets (n = 154) for model building and evaluation. MRI features (tumour diameter, enhancement type, background parenchymal enhancement, enhancement pattern, percentage of enhancement, signal enhancement ratio, breast oedema, and apparent diffusion coefficient) were reviewed. Logistic regression (LR), support vector machine (SVM), k-nearest neighbour (KNN), and extreme gradient boosting (XGBoost) models utilized MRI characteristics for HER2 status assessment in training and validation datasets. The best-performing model generated a HER2 score, which was subsequently correlated with pathological complete response (pCR) and disease-free survival (DFS). RESULTS The XGBoost model outperformed LR, SVM, and KNN, achieving an area under the receiver operating characteristic curve (AUC) of 0.783 (95% CI, 0.733-0.833) and 0.787 (95% CI, 0.709-0.865) in the validation dataset. Its HER2 score for predicting pCR had an AUC of 0.708 in the training datasets and 0.695 in the validation dataset. Additionally, the low HER2 score was significantly associated with shorter DFS in the validation dataset (hazard ratio: 2.748, 95% CI, 1.016-7.432, P = .037). CONCLUSIONS The XGBoost model could help distinguish HER2-zero and HER2-low breast cancers and has the potential to predict pCR and prognosis in breast cancer patients undergoing NAT. ADVANCES IN KNOWLEDGE HER2-low-expressing breast cancer can benefit from the HER2-targeted therapy. Prediction of HER2-low expression is crucial for appropriate management. MRI features offer a solution to this clinical issue.
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Affiliation(s)
- Xu Huang
- Department of Radiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou 510080, China
| | - Lei Wu
- Department of Radiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou 510080, China
| | - Yu Liu
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou 510080, China
- Department of Ultrasound, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Zeyan Xu
- Department of Radiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou 510080, China
| | - Chunling Liu
- Department of Radiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou 510080, China
| | - Zaiyi Liu
- Department of Radiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou 510080, China
| | - Changhong Liang
- Department of Radiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou 510080, China
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9
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Soldato D, Michiels S, Havas J, Di Meglio A, Pagliuca M, Franzoi MA, Pistilli B, Iyengar NM, Cottu P, Lerebours F, Coutant C, Bertaut A, Tredan O, Vanlemmens L, Jouannaud C, Hrab I, Everhard S, Martin AL, André F, Vaz-Luis I, Jones LW. Dose/Exposure Relationship of Exercise and Distant Recurrence in Primary Breast Cancer. J Clin Oncol 2024; 42:3022-3032. [PMID: 38838281 PMCID: PMC11361355 DOI: 10.1200/jco.23.01959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/15/2024] [Accepted: 04/02/2024] [Indexed: 06/07/2024] Open
Abstract
PURPOSE Postdiagnosis exercise is associated with lower breast cancer (BC) mortality but its link with risk of recurrence is less clear. We investigated the impact and dose-response relationship of exercise and recurrence in patients with primary BC. METHODS Multicenter prospective cohort analysis among 10,359 patients with primary BC from 26 centers in France between 2012 and 2018 enrolled in the CANcer TOxicities study, with follow-up through October 2021. Exercise exposure was assessed using the Global Physical Activity Questionnaire-16, quantified in standardized metabolic equivalent of task-hours per week (MET-h/wk). We examined the dose/exposure response of pretreatment exercise on distant recurrence-free interval (DRFI) for all patients and stratified by clinical subtype and menopausal status using inverse probability treatment weighted multivariable Cox models to estimate hazard ratios (HRs). RESULTS For the overall cohort, the relationship between exercise and DRFI was nonlinear: increasing exercise ≥ 5 MET-h/wk was associated with an inverse linear reduction in DRFI events up to approximately 25 MET-h/wk; increasing exercise over this threshold did not provide any additional DRFI benefit. Compared with <5 MET-h/wk, the adjusted HR for DRFI was 0.82 (95% CI, 0.61 to 1.00) for ≥ 5 MET-h/wk. Stratification by subtype revealed the hormone receptor-/human epidermal growth factor receptor 2- (HR-/HER2-; HR, 0.59 [95% CI, 0.38 to 0.92]) and HR-/HER2+ (HR, 0.37 [95% CI, 0.14 to 0.96]) subtypes were preferentially responsive to exercise. The benefit of exercise was observed especially in the premenopausal population. CONCLUSION Postdiagnosis/pretreatment exercise is associated with lower risk of DRFI events in a nonlinear fashion in primary BC; exercise has different impact on DRFI as a function of subtype and menopausal status.
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Affiliation(s)
- Davide Soldato
- INSERM U981—Prédicteurs moléculaires et nouvelles cibles en oncologie, Gustave Roussy, Villejuif, France
| | - Stefan Michiels
- INSERM U1018 CESP, Service de Biostatistique et d’Epidemiologie, Institut Gustave Roussy, Villejuif, France
| | - Julie Havas
- INSERM U981—Prédicteurs moléculaires et nouvelles cibles en oncologie, Gustave Roussy, Villejuif, France
| | - Antonio Di Meglio
- INSERM U981—Prédicteurs moléculaires et nouvelles cibles en oncologie, Gustave Roussy, Villejuif, France
| | - Martina Pagliuca
- INSERM U981—Prédicteurs moléculaires et nouvelles cibles en oncologie, Gustave Roussy, Villejuif, France
- Division of Breast Medical Oncology, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Maria Alice Franzoi
- INSERM U981—Prédicteurs moléculaires et nouvelles cibles en oncologie, Gustave Roussy, Villejuif, France
| | | | - Neil M. Iyengar
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | | | | | | | | | | | | | - Iona Hrab
- Centre François Baclesse, Caen, France
| | | | | | - Fabrice André
- INSERM U981—Prédicteurs moléculaires et nouvelles cibles en oncologie, Gustave Roussy, Villejuif, France
- Medical Oncology Department, Gustave Roussy, Villejuif, France
| | - Ines Vaz-Luis
- INSERM U981—Prédicteurs moléculaires et nouvelles cibles en oncologie, Gustave Roussy, Villejuif, France
- Medical Oncology Department, Gustave Roussy, Villejuif, France
- Supportive Care and Pathways Department (DIOPP), Gustave Roussy, Villejuif, France
| | - Lee W. Jones
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
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10
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Chang SH, Svensson M, Hsin-Min Wang G, Wang Y, Kang HR, Park H. Cost-effectiveness of early vs delayed use of abemaciclib combination therapy for patients with high-risk hormone receptor-positive/human epidermal growth factor receptor 2-negative early breast cancer. J Manag Care Spec Pharm 2024; 30:942-953. [PMID: 39213142 PMCID: PMC11365564 DOI: 10.18553/jmcp.2024.30.9.942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Abemaciclib was newly approved for hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) high-risk early breast cancer (EBC). Clinical guidelines recommended abemaciclib as the first-line treatment for HR+/ HER2- EBC (early use) or HR+/ HER2- metastatic breast cancer (MBC) (delayed use). OBJECTIVE To compare the cost-effectiveness of early vs delayed use of abemaciclib for treatment of HR+/HER2- high-risk EBC. Early use was defined as combined abemaciclib and endocrine therapy as first-line therapy for EBC, followed by treatment with fulvestrant for MBC. Delayed use was defined as endocrine therapy for EBC, followed by combined abemaciclib and fulvestrant therapy for MBC. METHODS A 5-state model was developed to estimate lifetime costs, life-years (LYs), and quality-adjusted life-years (QALYs) of hypothetical patients with HR+/ HER2- EBC from a third-party US payer's perspective. Key clinical and safety data were derived from the monarchE and MONARCH 2 clinical trials. Costs, utilities, and disutility values of adverse events were obtained from the literature. We calculated the incremental cost-effectiveness ratio (ICER) of early vs delayed abemaciclib use and compared it with a willingness-to-pay (WTP) threshold of $100,000 per LY or QALY. Deterministic and probabilistic sensitivity analyses (PSAs) were performed to test the robustness of the base-case model. RESULTS Base-case analysis showed early use yielded 21.08 LYs and 17.93 QALYs for $586,213 and delayed use yielded 11.14 LYs and 9.38 QALYs for $157,576. The ICER of early vs delayed use was $43,136/LY and $50,104/QALY, which was cost-effective at the WTP threshold of $100,000. The PSA result indicated that a 94.6% likelihood of early use (vs delayed use) was cost-effective at the WTP threshold of $100,000 per QALY. CONCLUSIONS This study suggests that giving abemaciclib in the early stage rather than waiting until patients develop metastatic disease (current standard of care in MBC) is a cost-effective strategy.
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Affiliation(s)
- Shao-Hsuan Chang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Mikael Svensson
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Grace Hsin-Min Wang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Yehua Wang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Hye-Rim Kang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Haesuk Park
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
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11
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Gagliato D, Reinert T, Rocha C, Tavares M, Pimentel S, Fuzita W, Araújo M, Matias D, Aleixo S, França B, Magaton É, Brito N, Cardoso AC, Castilho V. Real-World Study of Adjuvant Biosimilar Trastuzumab-dkst for HER2-Positive Breast Cancer Treatment in a Brazilian Population. Oncol Ther 2024; 12:437-449. [PMID: 38836997 PMCID: PMC11333778 DOI: 10.1007/s40487-024-00284-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Biological monoclonal antibodies play a pivotal role in cancer treatment, with biosimilars significantly enhancing their accessibility. In Brazil's ethnically diverse setting, real-world evidence is crucial for assessing the effectiveness and applicability of these therapies in routine clinical practice. METHODS We performed a multicentric, observational, prospective real-world study on biosimilar trastuzumab-dkst for adjuvant treatment of early HER2-positive breast cancer in Brazilian patients. Data were collected using a case-report form. RESULTS Of the 176 recruited, we present data from the first 59 patients (mean age 51.7 ± 12.9 years) who had completed treatment with trastuzumab-dkst. The mean time from diagnosis to the first adjuvant treatment with trastuzumab-dkst was 5.5 ± 2.7 months. Of the patients, 59% of patients achieved at least a 30-month follow-up. The 31.7-month invasive disease-free survival rate (IDFS) was 94.5% (95% CI 83.9-98.2%) and median IDFS was not achieved, since only three patients had invasive disease recurrence. The overall survival rate was 100% until the last assessment. The observed adverse events were similar to those presented by other studies using biosimilar or reference trastuzumab. Four serious adverse events (8.5%) were observed. A reduction in left ventricular ejection fraction of at least 10% was observed in 16.9% of participants. There was no treatment interruption, and three participants (5.1%) had their trastuzumab-dkst dose reduced. CONCLUSION Our study reinforces the existing pivotal data, underscoring the real-world efficacy and safety of biosimilar trastuzumab-dkst in the adjuvant treatment for early HER2-positive breast cancer. The preliminary long-term effectiveness and safety data we present further validate trastuzumab-dkst's role as a cost-saving alternative in oncological care. These findings have important implications for improving patient access to crucial treatments and for the more efficient use of healthcare resources. CLINICALTRIALS GOV REGISTRATION NCT03892655.
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Affiliation(s)
- Debora Gagliato
- Beneficência Portuguesa de São Paulo, Rua Maestro Cardim, 637-Bela Vista, São Paulo, SP, 01323-001, Brazil
| | - Tomás Reinert
- Centro de Pesquisa da Serra Gaúcha (CEPESG), Rua Vinte de Setembro, 2304, Bairro Centro, Caxias do Sul, RS, 95020-450, Brazil
| | - Cláudio Rocha
- Vencer e Oncoclínica Centro de Pesquisa, Rua Gardênia, 710-Jóquei, Teresina, PI, 64049-200, Brazil
| | - Monique Tavares
- A.C. Camargo Cancer Center, Rua Tamandaré, 753-Liberdade, São Paulo, SP, 01525-001, Brazil
| | - Sâmio Pimentel
- Ser Clínica Oncológica, Rua Passagem Euclídes da Cunha, 50-Batista Campos, Belém, PA, 66035-265, Brazil
| | - William Fuzita
- Instituto Sensumed de Ensino e Pesquisa (ISENP), Rua São Luíz, 510-Adrianópolis, Manaus, AM, 69029-520, Brazil
| | - Márcia Araújo
- Centro de Oncologia Leonardo da Vinci Ltda, Rua Rocha Lima, 1563-Aldeota, Fortaleza, CE, 60135-285, Brazil
| | - Danielli Matias
- Liga Norte Riograndense Contra O Câncer, Avenida Miguel Castro, 1355-Nossa Senhora de Nazaré, Natal, RN, 59062-000, Brazil
| | - Sabina Aleixo
- Hospital Evangélico de Cachoeiro de Itapemirim (CPCO/HECI), Rua Manoel Braga Machado, 2-Nossa Sra. da Penha, Cachoeiro de Itapemirim, ES, 29308-020, Brazil
| | - Bruno França
- Oncologia|Hematologia|Centro de Infusão, Av. das Américas, 2251-Barra da Tijuca, Rio de Janeiro, RJ, 22,631-001, Brazil
| | - Érida Magaton
- Libbs Farmacêutica, Av. Marquês de São Vicente, 2219-Jardim das Perdizes, São Paulo, SP, 05036-040, Brazil
| | - Natália Brito
- Libbs Farmacêutica, Av. Marquês de São Vicente, 2219-Jardim das Perdizes, São Paulo, SP, 05036-040, Brazil.
| | - Ana Carolina Cardoso
- Libbs Farmacêutica, Av. Marquês de São Vicente, 2219-Jardim das Perdizes, São Paulo, SP, 05036-040, Brazil
| | - Vivienne Castilho
- Libbs Farmacêutica, Av. Marquês de São Vicente, 2219-Jardim das Perdizes, São Paulo, SP, 05036-040, Brazil
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12
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Chapman JAW, Bayani J, SenGupta S, Bartlett JMS, Piper T, Quintayo MA, Virk S, Goss PE, Ingle JN, Ellis MJ, Sledge GW, Budd GT, Rabaglio M, Ansari RH, Tozer R, D'Souza DP, Chalchal H, Spadafora S, Stearns V, Perez EA, Gelmon KA, Whelan TJ, Elliott C, Shepherd LE, Chen BE, Taylor KJ. Adjunctive Statistical Standardization of Adjuvant Estrogen Receptor and Progesterone Receptor in Canadian Cancer Trials Group MA.27 Postmenopausal Breast Cancer Trial of Exemestane Versus Anastrozole. J Clin Oncol 2024; 42:2887-2898. [PMID: 38824432 DOI: 10.1200/jco.24.00835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 04/29/2024] [Accepted: 05/03/2024] [Indexed: 06/03/2024] Open
Abstract
PURPOSE ASCO/College of American Pathologists guidelines recommend reporting estrogen receptor (ER) and progesterone receptor (PgR) as positive with (1%-100%) staining. Statistically standardized quantitated positivity could indicate differential associations of positivity with breast cancer outcomes. METHODS MA.27 (ClinicalTrials.gov identifier: NCT00066573) was a phase III adjuvant trial of exemestane versus anastrozole in postmenopausal women with early-stage breast cancer. Immunochemistry ER and PgR HSCORE and % positivity (%+) were centrally assessed by machine image quantitation and statistically standardized to mean 0 and standard deviation (SD) 1 after Box-Cox variance stabilization transformations of square for ER; for PgR, (1) natural logarithm (0.1 added to 0 HSCOREs and 0%+) and (2) square root. Our primary end point was MA.27 distant disease-free survival (DDFS) at a median 4.1-year follow-up, and secondary end point was event-free survival (EFS). Univariate survival with cut points at SDs about a mean of 0 (≤-1; (-1, 0]; (0, 1]; >1) was described with Kaplan-Meier plots and examined with Wilcoxon (Peto-Prentice) test statistic. Adjusted Cox multivariable regressions had two-sided Wald tests and nominal significance P < .05. RESULTS Of 7,576 women accrued, 3,048 women's tumors had machine-quantitated image analysis results: 2,900 (95%) for ER, 2,726 (89%) for PgR, and 2,582 (85% of 3,048) with both ER and PgR. Higher statistically standardized ER and PgR HSCORE and %+ were associated with better univariate DDFS and EFS (P < .001). In multivariable assessments, ER HSCORE and %+ were not significantly associated (P = .52-.88) with DDFS in models with PgR, whereas higher PgR HSCORE and %+ were significantly associated with better DDFS (P = .001) in models with ER. CONCLUSION Adjunctive statistical standardization differentiated quantitated levels of ER and PgR. Patients with higher ER- and PgR-standardized units had superior DDFS compared with those with HSCOREs and %+ ≤-1.
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Affiliation(s)
| | - Jane Bayani
- Ontario Institute for Cancer Research, Toronto, Canada
- University of Toronto, Toronto, Canada
| | | | | | - Tammy Piper
- University of Edinburgh, Edinburgh, United Kingdom
| | | | - Shakeel Virk
- Canadian Cancer Trials Group Queen's University, Kingston, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - Edith A Perez
- Harvard University, Boston, MA
- Mayo Clinic, Redwood City, CA
| | | | | | | | - Lois E Shepherd
- Canadian Cancer Trials Group Queen's University, Kingston, Canada
| | - Bingshu E Chen
- Canadian Cancer Trials Group Queen's University, Kingston, Canada
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13
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Engel J, Wieder V, Bauer M, Kaufhold S, Stückrath K, Wilke J, Hanf V, Uleer C, Lantzsch T, Peschel S, John J, Pöhler M, Weigert E, Bürrig KF, Buchmann J, Santos P, Kantelhardt EJ, Thomssen C, Vetter M. Prognostic and predictive impact of NOTCH1 in early breast cancer. Breast Cancer Res Treat 2024:10.1007/s10549-024-07444-1. [PMID: 39153127 DOI: 10.1007/s10549-024-07444-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/22/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE Systemic therapy plays a major part in the cure of patients with early breast cancer (eBC). However, personalized treatment concepts are required to avoid potentially harmful overtreatment. Biomarkers are pivotal for individualized therapy. The Notch signalling pathway is widely considered as a suitable prognostic or predictive marker in eBC. This study aimed primarily at assessing the relationship between NOTCH1 mRNA expression levels and histopathological features of breast cancer tumors, as well as clinical characteristics of the correspondent eBC patients. As a secondary aim, we investigated the prognostic and predictive value of NOTCH1 by assessing possible associations between NOTCH1 mRNA expression and recurrence-free interval (RFI) and overall survival after five years of observation. PATIENTS AND METHODS The relative NOTCH1 mRNA expression was determined in 414 tumour samples, using quantitative PCR in a prospective, multicenter cohort (Prognostic Assessment in Routine Application (PiA), 2009-2011, NCT01592825) of 1,270 female eBC patients. RESULTS High NOTCH1 mRNA expression was detected in one-third of the tumours and was associated with negative hormone receptor status and high uPA/PAI-1 status. In addition, high NOTCH1 mRNA expression was found to be associated with more RFI related events (adjusted hazard ratio 2.1, 95% CI 1.077-4.118). Patients who received adjuvant chemotherapy and had high NOTCH1 mRNA expression in the tumour (n = 86) were three times more likely to have an RFI event (adjusted hazard ratio 3.1, 95% CI 1.321-7.245, p = 0.009). CONCLUSION In this cohort, NOTCH1 mRNA expression had a prognostic and predictive impact. Tumours with high NOTCH1 mRNA expression may be less sensitive to cytotoxic treatment and downregulation of the Notch signalling pathway (e.g. by γ-secretase inhibitors) may be valuable for eBC therapy as an individualised treatment option.
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Affiliation(s)
- Julia Engel
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Vanessa Wieder
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Marcus Bauer
- Institute of Pathology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Sandy Kaufhold
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kathrin Stückrath
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Jochen Wilke
- Onkologische Gemeinschaftspraxis, Fürth, Germany
| | - Volker Hanf
- Department of Obstetrics and Gynaecology, Klinikum Fürth, Nathanstift Fürth, Germany
| | - Christoph Uleer
- Gynäkologisch-Onkologische Praxis, Hildesheim, Germany
- Frauenärzte Am Bahnhofsplatz, Hildesheim, Germany
| | - Tilmann Lantzsch
- Department of Gynaecology, Hospital St. Elisabeth and St. Barbara, Halle (Saale), Germany
| | - Susanne Peschel
- Department of Gynaecology, St. Bernward Hospital, Hildesheim, Germany
| | - Jutta John
- Department of Gynaecology, Helios Hospital Hildesheim, Hildesheim, Germany
| | - Marleen Pöhler
- Department of Gynaecology, Asklepios Hospital Goslar, Goslar, Germany
- Department of Gynaecology and Obstretrics, Hospital Wolfenbüttel, Wolfenbüttel, Germany
| | - Edith Weigert
- Institute of Pathology, Hospital Fürth, Fürth, Germany
- Gemeinschaftspraxis Amberg, Amberg, Germany
| | | | - Jörg Buchmann
- Institute of Pathology, Hospital Martha-Maria, Halle (Saale), Germany
| | - Pablo Santos
- Institute of Epidemiology, Biometry and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Eva Johanna Kantelhardt
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute of Epidemiology, Biometry and Informatics, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Christoph Thomssen
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Martina Vetter
- Department of Gynaecology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
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14
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Haslam A, Ranganathan S, Prasad V, Olivier T. CDK4/6 inhibitors as adjuvant therapy in early breast cancer? Uncertain benefits, guaranteed harms. Eur J Cancer 2024; 207:114192. [PMID: 38959677 DOI: 10.1016/j.ejca.2024.114192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/05/2024]
Abstract
CDK4/6 inhibitors are oral agents inhibiting key molecules of the cell cycle regulation. In patients with endocrine receptor positive (ER+), human epidermal growth factor receptor 2 negative (HER2-) breast cancer, the combination of CDK4/6 inhibitors with endocrine therapy is an effective treatment in the metastatic setting. Now, two studies in the adjuvant setting - MonarchE (2 years of abemaciclib) and NATALEE (3 years of ribociclib) - report positive invasive disease-free survival. Here, we re-evaluate these seminal trials. First, an excess drop-out or loss-to-follow up occurred early in the control arms of both studies. Since both trials are open-label, there is concern that the patients who drop-out do not do so at random but based on socioeconomic factors and alternative options. Is it possible that the results merely appear favorable due to loss to follow up? Based on re-constructed Kaplan-Meier curves, we concluded the results of these studies remain fragile, being prone to informative censoring. Secondly, adverse events were notably higher in both trials, and some of them, like COVID-19 related deaths in NATALEE, raise serious concerns. Third, the potential costs associated with CDK4/6 inhibition given as adjuvant therapy are unprecedented. The NATALEE strategy, in particular, could affect up to 35 % of patients with newly diagnosed breast cancer, which is the cancer with the highest incidence worldwide. Without confirmatory data based on a placebo-controlled trial, or better identification of patients that would benefit from the addition of CDK4/6 inhibitors in the adjuvant setting, we argue against their routine use as adjuvant therapy in ER+ /HER2- early breast cancer.
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Affiliation(s)
- Alyson Haslam
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St, 2nd Fl, San Francisco, CA 94158, USA
| | - Sruthi Ranganathan
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St, 2nd Fl, San Francisco, CA 94158, USA
| | - Timothée Olivier
- Department of Oncology, Geneva University Hospital, 4 Gabrielle-Perret-Gentil Street, 1205 Geneva, Switzerland.
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15
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Chin K, Landén AH, Kovács A, Wärnberg F, Ekholm M, Karlsson P, Olofsson Bagge R. Tumor-infiltrating lymphocytes as a predictor of axillary and primary tumor pathological response after neoadjuvant chemotherapy in patients with breast cancer: a retrospective cohort study. Breast Cancer Res Treat 2024; 207:49-63. [PMID: 38703286 PMCID: PMC11230953 DOI: 10.1007/s10549-024-07334-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 04/08/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Tumor-infiltrating lymphocytes (TILs) can predict complete pathological response (pCR) of tumor in the breast but not so well-defined in the axilla after neoadjuvant chemotherapy. Since axillary surgery is being increasingly de-escalated after NACT, we aimed to investigate the relationship between TILs and pCR in the axilla and breast, as well as survival amongst NACT patients. METHODS Clinicopathological data on patients who underwent NACT between 2013 and 2020 were retrospectively examined. Specifically, pre-TILs (before NACT), post-TILs (after NACT) and ΔTIL (changes in TILs) were assessed. Primary endpoint was pCR and secondary endpoints were breast cancer-free interval (BCFI) and overall survival (OS). RESULTS Two hundred and twenty patients with nodal metastases were included. Overall axillary and breast pCR rates were 42.7% (94/220) and 39.1% (86/220), respectively, whereas the combined pCR rate was 32.7% (72/220). High pre-TILs (OR 2.03, 95% CI 1.02-4.05; p = 0.04) predicted axillary pCR whereas, high post-TILs (OR 0.33, 95% CI 0.14-0.76; p = 0.009) and increased ΔTILs (OR 0.25, 95% CI 0.08-0.79; p = 0.02) predicted non-axillary pCR. TILs were not a significant predictor for BCFI and OS. CONCLUSIONS This study supports the potential use of pre-TILs to select initially node-positive patients for axillary surgical de-escalation after NACT.
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Affiliation(s)
- Kian Chin
- Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden.
| | - Amalia H Landén
- Department of Oncology, Institute of Clinical Sciences in Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fredrik Wärnberg
- Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Maria Ekholm
- Department of Oncology, Ryhov County Hospital, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Division of Oncology, Linköping University, Linköping, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences in Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
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16
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Tu H, Zhang Y, You Z. Prognostic Value of Tumor-Infiltrating Lymphocytes for Patients With Triple-Negative Breast Cancer. JAMA 2024; 332:337. [PMID: 38958961 DOI: 10.1001/jama.2024.10480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Hengjia Tu
- National Cancer Center, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuzhuo Zhang
- National Cancer Center, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhixuan You
- National Cancer Center, Chinese Academy of Medical Sciences, Beijing, China
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17
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Lim AM, Le Tourneau C, Hurt C, Laskar SG, Steuer CE, Chow VLY, Szturz P, Henson C, Day AT, Bates JE, Lazarakis S, McDowell L, Mehanna H, Yom SS. Assessment of endpoint definitions in recurrent and metastatic mucosal head and neck squamous cell carcinoma trials: Head and Neck Cancer International Group consensus recommendations. Lancet Oncol 2024; 25:e308-e317. [PMID: 38936389 DOI: 10.1016/s1470-2045(24)00068-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 06/29/2024]
Abstract
Transparent and precise endpoint definitions are a crucial aspect of clinical trial conduct and reporting, and are used to communicate the benefit of an intervention. Previous studies have identified inconsistencies in endpoint definitions across oncological clinical trials. Here, the Head and Neck Cancer International Group assessed endpoint definitions from phase 3 trials or trials considered practice-changing for patients with recurrent or metastatic mucosal head and neck squamous cell carcinoma, published between 2008 and 2021. We identify considerable and global heterogeneity in endpoint definitions, which undermines the interpretation of results and development of future studies. We show how fundamental components of even incontrovertible endpoints such as overall survival vary widely, highlighting an urgent need for increased rigour in reporting and harmonisation of endpoints.
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Affiliation(s)
- Annette M Lim
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.
| | - Christophe Le Tourneau
- Department of Drug Development and Innovation (D3i), Institut Curie, Paris, France; INSERM U900 Research unit, Institut Curie, Paris, France; Paris-Saclay University, Paris, France
| | - Chris Hurt
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Sarbani G Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Conor E Steuer
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Velda L Y Chow
- Division of Head and Neck Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong Special Administrative Region, China
| | - Petr Szturz
- Department of Oncology, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland
| | - Christina Henson
- Department of Radiation Oncology, Stephenson Cancer Center, University of Oklahoma, OK, USA
| | - Andrew T Day
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, TX, USA
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Lachlan McDowell
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, QLD, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), University of Birmingham, Edgbaston, Birmingham, UK
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, CA, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, CA, USA.
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18
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Vaklavas C, Matsen CB, Chu Z, Boucher KM, Scherer SD, Pathi S, Beck A, Brownson KE, Buys SS, Chittoria N, D'Astous E, Gulbahce HE, Henry NL, Kimani S, Porretta J, Rosenthal R, Ward J, Wei M, Welm BE, Welm AL. TOWARDS Study: Patient-Derived Xenograft Engraftment Predicts Poor Survival in Patients With Newly Diagnosed Triple-Negative Breast Cancer. JCO Precis Oncol 2024; 8:e2300724. [PMID: 39074345 PMCID: PMC11371112 DOI: 10.1200/po.23.00724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/04/2024] [Accepted: 05/28/2024] [Indexed: 07/31/2024] Open
Abstract
PURPOSE Assessing risk of recurrence for nonmetastatic triple-negative breast cancer (TNBC) is a key determinant of therapeutic strategy. The best predictor of recurrence risk is failure to achieve a pathologic complete response after preoperative chemotherapy, but it imperfectly correlates with the definitive end points of relapse-free and overall survival (OS). The inability to accurately predict recurrence has led to increasingly toxic treatment regimens for patients with early-stage TNBC. Better assays for recurrence risk are needed to tailor aggressive therapy for patients who need it and avoid overtreatment and unnecessary toxicity for those at low risk. The purpose of this study was to determine if patient-derived xenograft (PDX) engraftment of newly diagnosed breast tumors can serve as an accurate predictor of recurrence and death from breast cancer. METHODS This study was a blinded noninterventional trial comprising 80 patients with newly diagnosed, nonmetastatic, estrogen receptor (ER)-negative or ER-low breast cancer. RESULTS PDX engraftment was strongly associated with relapse in 1 year: 8 of 18 (44.4%) patients whose tumors engrafted relapsed versus 1 of 62 (1.6%) patients whose tumors did not engraft (P < .0001). Patients whose tumors engrafted had a hazard ratio (HR) for relapse of 17.5. HRs for OS and breast cancer-specific survival in PDX+ patients were 21.1 and 39.5, respectively. CONCLUSION We report that the ability of a tumor to engraft as a PDX predicts early recurrence by serving as a functional readout of aggressiveness and prospectively identifies the most devastating tumors. This provides new opportunity to develop surrogate assays, such as biomarkers of engraftment, which will extend the clinical feasibility of this finding.
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Affiliation(s)
- Christos Vaklavas
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Cindy B Matsen
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Zhengtao Chu
- Department of Oncological Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Kenneth M Boucher
- Department of Internal Medicine, Division of Epidemiology, Salt Lake City, UT
| | - Sandra D Scherer
- Department of Oncological Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Satya Pathi
- Department of Oncological Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Anna Beck
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Kirstyn E Brownson
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Saundra S Buys
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Namita Chittoria
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Elyse D'Astous
- Huntsman Cancer Institute Clinical Trials Office, Salt Lake City, UT
| | - H Evin Gulbahce
- Department of Pathology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - N Lynn Henry
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
- Current Address: Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Stephen Kimani
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Jane Porretta
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Regina Rosenthal
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - John Ward
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Mei Wei
- Department of Internal Medicine, Division of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Bryan E Welm
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Alana L Welm
- Department of Oncological Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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19
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Li J, Qu F, Gong J, Sun S, Gu Y, You C, Peng W. Magnetic resonance imaging-based prognostic model for subsequent distant metastasis in patients with ipsilateral breast tumor recurrence following breast-conserving surgery. Quant Imaging Med Surg 2024; 14:4506-4519. [PMID: 39022241 PMCID: PMC11250317 DOI: 10.21037/qims-23-1831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 05/11/2024] [Indexed: 07/20/2024]
Abstract
Background Ipsilateral breast tumor recurrence (IBTR) following breast-conserving surgery (BCS) has been considered a risk factor for distant metastasis (DM). Limited data are available regarding the subsequent outcomes after IBTR. Therefore, this study aimed to determine the clinical course after IBTR and develop a magnetic resonance imaging (MRI)-based predictive model for subsequent DM. Methods We retrospectively extracted quantitative features from MRI to construct a radiomics cohort, with all eligible patients undergoing preoperative MRI at time of primary tumor and IBTR between 2010 and 2018. Multivariate Cox analysis was performed to identify factors associated with DM. Three models were constructed using different sets of clinicopathological, qualitative, and quantitative MRI features and compared. Additionally, Kaplan-Meier analysis was performed to assess the prognostic value of the optimal model. Results Among the 183 patients who experienced IBTR, 47 who underwent MRI for both primary and recurrent tumors were enrolled. Multivariate analysis demonstrated that the independent prognostic factors were human epidermal growth factor receptor 2 (HER2) status [hazard ratio (HR) =5.40] and background parenchymal enhancement (BPE) (HR =7.94) (all P values <0.01). Furthermore, four quantitative MRI features of recurrent tumors were selected through the least absolute shrinkage and selection operator (LASSO) method. The combined model exhibited superior performance [concordance index (C-index) 0.77] compared to the clinicoradiological model (C-index 0.71; P=0.006) and radiomics model (C-index 0.70; and P=0.01). Furthermore, the combined model successfully categorized patients into low- and high-risk subgroups with distinct prognoses (P<0.001). Conclusions The clinicopathological and MRI features of IBTR were associated with secondary events following surgery. Additionally, the MRI-based combined model exhibited the highest predictive efficacy. These findings could be helpful in risk stratification and tailoring follow-up strategies in patients with IBTR.
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Affiliation(s)
- Jinhui Li
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Feilin Qu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jing Gong
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shiyun Sun
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yajia Gu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chao You
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Weijun Peng
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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20
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Tolaney SM, DeMichele A, Takano T, Rugo HS, Perou C, Lynce F, Parsons HA, Santa-Maria CA, Rocque GB, Yao W, Sun SW, Mocci S, Partridge AH, Carey LA. OptimICE-RD: sacituzumab govitecan + pembrolizumab vs pembrolizumab (± capecitabine) for residual triple-negative breast cancer. Future Oncol 2024:1-21. [PMID: 38922307 DOI: 10.1080/14796694.2024.2357534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 05/16/2024] [Indexed: 06/27/2024] Open
Abstract
Patients with early-stage triple-negative breast cancer (TNBC) with residual invasive disease after neoadjuvant therapy have a high risk of recurrence even with neoadjuvant and adjuvant treatment with pembrolizumab. Sacituzumab govitecan, a Trop-2-directed antibody-drug conjugate with a topoisomerase I inhibitor payload, improved progression-free survival (PFS) and overall survival (OS) versus chemotherapy in patients with pre-treated metastatic TNBC. Moreover, preclinical data suggest that topoisomerase I inhibitors may enhance the effects of immune checkpoint inhibitors through activation of the cGAS-STING pathway. Here we describe the international randomized phase III AFT-65/ASCENT-05/OptimICE-RD trial, which evaluates the efficacy and safety of sacituzumab govitecan plus pembrolizumab versus treatment of physician's choice (pembrolizumab ± capecitabine) among patients with early-stage TNBC with residual invasive disease after neoadjuvant therapy.Clinical Trial Registration: NCT05633654 (ClinicalTrials.gov)Other Study ID Number(s): Gilead Study ID: GS-US-595-6184Registration date: 1 December 2022Study start date: 12 December 2022Recruitment status: Recruiting.
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Affiliation(s)
- Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215,USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Angela DeMichele
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Toshimi Takano
- The Cancer Institute Hospital of JFCR, Koto City, Tokyo, 135-8550, Japan
| | - Hope S Rugo
- University of California Comprehensive Cancer Center, San Francisco, CA 94143, USA
| | - Charles Perou
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Filipa Lynce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215,USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Heather Anne Parsons
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215,USA
- Harvard Medical School, Boston, MA 02115, USA
| | | | | | - Wenliang Yao
- Gilead Sciences, Inc., Foster City, CA 94404, USA
| | - Shawn W Sun
- Gilead Sciences, Inc., Foster City, CA 94404, USA
| | | | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215,USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Lisa A Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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21
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Johnson KCC, Ni A, Quiroga D, Pariser AC, Sudheendra PK, Williams NO, Sardesai SD, Cherian M, Stover DG, Gatti-Mays M, Ramaswamy B, Lustberg M, Jhawar S, Skoracki R, Wesolowski R. The survival benefit of adjuvant trastuzumab with or without chemotherapy in the management of small (T1mic, T1a, T1b, T1c), node negative HER2+ breast cancer. NPJ Breast Cancer 2024; 10:49. [PMID: 38898072 PMCID: PMC11187074 DOI: 10.1038/s41523-024-00652-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 06/01/2024] [Indexed: 06/21/2024] Open
Abstract
There is limited data regarding the added benefit of adjuvant systemic therapy in the management of small, node-negative, HER2+ breast cancer. In a multi-institutional retrospective analysis using the American Society of Clinical Oncology CancerLinQ database, we compared survival outcomes among T1a-c N0 HER2+ patients diagnosed between 2010 to 2021 who received locoregional therapy alone or in combination with adjuvant trastuzumab (+/- chemotherapy). Primary outcomes were invasive disease-free survival (iDFS) and overall survival (OS). Of the 1,184 patients, 436 received locoregional therapy alone. We found a statistically significant improvement in iDFS (HR 0.73, P = 0.003) and OS (HR 0.63, P = 0.023) on univariate analysis with adjuvant trastuzumab with or without chemotherapy which remained statistically significant on multivariate analysis. Three-arm univariate analysis found that iDFS was significantly improved with trastuzumab monotherapy (P = 0.003) and combination therapy (P = 0.027) compared to observation. Subgroup data suggests that T1b/c tumors derive the greatest benefit.
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Affiliation(s)
- Kai C C Johnson
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Ai Ni
- Division of Biostatistics, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Dionisia Quiroga
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Ashley C Pariser
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | - Nicole O Williams
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Sagar D Sardesai
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Mathew Cherian
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Daniel G Stover
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | - Maryam Lustberg
- Smilow Cancer Hospital, Yale Cancer Center, New Haven, CT, USA
| | - Sachin Jhawar
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Roman Skoracki
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Robert Wesolowski
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
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22
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Kennedy A, Richardson E, Higham J, Kotsantis P, Mort R, Shih BBJ. Evergene: an interactive webtool for large-scale gene-centric analysis of primary tumours. BIOINFORMATICS ADVANCES 2024; 4:vbae092. [PMID: 38948009 PMCID: PMC11213629 DOI: 10.1093/bioadv/vbae092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/24/2024] [Accepted: 06/15/2024] [Indexed: 07/02/2024]
Abstract
Motivation The data sharing of large comprehensive cancer research projects, such as The Cancer Genome Atlas (TCGA), has improved the availability of high-quality data to research labs around the world. However, due to the volume and inherent complexity of high-throughput omics data, analysis of this is limited by the capacity for performing data processing through programming languages such as R or Python. Existing webtools lack functionality that supports large-scale analysis; typically, users can only input one gene, or a gene list condensed into a gene set, instead of individual gene-level analysis. Furthermore, analysis results are usually displayed without other sample-level molecular or clinical annotations. To address these gaps in the existing webtools, we have developed Evergene using R and Shiny. Results Evergene is a user-friendly webtool that utilizes RNA-sequencing data, alongside other sample and clinical annotation, for large-scale gene-centric analysis, including principal component analysis (PCA), survival analysis (SA), and correlation analysis (CA). Moreover, Evergene achieves in-depth analysis of cancer transcriptomic data which can be explored through dimensional reduction methods, relating gene expression with clinical events or other sample information, such as ethnicity, histological classification, and molecular indices. Lastly, users can upload custom data to Evergene for analysis. Availability and implementation Evergene webtool is available at https://bshihlab.shinyapps.io/evergene/. The source code and example user input dataset are available at https://github.com/bshihlab/evergene.
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Affiliation(s)
- Anna Kennedy
- Division of Biomedical and Life Sciences, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YG, United Kingdom
| | - Ella Richardson
- Division of Biomedical and Life Sciences, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YG, United Kingdom
| | - Jonathan Higham
- Department of Mathematics and Statistics, Faculty of Science and Technology, Lancaster University, Lancaster LA1 4YF, United Kingdom
| | - Panagiotis Kotsantis
- Division of Biomedical and Life Sciences, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YG, United Kingdom
| | - Richard Mort
- Division of Biomedical and Life Sciences, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YG, United Kingdom
| | - Barbara Bo-Ju Shih
- Division of Biomedical and Life Sciences, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YG, United Kingdom
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23
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Garcia-Torralba E, Pérez Ramos M, Ivars Rubio A, Navarro Manzano E, Blaya Boluda N, Lloret Gil M, Aller A, de la Morena Barrio P, García Garre E, Martínez Díaz F, García Molina F, Chaves Benito A, García-Martínez E, Ayala de la Peña F. Deconstructing neutrophil to lymphocyte ratio (NLR) in early breast cancer: lack of prognostic utility and biological correlates across tumor subtypes. Breast Cancer Res Treat 2024; 205:475-485. [PMID: 38453782 PMCID: PMC11101577 DOI: 10.1007/s10549-024-07286-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/07/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE The prognostic utility and biological correlates of neutrophil to lymphocyte ratio (NLR), a potential biomarker of the balance between immune response and the inflammatory status, are still uncertain in breast cancer (BC). METHODS We analysed a cohort of 959 women with early breast cancer, mostly treated with neoadjuvant or adjuvant chemotherapy. Clinical and pathological data, survival, NLR (continuous and categorical) and stromal tumor infiltrating lymphocytes (sTIL) were evaluated. RESULTS NLR was only weakly associated with Ki67, while no association was found for grade, histology, immunohistochemical subtype or stage. Lymphocyte infiltration of the tumor did not correlate with NLR (Rho: 0.05, p = 0.30). These results were similar in the whole group and across the different BC subtypes, with no differences in triple negative BC. Relapse free interval (RFI), breast cancer specific survival (BCSS) and overall survival (OS) changed according to pre-treatment NLR neither in the univariate nor in the multivariate Cox models (RFI: HR 0.948, p = 0.61; BCSS: HR 0.920, p = 0.57; OS: HR 0.96, p = 0.59). CONCLUSION These results question the utility of NLR as a prognostic biomarker in early breast cancer and suggest the lack of correlation of NLR with tumor microenvironment immune response.
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Affiliation(s)
- Esmeralda Garcia-Torralba
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
- Department of Medicine, Medical School, University of Murcia, Murcia, 30001, Spain
- Instituto Murciano de Investigación Biosanitaria, IMIB, Murcia, 30120, Spain
| | - Miguel Pérez Ramos
- Department of Pathology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
| | - Alejandra Ivars Rubio
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
- Department of Medicine, Medical School, University of Murcia, Murcia, 30001, Spain
- Instituto Murciano de Investigación Biosanitaria, IMIB, Murcia, 30120, Spain
| | - Esther Navarro Manzano
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
- Instituto Murciano de Investigación Biosanitaria, IMIB, Murcia, 30120, Spain
- Centro Regional de Hemodonación, Murcia, 30003, Spain
| | - Noel Blaya Boluda
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
- Department of Medicine, Medical School, University of Murcia, Murcia, 30001, Spain
- Instituto Murciano de Investigación Biosanitaria, IMIB, Murcia, 30120, Spain
| | - Miguel Lloret Gil
- Department of Medicine, Medical School, University of Murcia, Murcia, 30001, Spain
| | - Alberto Aller
- Department of Medicine, Medical School, University of Murcia, Murcia, 30001, Spain
| | - Pilar de la Morena Barrio
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
- Instituto Murciano de Investigación Biosanitaria, IMIB, Murcia, 30120, Spain
| | - Elisa García Garre
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
- Instituto Murciano de Investigación Biosanitaria, IMIB, Murcia, 30120, Spain
| | - Francisco Martínez Díaz
- Instituto Murciano de Investigación Biosanitaria, IMIB, Murcia, 30120, Spain
- Department of Pathology, Hospital Universitario Reina Sofía, Murcia, 30003, Spain
- Department of Pathology, Medical School, University of Murcia, Murcia, 30001, Spain
| | - Francisco García Molina
- Department of Pathology, Hospital Universitario Reina Sofía, Murcia, 30003, Spain
- Department of Pathology, Medical School, University of Murcia, Murcia, 30001, Spain
| | - Asunción Chaves Benito
- Department of Pathology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
- Department of Pathology, Medical School, University of Murcia, Murcia, 30001, Spain
| | - Elena García-Martínez
- Department of Medical Oncology, Hospital Universitario Morales Meseguer, Murcia, 30008, Spain
- Instituto Murciano de Investigación Biosanitaria, IMIB, Murcia, 30120, Spain
- Medical School, Universidad Católica San Antonio, Murcia, 30107, Spain
| | - Francisco Ayala de la Peña
- Department of Medical Oncology, School of Medicine, Hospital Universitario Morales Meseguer, University of Murcia, Avda. Marqués de los Vélez, s/n, Murcia, 30008, Spain.
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24
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Untch M, Pérol D, Mayer EL, Cortes J, Nusch A, Cameron D, Barrios C, Delea T, Danyliv A, Mishra N, Gupta R, Pathak P, Fasching PA. Disease-free survival as a surrogate for overall survival in HR+/HER2- early breast cancer: A correlation analysis. Eur J Cancer 2024; 202:113977. [PMID: 38460476 DOI: 10.1016/j.ejca.2024.113977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Overall survival (OS) is a universally accepted measure of clinical benefit; however, prolonged follow-up is needed to observe sufficient events. Disease-free survival (DFS) has been widely adopted as a primary endpoint for early breast cancer (EBC) trials, as follow-up is comparatively shorter. Here, we present an analysis evaluating DFS as a surrogate for OS for adjuvant treatment of hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) EBC. METHODS A systematic literature review which included randomized controlled trials (RCTs) with ≥80% of adult patients with HR+/HER2- EBC was conducted. The RCTs evaluated various systemic therapeutic categories; key inclusion criteria included reporting of DFS and OS hazard ratios (HRs) and mature OS data. Spearman rank correlation and weighted linear regression analyses evaluated DFS and OS HR correlation. A scenario analysis tested base-case analysis robustness, and a parallel analysis using patient-level data was conducted. RESULTS The base case (N = 14 RCTs) showed an unweighted Spearman coefficient of 0.81 between OS and DFS (weighted: 0.81), with 84% of the variability in OS explained by DFS differences (R2 from weighted regression). The surrogate threshold effect (Burzykowski T, Buyse M. Pharm Stat. 2006;5:173-186) was 0.82 for DFS/OS HR. Scenario analysis (n = 9 RCTs), which excluded chemotherapy trials, and patient-level analysis using FACE trial data were consistent with the base-case analysis. CONCLUSIONS These analyses support DFS as a reliable surrogate endpoint for OS in adjuvant HR+/HER2- EBC trials. Using DFS as a surrogate measure will permit timelier access to novel treatments for patients with HR+/HER2- EBC.
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Affiliation(s)
- Michael Untch
- Interdisciplinary Breast Cancer Center, Helios Klinikum Berlin-Buch, Berlin, Germany.
| | | | - Erica L Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Javier Cortes
- International Breast Cancer Center (IBCC), Grupo Quiron, Madrid & Barcelona, Spain
| | - Arnd Nusch
- Practice for Hematology and Internal Oncology, Velbert, Germany
| | - David Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Carlos Barrios
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | | | | | | | - Rhea Gupta
- Novartis Healthcare Pvt Ltd, Hyderabad, India
| | - Purnima Pathak
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Peter A Fasching
- University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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25
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Morganti S, Jin Q, Vincuilla J, Buehler R, Ryan S, Stokes S, Parker T, Mittendorf EA, King TA, Weiss A, Partridge AH, Bychkovsky BL, Curigliano G, Tayob N, Lin NU, Garber JE, Tolaney SM, Lynce F. Clinicopathological characteristics and eligibility for adjuvant olaparib of germline BRCA1/2 mutation carriers with HER2-negative early breast cancer. NPJ Breast Cancer 2024; 10:28. [PMID: 38627457 PMCID: PMC11021554 DOI: 10.1038/s41523-024-00632-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
Following the survival benefit demonstrated in the OlympiA trial, one year of adjuvant olaparib is now recommended for all patients with germline BRCA1/2 pathogenic/likely pathogenic variants (PV) and high-risk, HER2-negative early breast cancer after chemotherapy. However, optimal identification of high-risk patients who may derive benefit from this genomically-directed therapy is debated. In this study, we sought to characterize the real-world proportion of gBRCA1/2 PV carriers eligible for adjuvant olaparib according to the OlympiA criteria, and to compare clinicopathologic characteristics and outcomes between eligible and ineligible patients.
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Affiliation(s)
- Stefania Morganti
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Boston, MA, USA
| | - Qingchun Jin
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Julie Vincuilla
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Ryan Buehler
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sean Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | | | - Tonia Parker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Tari A King
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Anna Weiss
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Division of Surgical Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brittany L Bychkovsky
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Giuseppe Curigliano
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- European Institute of Oncology IRCCS, Milan, Italy
| | - Nabihah Tayob
- Harvard Medical School, Boston, MA, USA
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Judy E Garber
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Filipa Lynce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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26
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Xiang Y, Liu X, Wang Y, Zheng D, Meng Q, Jiang L, Yang S, Zhang S, Zhang X, Liu Y, Wang B. Mechanisms of resistance to targeted therapy and immunotherapy in non-small cell lung cancer: promising strategies to overcoming challenges. Front Immunol 2024; 15:1366260. [PMID: 38655260 PMCID: PMC11035781 DOI: 10.3389/fimmu.2024.1366260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/18/2024] [Indexed: 04/26/2024] Open
Abstract
Resistance to targeted therapy and immunotherapy in non-small cell lung cancer (NSCLC) is a significant challenge in the treatment of this disease. The mechanisms of resistance are multifactorial and include molecular target alterations and activation of alternative pathways, tumor heterogeneity and tumor microenvironment change, immune evasion, and immunosuppression. Promising strategies for overcoming resistance include the development of combination therapies, understanding the resistance mechanisms to better use novel drug targets, the identification of biomarkers, the modulation of the tumor microenvironment and so on. Ongoing research into the mechanisms of resistance and the development of new therapeutic approaches hold great promise for improving outcomes for patients with NSCLC. Here, we summarize diverse mechanisms driving resistance to targeted therapy and immunotherapy in NSCLC and the latest potential and promising strategies to overcome the resistance to help patients who suffer from NSCLC.
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Affiliation(s)
- Yuchu Xiang
- West China Hospital of Sichuan University, Sichuan University, Chengdu, China
| | - Xudong Liu
- Institute of Medical Microbiology and Hygiene, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Yifan Wang
- State Key Laboratory for Oncogenes and Related Genes, Division of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Cancer Institute, Shanghai, China
| | - Dawei Zheng
- The College of Life Science, Sichuan University, Chengdu, China
| | - Qiuxing Meng
- Department of Laboratory Medicine, Liuzhou People’s Hospital, Liuzhou, China
- Guangxi Health Commission Key Laboratory of Clinical Biotechnology (Liuzhou People’s Hospital), Liuzhou, China
| | - Lingling Jiang
- Guangxi Medical University Cancer Hospital, Nanning, China
| | - Sha Yang
- Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, China
| | - Sijia Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Zhang
- Zhongshan Hospital of Fudan University, Xiamen, Fujian, China
| | - Yan Liu
- Department of Organ Transplantation, Guizhou Provincial People’s Hospital, Guiyang, Guizhou, China
| | - Bo Wang
- Institute of Medical Microbiology and Hygiene, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Urology, Guizhou Provincial People’s Hospital, Guiyang, Guizhou, China
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27
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de Boniface J, Filtenborg Tvedskov T, Rydén L, Szulkin R, Reimer T, Kühn T, Kontos M, Gentilini OD, Olofsson Bagge R, Sund M, Lundstedt D, Appelgren M, Ahlgren J, Norenstedt S, Celebioglu F, Sackey H, Scheel Andersen I, Hoyer U, Nyman PF, Vikhe Patil E, Wieslander E, Dahl Nissen H, Alkner S, Andersson Y, Offersen BV, Bergkvist L, Frisell J, Christiansen P. Omitting Axillary Dissection in Breast Cancer with Sentinel-Node Metastases. N Engl J Med 2024; 390:1163-1175. [PMID: 38598571 DOI: 10.1056/nejmoa2313487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Trials evaluating the omission of completion axillary-lymph-node dissection in patients with clinically node-negative breast cancer and sentinel-lymph-node metastases have been compromised by limited statistical power, uncertain nodal radiotherapy target volumes, and a scarcity of data on relevant clinical subgroups. METHODS We conducted a noninferiority trial in which patients with clinically node-negative primary T1 to T3 breast cancer (tumor size, T1, ≤20 mm; T2, 21 to 50 mm; and T3, >50 mm in the largest dimension) with one or two sentinel-node macrometastases (metastasis size, >2 mm in the largest dimension) were randomly assigned in a 1:1 ratio to completion axillary-lymph-node dissection or its omission (sentinel-node biopsy only). Adjuvant treatment and radiation therapy were used in accordance with national guidelines. The primary end point was overall survival. We report here the per-protocol and modified intention-to-treat analyses of the prespecified secondary end point of recurrence-free survival. To show noninferiority of sentinel-node biopsy only, the upper boundary of the confidence interval for the hazard ratio for recurrence or death had to be below 1.44. RESULTS Between January 2015 and December 2021, a total of 2766 patients were enrolled across five countries. The per-protocol population included 2540 patients, of whom 1335 were assigned to undergo sentinel-node biopsy only and 1205 to undergo completion axillary-lymph-node dissection (dissection group). Radiation therapy including nodal target volumes was administered to 1192 of 1326 patients (89.9%) in the sentinel-node biopsy-only group and to 1058 of 1197 (88.4%) in the dissection group. The median follow-up was 46.8 months (range, 1.5 to 94.5). Overall, 191 patients had recurrence or died. The estimated 5-year recurrence-free survival was 89.7% (95% confidence interval [CI], 87.5 to 91.9) in the sentinel-node biopsy-only group and 88.7% (95% CI, 86.3 to 91.1) in the dissection group, with a country-adjusted hazard ratio for recurrence or death of 0.89 (95% CI, 0.66 to 1.19), which was significantly (P<0.001) below the prespecified noninferiority margin. CONCLUSIONS The omission of completion axillary-lymph-node dissection was noninferior to the more extensive surgery in patients with clinically node-negative breast cancer who had sentinel-node macrometastases, most of whom received nodal radiation therapy. (Funded by the Swedish Research Council and others; SENOMAC ClinicalTrials.gov number, NCT02240472.).
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Affiliation(s)
- Jana de Boniface
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Tove Filtenborg Tvedskov
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Lisa Rydén
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Robert Szulkin
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Toralf Reimer
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Thorsten Kühn
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Michalis Kontos
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Oreste D Gentilini
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Roger Olofsson Bagge
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Malin Sund
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Dan Lundstedt
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Matilda Appelgren
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Johan Ahlgren
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Sophie Norenstedt
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Fuat Celebioglu
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Helena Sackey
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Inge Scheel Andersen
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Ute Hoyer
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Per F Nyman
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Eva Vikhe Patil
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Elinore Wieslander
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Henrik Dahl Nissen
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Sara Alkner
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Yvette Andersson
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Birgitte V Offersen
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Leif Bergkvist
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Jan Frisell
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
| | - Peer Christiansen
- From the Departments of Molecular Medicine and Surgery (J.B., M.A., H.S., J.F.) and Medical Epidemiology and Biostatistics (R.S.), Karolinska Institutet, the Department of Surgery, Capio St. Göran's Hospital (J.B., M.A., S.N.), Cytel (R.S.), the Department of Surgery, Södersjukhuset (F.C.), and Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital (H.S., J.F.), Stockholm, the Faculty of Medicine, Institute of Clinical Sciences, Lund University (L.R., S.A.), and the Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital Lund (S.A.), Lund, the Department of Gastroenterology and Surgery (L.R.), and Radiation Physics, Department of Hematology, Oncology, and Radiation Physics (E.W.), Skåne University Hospital Lund, Malmö, the Departments of Surgery (R.O.B.) and Oncology (D.L.), Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, and the Departments of Surgery (R.O.B.) and Oncology (D.L.), Sahlgrenska University Hospital, Gothenburg, the Department of Diagnostics and Intervention-Surgery, Umeå University, Umeå (M.S.), the Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro (J.A.), Regional Cancer Center of Mid-Sweden, Uppsala (J.A.), the Department of Surgery, Skaraborg Hospital, Lidköping (P.F.N.), the Department of Biomedical and Clinical Sciences (E.V.P.), Linköping University, and the Department of Surgery, Linköping University Hospital (E.V.P.), Linköping, and the Department of Surgery (Y.A.) and the Center for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital (Y.A., L.B.), Vasteras - all in Sweden; the Faculty of Health and Medical Sciences, University of Copenhagen (T.F.T.), the Department of Breast Surgery, Gentofte Hospital, Gentofte (T.F.T.), the Department of Surgery, Breast Clinic, Viborg Hospital, Viborg (I.S.A.), the Department of Plastic and Breast Surgery, Aalborg University Hospital, Aalborg (U.H.), the Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle (H.D.N.), and the Departments of Oncology (B.V.O.) and Plastic and Breast Surgery (P.C.), Aarhus University Hospital, the Departments of Oncology (B.V.O.) and Clinical Medicine (P.C.), Aarhus University, and the Department of Experimental Clinical Oncology, Danish Center for Particle Therapy (B.V.O.), Aarhus - all in Denmark; the Department of Obstetrics and Gynecology, University of Rostock, Rostock (T.R.), the Breast Center, Die Filderklinik, Filderstadt (T.K.), and the Department of Gynecology and Obstetrics, University of Ulm, Ulm (T.K.) - all in Germany; the First Department of Surgery, National and Kapodistrian University of Athens, Athens (M.K.); the Department of Breast Surgery, IRCCS Ospedale San Raffaele (O.D.G.), and Vita-Salute San Raffaele University (O.D.G.) - both in Milan; and the Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki (M.S.)
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Leon-Ferre RA, Jonas SF, Salgado R, Loi S, de Jong V, Carter JM, Nielsen TO, Leung S, Riaz N, Chia S, Jules-Clément G, Curigliano G, Criscitiello C, Cockenpot V, Lambertini M, Suman VJ, Linderholm B, Martens JWM, van Deurzen CHM, Timmermans AM, Shimoi T, Yazaki S, Yoshida M, Kim SB, Lee HJ, Dieci MV, Bataillon G, Vincent-Salomon A, André F, Kok M, Linn SC, Goetz MP, Michiels S. Tumor-Infiltrating Lymphocytes in Triple-Negative Breast Cancer. JAMA 2024; 331:1135-1144. [PMID: 38563834 PMCID: PMC10988354 DOI: 10.1001/jama.2024.3056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/20/2024] [Indexed: 04/04/2024]
Abstract
Importance The association of tumor-infiltrating lymphocyte (TIL) abundance in breast cancer tissue with cancer recurrence and death in patients with early-stage triple-negative breast cancer (TNBC) who are not treated with adjuvant or neoadjuvant chemotherapy is unclear. Objective To study the association of TIL abundance in breast cancer tissue with survival among patients with early-stage TNBC who were treated with locoregional therapy but no chemotherapy. Design, Setting, and Participants Retrospective pooled analysis of individual patient-level data from 13 participating centers in North America (Rochester, Minnesota; Vancouver, British Columbia, Canada), Europe (Paris, Lyon, and Villejuif, France; Amsterdam and Rotterdam, the Netherlands; Milan, Padova, and Genova, Italy; Gothenburg, Sweden), and Asia (Tokyo, Japan; Seoul, Korea), including 1966 participants diagnosed with TNBC between 1979 and 2017 (with follow-up until September 27, 2021) who received treatment with surgery with or without radiotherapy but no adjuvant or neoadjuvant chemotherapy. Exposure TIL abundance in breast tissue from resected primary tumors. Main Outcomes and Measures The primary outcome was invasive disease-free survival [iDFS]. Secondary outcomes were recurrence-free survival [RFS], survival free of distant recurrence [distant RFS, DRFS], and overall survival. Associations were assessed using a multivariable Cox model stratified by participating center. Results This study included 1966 patients with TNBC (median age, 56 years [IQR, 39-71]; 55% had stage I TNBC). The median TIL level was 15% (IQR, 5%-40%). Four-hundred seventeen (21%) had a TIL level of 50% or more (median age, 41 years [IQR, 36-63]), and 1300 (66%) had a TIL level of less than 30% (median age, 59 years [IQR, 41-72]). Five-year DRFS for stage I TNBC was 94% (95% CI, 91%-96%) for patients with a TIL level of 50% or more, compared with 78% (95% CI, 75%-80%) for those with a TIL level of less than 30%; 5-year overall survival was 95% (95% CI, 92%-97%) for patients with a TIL level of 50% or more, compared with 82% (95% CI, 79%-84%) for those with a TIL level of less than 30%. At a median follow-up of 18 years, and after adjusting for age, tumor size, nodal status, histological grade, and receipt of radiotherapy, each 10% higher TIL increment was associated independently with improved iDFS (hazard ratio [HR], 0.92 [0.89-0.94]), RFS (HR, 0.90 [0.87-0.92]), DRFS (HR, 0.87 [0.84-0.90]), and overall survival (0.88 [0.85-0.91]) (likelihood ratio test, P < 10e-6). Conclusions and Relevance In patients with early-stage TNBC who did not undergo adjuvant or neoadjuvant chemotherapy, breast cancer tissue with a higher abundance of TIL levels was associated with significantly better survival. These results suggest that breast tissue TIL abundance is a prognostic factor for patients with early-stage TNBC.
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Affiliation(s)
| | - Sarah Flora Jonas
- Office of Biostatistics and Epidemiology, Gustave Roussy, Oncostat U1018, Inserm, University Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif, France
| | - Roberto Salgado
- GZA-ZNA-Hospitals, Antwerp, Belgium
- Peter Mac Callum Cancer Centre, Melbourne, Victoria, Australia
| | - Sherene Loi
- Peter Mac Callum Cancer Centre, Melbourne, Victoria, Australia
| | - Vincent de Jong
- Department of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jodi M. Carter
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Samuel Leung
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Nazia Riaz
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephen Chia
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Gérôme Jules-Clément
- Bioinformatics Core Facility, Gustave Roussy, Université Paris-Saclay, Inserm US23, CNRS UMS 3655, Villejuif, France
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapy, IEO, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Carmen Criscitiello
- Division of Early Drug Development for Innovative Therapy, IEO, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Matteo Lambertini
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Vera J. Suman
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Barbro Linderholm
- Sahlgrenska University Hospital, and Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | | | | | | | | | - Shu Yazaki
- National Cancer Center Hospital, Tokyo, Japan
| | | | - Sung-Bae Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Jin Lee
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Maria Vittoria Dieci
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
- Oncology 2, Veneto Institute of Oncology IOV—IRCCS, Padova, Italy
| | | | | | - Fabrice André
- Office of Biostatistics and Epidemiology, Gustave Roussy, Oncostat U1018, Inserm, University Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif, France
| | - Marleen Kok
- Department of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Sabine C. Linn
- Department of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Stefan Michiels
- Office of Biostatistics and Epidemiology, Gustave Roussy, Oncostat U1018, Inserm, University Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif, France
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Blondeaux E, Xie W, Carmisciano L, Mura S, Sanna V, De Laurentiis M, Caputo R, Turletti A, Durando A, De Placido S, De Angelis C, Bisagni G, Gasparini E, Rimanti A, Puglisi F, Mansutti M, Landucci E, Fabi A, Arecco L, Perachino M, Bruzzone M, Boni L, Lambertini M, Del Mastro L, Regan MM. Intermediate clinical endpoints in early-stage breast cancer: an analysis of individual patient data from the Gruppo Italiano Mammella and Mammella Intergruppo trials. EClinicalMedicine 2024; 70:102501. [PMID: 38685923 PMCID: PMC11056413 DOI: 10.1016/j.eclinm.2024.102501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 05/02/2024] Open
Abstract
Background Intermediate clinical endpoints (ICEs) are frequently used as primary endpoint in randomised trials (RCTs). We aim to assess whether changes in different ICEs can be used to predict changes in overall survival (OS) in adjuvant breast cancer trials. Methods Individual patient level data from adjuvant phase III RCTs conducted by the Gruppo Italiano Mammella (GIM) and Mammella Intergruppo (MIG) study groups were used. ICEs were computed according to STEEP criteria. Using a two-stage meta-analytic model, we assessed the surrogacy of each ICE at both the outcome (i.e., OS and ICE are correlated irrespective of treatment) and trial (i.e., treatment effects on ICE and treatment effect on OS are correlated) levels. The following ICEs were considered as potential surrogate endpoints of OS: disease-free survival (DFS), distant disease-free survival (DDFS), distant relapse-free survival (DRFS), recurrence-free survival (RFS), recurrence-free interval (RFI), distant recurrence-free interval (DRFI), breast cancer-free interval (BCFI), and invasive breast cancer-free survival (IBCFS). The estimates of the degree of correlation were obtained by copula models and weighted linear regression. Kendall's τ and R2 ≥ 0.70 were considered as indicators of a clinically relevant surrogacy. Findings Among the 12,397 patients enrolled from November 1992 to July 2012 in six RCTs, median age at enrolment was 57 years (interquartile range (IQR) 49-65). After a median follow-up of 10.3 years (IQR 6.4-14.5), 2131 (17.2%) OS events were observed, with 1390 (65.2%) attributed to breast cancer. At the outcome-level, Kendall's τ ranged from 0.69 for BCFI to 0.84 for DRFS. For DFS, DDFS, DRFS, RFS, RFI, DRFI, BCFI, and IBCFS endpoints, over 95% of the 8-year OS variability was attributable to the variation of the 5-year ICE. At the trial-level, treatment effects for the different ICEs and OS were strongly correlated, with the highest correlation for RFS and DRFS and the lowest for BCFI. Interpretation Our results provide evidence supporting the use of DFS, DDFS, DRFS, RFS, RFI, DRFI, and IBCFS as primary endpoint in breast cancer adjuvant trials. Funding This analysis was supported by the Italian Association for Cancer Research ("Associazione Italiana per la Ricerca sul Cancro", AIRC; IG 2017/20760) and by Italian Ministry of Health-5 × 1000 funds (years 2021-2022).
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Affiliation(s)
- Eva Blondeaux
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Wanling Xie
- Division of Biostatistics, Dana-Farber Cancer Institute, Boston, USA
| | - Luca Carmisciano
- Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy
| | - Silvia Mura
- Department of Medical Oncology, UOC Oncologia Medica, University Hospital of Sassari, Sassari, Italy
| | - Valeria Sanna
- Department of Medical Oncology, UOC Oncologia Medica, University Hospital of Sassari, Sassari, Italy
| | - Michelino De Laurentiis
- Istituto Nazionale per lo Studio e la Cura dei Tumouri, Fondazione Pascale IRCCS, Napoli, Italy
| | - Roberta Caputo
- Istituto Nazionale per lo Studio e la Cura dei Tumouri, Fondazione Pascale IRCCS, Napoli, Italy
| | - Anna Turletti
- Medical Oncology, Ospedale Martini ASL Città di Torino, Torino, Italy
| | - Antonio Durando
- Breast Unit, Città della Salute e della Scienza, Ospedale S. Anna, Torino, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Carmine De Angelis
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Giancarlo Bisagni
- Department of Oncology and Advanced Technology, Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elisa Gasparini
- Department of Oncology and Advanced Technology, Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Anita Rimanti
- ASST Mantova, Azienda Ospedaliera Carlo Poma, Mantova, Italy
| | - Fabio Puglisi
- Department of Medical Oncology, Unit of Medical Oncology and Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Mauro Mansutti
- Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | | | - Alessandra Fabi
- Precision Medicine Breast Unit, Scientific Directorate, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Arecco
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Marta Perachino
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Marco Bruzzone
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Boni
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Lambertini
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Lucia Del Mastro
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Meredith M. Regan
- Division of Biostatistics, Dana-Farber Cancer Institute, Boston, USA
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McKechnie T, Brown Z, Lovrics O, Yang S, Kazi T, Eskicioglu C, Parvez E. Concurrent Use of Statins in Patients Undergoing Curative Intent Treatment for Triple Negative Breast Cancer: A Systematic Review and Meta-Analysis. Clin Breast Cancer 2024; 24:e103-e115. [PMID: 38296737 DOI: 10.1016/j.clbc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 02/02/2024]
Abstract
Pre-clinical studies in triple negative breast cancer (TNBC) suggest that statins may inhibit cell proliferation, promote cell-cycle arrest, induce apoptosis, change the tumor microenvironment, and improve effectiveness of other therapies. Observational studies have demonstrated variable effects from statin therapy on oncologic outcomes in these patients. As such, we aimed to pool previous data via a systematic review and meta-analysis to elucidate the impact of concurrent statin use on oncologic outcomes for patients with TNBC. Medline, EMBASE, CENTRAL, and PubMed were systematically searched from inception through to June 2022. Studies were included if they compared patients with TNBC receiving and not receiving statin therapy concurrently with oncologic treatment for curative intent in terms of recurrence and survival in a non-metastatic setting. The primary outcomes were 5-year disease-free survival (DFS) and 5-year overall survival (OS). A pairwise meta-analyses was performed using inverse variance random effects. Risk of bias was assessed with the ROBINS-I and the GRADE approach was conducted to assess quality of evidence. From 4014 citations, 5 studies with 625 patients on statin therapy and 2707 patients not on statin therapy were included. There was a significant increase in 5-year DFS for patients on statin therapy compared to patients not on statin therapy (OR 1.44, 95% CI 1.04-1.98, P = .03). No significant difference was noted in 5-year OS between the 2 groups (OR 1.12, 95% CI 0.86-1.47, P = .40). Included studies were at moderate-to-high risk of bias. The GRADE quality of evidence was very low. This review presents very low-quality evidence that concurrent use of statins with oncologic treatment may potentially improve long-term DFS for patients with TNBC undergoing curative intent therapy. Future research by way of large, prospective study is required to further clarify the clinical utility of statins on patients undergoing treatment for TNBC.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Zachary Brown
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Olivia Lovrics
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Shuling Yang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tania Kazi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Elena Parvez
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
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31
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Leon-Ferre RA, Carter JM, Zahrieh D, Sinnwell JP, Salgado R, Suman VJ, Hillman DW, Boughey JC, Kalari KR, Couch FJ, Ingle JN, Balkenhol M, Ciompi F, van der Laak J, Goetz MP. Automated mitotic spindle hotspot counts are highly associated with clinical outcomes in systemically untreated early-stage triple-negative breast cancer. NPJ Breast Cancer 2024; 10:25. [PMID: 38553444 PMCID: PMC10980681 DOI: 10.1038/s41523-024-00629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 03/08/2024] [Indexed: 04/02/2024] Open
Abstract
Operable triple-negative breast cancer (TNBC) has a higher risk of recurrence and death compared to other subtypes. Tumor size and nodal status are the primary clinical factors used to guide systemic treatment, while biomarkers of proliferation have not demonstrated value. Recent studies suggest that subsets of TNBC have a favorable prognosis, even without systemic therapy. We evaluated the association of fully automated mitotic spindle hotspot (AMSH) counts with recurrence-free (RFS) and overall survival (OS) in two separate cohorts of patients with early-stage TNBC who did not receive systemic therapy. AMSH counts were obtained from areas with the highest mitotic density in digitized whole slide images processed with a convolutional neural network trained to detect mitoses. In 140 patients from the Mayo Clinic TNBC cohort, AMSH counts were significantly associated with RFS and OS in a multivariable model controlling for nodal status, tumor size, and tumor-infiltrating lymphocytes (TILs) (p < 0.0001). For every 10-point increase in AMSH counts, there was a 16% increase in the risk of an RFS event (HR 1.16, 95% CI 1.08-1.25), and a 7% increase in the risk of death (HR 1.07, 95% CI 1.00-1.14). We corroborated these findings in a separate cohort of systemically untreated TNBC patients from Radboud UMC in the Netherlands. Our findings suggest that AMSH counts offer valuable prognostic information in patients with early-stage TNBC who did not receive systemic therapy, independent of tumor size, nodal status, and TILs. If further validated, AMSH counts could help inform future systemic therapy de-escalation strategies.
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Affiliation(s)
| | | | | | | | - Roberto Salgado
- GZA-ZNA-Hospitals, Antwerp, Belgium
- Peter Mac Callum Cancer Centre, Melbourne, Australia
| | | | | | | | | | | | | | | | | | - Jeroen van der Laak
- Radboud University Medical Center, Nijmegen, Netherlands
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
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32
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de Boo LW, Jóźwiak K, Ter Hoeve ND, van Diest PJ, Opdam M, Wang Y, Schmidt MK, de Jong V, Kleiterp S, Cornelissen S, Baars D, Koornstra RHT, Kerver ED, van Dalen T, Bins AD, Beeker A, van den Heiligenberg SM, de Jong PC, Bakker SD, Rietbroek RC, Konings IR, Blankenburgh R, Bijlsma RM, Imholz ALT, Stathonikos N, Vreuls W, Sanders J, Rosenberg EH, Koop EA, Varga Z, van Deurzen CHM, Mooyaart AL, Córdoba A, Groen E, Bart J, Willems SM, Zolota V, Wesseling J, Sapino A, Chmielik E, Ryska A, Broeks A, Voogd AC, van der Wall E, Siesling S, Salgado R, Dackus GMHE, Hauptmann M, Kok M, Linn SC. Prognostic value of histopathologic traits independent of stromal tumor-infiltrating lymphocyte levels in chemotherapy-naïve patients with triple-negative breast cancer. ESMO Open 2024; 9:102923. [PMID: 38452438 PMCID: PMC10937239 DOI: 10.1016/j.esmoop.2024.102923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/09/2024] [Accepted: 02/04/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND In the absence of prognostic biomarkers, most patients with early-stage triple-negative breast cancer (eTNBC) are treated with combination chemotherapy. The identification of biomarkers to select patients for whom treatment de-escalation or escalation could be considered remains an unmet need. We evaluated the prognostic value of histopathologic traits in a unique cohort of young, (neo)adjuvant chemotherapy-naïve patients with early-stage (stage I or II), node-negative TNBC and long-term follow-up, in relation to stromal tumor-infiltrating lymphocytes (sTILs) for which the prognostic value was recently reported. MATERIALS AND METHODS We studied all 485 patients with node-negative eTNBC from the population-based PARADIGM cohort which selected women aged <40 years diagnosed between 1989 and 2000. None of the patients had received (neo)adjuvant chemotherapy according to standard practice at the time. Associations between histopathologic traits and breast cancer-specific survival (BCSS) were analyzed with Cox proportional hazard models. RESULTS With a median follow-up of 20.0 years, an independent prognostic value for BCSS was observed for lymphovascular invasion (LVI) [adjusted (adj.) hazard ratio (HR) 2.35, 95% confidence interval (CI) 1.49-3.69], fibrotic focus (adj. HR 1.61, 95% CI 1.09-2.37) and sTILs (per 10% increment adj. HR 0.75, 95% CI 0.69-0.82). In the sTILs <30% subgroup, the presence of LVI resulted in a higher cumulative incidence of breast cancer death (at 20 years, 58%; 95% CI 41% to 72%) compared with when LVI was absent (at 20 years, 32%; 95% CI 26% to 39%). In the ≥75% sTILs subgroup, the presence of LVI might be associated with poor survival (HR 11.45, 95% CI 0.71-182.36, two deaths). We confirm the lack of prognostic value of androgen receptor expression and human epidermal growth factor receptor 2 -low status. CONCLUSIONS sTILs, LVI and fibrotic focus provide independent prognostic information in young women with node-negative eTNBC. Our results are of importance for the selection of patients for de-escalation and escalation trials.
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Affiliation(s)
- L W de Boo
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - K Jóźwiak
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - N D Ter Hoeve
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Opdam
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Y Wang
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M K Schmidt
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - V de Jong
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S Kleiterp
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S Cornelissen
- Core Facility Molecular Pathology and Biobanking, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - D Baars
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - R H T Koornstra
- Department of Medical Oncology, Rijnstate Medical center, Arnhem, The Netherlands
| | - E D Kerver
- Department of Medical Oncology, OLVG, Amsterdam, The Netherlands
| | - T van Dalen
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - A D Bins
- Department of Medical Oncology, Amsterdam UMC, Amsterdam, The Netherlands
| | - A Beeker
- Department of Medical Oncology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | | | - P C de Jong
- Department of Medical Oncology, Sint Antonius Hospital, Utrecht, The Netherlands
| | - S D Bakker
- Department of Internal Medicine, Zaans Medical Centre, Zaandam, The Netherlands
| | - R C Rietbroek
- Department of Medical Oncology, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - I R Konings
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - R Blankenburgh
- Department of Medical Oncology, Saxenburgh Medical Center, Hardenberg, The Netherlands
| | - R M Bijlsma
- Department of Medical Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - A L T Imholz
- Department of Internal Medicine, Deventer Hospital, Deventer, The Netherlands
| | - N Stathonikos
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Vreuls
- Department of Pathology, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - J Sanders
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - E H Rosenberg
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - E A Koop
- Department of Pathology, Gelre Ziekenhuizen, Apeldoorn, The Netherlands
| | - Z Varga
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - C H M van Deurzen
- Department of Pathology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A L Mooyaart
- Department of Pathology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A Córdoba
- Department of Pathology, Complejo Hospitalaria de Navarra, Pamplona, Spain
| | - E Groen
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J Bart
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, The Netherlands
| | - S M Willems
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, The Netherlands
| | - V Zolota
- Department of Pathology, Rion University Hospital, Patras, Greece
| | - J Wesseling
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - A Sapino
- Department of Medical Sciences, University of Torino, Torino, Italy; Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - E Chmielik
- Tumor Pathology Department, Maria Sklodowska-Curie Memorial National Research Institute of Oncology, Gliwice, Poland
| | - A Ryska
- Charles University Medical Faculty and University Hospital, Hradec Kralove, Czech Republic
| | - A Broeks
- Core Facility Molecular Pathology and Biobanking, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - E van der Wall
- Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands; Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - R Salgado
- Division of Clinical Medicine and Research, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Pathology, GZA-ZNA Hospitals, Antwerp, Belgium
| | - G M H E Dackus
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - M Kok
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Tumorbiology & Immunology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S C Linn
- Department of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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33
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Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:112-132. [PMID: 37977261 DOI: 10.1016/j.prro.2023.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.
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Affiliation(s)
- Simona F Shaitelman
- Department of Breast Radiation Oncology, University of Texas MD - Anderson Cancer Center, Houston, Texas.
| | - Bethany M Anderson
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Naamit K Gerber
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Madeera Kathpal
- Department of Radiation Oncology, Duke University Wake County Campus, Raleigh, North Carolina
| | - Leonard Kim
- Department of Radiation Oncology, MD - Anderson Cancer Center at Cooper, Camden, New Jersey
| | - Christine Laronga
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Icro Meattini
- Department of Radiation Oncology, University of Florence, Florence, Italy
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia A Spears
- Patient Representative, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shaveta Vinayak
- Department of Medical Oncology, University of Washington, Seattle, Washington
| | - Timothy Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Janice A Lyons
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio
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Hyung J, Lee SB, Kim J, Kim HJ, Ko B, Lee JW, Son BH, Lee HJ, Gong G, Jeong H, Jeong JH, Kim JE, Ahn JH, Jung KH, Kim SB. 21-gene expression assay and clinical outcomes of premenopausal patients with hormone receptor-positive breast cancer. Int J Cancer 2024; 154:748-756. [PMID: 37718333 DOI: 10.1002/ijc.34728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/24/2023] [Accepted: 08/14/2023] [Indexed: 09/19/2023]
Abstract
The prognostic role of the recurrence score (RS) based on the 21-gene expression assay in premenopausal women is not well delineated, and we investigated the association of outcomes and the RS in premenopausal patients who had 21-gene expression assay at Asan Medical Center, Seoul, Korea, between June 2005 and July 2018. Invasive breast cancer-free survival (IBCFS) by STEEP version 2.0 was compared according to the RS and clinical risk factors. A total of 554 patients were included in our study and 116 patients (20.9%) had age <40 years, 238 patients (43.0%) had luminal B subtype (Ki67 ≥ 20%), and 83 patients (15.0%) had RS >25. All patients received adjuvant tamoxifen ± chemotherapy. Overall, patients with RS >25 showed trend toward worse IBCFS from multivariable analysis (adjusted HR 1.89 [95% CI: 0.95-3.73], P = .069). When comparing outcomes according to age and luminal subtypes, patients with luminal B subtype and age <40 years (n = 60) showed significantly worse outcomes compared to the others (luminal A or luminal B + age ≥40 years, n = 494; adjusted HR 2.95 [95% CI: 1.49-5.82], log-rank P < .001). Among patients with luminal B subtype and age <40 years, there was no significant association observed between IBCFS and the RS (log-rank P = .51). In conclusion, while RS >25 showed association with poor outcomes in premenopausal women, it may have less prognostic significance among those with luminal B subtype and age <40 years.
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Affiliation(s)
- Jaewon Hyung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sae Byul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jisun Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Jeong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - BeomSeok Ko
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Won Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung-Ho Son
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Jin Lee
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyungyub Gong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyehyun Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Hee Ahn
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Bae Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Rönnlund C, Sifakis EG, Schagerholm C, Yang Q, Karlsson E, Chen X, Foukakis T, Weidler J, Bates M, Fredriksson I, Robertson S, Hartman J. Prognostic impact of HER2 biomarker levels in trastuzumab-treated early HER2-positive breast cancer. Breast Cancer Res 2024; 26:24. [PMID: 38321542 PMCID: PMC10848443 DOI: 10.1186/s13058-024-01779-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/24/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Overexpression of human epidermal growth factor receptor 2 (HER2) caused by HER2 gene amplification is a driver in breast cancer tumorigenesis. We aimed to investigate the prognostic significance of manual scoring and digital image analysis (DIA) algorithm assessment of HER2 copy numbers and HER2/CEP17 ratios, along with ERBB2 mRNA levels among early-stage HER2-positive breast cancer patients treated with trastuzumab. METHODS This retrospective study comprised 371 early HER2-positive breast cancer patients treated with adjuvant trastuzumab, with HER2 re-testing performed on whole tumor sections. Digitized tumor tissue slides were manually scored and assessed with uPath HER2 Dual ISH image analysis, breast algorithm. Targeted ERBB2 mRNA levels were assessed by the Xpert® Breast Cancer STRAT4 Assay. HER2 copy number and HER2/CEP17 ratio from in situ hybridization assessment, along with ERBB2 mRNA levels, were explored in relation to recurrence-free survival (RFS). RESULTS The analysis showed that patients with tumors with the highest and lowest manually counted HER2 copy number levels had worse RFS than those with intermediate levels (HR = 2.7, CI 1.4-5.3, p = 0.003 and HR = 2.1, CI 1.1-3.9, p = 0.03, respectively). A similar trend was observed for HER2/CEP17 ratio, and the DIA algorithm confirmed the results. Moreover, patients with tumors with the highest and the lowest values of ERBB2 mRNA had a significantly worse prognosis (HR = 2.7, CI 1.4-5.1, p = 0.003 and HR = 2.8, CI 1.4-5.5, p = 0.004, respectively) compared to those with intermediate levels. CONCLUSIONS Our findings suggest that the association between any of the three HER2 biomarkers and RFS was nonlinear. Patients with tumors with the highest levels of HER2 gene amplification or ERBB2 mRNA were associated with a worse prognosis than those with intermediate levels, which is of importance to investigate in future clinical trials studying HER2-targeted therapy.
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Affiliation(s)
- Caroline Rönnlund
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden.
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden.
| | - Emmanouil G Sifakis
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden
| | - Caroline Schagerholm
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden
| | - Qiao Yang
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden
| | - Emelie Karlsson
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden
| | - Xinsong Chen
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden
| | - Theodoros Foukakis
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden
- Breast Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Jodi Weidler
- Medical and Scientific Affairs and Strategy, Oncology, Cepheid, Sunnyvale, CA, USA
| | - Michael Bates
- Medical and Scientific Affairs and Strategy, Oncology, Cepheid, Sunnyvale, CA, USA
| | - Irma Fredriksson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast-, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Stephanie Robertson
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden
| | - Johan Hartman
- Department of Oncology and Pathology, Karolinska Institutet, Visionsgatan 56, CCK R8:04, 17176, Stockholm, Sweden
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
- Medtechlabs, Bioclinicum, Karolinska University Hospital, Stockholm, Sweden
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Walia A, Tuia J, Prasad V. Progression-free survival, disease-free survival and other composite end points in oncology: improved reporting is needed. Nat Rev Clin Oncol 2023; 20:885-895. [PMID: 37828154 DOI: 10.1038/s41571-023-00823-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
Composite outcome measures such as progression-free survival and disease-free survival are increasingly used as surrogate end points in oncology research, frequently serving as the primary end point of pivotal trials that form the basis for FDA and EMA approvals. Such outcome measures combine two or more distinct events (for example, tumour (re)growth, new lesions and/or death) into a single, time-to-event end point. The use of a composite end point can increase the statistical power of a clinical trial and decrease the follow-up period required to demonstrate efficacy, thus lowering costs; however, these end points have a number of limitations. Composite outcomes are often vaguely defined, with definitions that vary greatly between studies, complicating comparisons of results across trials. Altering the makeup of events included in a composite outcome can alter study conclusions, including whether treatment effects are statistically significant. Moreover, the events included in a composite outcome often vary in clinical significance, reflect distinct biological pathways and/or are affected differently by treatment. Therefore, knowing the precise breakdown of the component events is essential to accurately interpret trial results and gauge the true benefit of an intervention. In oncology clinical trials, however, such information is rarely provided. In this Perspective, we emphasize this deficiency through a review of 50 studies with progression-free survival as an outcome published in five top oncology journals, discuss the advantages and challenges of using composite end points, and highlight the need for transparent reporting of the component events.
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Affiliation(s)
- Anushka Walia
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Jordan Tuia
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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Dong X, Yu J, Nie L, Wu Y, Lu Y, Qin Y, Jin Y, Chen Y, Gu C, Gan L, Zhang N. Information Support Provided by Specialized Nurses via Mobile Healthcare App May Improve Treatment Adherence of Breast Cancer Patients: An Observational Study. Semin Oncol Nurs 2023; 39:151511. [PMID: 37880011 DOI: 10.1016/j.soncn.2023.151511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 08/02/2023] [Accepted: 09/14/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Mobile devices facilitate the healthcare management of breast cancer. Meanwhile, specialist nurses play an important role in disease management. We established a smartphone-based app that enables patients to raise questions to specialist nurses. We aimed to evaluate whether the information support provided by specialist nurses via smartphone app could improve the treatment adherence of breast cancer patients. DATA SOURCE Breast cancer patients who received surgery and registered for the app between March 2013 and April 2020 were included. Data related to the use of the app, the number of raised questions, and the specific content of each question were retrieved. Overall, 2675 patients were included, with 560 patients raising questions to specialist nurses via the app. Patients with higher educational levels, postmenopause status, and more advanced diseases were more likely to seek informational support via a smartphone app. The treatment adherence was 86.4%. Multivariate analysis demonstrated that raising questions was associated with better compliance. Regarding the distribution of questions, 78.8% of patients had questions about the treatment schedule and procedure, 65.9% of patients had questions during the adjuvant treatment, and only 19.6% of patients raised questions about follow-up and rehabilitation. After a median follow-up of 44 months, there was no survival difference between patients who raised questions and those who did not. CONCLUSION Seeking information support from specialist nurses was associated with better treatment adherence. The smartphone-based healthcare app enables specialist nurses to provide more conducive service for patients, and validation of this finding in further studies is warranted. IMPLICATIONS FOR NURSING PRACTICE Breast cancer patients were more interested in problems with treatment procedures and schedules. Those who asked questions had better treatment adherence. The smartphone-based app could not only provide patients with a platform to seek information support but also help specialist nurses understand the needs of patients.
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Affiliation(s)
- Xiaojing Dong
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Yu
- Physician, Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lijing Nie
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiying Wu
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Lu
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanwen Qin
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yufei Jin
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yunyun Chen
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengjia Gu
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lu Gan
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Zhang
- Specialist nurse, Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Head nurse and supervisor, Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Kantor O, King TA, Jones A, Glass C, Leonard SJ, Ogayo ER, Mayer EL, Chavez-MacGregor M, Newman LA, Freedman RA, Mittendorf EA. Racial and Ethnic Disparities in Outcomes After Breast-Conserving Therapy and Endocrine Therapy for DCIS: A Post-Hoc Analysis of the NSABP B-35 Randomized Clinical Trial. Ann Surg Oncol 2023; 30:8404-8411. [PMID: 37777685 DOI: 10.1245/s10434-023-14344-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/14/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Racial and ethnic disparities in outcomes after treatment for ductal carcinoma in situ (DCIS) are largely unknown. The objective of this study was to examine breast cancer outcomes by race and ethnicity in the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-35 clinical trial. PATIENTS AND METHODS The NSABP B-35 trial randomized postmenopausal women with hormone receptor-positive DCIS treated with breast-conserving therapy to 5 years of tamoxifen or anastrozole. In total, 3104 women were enrolled between 2003 and 2006. For this analysis, patients without complete self-reported race and ethnicity or with immediate trial dropout were excluded. Kaplan-Meier curves and adjusted Cox-proportional hazards models were used for analyses. RESULTS Of the 3061 women included, 2614 (85.4%) were non-Hispanic white (NHW), 255 (8.3%) were non-Hispanic Black (NHB), 95 (3.1%) were Hispanic, and 96 (3.1%) were Asian or Pacific Islander (API). Endocrine therapy assignment and duration were well balanced between racial and ethnic groups. Median follow-up was 9 years; unadjusted Kaplan-Meier curves did not show any racial differences in disease events. Adjusted Cox-proportional hazards models found API (versus NHW) race to be associated with higher local recurrence [hazard ratio (HzR) 2.45, p = 0.035] and NHB race to be associated with higher distant recurrence (HzR 5.03, p = 0.020) and breast cancer mortality (HzR 3.83, p = 0.046). CONCLUSIONS Despite similar locoregional treatments and standard endocrine therapy in a clinical trial population, racial and ethnic disparities exist in long-term outcomes for hormone-receptor-positive DCIS. These findings suggest that factors outside of access and treatment may impact DCIS outcomes by race and ethnicity.
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Affiliation(s)
- Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alyssa Jones
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Charity Glass
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Saskia J Leonard
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Esther R Ogayo
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Erica L Mayer
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lisa A Newman
- Department of Surgery, Weill-Cornell Medicine, New York, NY, USA
| | - Rachel A Freedman
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Pfeiler G, Hlauschek D, Mayer EL, Deutschmann C, Kacerovsky-Strobl S, Martin M, Meisel JL, Zdenkowski N, Loibl S, Balic M, Park H, Prat A, Isaacs C, Bajetta E, Balko JM, Bellet-Ezquerra M, Bliss J, Burstein H, Cardoso F, Fohler H, Foukakis T, Gelmon KA, Goetz M, Haddad TC, Iwata H, Jassem J, Lee SC, Linderholm B, Los M, Mamounas EP, Miller KD, Morris PG, Munzone E, Gal-Yam EN, Ring A, Shepherd L, Singer C, Thomssen C, Tseng LM, Valagussa P, Winer EP, Wolff AC, Zoppoli G, Machacek-Link J, Schurmans C, Huang X, Gauthier E, Fesl C, Dueck AC, DeMichele A, Gnant M. Impact of BMI in Patients With Early Hormone Receptor-Positive Breast Cancer Receiving Endocrine Therapy With or Without Palbociclib in the PALLAS Trial. J Clin Oncol 2023; 41:5118-5130. [PMID: 37556775 DOI: 10.1200/jco.23.00126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/03/2023] [Accepted: 06/21/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE BMI affects breast cancer risk and prognosis. In contrast to cytotoxic chemotherapy, CDK4/6 inhibitors are given at a fixed dose, irrespective of BMI or weight. This preplanned analysis of the global randomized PALLAS trial investigates the impact of BMI on the side-effect profile, treatment adherence, and efficacy of palbociclib. METHODS Patients were categorized at baseline according to WHO BMI categories. Neutropenia rates were assessed with univariable and multivariable logistic regression. Time to early discontinuation of palbociclib was analyzed with Fine and Gray competing risk models. Unstratified Cox models were used to investigate the association between BMI category and time to invasive disease-free survival (iDFS). 95% CIs were derived. RESULTS Of 5,698 patients included in this analysis, 68 (1.2%) were underweight, 2,082 (36.5%) normal weight, 1,818 (31.9%) overweight, and 1,730 (30.4%) obese at baseline. In the palbociclib arm, higher BMI was associated with a significant decrease in neutropenia (unadjusted odds ratio for 1-unit change, 0.93; 95% CI, 0.91 to 0.94; adjusted for age, race ethnicity, region, chemotherapy use, and Eastern Cooperative Oncology Group at baseline, 0.93; 95% CI, 0.92 to 0.95). This translated into a significant decrease in treatment discontinuation rate with higher BMI (adjusted hazard ratio [HR] for 10-unit change, 0.75; 95% CI, 0.67 to 0.83). There was no significant improvement in iDFS with the addition of palbociclib to ET in any weight category (normal weight HR, 0.84; 95% CI, 0.63 to 1.12; overweight HR, 1.10; 95% CI, 0.82 to 1.49; and obese HR, 0.95; 95% CI, 0.69 to 1.30) in this analysis early in follow-up (31 months). CONCLUSION This preplanned analysis of the PALLAS trial demonstrates a significant impact of BMI on side effects, dose reductions, early treatment discontinuation, and relative dose intensity. Additional long-term follow-up will further evaluate whether BMI ultimately affects outcome.
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Affiliation(s)
- Georg Pfeiler
- Department of Gynecology and Gynecological Oncology, Medical University of Vienna, Vienna, Austria
| | | | | | - Christine Deutschmann
- Department of Gynecology and Gynecological Oncology, Medical University of Vienna, Vienna, Austria
| | | | - Miguel Martin
- Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | | | | | - Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany
- Goethe University Frankfurt/M, Frankfurt/M, Germany
- Centre for Haematology and Oncology/Bethanien, Frankfurt/M, Germany
| | - Marija Balic
- Division of Oncology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Haeseong Park
- Siteman Cancer Center, Washington University, St Louis, MO
| | - Aleix Prat
- Department of Medical Oncology, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Emilio Bajetta
- Gruppo I.T.M.O., Monza, Italy
- Fondazione Policlinico di Monza, Monza, Italy
| | - Justin M Balko
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | | | - Judith Bliss
- The Institute of Cancer Research, London, United Kingdom
| | - Harold Burstein
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Hannes Fohler
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Theodoros Foukakis
- Breast Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology/Pathology, Karolinska Institute, Stockholm, Sweden
| | | | | | - Tufia C Haddad
- Mayo Clinic College of Medicine and Science, Rochester, MN
| | | | - Jacek Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland
| | - Soo-Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute (NCIS), Singapore, Singapore
- Cancer Science Institute (CSI), Singapore, Singapore
- National University of Singapore (NUS), Singapore, Singapore
| | - Barbro Linderholm
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Oncology, Institution of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Maartje Los
- St Antonius Ziekenhuis Nieuwegein, Utrecht, the Netherlands
| | | | - Kathy D Miller
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | - Patrick G Morris
- Cancer Trials Ireland, Dublin, Ireland
- Beaumont RCSI Cancer Centre, Dublin, Ireland
| | | | - Einav Nili Gal-Yam
- The Talpiot Medical Leadership Program, Breast Oncology Institute, Sheba Medical Center, Ramat-Gam, Israel
| | - Alistair Ring
- Royal Marsden Hospital, NHS Foundation Trust, London, United Kingdom
| | - Lois Shepherd
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Christian Singer
- Department of Gynecology and Gynecological Oncology, Medical University of Vienna, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Ling-Ming Tseng
- Taipei-Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Eric P Winer
- Yale Cancer Center, Smilow Cancer Network, Yale University, New Haven, CT
| | | | - Gabriele Zoppoli
- Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC), Università degli Studi di Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | | | - Christian Fesl
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Amylou C Dueck
- Alliance Statistics and Data Center, Mayo Clinic, Phoenix, AZ
| | | | - Michael Gnant
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Decker NS, Johnson T, Vey JA, Le Cornet C, Behrens S, Obi N, Kaaks R, Chang-Claude J, Fortner RT. Circulating oxysterols and prognosis among women with a breast cancer diagnosis: results from the MARIE patient cohort. BMC Med 2023; 21:438. [PMID: 37964298 PMCID: PMC10648629 DOI: 10.1186/s12916-023-03152-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/02/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Breast cancer is the most commonly diagnosed cancer in women worldwide, and underlying mechanistic pathways associated with breast cancer-specific and non-breast cancer-related deaths are of importance. Emerging evidence suggests a role of oxysterols, derivates of cholesterol, in multiple chronic diseases including breast cancer and coronary artery diseases. However, associations between oxysterols and survival have been minimally studied in women diagnosed with breast cancer. In this large breast cancer patient cohort, we evaluated associations between a panel of circulating oxysterols and mortality and recurrence outcomes. METHODS Concentrations of 13 circulating oxysterols representing different pathways of cholesterol metabolism were quantified using liquid-chromatography mass-spectrometry. Associations between baseline levels of oxysterols and cause-specific mortality outcomes and recurrence following a breast cancer diagnosis were assessed in 2282 women from the MARIE study over a median follow-up time of 11 years. We calculated hazard ratios (HR) and 95% confidence intervals (CI) using multivariable Cox proportional hazard models and competing risks models. RESULTS We observed no associations for circulating oxysterols and breast cancer-specific outcomes. Higher levels of six oxysterols were associated with an increased risk of cardiovascular disease death, including 24S-hydroxycholesterol (alternative bile acid pathway, HRlog2 = 1.73 (1.02, 2.93)), lanosterol (cholesterol biosynthesis pathway, HRlog2 = 1.95 (1.34, 2.83)), 7-ketocholesterol (HRlog2 = 1.26 (1.03, 1.55)), 5α,6α-epoxycholesterol (HRlog2 = 1.34 (1.02-1.77)), and 5a,6β-dihydroxycholestanol (HRlog2 = 1.34 (1.03, 1.76)). After adjusting for multiple comparisons, none of the associations were statistically significant. CONCLUSION We provide first evidence on a range of circulating oxysterols and mortality following a breast cancer diagnosis, contributing to a better understanding of associations between different pathways of cholesterol metabolism and prognosis in women with a breast cancer diagnosis. The findings of this study suggest circulating oxysterols may be associated with cardiovascular mortality among women diagnosed with breast cancer. Further studies are needed to evaluate these oxysterols as potential markers of risk for cardiovascular mortality among women with a breast cancer diagnosis as well as their clinical potential.
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Affiliation(s)
- Nina Sophia Decker
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
- Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Theron Johnson
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Johannes A Vey
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Charlotte Le Cornet
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Sabine Behrens
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Nadia Obi
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
- University Cancer Center Hamburg, Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Renée Turzanski Fortner
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
- Department of Research, Cancer Registry of Norway, Ullernchausseen 64, 0379, Oslo, Norway.
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Hennessy MA, Leal JP, Huang CY, Solnes LB, Denbow R, Abramson VG, Carey LA, Liu MC, Rimawi M, Specht J, Storniolo AM, Valero V, Vaklavas C, Winer EP, Krop IE, Wolff AC, Cimino-Mathews A, Wahl RL, Stearns V, Connolly RM. Correlation of SUV on Early Interim PET with Recurrence-Free Survival and Overall Survival in Primary Operable HER2-Positive Breast Cancer (the TBCRC026 Trial). J Nucl Med 2023; 64:1690-1696. [PMID: 37652539 DOI: 10.2967/jnumed.123.265853] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/06/2023] [Indexed: 09/02/2023] Open
Abstract
Predictive biomarkers of response to human epidermal growth factor receptor 2 (HER2)-directed therapy are essential to inform treatment decisions. The TBCRC026 trial reported that early declines in tumor SUVs corrected for lean body mass (SULmax) on 18F-FDG PET/CT predicted a pathologic complete response (pCR) to HER2 therapy with neoadjuvant trastuzumab and pertuzumab (HP) without chemotherapy in estrogen receptor (ER)-negative, HER2-positive breast cancer. We hypothesized that 18F-FDG PET/CT SULmax parameters would predict recurrence-free survival (RFS) and overall survival (OS). Methods: Patients with stage II/III ER-negative, HER2-positive breast cancer received neoadjuvant HP (n = 88). pCR after HP alone was 22% (18/83), additional nonstudy neoadjuvant therapy was administered in 28% (25/88), and the majority received adjuvant therapy per physician discretion. 18F-FDG PET/CT was performed at baseline and at cycle 1, day 15 (C1D15). RFS and OS were summarized using the Kaplan-Meier method and compared between subgroups using logrank tests. Associations between 18F-FDG PET/CT (≥40% decline in SULmax between baseline and C1D15, or C1D15 SULmax ≤ 3) and pCR were evaluated using Cox regressions, where likelihood ratio CIs were reported because of the small numbers of events. Results: Median follow-up was 53.7 mo (83/88 evaluable), with 6 deaths and 14 RFS events. Estimated RFS and OS at 3 y was 84% (95% CI, 76%-92%) and 92% (95% CI, 87%-98%), respectively. A C1D15 SULmax of 3 or less was associated with improved RFS (hazard ratio [HR], 0.36; 95% CI, 0.11-1.05; P = 0.06) and OS (HR, 0.14; 95% CI, 0.01-0.85; P = 0.03), the latter statistically significant. The association of an SULmax decline of at least 40% (achieved in 59%) with RFS and OS did not reach statistical significance. pCR was associated with improved RFS (HR, 0.25; 95% CI, 0.01-1.24; P = 0.10) but did not reach statistical significance. Conclusion: For the first time, we report a potential association between a C1D15 SULmax of 3 or less on 18F-FDG PET/CT and RFS and OS outcomes in patients with ER-negative, HER2-positive breast cancer receiving neoadjuvant HP alone. If confirmed in future studies, this imaging-based biomarker may facilitate early individualization of therapy.
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Affiliation(s)
| | - Jeffrey P Leal
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland
| | - Chiung-Yu Huang
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland
- University of California, San Francisco, California
| | - Lilja B Solnes
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland
| | - Rita Denbow
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland
| | | | - Lisa A Carey
- University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | - Anna Maria Storniolo
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University, Indianapolis, Indiana
| | | | | | | | - Ian E Krop
- Yale Cancer Center, New Haven, Connecticut; and
| | - Antonio C Wolff
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland
| | | | | | - Vered Stearns
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland
| | - Roisin M Connolly
- Cancer Research @UCC, Cork, Ireland;
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland
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Lipsyc-Sharf M, Ballman KV, Campbell JD, Muss HB, Perez EA, Shulman LN, Carey LA, Partridge AH, Warner ET. Age, Body Mass Index, Tumor Subtype, and Racial and Ethnic Disparities in Breast Cancer Survival. JAMA Netw Open 2023; 6:e2339584. [PMID: 37878313 PMCID: PMC10600583 DOI: 10.1001/jamanetworkopen.2023.39584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Importance Black women in the United States have higher breast cancer (BC) mortality rates than White women. The combined role of multiple factors, including body mass index (BMI), age, and tumor subtype, remains unclear. Objective To assess the association of race and ethnicity with survival among clinical trial participants with early-stage BC (eBC) according to tumor subtype, age, and BMI. Design, Setting, and Participants This cohort study analyzed survival data, as of November 12, 2021, from participants enrolled between 1997 and 2010 in 4 randomized adjuvant chemotherapy trials: Cancer and Leukemia Group B (CALGB) 9741, 49907, and 40101 as well as North Central Cancer Treatment Group (NCCTG) N9831, legacy groups of the Alliance of Clinical Trials in Oncology. Median follow-up was 9.8 years. Exposures Non-Hispanic Black and Hispanic participants were compared with non-Hispanic White participants within subgroups of subtype (hormone receptor positive [HR+]/ERBB2 [formerly HER2] negative [ERBB2-], ERBB2+, and HR-/ERBB2-), age (<50, 50 to <65, and ≥65 years), and BMI (<18.5, 18.5 to <25.0, 25.0 to <30.0, and ≥30.0). Main Outcomes and Measures Recurrence-free survival (RFS) and overall survival (OS). Results Of 9479 participants, 436 (4.4%) were Hispanic, 871 (8.8%) non-Hispanic Black, and 7889 (79.5%) non-Hispanic White. The median (range) age was 52 (19.0-89.7) years. Among participants with HR+/ERBB2- tumors, non-Hispanic Black individuals had worse RFS (hazard ratio [HR], 1.49; 95% CI, 1.04-2.12; 5-year RFS, 88.5% vs 93.2%) than non-Hispanic White individuals, although the global test for association of race and ethnicity with RFS was not significant within any tumor subtype. There were no OS differences by race and ethnicity in any subtype. Race and ethnicity were associated with OS in young participants (age <50 years; global P = .008); young non-Hispanic Black participants (HR, 1.34; 95% CI, 1.04-1.71; 5-year OS, 86.6% vs 92.0%) and Hispanic participants (HR, 1.62; 95% CI, 1.16-2.29; 5-year OS, 86.2% vs 92.0%) had worse OS than young non-Hispanic White participants. Race and ethnicity were associated with RFS in participants with BMIs of 25 to less than 30, with non-Hispanic Black participants having worse RFS (HR, 1.81; 95% CI, 1.23-2.68; 5-year RFS, 83.2% vs 87.3%) than non-Hispanic White participants. Conclusions and Relevance In this cohort study, racial and ethnic survival disparities were identified in patients with eBC receiving standardized initial care, and potentially at-risk subgroups, for whom focused interventions may improve outcomes, were found.
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Affiliation(s)
- Marla Lipsyc-Sharf
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- David Geffen School of Medicine at UCLA/Jonsson Comprehensive Cancer Center, Los Angeles, California
| | - Karla V. Ballman
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, Minnesota
| | - Jordan D. Campbell
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, Minnesota
| | - Hyman B. Muss
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
| | | | | | - Lisa A. Carey
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
| | - Ann H. Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Erica T. Warner
- Clinical Translational Epidemiology Unit, Mongan Institute, Massachusetts General Hospital, Boston
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Zhu S, Lu Y, Fei X, Shen K, Chen X. Pathological complete response, category change, and prognostic significance of HER2-low breast cancer receiving neoadjuvant treatment: a multicenter analysis of 2489 cases. Br J Cancer 2023; 129:1274-1283. [PMID: 37604930 PMCID: PMC10575949 DOI: 10.1038/s41416-023-02403-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND HER2-low breast cancers (BC) show a good response to novel anti-HER2 antibody-drug conjugates (ADCs) in advanced setting. Nevertheless, little is known about the response, category change, and prognosis of HER2-low BC receiving neoadjuvant treatment (NAT). METHODS Consecutive invasive BC patients who underwent ≥ 4 cycles of NAT and surgery from January 2009 to December 2020 were retrospectively reviewed. HER2-low was defined as IHC 1+ or 2+ and FISH negative. Concordance rates of HER2 and other biomarkers were analyzed by Kappa test. Kaplan-Meier analysis and Cox regression were used to assess the recurrence-free interval (RFI) and overall survival (OS). RESULTS A total of 2489 patients were included, of whom 1023 (41.1%) had HER2-low tumors. HER2-low patients had a higher ER positivity rate than HER2-0 patients (78.5% vs. 63.6%, P < 0.001), and a similar breast pathological complete response (pCR) rate (20.6% vs. 21.8%, P = 0.617). Among non-pCR cases, 39.5% of HER2-0 tumors changed to HER2-low, and 14.3% of HER2-low tumors changed to HER2-0 after NAT. Low concordance rates of HER2-low status were found in both ER-positive (Kappa = 0.368) and ER-negative (Kappa = 0.444) patients. Primary HER2-low patients had a significantly better RFI than HER2-0 patients (P = 0.014), especially among ER-positive subset (P = 0.016). Moreover, HER2-low category change was associated with RFI in ER-positive subset (adjusted P = 0.043). CONCLUSIONS Compared with HER2-0 patients, HER2-low patients had a high proportion of ER-positive tumor and a similar pCR rate, which were related with better prognosis, especially in residual cases after NAT. A remarkable instability of HER2-low status was found between the primary and residual tumor, indicating re-testing HER2 status after NAT in the new era of anti-HER2 ADCs therapy.
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Affiliation(s)
- Siji Zhu
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yujie Lu
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Xiaochun Fei
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Kunwei Shen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Xiaosong Chen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Litton JK, Regan MM, Pusztai L, Rugo HS, Tolaney SM, Garrett-Mayer E, Amiri-Kordestani L, Basho RK, Best AF, Boileau JF, Denkert C, Foster JC, Harbeck N, Jacene HA, King TA, Mason G, O'Sullivan CC, Prowell TM, Richardson AL, Sepulveda KA, Smith ML, Tjoe JA, Turashvili G, Woodward WA, Butler LP, Schwartz EI, Korde LA. Standardized Definitions for Efficacy End Points in Neoadjuvant Breast Cancer Clinical Trials: NeoSTEEP. J Clin Oncol 2023; 41:4433-4442. [PMID: 37433103 PMCID: PMC10522109 DOI: 10.1200/jco.23.00435] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/25/2023] [Accepted: 06/06/2023] [Indexed: 07/13/2023] Open
Abstract
PURPOSE The Standardized Definitions for Efficacy End Points (STEEP) criteria, established in 2007 and updated in 2021 (STEEP 2.0), provide standardized definitions of adjuvant breast cancer (BC) end points. STEEP 2.0 identified a need to separately address end points for neoadjuvant clinical trials. The multidisciplinary NeoSTEEP working group of experts was convened to critically evaluate and align neoadjuvant BC trial end points. METHODS The NeoSTEEP working group concentrated on neoadjuvant systemic therapy end points in clinical trials with efficacy outcomes-both pathologic and time-to-event survival end points-particularly for registrational intent. Special considerations for subtypes and therapeutic approaches, imaging, nodal staging at surgery, bilateral and multifocal diseases, correlative tissue collection, and US Food and Drug Administration regulatory considerations were contemplated. RESULTS The working group recommends a preferred definition of pathologic complete response (pCR) as the absence of residual invasive cancer in the complete resected breast specimen and all sampled regional lymph nodes (ypT0/Tis ypN0 per AJCC staging). Residual cancer burden should be a secondary end point to facilitate future assessment of its utility. Alternative end points are needed for hormone receptor-positive disease. Time-to-event survival end point definitions should pay particular attention to the measurement starting point. Trials should include end points originating at random assignment (event-free survival and overall survival) to capture presurgery progression and deaths as events. Secondary end points adapted from STEEP 2.0, which are defined from starting at curative-intent surgery, may also be appropriate. Specification and standardization of biopsy protocols, imaging, and pathologic nodal evaluation are also crucial. CONCLUSION End points in addition to pCR should be selected on the basis of clinical and biologic aspects of the tumor and the therapeutic agent investigated. Consistent prespecified definitions and interventions are paramount for clinically meaningful trial results and cross-trial comparison.
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Affiliation(s)
- Jennifer K. Litton
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Meredith M. Regan
- Division of Biostatistics, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Lajos Pusztai
- Breast Medical Oncology, Yale Cancer Center, Yale School of Medicine, New Haven, CT
| | - Hope S. Rugo
- University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Sara M. Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Reva K. Basho
- The Lawrence J. Ellison Institute for Transformative Medicine, Los Angeles, CA
| | - Ana F. Best
- Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD
| | | | - Carsten Denkert
- Institute of Pathology, Philipps University Marburg and University Hospital Marburg (UKGM), Marburg, Germany
| | - Jared C. Foster
- Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD
| | - Nadia Harbeck
- The Breast Center, Department of Obstetrics and Gynecology and Comprehensive Cancer Center Munich, LMU University Hospital, Munich, Germany
| | | | - Tari A. King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Ginny Mason
- The Inflammatory Breast Cancer Research Foundation, Broadway, VA
| | | | - Tatiana M. Prowell
- US Food and Drug Administration, Silver Spring, MD
- Women's Malignancies Disease Group, Johns Hopkins Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | | | - Judy A. Tjoe
- Division of Breast Surgery, Department of Surgery, Novant Health, Greensboro, NC
| | - Gulisa Turashvili
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, GA
| | - Wendy A. Woodward
- Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Elena I. Schwartz
- Coordinating Center for Clinical Trials, National Cancer Institute, Rockville, MD
| | - Larissa A. Korde
- Cancer Therapy and Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD
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45
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Vliek S, Hilbers FS, van Werkhoven E, Mandjes I, Kessels R, Kleiterp S, Lips EH, Mulder L, Kayembe MT, Loo CE, Russell NS, Vrancken Peeters MJTFD, Holtkamp MJ, Schot M, Baars JW, Honkoop AH, Vulink AJE, Imholz ALT, Vrijaldenhoven S, van den Berkmortel FWPJ, Meerum Terwogt JM, Schrama JG, Kuijer P, Kroep JR, van der Padt-Pruijsten A, Wesseling J, Sonke GS, Gilhuijs KGA, Jager A, Nederlof P, Linn SC. High-dose alkylating chemotherapy in BRCA-altered triple-negative breast cancer: the randomized phase III NeoTN trial. NPJ Breast Cancer 2023; 9:75. [PMID: 37689749 PMCID: PMC10492793 DOI: 10.1038/s41523-023-00580-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/30/2023] [Indexed: 09/11/2023] Open
Abstract
Exploratory analyses of high-dose alkylating chemotherapy trials have suggested that BRCA1 or BRCA2-pathway altered (BRCA-altered) breast cancer might be particularly sensitive to this type of treatment. In this study, patients with BRCA-altered tumors who had received three initial courses of dose-dense doxorubicin and cyclophosphamide (ddAC), were randomized between a fourth ddAC course followed by high-dose carboplatin-thiotepa-cyclophosphamide or conventional chemotherapy (initially ddAC only or ddAC-capecitabine/decetaxel [CD] depending on MRI response, after amendment ddAC-carboplatin/paclitaxel [CP] for everyone). The primary endpoint was the neoadjuvant response index (NRI). Secondary endpoints included recurrence-free survival (RFS) and overall survival (OS). In total, 122 patients were randomized. No difference in NRI-score distribution (p = 0.41) was found. A statistically non-significant RFS difference was found (HR 0.54; 95% CI 0.23-1.25; p = 0.15). Exploratory RFS analyses showed benefit in stage III (n = 35; HR 0.16; 95% CI 0.03-0.75), but not stage II (n = 86; HR 1.00; 95% CI 0.30-3.30) patients. For stage III, 4-year RFS was 46% (95% CI 24-87%), 71% (95% CI 48-100%) and 88% (95% CI 74-100%), for ddAC/ddAC-CD, ddAC-CP and high-dose chemotherapy, respectively. No significant differences were found between high-dose and conventional chemotherapy in stage II-III, triple-negative, BRCA-altered breast cancer patients. Further research is needed to establish if there are patients with stage III, triple negative BRCA-altered breast cancer for whom outcomes can be improved with high-dose alkylating chemotherapy or whether the current standard neoadjuvant therapy including carboplatin and an immune checkpoint inhibitor is sufficient. Trial Registration: NCT01057069.
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Affiliation(s)
- Sonja Vliek
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Florentine S Hilbers
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ingrid Mandjes
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Rob Kessels
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sieta Kleiterp
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Esther H Lips
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lennart Mulder
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Mutamba T Kayembe
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Claudette E Loo
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nicola S Russell
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical center, Amsterdam, The Netherlands
| | - Marjo J Holtkamp
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Margaret Schot
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Joke W Baars
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Aafke H Honkoop
- Department of Internal Medicine, Isala Klinieken, Zwolle, The Netherlands
| | - Annelie J E Vulink
- Division of Medical Oncology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Alex L T Imholz
- Department of Internal Medicine, Deventer Ziekenhuis, Deventer, The Netherlands
| | | | | | | | - Jolanda G Schrama
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Philomeen Kuijer
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jelle Wesseling
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Kenneth G A Gilhuijs
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Petra Nederlof
- Department of Molecular diagnostics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sabine C Linn
- Department of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Debien V, Adam V, Coart E, Agostinetto E, Goulioti T, Molinelli C, Arahmani A, Zoppoli G, Piccart M. DECRESCENDO: de-escalating chemotherapy in HER2-positive, estrogen receptor-negative, node-negative early breast cancer. Future Oncol 2023; 19:1655-1667. [PMID: 37609714 DOI: 10.2217/fon-2022-1282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
The human epidermal growth factor receptor 2 (HER2)-enriched intrinsic subtype represents up to 75% of all HER2-positive hormone receptor (HR)-negative breast cancer (BC). Optimizing HER2-targeting therapy in this population might allow the omission of anthracycline-based chemotherapy, which is associated with potentially severe toxicities. DECRESCENDO (NCT04675827) is a large, multicenter, single-arm phase II trial in patients with HR-negative, HER2-positive, node-negative early BC evaluating a neoadjuvant pertuzumab and trastuzumab fixed-dose combination administered subcutaneously plus taxane-based chemotherapy followed by adjuvant treatment, adapted according to response to neoadjuvant therapy. The primary end point is the 3-year recurrence-free survival rate in patients with 'HER2-enriched' tumors and a pathological complete response. This flexible care substudy offers adjuvant treatment administration outside the hospital to some patients.
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Affiliation(s)
- Véronique Debien
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | | | | | - Elisa Agostinetto
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | | | - Chiara Molinelli
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | | | - Gabriele Zoppoli
- Gruppo Oncologico Italiano di Ricerca Clinica (GOIRC), Parma, Department of Internal Medicine, Università degli Studi di Genova, & Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Martine Piccart
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
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47
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Decker NS, Johnson T, Behrens S, Obi N, Kaaks R, Chang-Claude J, Fortner RT. Endogenous estrogen receptor modulating oxysterols and breast cancer prognosis: Results from the MARIE patient cohort. Br J Cancer 2023; 129:492-502. [PMID: 37355720 PMCID: PMC10403581 DOI: 10.1038/s41416-023-02315-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/15/2023] [Accepted: 06/08/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND 27-hydroxycholesterol (HC) and 25-HC were identified as endogenous selective estrogen receptor modulators (SERMs) and estrogen receptor (ER) modulators, respectively. They are hypothesized to play a role in multiple physiologic processes and pathologies, including breast cancer development and progression. METHODS We evaluated circulating 27-HC and 25-HC, and outcomes following a breast cancer diagnosis in 2282 women from the MARIE study over median follow-up of 11.6 years. 27-HC and 25-HC were quantified by liquid chromatography-mass spectrometry. We calculated hazard ratios (HR) and 95% confidence intervals [CI] using multivariable Cox Proportional Hazards regression. RESULTS We observed no associations between 27-HC and breast cancer prognosis overall. Associations between 27-HC and survival differed by circulating estradiol concentrations and endocrine therapy, but not by hormone receptor status. Among women with estradiol levels below the median (0.08 nM), 27-HC was associated with higher risk of all-cause mortality (HRlog2 = 1.80 [1.20-2.71]) and breast cancer-specific mortality (HRlog2 = 1.95 [1.14-3.31]). No associations were observed in women with estradiol levels above the median. Higher 25-HC levels were associated with lower risk of recurrence (HRlog2 = 0.87 [0.77-0.98]). CONCLUSION Associations between 27-HC and breast cancer prognosis varied by circulating estradiol levels and endocrine therapy. Less consistent results were observed for 25-HC.
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Affiliation(s)
- Nina Sophia Decker
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
- Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Theron Johnson
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Sabine Behrens
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Nadia Obi
- Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
- University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Renée Turzanski Fortner
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
- Department of Research, Cancer Registry of Norway, Ullernchausseen 64, 0379, Oslo, Norway.
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48
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Shah H, Wolfe D, Clemons M, Liu M, Thavorn K, Veroniki AA, Lunny C, Pond G, McGee S, Skidmore B, Arnaout A, Hutton B. Can routinely collected administrative data effectively be used to evaluate and validate endpoints used in breast cancer clinical trials? Protocol for a scoping review of the literature. Syst Rev 2023; 12:117. [PMID: 37422656 PMCID: PMC10329388 DOI: 10.1186/s13643-023-02283-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) are a critical component of evidence-based medicine and the evolution of patient care. However, the costs of conducting a RCT can be prohibitive. A promising approach toward reduction of costs and lessening of the burden of intensive and lengthy patient follow-up is the use of routinely collected healthcare data (RCHD), commonly called real-world data. We propose a scoping review to identify existing RCHD case definitions of breast cancer progression and survival and their diagnostic performance. METHODS We will search MEDLINE, EMBASE, and CINAHL to identify primary studies of women with either early-stage or metastatic breast cancer, managed with established therapies, that evaluated the diagnostic accuracy of one or more RCHD-based case definitions or algorithms of disease progression (i.e., recurrence, progression-free survival, disease-free survival, or invasive disease-free survival) or survival (i.e., breast-cancer-free survival or overall survival) compared with a reference standard measure (e.g., chart review or a clinical trial dataset). Study characteristics and descriptions of algorithms will be extracted along with measures of the diagnostic accuracy of each algorithm (e.g., sensitivity, specificity, positive predictive value, negative predictive value), which will be summarized both descriptively and in structured figures/tables. DISCUSSION Findings from this scoping review will be clinically meaningful for breast cancer researchers globally. Identification of feasible and accurate strategies to measure patient-important outcomes will potentially reduce RCT budgets as well as lessen the burden of intensive trial follow-up on patients. SYSTEMATIC REVIEW REGISTRATION Open Science Framework ( https://doi.org/10.17605/OSF.IO/6D9RS ).
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Affiliation(s)
- Hely Shah
- Department of Oncology, Ottawa Hospital, Ottawa, ON Canada
| | - Dianna Wolfe
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Mark Clemons
- Department of Oncology, Ottawa Hospital, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Michelle Liu
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | | | - Areti-Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON Canada
| | - Carole Lunny
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON Canada
| | - Greg Pond
- Department of Oncology, McMaster University, Hamilton, ON Canada
| | - Sharon McGee
- Department of Oncology, Ottawa Hospital, Ottawa, ON Canada
| | | | - Angel Arnaout
- Department of Oncology, Ottawa Hospital, Ottawa, ON Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, ON Canada
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49
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Kaidar-Person O, Pfob A, Gentilini OD, Borisch B, Bosch A, Cardoso MJ, Curigliano G, De Boniface J, Denkert C, Hauser N, Heil J, Knauer M, Kühn T, Lee HB, Loibl S, Mannhart M, Meattini I, Montagna G, Pinker K, Poulakaki F, Rubio IT, Sager P, Steyerova P, Tausch C, Tramm T, Vrancken Peeters MJ, Wyld L, Yu JH, Weber WP, Poortmans P, Dubsky P. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus. EClinicalMedicine 2023; 61:102085. [PMID: 37528842 PMCID: PMC10388578 DOI: 10.1016/j.eclinm.2023.102085] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy ( ± targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - André Pfob
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Bettina Borisch
- Department of Histopathology, University of Geneva, 1202 Geneva, Switzerland
| | - Ana Bosch
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23A, 22241, Lund, Sweden
| | - Maria João Cardoso
- Breast Unit, Champalimaud Foundation and University of Lisbon Faculty of Medicine, Lisbon, Portugal
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Via Giuseppe Ripamonti, 435, 20141 Milano MI, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Jana De Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden
| | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg, Marburg, Germany
| | - Nik Hauser
- Breast Center, Hirslanden Clinic Aarau, Frauenarztzentrum Aargau AG, Baden, Switzerland
| | - Jörg Heil
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- Breast Center Heidelberg, Klinik St. Elisabeth, Heidelberg, Germany
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Sibylle Loibl
- German Breast Group (GBG), C/o GBG Forschungs GmbH 63263 - Neu-Isenberg/, Germany
- Centre for Haematology and Oncology Bethanien, Frankfurt, Germany
| | | | - Icro Meattini
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Isabel T. Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Patrizia Sager
- Breast Center Bern-Biel, Hirslanden Clinic Salem, Bern, Switzerland
| | - Petra Steyerova
- Breast Cancer Screening and Diagnostic Center, Clinic of Radiology, General University Hospital in Prague, Prague, Czech Republic
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology Netherlands Cancer Institute, Antoni van Leeuwenhoek & Amsterdam University Medical Center, Netherlands
| | - Lynda Wyld
- Department of Oncology and Metabolism, The University of Sheffield, The Medical School, Sheffield, UK
| | - Jong Han Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Walter Paul Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp 2610, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Peter Dubsky
- Breast Center, Hirslanden Clinic St Anna, 6006, Lucerne, Switzerland
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland
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Meng X, Morita M, Kuba S, Hayashi H, Otsubo R, Matsumoto M, Yamanouchi K, Kobayashi K, Soyama A, Hidaka M, Kanetaka K, Nagayasu T, Eguchi S. Association of quantitative analysis of intratumoral reduced E-cadherin expression with lymph node metastasis and prognosis in patients with breast cancer. Sci Rep 2023; 13:10434. [PMID: 37369698 PMCID: PMC10300190 DOI: 10.1038/s41598-023-37012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Loss of E-cadherin expression is a poor prognostic factor in patients with breast cancer. Breast cancer cells co-cultured with adipocytes reportedly promote E-cadherin attenuation and tumor progression. The current study aimed to investigate the association of reduced E-cadherin expression with adipose tissue invasion (ATI) and prognosis in breast cancer. Surgical specimens were collected from 188 women with invasive ductal carcinoma of the breast who had undergone surgery without neoadjuvant treatment. We compared E-cadherin expression in ATI and invasive front (IF) using immunohistochemistry with ImageJ. Reduced E-cadherin expression was detected not only in the ATI area but also in the IF, and the degree of reduced E-cadherin expression was positively correlated with both areas. In patients with lymph node metastasis compared to those without, E-cadherin expression was reduced and this reduction was associated with poor recurrence-free survival. We concluded that E-cadherin expression is reduced not only at the ATI area but also at the IF of the tumor. Reduced E-cadherin expression is a clear prognostic factor for breast cancer. Hence, future research is warranted for establishing an objective and quantitative E-cadherin staining assay that will allow clinical use of E-cadherin as a prognostic factor.
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Affiliation(s)
- Xiangyue Meng
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan
| | - Michi Morita
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan
| | - Sayaka Kuba
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan.
| | - Hiroko Hayashi
- Department of Pathology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Ryota Otsubo
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Megumi Matsumoto
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Kosho Yamanouchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan
| | - Kazuma Kobayashi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan
| | - Kengo Kanetaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto-Machi, Nagasaki, 852-8501, Japan
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