Intact predictive motor sequence learning in autism spectrum disorder

Atypical motor learning has been suggested to underpin the development of motoric challenges (e.g., handwriting difficulties) in autism. Bayesian accounts of autistic cognition propose a mechanistic explanation for differences in the learning process in autism. Specifically, that autistic individuals overweight incoming, at the expense of prior, information and are thus less likely to (a) build stable expectations of upcoming events and (b) react to statistically surprising events. Although Bayesian accounts have been suggested to explain differences in learning across a range of domains, to date, such accounts have not been extended to motor learning. 28 autistic and 35 non-autistic controls (IQ > 70) completed a computerised task in which they learned sequences of actions. On occasional "surprising" trials, an expected action had to be replaced with an unexpected action. Sequence learning was indexed as the reaction time difference between blocks which featured a predictable sequence and those that did not. Surprise-related slowing was indexed as the reaction time difference between surprising and unsurprising trials. No differences in sequence-learning or surprise-related slowing were observed between the groups. Bayesian statistics provided anecdotal to moderate evidence to support the conclusion that sequence learning and surprise-related slowing were comparable between the two groups. We conclude that individuals with autism do not show atypicalities in response to surprising events in the context of motor sequence-learning. These data demand careful consideration of the way in which Bayesian accounts of autism can (and cannot) be extended to the domain of motor learning.

Abstract PD8-08: Development of humanized immune DCIS models using patient peripheral blood derived hematopoietic stem cells (CD34+)

Background:

Ductal carcinoma in situ (DCIS) is the most common form of non-invasive breast cancer. To accurately study the natural progression of DCIS lesions in mice, we devised the mouse-intraductal (MIND) animal model, which involves intraductal injection of human DCIS epithelial cells into the mammary ducts of immunocompromised mice. To improve the translational application of the MIND model, we aimed to mimic the natural microenvironment of human DCIS with patient-derived immune cells and assess the role of engrafted immune cells on human DCIS progression. In order to achieve successful engraftment of the entire immune system in mice, we utilized MISTRG mice. These mice were developed by Rongvaux et al., on an immunodeficient (Rag2-/-IL2rγ-/-) background. The genes encoding human M-CSF (M), human IL-3 (I), SIRP1α (S), human thrombopoietin (TPO)(TR), and GM-CSF (G) were knocked into their respective mouse loci. As such, MISTRG mice are highly permissive for human hematopoiesis, supporting the development and function of lymphocytes, monocytes, and natural killer (NK) cells. In contrast, previous studies have used the humanized CD34+ NOD-SCID IL2rγ-/- mice (CD34+NSG), which are unable to support myeloid cell differentiation due to lack of expression of human-specific cytokines. Moreover, prior xenograft studies in the CD34+NSG mice have not used immune cells derived from the same patient as the tumor.

Results:

Human CD34+ cells derived from patients' peripheral blood were expanded ex vivo ˜100-fold using a novel formulation of culture medium. Transplantation of ex vivo expanded CD34+ cells via tail vein injection of MISTRG mice resulted in the successful engraftment of human immune cells as early as 4 weeks following injection. Successful engraftment was confirmed by flow cytometry using human specific antibodies that recognize human leukocytes (anti-CD45), T cells (anti-CD3), B cells (anti-CD20), and myeloid cells (anti-CD33) in spleen, bone marrow, and peripheral blood of MISTRG mice. Once engraftment was confirmed, DCIS epithelial cells from the same DCIS patients or DCIS cell lines were injected intraductally. Recruitment of patient-derived immune cells to the DCIS lesions was confirmed by immunofluorescence using human-specific antibodies that recognize neutrophils (anti-myeloperoxidase), macrophages (anti-CD68), M2-polarized macrophages (anti-c-MAF), natural killer cells (anti-CD56), dendritic cells (anti-CD21), T cells (anti-CD3) and B cells (anti-CD20).

Conclusion:

This model represents the first to enable the study of mechanisms of DCIS progression in a manner that fully represents the heterogeneity of human disease, including the influence of the patients' own immune cells on DCIS progression.

Citation Format: Behbod F, Harper H, Hansford H, Limback D, Hong Y, Elsarraj H, Ricci LR, Fan F, Tawfik O, May L, Cusick T, Inciardi M, Redick M, Gatewood J, Winblad O, Fields TA, Fabian C, Godwin AK, Fields PE, Meierotto R, Perry J. Development of humanized immune DCIS models using patient peripheral blood derived hematopoietic stem cells (CD34+) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-08.

Abstract P6-12-11: Feasibility and biomarker modulation due to high levels of moderate to vigorous physical activity as part of a weight loss intervention in older, sedentary, obese breast cancer survivors

We sought to demonstrate that older, sedentary, obese breast cancer survivors could achieve > 200 minutes per week of moderate to vigorous physical activity (MVI PA) as part of a weight loss intervention; and to assess modulation of risk biomarkers. This level of PA in combination with moderate calorie restriction is associated with weight losses of >10% in women without cancer, which in turn is associated with significant modulation of cancer risk biomarkers.

Eleven participants with BMI > 30 kg/m2 enrolled in a 12-week program that consisted of moderate caloric restriction, weekly phone group behavioral sessions, and individualized exercise plans based on measured heart rate reserve. Women were provided an accelerometer with heart rate monitor linked to GarminConnect, membership to a YMCA, twice weekly supervised exercise sessions with a personal trainer, and weekly feedback regarding weight and physical activity progress. The goal was to increase MVI PA (≥45% heart rate reserve) gradually from <60 to >200 minutes per week.

The median age was 61, 5/11 women had received prior chemotherapy, and 7/11 were currently taking aromatase inhibitors. Median values of baseline anthropomorphic measures acquired by dual energy x-ray absorptiometry (GE Lunar iDXA) included BMI, 37.3 kg/m2; total mass, 97.5 kg; fat mass, 47.6 kg; visceral fat, 1.7 kg (range 1.4-3.0); and fat mass index, 17.6 kg/m2. The majority had a baseline VO2 peak in the poor range for their age. All 11 participants completed the intervention, with no reported serious adverse events. Median MVI PA achieved over weeks 5-12 was 161 minutes/week (range 48-320). VO2 peak was increased in 10/11 with a median relative change of 12% from baseline. All but one lost weight with an overall median of 8% total mass loss, which was associated with 13% total fat mass loss and 21% visceral fat mass loss. For those with MVI PA above the median, values were 11%, 17%, and 40%, respectively. Visceral fat mass loss was linearly correlated with minutes per week of MVI PA (p=0.032); these parameters in turn were associated with changes in a number of serum biomarkers, including adiponectin-leptin ratio, TNF-alpha, as well as circulating adipose stromal cells, a potential marker for metastasis. Insulin and hs-CRP were favorably modulated in almost all participants but change was not linearly correlated with activity or mass loss parameters; thus these may not be ideal biomarkers to document a dose response to level of MVI PA.

Conclusion: These results demonstrate that older, sedentary, obese breast cancer survivors can safely achieve a high level of MVI PA when provided a structured program that includes an exercise trainer. It is feasible to design a clinical trial for such breast cancer survivors to examine biomarker modulation as a function of level of physical activity.

Citation Format: Fabian CJ, Klemp JR, Burns JM, Vidoni ED, Nydegger JL, Kreutzjans AL, Phillips TL, Baker HA, Hendry B, John C, Amin AL, Khan QJ, Mitchell MP, O'Dea AP, Sharma P, Wagner JL, Hursting SD, Kimler BF. Feasibility and biomarker modulation due to high levels of moderate to vigorous physical activity as part of a weight loss intervention in older, sedentary, obese breast cancer survivors [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-11.

Abstract P1-15-01: Final analysis of SWOG S0230/Prevention of early menopause study (POEMS)

BACKGROUND: The SWOG S0230/POEMS study demonstrated a 70% reduction in ovarian failure (OF) with goserelin coadministration during chemotherapy (CT) for ER-negative early breast cancer (BC; Moore H et al, NEJM 2015). Goserelin use was also associated with more pregnancies as well as favorable disease free survival (DFS) and overall survival (OS). Here we report the final analysis after 5 years of follow-up.

METHODS: Premenopausal women age <50 with stage I-IIIA ER/PR-negative BC to be treated with cyclophosphamide-containing CT were randomized to receive standard CT with or without monthly goserelin 3.6 mg SQ starting at least 1 week prior to the first CT dose. The primary endpoint was OF at 2-years, defined as amenorrhea for the prior 6 months and post-menopausal FSH. Secondary endpoints included pregnancies, disease free survival (DFS) and overall survival (OS). An unplanned analysis of rate of menses recovery at 2 years (presence of menses within 6 months of the 2 year time-point or pregnancy within the first 2 years) was also conducted. OF and pregnancy endpoints were analyzed using multivariable logistic regression adjusting for stratification factors (age and CT regimen); DFS and OS were examined using multivariable Cox regression, adjusting for stratification factors and stage. Two-sided p-values are reported unless otherwise specified in accordance with protocol design.

RESULTS: Among 257 randomized participants, 218 were eligible and evaluable. One hundred thirty-six eligible and evaluable patients had OF data and 186 had menstrual data. Median age was 37.7 years. Among the 136 patients with OF data, the odds ratio (OR) for OF at 2 years was 0.30 (95% CI 0.1-0.98; one-sided p=0.023) comparing CT with goserelin to standard CT alone. Among 186 patients with menstrual data, 80% recovered menses by 2 years in the goserelin arm compared with 70% in the standard arm (OR=1.74, 95% CI: 0.83-3.66, p=0.15). Pregnancies, DFS and OS are reported for all 218 eligible and evaluable patients. With a median follow-up of 5.1 years, 22% of patients in the goserelin group had at least one pregnancy compared with 12% in the standard group (OR 2.38, 95% CI 1.08-5.26, p=0.03). Cumulative incidence of pregnancy at 5 years is 23% in the goserelin arm compared with 12% in the standard group. Five-year Kaplan-Meier DFS estimates are 88% in the goserelin arm compared with 79% in the standard arm (HR=0.50, p=0.05). Five-year OS is 92% with goserelin versus 83% in the standard arm (HR=0.47, p=0.06). Including all 257 randomized patients, HR for DFS and OS are 0.67 and 0.48 (p=0.18 and p=0.05).

CONCLUSION: Ovarian suppression with goserelin during chemotherapy for hormone receptor-negative breast cancer reduces OF risk and, after 5 years of follow-up, continues to be associated with more pregnancies and improved survival compared with chemotherapy without goserelin.

SUPPORT: NIH/NCI grant awards CA189974, CA180888, CA180819, CA074362; AstraZeneca

Citation Format: Moore HCF, Unger JM, Phillips K-A, Boyle F, Hitre E, Moseley A, Porter D, Francis PA, Goldstein LJ, Gomez HL, Vallejos CS, Partridge AH, Dakhil SR, Garcia AA, Gralow J, Lombard JM, Forbes JF, Martino S, Barlow WE, Fabian CJ, Minasian L, Meyskens FL, Gelber RD, Hortobagyi GN, Albain KS. Final analysis of SWOG S0230/Prevention of early menopause study (POEMS) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-15-01.

Abstract P4-06-01: Patient derived DCIS mouse-intraductal (MIND) models recapitulate the full spectrum of human patient pathology and histologic features including progression to invasion in a subset of cases

Introduction: The 20-year breast cancer mortality rate following a DCIS diagnosis is ∼3%. Radiation and anti-hormonal therapy of DCIS has not resulted in improved overall survival, which argues against the non-selective use of such therapies in DCIS management. However, some DCIS cases do progress to invasive cancer, and these patients may benefit from treatment. A study of 80 DCIS patients followed for up to 30 years reported a 43% progression rate. Notably, progression was not predicted by grade, as 39% of even low-grade DCIS ultimately progressed to invasive cancer. Clearly, there is a need to identify which DCIS lesions are likely to progress. We have developed a novel mouse xenograft model (mouse-intraductal; MIND) to study the molecular basis of DCIS progression and enable identification of suitable biomarkers that predict invasive progression.

Methods: MIND involves injection of epithelial cells derived from patient breast lesions into the mammary ducts of immunocompromised mice. Serial sections of mouse mammary glands containing DCIS xenograft lesions were examined at time intervals of 3-14 months post-engraftment by histology using hematoxylin and eosin (H&E) and immunohistochemistry using anti-human cytokeratin 5/19, smooth muscle actin, ER, PR, p53, Ki67 and HER-2.

Results: Intraductal injection of cells derived from breast lesions of 28 patients into 133 mice resulted in a successful engraftment rate of 60%. Among these, 12 pure DCIS samples were injected into 35 different mice to create MIND xenografts. As early as three months post-engraftment, the DCIS xenograft cells showed multilayered in situ growth consisting of atypical neoplastic cells with prominent and vesicular nuclei. DCIS MIND xenografts exhibited the full spectrum of human DCIS histologic features, including similar biomarker expression (ER, PR, Ki67, HER-2 and p53) at long-term follow-up after engraftment (up to 12 months). Most remarkably, a subset of xenografts representing 5 patients (5/12; 42%) showed progression to invasion 6-12 months post-engraftment in the absence of any external genetic manipulations. This rate is very similar to that reported for human DCIS progression in untreated patients. MIND DCIS xenograft lesions that progressed showed disruption of basement membrane and myoepithelial layer by the invasive cells, retraction of basement membrane, and micro-invasion. MIND DCIS lesions were enriched in small capillaries, and in some cases clusters of invasive cells appeared inside nearby blood vessels.

Conclusion: The MIND xenograft is a viable model for human DCIS progression that recapitulates histologic features of human DCIS, as well as reported rates of progression to invasion. The availability of this innovative model provides a valuable tool for the discovery of new biomarkers to identify DCIS with invasive potential. The identification of high risk DCIS will ultimately help patients and clinicians choose the best course of therapy and avoid the morbidity and costs associated with unnecessary treatment.

Citation Format: Behbod F, Limback D, Hong Y, Elsarraj H, Berger J, Heddens E, Valdez K, Smith WP, Inciardi M, Reddick M, Gatewood J, Darrah J, Winblad O, Meierotto R, Ricci L, Wagner J, Amin A, May L, Cusick T, Mammen J, Fields T, Godwin AK, Fabian C, Kaufman C, Tawfik O, Fan F. Patient derived DCIS mouse-intraductal (MIND) models recapitulate the full spectrum of human patient pathology and histologic features including progression to invasion in a subset of cases [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-06-01.

Abstract P4-13-03: Changes in the gut microbiome of post-menopausal women 2 weeks after initiating a structured weight loss intervention

Background

Change in the relative composition of the gut microbiome at the phyla level, particularly decreases in Bacteroidetes and increases in Firmicutes species, has been associated with both obesity and increased risk for breast cancer. It is unclear how rapidly the microbiome changes in response to a reduced calorie and fat diet during a weight loss intervention. As a planned sub-study of a clinical trial with a structured behavioral weight loss intervention with randomization to high dose omega-3 fatty acids or placebo (NCT02101970; clinical trials.gov), we evaluated changes in the gut microbiome after 2 weeks of dietary intervention.

Methods

46 post-menopausal women at increased risk for breast cancer with a BMI > 27 kg/m2 had a baseline 3 day food record, DXA, and blood and breast tissue sampling for biomarkers. They were then started on a reduced fat and calorie diet (~1200 kcal/day from 2 portion-controlled entrees, 3 low calorie high protein shakes, and 5 servings of fruits/vegetables daily), recommendation to exercise 225 minutes per week, and a weekly behavioral intervention. Fecal samples were collected at baseline, after 2 weeks of diet but prior to study agent, and after 6 months of weight loss intervention. Stool samples were stored at -20°C until brought to the clinic, and then at -80°C until DNA extraction. Bacterial taxonomic classification was performed using real-time PCR and 16S pyrosequencing using specific 16S rRNA primers. Baseline Healthy Eating Index (HEI) was calculated from the 3 day food record; fruit and vegetable servings were obtained from weekly food logs.

Results

42 women completed the 6 month weight loss intervention. At baseline, median BMI was 31.0 kg/m2 and HEI was 58 (range 28-90) with 12 and 23 servings of fruits and vegetables per week. Median relative weight loss at 6 months was -11.9 % (0 to -22.7 %). When dichotomized to relative losses of <10% vs >10% (which we have previously shown to be associated with significant improvement in blood and breast tissue risk biomarkers [Fabian Cancer Prev Res 2013]), women with 6 month >10% loss had favorable change in the two major stool phyla at 2 weeks with a median 10% increase for Bacteroidetes and 8% decrease for Firmicutes. Conversely, women with <10% loss showed a decrease (median -11%) in Bacteroidetes and an increase (median 16%) for Firmicutes. Fruit and vegetable consumption also differed between the weight loss groups. The >10% loss group had higher baseline consumption of vegetables and continued this after starting the diet. The more adherent a woman was to dietary recommendations in the first weeks of dietary intervention, the more likely she was to lose >10% weight by 6 months.

Conclusions

Favorable modulation of the gut microbiome early in a weight loss intervention is associated with subsequent substantial weight loss. Microbiome assessment after 6 months of weight loss intervention is in progress.

Supported by a grant from the Breast Cancer Research Foundation and pilot funds from National Cancer Institute Cancer Center Support Grant P30 CA168524.

Citation Format: Fabian CJ, Kimler BF, Umar S, Ahmed I, Befort CA, Nydegger JL, Kreutzjans AL, Powers KR, Klemp JR, Spaeth KR, Sullivan DK. Changes in the gut microbiome of post-menopausal women 2 weeks after initiating a structured weight loss intervention [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-13-03.

Effect of systemic transplantation of bone marrow-derived mesenchymal stem cells on neuropathology markers in APP/PS1 Alzheimer mice

AIMS

Mesenchymal stem cells (MSC) have recently attracted interest as a potential basis for a cell-based therapy of AD. We investigated the putative immune-modulatory effects in neuroinflammation of systemic transplantation of MSC into APP/PS1 transgenic mice.

METHODS

10⁶ MSC were injected into APP/PS1 mice via the tail vein and histological analysis was performed for microglia and amyloid (pE3-Aβ) plaque numbers, glial distribution and pE3-Aβ plaque size. In addition, a biochemical analysis by qPCR for pro-inflammatory, chemoattractant and neurotrophic factors was performed.

RESULTS

MSC are associated with pE3-Aβ plaques. The effects of transplantation on microglia-associated pathology could be observed after 28 days. Animals showed a reduction in microglial numbers in the cortex and in microglia size. Gene expression was reduced for TNF-α, IL-6, MCP-1, and for NGF, in MSC recipients. Also, we investigated for the first time and found no changes in expression of IL-10, CCR5, BDNF, VEGF and IFNγ. PTGER2 expression levels were increased in the hippocampus but were reduced in the cortex of MSC recipients. While there were no transplant-related changes in pE3-Aβ plaque numbers, a reduction in the size of pE3-Aβ plaques was observed in the hippocampus of transplant recipients.

CONCLUSION

This is the first study to show reduction in pE3-Aβ plaque size. pE3-Aβ plaques have gained attention as potential key participants in AD due to their increased aggregation propensity, the possibility for the initial seeding event, resistance against degradation and neurotoxicity. These findings support the hypothesis that MSC-transplants may affect AD pathology via an immune-modulatory function that includes an effect on microglial cells.

Abstract P3-08-02: Comparison of strategies for weight loss maintenance among rural breast cancer survivors: The rural women connecting for better health randomized controlled trial

Background: Breast cancer survivors who reside in rural areas represent one of the largest medically underserved populations of breast cancer survivors in the nation and have higher obesity prevalence compared to their urban counterparts. Given the evidence linking obesity with poor breast cancer prognosis, trials are needed to demonstrate ability to produce long-term weight loss maintenance in this hard-to-reach group. Group phone-based counseling via conference calls is a low-technology approach with excellent reach to rural areas. This treatment delivery approach capitalizes on the support benefits of in-person groups by allowing participants to interact in real time while also diminishing costs.

Methods: In this 2 phase trial, overweight and obese (BMI 27 to 45 kg/m2) rural breast cancer survivors (with initial stage 0-III disease) were randomized to one of two extended care interventions for weight loss maintenance (Phase 2) subsequent to an initial 6-month weekly group phone-based behavioral weight loss intervention (Phase 1). To be eligible for randomization for maintenance, participants must have lost ≥ 5% of their baseline weight during Phase 1. In Phase 2, participants were randomized to continued group phone-based counseling reduced in frequency to every other week during maintenance vs every other week mailed newsletters that followed the same content.

Results: 210 breast cancer survivors with a mean time since treatment of 3.5 years ± 2.4 years, mean age of 58.1 ± 9.9 years, and mean BMI of 33.9 ± 4.4 kg/m2 residing in a three state region of the rural Midwest were entered in the 6-month weight loss phase. Retention from baseline to 6 months (Phase 1) was 91%. Mean percent weight loss at 6 months for the total sample was 12.9% with 82% of enrolled participants ≥ 5% below baseline weight. 172 participants with a mean initial loss of 14.0% of baseline weight (12.8 ± 4.9 kg) were randomized to a maintenance intervention. Retention from 6 to 18 months (Phase 2) was 92%. Intent-to-treat analyses with imputation of missing data revealed participants in the group phone condition regained less weight (3.3 ± 4.8 kg) compared to participants in the newsletter condition (4.9 ± 4.8 kg; p = 0.03). Mean percent weight loss from baseline to 18 months did not significantly differ between the group phone condition (10.2 ± 7.5%) and the newsletter condition (9.2 ± 7.9%). However, at 18 months 75.3% of participants in the group phone condition remained ≥ 5% below baseline weight compared to 57.8% in the newsletter condition (p = .02).

Discussion: The initial group phone-based weight loss intervention exceeded typical weight losses reported in the literature with over 80% of enrolled participants achieving clinically meaningful weight loss. Continued group phone counseling was modestly better in sustaining weight loss at 18 months than a mailed newsletter. However, for both maintenance approaches, the majority of participants maintained a weight at 18 months that was 5% or more below baseline.

Citation Format: Befort CA, Klemp JR, Sullivan DK, Diaz FJ, Schmitz KH, Perri MG, Fabian CJ. Comparison of strategies for weight loss maintenance among rural breast cancer survivors: The rural women connecting for better health randomized controlled trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-08-02.

Abstract P5-13-03: Fulvestrant plus anastrozole as neoadjuvant therapy in postmenopausal women with hormone receptor positive early breast cancer

Background: Aromatase inhibitors (AIs) are effective in reducing the risk of recurrence from breast cancer (BC) but 20% of patients (pts) with early BC still recur despite adjuvant AIs. Thus more effective endocrine therapies (HTs) are needed. In metastatic BC (MBC), combination of lower dose fulvestrant plus anastrozole improves survival compared to anastrozole alone. The 21-gene Recurrence Score® (RS; Oncotype DX®) has been validated to predict benefit from adding chemotherapy (CT) to HT where pts with a low score have little benefit from CT and derive a large benefit from HT. Ki-67 response to neo-adjuvant HT may predict adjuvant outcomes to HT. Postoperative Endocrine Prognostic Index (PEPI) and modified PEPI may further identify a subset of HT sensitive cancers that do not require adjuvant CT (PEPI 0 category). We conducted a single arm phase II trial to assess the efficacy of fulvestrant plus anastrozole as neoadjuvant HT in pts with operable BC.

Methods: Postmenopausal pts with stage II and III, ER/PR+, HER2 (-) BC with a RS<25 (performed on initial core bx) were included. Duration of neo-adjuvant HT was 4 months. Pts received anastrozole 1mg (PO) daily continuously from day 1 until surgery + fulvestrant (IM) 500mg on day 1, 14 and 28 of cycle 1, and on the last day of three subsequent 28 day cycles (total 6 doses of fulvestrant). At week 4, an optional core bx was repeated to assess change in Ki-67. Response assessments were made clinically every 4 wks. All pts had breast/axillary surgery after the 6th dose of fulvestrant. Ki-67, histologic grade, ER/PR status, and RS were assessed at baseline, core bx at 4 wks, and at definitive surgery. Primary end points were pathologic complete response (pCR) rate and change in Ki-67. Adjuvant CT was left to the discretion of treating physician.

Results: 42 pts were enrolled 7/2009 to 11/2014. Median age was 62. 32 (76%) patients had stage IIA, 7 (17%) had stage IIB and 3 (7%) had stage III disease. 14% had clinically node positive disease. The median RS was 12 (0-24). Median tumor size was 3.5cm. 21%, 74%, and 5% had grade 1, 2 and 3 tumors respectively. Mean ER expression was 95%. 16 (38%) pts had a clinical complete response (cCR), 13 (31%) had a clinical partial response (cPR) and 12 (29%) had stable disease. One pt had progression on therapy. There were no pCRs. Median baseline Ki-67 was 5% (1-36%). 94% of pts had decrease in Ki-67 from baseline to 4-week bx and 97% of pts had decrease in Ki-67 from baseline to surgery. Modified PEPI score at surgery was 0 in 53% of patients. 78% of pts did not receive adjuvant CT. At median follow up of 38 mos only 1 pt had a recurrence with 98% free of a recurrence. There were no grade 3 or grade 4 toxicities.

Conclusions: The neoadjuvant combination of anastrozole and fulvestrant in pts with RS<25 markedly improves Ki-67 response with more than half of pts achieving a modified PEPI score of 0 at surgery. At a relatively short median follow up, recurrence rate is very low. Given the efficacy and tolerability of anastrozole plus fulvestrant in MBC and now in the neo-adjuvant setting, an adjuvant trial of this combination is warranted in pts with ER+ BC.

Citation Format: Khan QJ, Barr JA, Britt AS, Kimler BF, Connor CS, McGinness M, Mammen JMV, Wagner JL, Amin A, Springer M, Baccaray S, Fabian CJ, Sing AP, Sharma P. Fulvestrant plus anastrozole as neoadjuvant therapy in postmenopausal women with hormone receptor positive early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-13-03.

Abstract P2-05-28: The impact of the plant lignin secoisolariciresinol diglycoside on preclinical models of estrogen receptor positive breast cancer

Background: Several preclinical studies indicate that secoisolariciresinol diglycoside (SDG), a polyphenolic plant lignin found most abundantly in flaxseeds, inhibits the progression of both estrogen receptor (ER) positive and negative mammary tumors. SDG is metabolized by gut bacteria into the biologically active metabolites enterolactone (ENL) and enterodiol (END), which are known to have anti-estrogenic activity. However, the mechanisms mediating SDG's anti-tumor effects remain poorly understood.

Methods: In a dose-determination pilot study linked to an ongoing clinical trial of SDG in women at high risk for breast cancer, 18 week old C57BL/6 mice were randomized to a control diet or SDG-supplemented diets (25 or 74 mg/kg of food) for 8 weeks prior to euthanization, and the levels of serum and tissue SDG metabolites (particularly ENL and END), metabolic hormones and inflammatory markers were measured. In an ongoing tumor study, 12-week old C57BL/6 and foxn1 nu/nu mice were randomized to the control or control plus SDG (100 mg/kg of food, a dose projected to match ENL and END metabolite levels achieved in the clinical trial) diet regimen. After 8 weeks on diet, they will receive orthotopic injections of E0771 mouse mammary tumor cells or BT-483 human breast cancer cells (both ER positive), continuing on the same diets until euthanization. Cell culture studies examining the impact of biologically relevant concentrations of ENL and END on E0771 and BT-483 cells are also in progress.

Results: In comparison to those maintained on the control diet, the higher dose SDG diet reduced estrogen and pro-inflammatory signaling in the pilot study mice, as evidenced by higher interleukin 10 and lower C-reactive protein mammary fat pad expression as well as lower circulating levels of the adipokines leptin and resistin, which have been linked to chronic inflammation. High dose SDG also decreased serum insulin and glucose levels, indicating improved metabolic function. Because serum ENL and END levels in the pilot study did not reach those achieved in the SDG clinical trial, a 100 mg/kg SDG dose was chosen for the tumor study. Cell culture studies indicate that ENL (150 nM) inhibits E0771 and BT-483 cell proliferation and ER alpha:beta expression ratio.

Conclusions: Preliminary data suggests that the anti-tumor effects of SDG's metabolites may be mediated through multiple mechanisms, including improvements in metabolic function and inflammatory signaling as well as modulation of breast cancer cell gene expression. The results of the ongoing tumor study will inform the design of additional cell culture studies aimed at further defining these mechanisms.

Citation Format: Bowers LW, Ford NA, Rossi EL, Shamsunder MG, Kimler BF, Fabian CJ, Hursting SD. The impact of the plant lignin secoisolariciresinol diglycoside on preclinical models of estrogen receptor positive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-05-28.

Abstract OT3-01-12: Phase II trial of lapatinib and everolimus for HER2 positive metastatic breast cancer

Background:

Although the treatment of HER2 positive metastatic breast cancer (MBC) has improved with anti-HER2 agents and chemotherapy, most patients will eventually develop resistance to these agents. Preclinical studies have shown that mTOR inhibition may reverse trastuzumab resistance. We hypothesize that combining mTOR inhibitor everolimus with lapatinib will be an effective strategy for patients who have progressed on prior anti-HER2 therapies.

Trial Design:

We are conducting an open-label phase II pilot study of the combination of everolimus and lapatinib for pts with HER-2 positive MBC. Eligible pts must have histologically documented locally advanced (inoperable) or metastatic HER-2 positive breast cancer that have progressed on at least one HER-2 based regimen in the metastatic or locally advanced setting. Pts with disease progression during or within 12 mos of the completion of adjuvant trastuzumab are eligible. Pts with untreated asymptomatic brain metastases are allowed. Pts with symptomatic brain metastases are allowed to enroll after they have completed radiation and are off steroids. Eligible pts are started on everolimus 5 mg PO daily and lapatinib 1250 mg PO daily without interruption. Among subjects progressing on lapatinib, lapatinib is continued and everolimus initiated. Pts will continue to receive treatment until there is evidence of progressive disease (PD), unacceptable toxicity, or withdrawal of consent. Pts will have radiological evaluation every 8 weeks with CT, bone scan, and MRI brain (for pts with known brain metastasis at baseline).

Specific Aims:

Primary objective is to assess the effectiveness of the combination of RAD-001 and lapatinib as measured by the six-month Overall Response Rate in women with MBC who have progressed on trastuzumab and/or lapatinib based therapies. Secondary objectives are six-month PFS, safety and tolerability of the combination, six-month objective CNS response rate, six-month clinical benefit rate of systemic disease, and six-month clinical benefit rate in CNS.

Statistical methods:

The response rate of lapatinib monotherapy in heavily pre-treated patients is estimated to be 7% (Blackwell 2009). For an expected ORR of 17%, a sample size of 45 subjects will provide 79% power to detect the difference at 0.10 Type I error rate according to 1-sided exact binomial test.

Present accrual and target accrual:

The trial has accrued 20 patients with a target accrual of 45 patients.

Citation Format: Barr JA, Sharma P, Fabian CJ, Yeh H, Baccaray S, Springer M, Khan QJ. Phase II trial of lapatinib and everolimus for HER2 positive metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-01-12.

Abstract P4-10-01: High dose omega-3 fatty acid supplementation modulates breast tissue biomarkers in post-menopausal women at high risk for development of breast cancer

Background: We conducted a pilot study of high dose omega-3 fatty acid (FA) supplementation in post-menopausal women to determine if risk biomarkers for breast cancer in benign breast tissue sampled by random peri-areolar aspiration (RPFNA) could be favorably modulated and to acquire preliminary data on possible mechanism of action.

Methods: 35 post-menopausal women at increased risk for breast cancer were accrued to a trial of 6-month intervention with 4 g daily of omega-3-acid ethyl esters [1.86 g eicosapentaenoic acid (EPA), 1.5 g docosahexaenoic acid (DHA)]. Subjects had RPFNA performed pre- and post-intervention and specimens evaluated for cytomorphology and proliferation (Ki-67). FA composition was determined in plasma, red blood cells, and RPFNA specimens. Additional specimens were frozen for assessment of hormones, a panel of 11 adipokines and cytokines by Luminex, and gene expression.

Results: 34 subjects completed study with specimens evaluable for change in biomarkers. The ratio of (EPA+DHA):Arachidonic Acid (AA) levels in erythrocyte phospholipid increased significantly by a median of 2.7-fold. Although there was a significant decrease in blood EPA+DHA between discontinuation at 6 months and 2 weeks later when RPFNA was performed, all ratios were above the baseline value (median 1.6-fold). There was favorable but not statistically significant modulation for cytologic evidence of atypia (53% at baseline to 41% at off-study). However, favorable modulation was exhibited for Masood score (medians of 15 to 14; p = 0.014), number of epithelial cells recovered (p = 0.019) and Ki-67 expression (medians of 1.7% to 0.75%, p = 0.036, despite 8 subjects having no Ki-67 expression at baseline). Luminex assay of serum indicated a statistically significant increase (p = 0.003) for adiponectin and decrease (p = 0.016) for TNF-alpha between baseline and off-study. For RPFNA specimens, there was a significant decrease (P = 0.001) in MCP-1 levels adjusted for protein content. By ELISA, serum high molecular weight adiponection increased (p = 0.046) and molar ratio of IGF-1:IGFBP3 decreased (p = 0.006). Note that all analyses were exploratory and without correction for multiple analyses.

Conclusion: Favorable modulation of a variety of blood and tissue risk biomarkers, including cytomorphology and proliferation, along with good tolerability suggests that high dose omega-3 FA esters should be tested further in a placebo-controlled trial.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-10-01.

Abstract P4-09-02: Omega-3 ethyl esters suppress breast cancer growth by modulating inflammatory signaling

Introduction: Inflammation has been identified as a key contributor to breast cancer development. Both clinical and preclinical studies confirm a role for inflammatory mediators such as cytokines, interleukins, embedded immune cells and prostaglandins in promoting development of breast cancer. Elevated levels/activity of cyclooxygenase-2 (COX-2) and interleukin-6 (IL-6) are correlated with a more aggressive disease. Omega-3 fatty acid (n-3) intake is correlated with an inverse risk for breast cancer development and improvement in prognostic markers. One key target of omega-3 fatty acids is the COX-2 enzyme. We hypothesize that one mechanism by which omega-3 fatty acids suppress breast cancer progression is through inhibition of inflammatory signaling.

Methods: The impact of omega-3 ethyl esters (n-3 EE), a component of some omega-3 supplements, on the viability of MCF-7 breast cancer cells grown in a pro-inflammatory environment was assessed by MTT analysis and on proliferation by cell counting. Supplementation of the growth media with IL-6 (10ng/mL) was used to simulate a pro-inflammatory environment. Changes in expression levels of key components of inflammatory pathways were assessed by Western blot analyses and quantitative PCR. Prostaglandin E2 (PGE2) levels were measured using ELISA assays.

Results: A significant suppression in IL-6-induced proliferation was observed when cells were exposed to physiological concentrations (20 uM) of n-3 EE for 96 hrs. Molecular analyses suggest that the suppression of the NF-kB/COX-2/PGE2 signaling axis was important for mediating this effect. These results are consistent with other studies using specific COX-2 inhibitors.

Conclusions: With their potent anti-inflammatory activity, n-3 EE may prove useful in reducing malignancy of breast cancer and also slow development of new breast cancers. Importantly, they appear to have none of the toxicities associated with pharmaceutical COX inhibitors (NSAIDs). Future studies are planned to incorporate nutraceutical compounds to standard therapy to improve efficacy and reduce associated side effects.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-09-02.

Abstract P2-11-17: Pilot Study to Evaluate a Home-based Exercise and Weight Loss Intervention on Cardiopulmonary Fitness and Markers of Breast Cancer Risk in Postmenopausal Breast Cancer Survivors

Background: BrCa survivors have an estimated 4-fold increase in risk for developing cardiovascular disease compared to women never treated for breast cancer and a nearly 3-fold increase in breast cancer mortality in women with an exercise capacity (VO2max) less than 28mL kg−1 min−1. Cardiac events are the second most common cause of death in long-term breast cancer (BrCa) survivors.

Purpose: We conducted a study to investigate the effects of standard exercise or structured exercise on targeted cardiovascular outcomes during a home-based diet and exercise intervention for breast cancer survivors.

Method: Cross-sectional within- and between-group design. A total of 19 breast cancer survivors, average age of 52.6+/−9.3, were enrolled in the study. A convenient sample was enrolled into two exercise groups receiving either: standard (150 minutes per week of usual care (exercise without instruction) cardiovascular exercise + resistance training) or structured (150 minutes per week of gradual increased intensity cardiovascular exercise + resistance training) exercise instruction along with a group based behavioral weight loss intervention. All participants underwent baseline and 17 week assessments including maximal exercise testing (VO2max and minutes on the treadmill), measurements of body composition (weight, BMI, % body fat), and assessment of quality of life.

Results: We report on the 16 participants who completed the baseline and 17 week assessments (9 = Standard Exercise Group; 7 = Structured Exercise Group). The structured exercise group exhibited significantly greater improvements in measures of cardiorespiratory fitness: VO2max (p = 0.05) and duration on treadmill (p = 0.02). No significant differences were noted for all other cardiorespiratory fitness testing outcomes. Significant improvements from baseline to 17 weeks were seen across both groups for all measures of body composition. Lean body mass did not significantly change from baseline to 17 weeks in both groups. There were no significant between group differences for change in body composition.

Abstract PD09-02: BRCA1 insufficiency is predictive of superior survival in patients with triple negative breast cancer treated with platinum based chemotherapy

Introduction: Triple negative breast cancer (TNBC) and BRCA1-associated breast cancers share many histopathologic and molecular features. BRCA1 plays a crucial role in HR-dependent DNA repair and BRCA1-deficient cells are particularly susceptible to the DNA damaging agents like platinums. Increasing evidence suggests that in addition to germline BRCA defects, other mechanisms (like epigenetic BRCA1 silencing) can lead to BRCA1 insufficiency in TNBC. However, the impact of BRCA1 insufficiency on the efficacy of DNA damaging agents in TNBC is not known.

Aim: To investigate the impact of BRCA1 insufficiency on relapse-free survival (RFS) and overall survival (OS) in patients with stage II-III TNBC treated with neoadjuvant platinum-based chemotherapy. BRCA1 insufficiency (BRCA1insuf) state was defined as presence of germline BRCA1/2 mutation or BRCA1 promoter methylation (PM) and/or low BRCA1 expression (lowest quartile).

Methods: Thirty patients with stage II/III TNBC received neoadjuvant chemotherapy (6 cycles of Carboplatin AUC 6, Docetaxel 75mg/m2 and Erlotinib 150 mg PO) on a phase II trial between 8/2007–6/2010. All but one patient underwent comprehensive BRCA analysis (Myriad Genetic Laboratories). Pre-treatment tumor specimens were used for evaluation of BRCA1 PM and expression. Genomic DNA was isolated from FFPE samples, bisulfite converted and then subjected to methylation-specific PCR (MSP). RNA was isolated, reverse transcribed to cDNA and assayed by quantitative real-time PCR (qRT-PCR) for determination of BRCA1 mRNA transcript levels. RFS and OS were estimated according to the Kaplan-Meier method and compared among groups with log-rank statistic. Cox proportional hazards models were fit to determine the association of BRCA1insuf with the risk of death after adjustment for other characteristics.

Results: Median age: 51yrs, African American: 20%, Median tumor size: 3.3 cm, LN positive: 40%. Six of 30 patients (20%) harbored germline BRCA mutation (4 BRCA1, 2 BRCA2). Baseline tumor specimen was available for 26/30 patients. BRCA1 MSP was successful in 92% and BRCA1 qRT-PCR was successful in 84% of specimens. BRCA1 PM and low BRCA1 expression was present in 30% and 15% of subjects, respectively. There was evidence of BRCA1insuf in 53% (16/30) of subjects. At a median time from diagnosis of 42 months (range, 23–59 months) there have been 9(30%) recurrences and 7(23%) deaths. On univariate analysis node negativity, lower stage and presence of BRCA1insuf were associated with better OS. At the median follow up, RFS is 81% for patients with BRCA1insuf versus 54% for patients without BRCA1insuf (p = 0.16); OS is 83% for patients with BRCA1insuf versus 46% for patients without BRCA1insuf (p = 0.021). After adjustment for clinical variables patients with BRCA1insuf had a significantly better OS compared to patients without BRCA1insuf (p = 0.036).

Conclusions: Germline BRCA testing plus tissue BRCA1 PM/expression can be used to identify a BRCA1insuf sub-population within TNBC demonstrating a favorable outcome with platinum treatment. This BRCA1insuf criteria can be easily used to select TNBC patients likely to benefit from DNA damaging agents like platinums and PARP inhibitors.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD09-02.

Effects of three modifiers of glycolysis on ATP, lactate, hypoxia, and growth in human tumor cell lines in vivo

BACKGROUND

High pretreatment tumor lactate content is associated with poor outcome after fractionated irradiation in human squamous cell carcinoma (hSCC) xenografts. Therefore, decreasing lactate content might be a promising approach for increasing tumor radiosensitivity. As the basis for such experiments, the effects of the biochemical inhibitors pyruvate dehydrogenase kinase dichloroacetate (DCA), lactate dehydrogenase oxamate, and monocarboxylic acid transporter-1 α-cyano-4-hydroxycinnamate (CHC) on tumor micromilieu and growth were investigated.

MATERIALS AND METHODS

Oxygen consumption (OCR) and extracellular acidification rates (ECAR) were measured in FaDu and UT-SCC-5 hSCC in response to DCA in vitro. Mice bearing FaDu, UT-SCC-5, and WiDr colorectal adenocarcinoma received either DCA in drinking water or DCA injected twice a day, or CHC injected daily. WiDr was also treated daily with oxamate. FaDu and UT-SCC-5 were either excised 8 days after treatment for histology or tumor growth was monitored. WiDr tumors were excised at 8 mm. Effect of inhibitors on ATP, lactate, hypoxia, and Ki67 labeling index (LI) was evaluated.

RESULTS

DCA increased OCR and decreased ECAR in vitro. None of the treatments with inhibitors significantly changed lactate content, hypoxia levels, and Ki67 LI in the three tumor lines in vivo. ATP concentration significantly decreased after only daily twice injections of DCA in FaDu accompanied by a significant increase in necrotic fraction. Tumor growth was not affected by any of the treatments.

CONCLUSION

Overall, tumor micromilieu and tumor growth could not be changed by glycolysis modifiers in the three tumor cell lines in vivo. Further studies are necessary to explore the impact of metabolic targets on radiation response.

P4-11-13: Influence of Two Years of Exemestane on Bone Mineral Density in Postmenopausal Women at Increased Risk of Developing Breast Cancer; a Companion Study to the NCIC CTG MAP.3 Trial

Background

Exemestane significantly reduced invasive and preinvasive breast cancers in postmenopausal women at increased risk for breast cancer in the NCIC CTG MAP3 trial with no serious toxicities, including excess fractures or osteoporosis.

Purpose: To provide additional information on the effect of exemestane on bone loss in women at high risk for breast cancer, within a subset of women participating on the NCIC CTG MAP.3B study. The primary hypothesis is that exemestane does not induce clinically significant bone loss in postmenopausal women at increased risk of developing breast cancer at 2 years. The primary objective of this companion study is to examine the effect of exemestane on lumbar spine and total hip BMD by DEXA at 2 years in women participating in the MAP3 trial.

Methods: The MAP.3B bone sub-study registered women from the main MAP. 3 trial from May 2008 to March 2010. Eligible women had to have an acceptable quality BMD scan by DEXA taken within 12 months prior to randomization to MAP.3. A BMD T-score >-2.0 SD (i.e. better than 2 standard deviations below the average peak BMD of a young adult woman) was established as the study population cutoff. A questionnaire including information on height, falls, fractures, lifestyle information including physical activity, tobacco and alcohol use was completed at baseline, 12 months, 24 months and at last visit. Fasting serum for bone biomarkers was collected at 12 months and total hip and L1-L4 (postero-anterior) spine BMD were measured 2 years after randomization on the same Lunar or Hologic scanner. The primary objective was to determine differences in hip and spine BMD at 2 years. Secondary outcomes include number of skeletal fractures and development of osteoporosis 2 years after randomization and changes in bone biomarkers at 1 year after randomization. For the analysis of the primary endpoints, the upper limit of a one sided 95% confidence interval for the difference in mean percentage changes between placebo and exemestane will be calculated for the BMD by DEXA at each site. We will conclude that exemestane does not induce significant bone loss in postmenopausal women at increased risk of developing breast cancer at 2 years when the upper limit is less than 3% for both sites. Similar confidence interval approach will be used to analyze the secondary endpoints.

Results: Between May 2008 and March 2010, 238 postmenopausal women were recruited. Median age was 61.8 years, and the majority of women were Caucasian (91%), with approximately 20% of the participants reporting a recent fall (within past 12 months) and another 13% reporting a recent fracture prior to randomization. We will report results from the primary as well as the secondary endpoints at the SABCS meeting.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-13.

S6-1: Menopause-Specific and Health-Related Qualities of Life among Post-Menopausal Women Taking Exemestane for Prevention of Breast Cancer: Results from the NCIC CTG MAP.3 Placebo-Controlled Randomized Controlled Trial

Background: Exemestane, a steroidal aromatase inhibitor, reduced the incidence of invasive breast cancers by 65% among 4560 post-menopausal randomized to exemestane or placebo for 5 years on MAP.3. Differences in quality of life (QOL) were judged to be minimal, but only summary information was reported.

Purpose: To provide more detailed information about effects of exemestane on menopause-specific and health-related qualities of life.

Method: Participation in quality of life assessment was an eligibility criterion. Menopause-specific and health-related qualities of life were assessed using the MENQOL (4 scales; physical, vasomotor, psychosocial, sexual) and SF-36 (8 scales; physical health, role function — physical, bodily pain, general health, vitality, social function, role function — emotional, mental health, and 2 summary scales) instruments, respectively at baseline, 6 months and then yearly after randomization. Compliance with QOL questionnaire completion at each follow-up visit ranged from 93–98%, and did not differ by group. Change scores for each MENQOL and SF-36 scale, calculated for each assessment time relative to baseline, were compared using the Wilcoxon Rank-Sum test. Summary scores were used to summarize the QOL scores observed at each time point for each SF-36 dimension and overall mental (MCS) and physical component summaries (PCS) and MENQOL domains. Clinically important worsening of MENQOL change scores was defined as an increase of ≥0.5/8 points. SF-36 change scores were considered worsened if scores decreased by ≥ 5 points from baseline.

Results: Both groups were balanced on scores for MENQOL and SF-36 at baseline. Median follow-up was 35 months and the proportion of women who stopped study medication early for toxicity reasons was 15% in the exemestane arm and 11% in the placebo arm. There was a statistically significant difference in change scores for vasomotor symptoms among women on exemestane during the first 4 years (p-values <0.01), compared to placebo. However, no between-group differences in vasomotor change met the criterion for clinical importance. Women on exemestane had statistically poorer sexual functioning (mean change = −0.02, SD=1.37) compared to placebo (mean change = −0.12, SD=1.32) during the first 6 months on study (p-value = 0.03) but the differences were not statistically significant thereafter or clinically important at any time. Among the 8 SF-36 scales, only bodily pain was statistically different between exemestane and placebo for the first 24 months on study medication (p-value <0.01), but no between-group difference in change scores exceeded 5 points. Overall SF-36 PCS and MCS assessing changes in overall physical and mental health-related QOL did not differ significantly by group at any assessment.

Conclusion: Our assessment that early differences in vasomotor symptoms and pain were probably not clinically important is supported by the observation of no between-group differences when overall physical and mental health-related QOL changes were compared. Exemestane does not appear to have a major negative impact on the quality of life among these women.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr S6-1.

P3-09-03: Long-Chain Polyunsaturated Fatty Acid Intake and Its Relationship to Long-Chain Polyunsaturated Fatty Acids in Serum, Red Blood Cells and Breast Tissue

Background

Long chain omega-3 (n-3) poly unsaturated fatty acids (LCPUFA) have anti-inflammatory effects and are able to counteract the effects of the pro-inflammatory omega-6 (n-6) fatty acids such as arachidonic acid (AA) by substituting for the n-6 fatty acids in triglycerides (TG) and phospholipids (PL). Several pre-clinical, observational, and case control studies suggest that intake or tissue content of n-3 LCPUFA such as eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA), relative to intake or tissue content of long chain n-6 fatty acids such as AA may be associated with reduced risk of breast cancer. The goal of this study was to determine the relationships between dietary intake of fatty acids, tissue levels of fatty acids, and breast tissue biomarkers for risk of breast cancer.

Methods: Women (n=74) were recruited from a clinic in which women at increased risk for breast cancer had breast tissue acquired by random periareolar fine needle aspiration (RPFNA). Breast epithelial cells were assessed for cytomorphology and proliferation (Ki-67 immunochemistry). Fatty acid dietary intake was assessed with the National Cancer Institute Diet History Questionnaire. Plasma, erythrocyte, and breast specimens were processed for membrane PL and TG and analyzed for individual fatty acids by gas liquid chromatography.

Results: Total intake of n-3 PUFA was 1.1 ± 0.5 g/d, and the ratio of EPA+DHA:AA was 0.1:1.0 (n=66). Dietary n-3 LCPUFA correlated with n-3 LCPUFA in both plasma and erthyrocyte PL (n=62). Breast epithelial cell number, Masood cytomorphology score, and percent Ki-67 positive cells were higher in RPFNA specimens which exhibited cytologic atypia compared to those which did not (n=74; p<0.001, Mann-Whitney Test). Subjects with atypia consumed less dietary n-3 PUFA (n=66, p=0.020), had lower plasma and erythrocyte PL and plasma TG EPA, DHA, total n-3, and EPA+DHA:AA (n=70; p<0.05). In breast tissue TG, the ratio of n-3:n-6 was also lower in subjects with atypia (n=40; p=0.025).

Conclusions: Overall, women in this high risk cohort consumed very low amounts of n-3 LCPUFAs. Dietary intake of n-3 LCPUFA was related to levels of n-3 LCPUFA in erythrocyte and plasma PL. Given the association of low levels of n-3 fatty acids with cytologic atypia (a known risk factor for breast cancer development), an intervention to increase n-3 fatty acids and n-3:n-6 ratios has merit and clinical trials in high risk women have been initiated.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-09-03.

P4-12-07: Outcomes of a Behavioral Weight Control Intervention among Rural Breast Cancer Survivors

Background: Obese breast cancer survivors have 1.5 to 2.5 fold increased risk of recurrence and death compared to their normal weight counterparts. Rural women, who comprise over 20% of the U.S. population of women, have significantly higher obesity rates as well as breast cancer treatment-related disparities. Thus, weight control intervention is a key strategy for secondary breast cancer prevention in this population. However, access can be challenging in the rural setting. Using conference call technology to deliver group-based intervention is well-suited for rural breast cancer survivors because it is easily accessible and provides real-time peer support. The purpose of this one-arm treatment study was to examine the impact of a 6-month group phone-based behavioral weight control intervention on anthropomorphic, diet, physical activity, and psychosocial/quality of life outcomes.

Methods: Eligible participants were post-menopausal breast cancer survivors (Stage I-IIIc, 3 months to 10 years since surgery, radiation, or chemotherapy, < 75 years of age, BMI 27–45 kg/m2) who resided in a rural area. The weight control intervention included a reduced calorie diet with 2 prepackaged meals and ≥5 fruit and vegetables servings daily, home-based physical activity gradually increased to 225 min/week of moderate intensity exercise, weekly self-monitoring logs, and weekly 60-minute group phone sessions that addressed behavioral modification and breast cancer survivorship topics. Group size ranged from 9 to 13 women. Measures included anthropometrics, two 24-hour dietary recall interviews, and questionnaires measuring physical activity, fatigue, depression, body image and sexuality, and self-efficacy for diet and physical activity behavior change. Results: Participants (n = 34) were 58.9 ± 7.8 years-old, 3.1 ± 1.6 years out from treatment, had a baseline BMI of 33.7 ± 4.4 kg/m2, and 63% were on anti-hormone therapy. Average sessions attendance among all participants, including 3 non-completers, was 90%. Ninety-one percent of participants (n = 31) attended > 75% of intervention sessions and completed post-treatment data collection visits. At 6 months, significant changes were observed for weight (−12.5 ± 5.8 kg, 13.9% of baseline weight), waist circumference (−9.4 ± 6.3 cm), daily energy intake (−349 ± 550 kcal/day), fruits and vegetables (+3.7 ± 4.3 servings/day), percent kcal from fat (−12.6 ± 8.6%), and physical activity (+1235 ± 832 kcal/week; all p's < .001). Significant improvements were also seen for Body Image subscales (Strength and Health, Social Barriers, Appearance and Sexuality), Depression, and Self-Efficacy for diet and physical activity behaviors (all p's < .05). Discussion: The intervention produced significant improvements in weight, diet, physical activity, and quality of life outcomes that compare favorably to the literature. The group phone-based treatment delivery approach appears feasible and effective for weight control intervention among obese rural breast cancer survivors.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-07.

A randomized, placebo-controlled trial (NCIC CTG MAP.2) examining the effects of exemestane on mammographic breast density, bone density, markers of bone metabolism and serum lipid levels in postmenopausal women

We hypothesized that exemestane (EXE) would reduce mammographic breast density and have unique effects on biomarkers of bone and lipid metabolism. Healthy postmenopausal women were randomized to EXE (25 mg daily) or placebo (PLAC) for 12 months and followed for a total of 24 months. The primary endpoint was change in percent breast density (PD) between the baseline and 12-month mammograms and secondary endpoints were changes in serum lipid levels, bone biomarkers, and bone mineral density (BMD). Ninety-eight women were randomized (49 to EXE; 49 to PLAC) and 65 had PD data at baseline and 12 months. Among women treated with EXE, PD was not significantly changed from baseline at 6, 12, or 24 months and was not different from PLAC. EXE was associated with significant percentage increase from baseline in N-telopeptide at 12 months compared with PLAC. No differences in percent change from baseline in BMD (lumbar spine and femoral neck) were observed between EXE and PLAC at either 12 or 24 months. Patients on EXE had a significantly larger percent decrease in total cholesterol than in the PLAC arm at 6 months and in HDL cholesterol at 3, 6, and 12 months. No significant differences in percent change in LDL or triglycerides were noted at any time point between the two treatment arms. EXE administered for 1 year to healthy postmenopausal women did not result in significant changes in mammographic density. A reversible increase in the bone resorption marker N-telopeptide without significant change in bone specific alkaline phosphatase or BMD during the 12 months treatment period and 1 year later was noted. Changes in lipid parameters on this trial were modest and reversible.

Abstract PD09-04: Weight Loss in Postmenopausal Women Is Associated with Modulation of Serum and Tissue Based Risk Biomarkers

Background

In a pilot study, a structured program of reduced energy diet, physical activity, and weekly group behavioral intervention with other high risk women was successful at producing a median 11% weight loss with at least a 5% weight loss in 88% of subjects. We evaluated the association of weight loss with changes in serum and breast tissue risk and mechanisms of action biomarkers. Methods

High risk postmenopausal women with BMI >25 kg/m2 had breast tissue harvested by random periareolar fine needle aspiration (RPFNA) before and after a 6-month energy balance intervention. Specimens were evaluated for biomarkers including cytomorphology, proliferation (immunocytochemical Ki-67), gene expression by RT-qPCR, and expression of cytokines and adpokines by Luminex assay. Fasting serum was assayed for insulin, glucose, adiponectin, leptin, high sensitivity CRP, IL-6, prolactin, SHBG, estradiol and testosterone using ELISA or Luminex.

Results

For 24 biomarker evaluable subjects, 21 had >5% weight loss (median = 11%). Cytologic atypia was present in 10/24 at baseline and 4/24 at 6 months (p=0.034). For 20 subjects with sufficient cells for assessment of Ki-67 at both times, median baseline Ki-67 was 0.7% and off study 0.3%, with a median change of -0.2% (p=0.19). Statistically significant changes (≥0.003; Wilcoxon) were observed for serum levels of adiponectin, adiponectin:leptin ratio, and SHBG (increases); and leptin, bioavailable estradiol and hsCRP (decreases). Reduction was also observed for insulin (p=0.018) and bioavailable testosterone (p=0.033). These results were duplicated (p≥0.014) by Luminex for adiponectin, leptin, adiponectin: leptin ratio, and insulin; plus hepatocyte growth factor (HGF, decrease). Also, an increase in the adiponectin:leptin ratio was observed for the RPFNA specimens (p=0.012). Gene expression (RT-qPCR) of pS2 was significantly modified (decrease, p=0.035). Further, the weight loss (expressed as relative change) was highly statistically correlated with change (relative) in serum leptin, adiponectin:leptin ratio, SHGB, and free estradiol; as well as with relative change in adiponectin:leptin ratio in RPFNA specimens. Conclusion

Weight loss in high risk postmenopausal women is accompanied by significant modulation of numerous serum and breast tissue-based biomarkers. For several risk and response biomarkers there is a significant correlation between change in the biomarker and the weight loss achieved. This suggests the possibility of identifying mechanisms of action and signaling pathways for dietary/energy balance interventions that may reduce risk for development of breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD09-04.

Abstract P1-06-01: Omega-3 Fatty Acids for Chemoprevention: NF-Kb as a Molecular Target in Both Pre and Post Menopausal High-Risk Breast Cancer Models

Genetic heterogeneity of human breast cancer has complicated treatment, prevention and therapeutic regimens in both clinical and personal care settings. With the recent advances in genetic analyses, human breast tumors are now segregated into four principle molecular subtypes: luminal A, luminal B, basal and HER2 overexpressors, each differing in their driver mutations, estrogen receptor status and dependence on specific cell signaling pathways to maintain growth and tumorigenicity. Omega-3 fatty acids have been shown in previous studies to be effective in modulating tumor growth in preclinical models of breast cancer, but epidemiological studies have been less clear regarding their efficacy as chemopreventive agents. Like many targeted therapies, we hypothesize that omega-3 fatty acids will be most effective against specific subtypes of disease, and it will be critical to identify these subtypes if these dietary agents are to be exploited most effectively. In this current study, the genetic diversity of breast cancer was represented by appropriate cell lines of matching molecular backgrounds and each class of breast cancer were subjected to exposures of omega-3 fatty ethyl esters derived from Lovaza®, an anti-hypertriglyceride medication that is currently under clinical evaluation as a chemopreventive for breast cancer. Previous studies have suggested that a target for omega-3 fatty acid modulation is the transcription factor NF-kB, a central key mediator of inflammation and cancer cell survival. Coined the single most important molecular machinery required for cancer initiation and promotion, NF-kB has been identified to play critical roles in all stages of breast cancer development. The omega-3 ethyl esters demonstrated suppression of NF-kB transcriptional activity, nuclear localization and overall function with high efficacy in the cell lines reflective of the luminal A, luminal B and basal subtypes, correlating with inhibition of proliferation and overall survival. Interestingly, among the panel of breast cancer subtypes, the aggressive HER2 overexpressing cell lines were resistant to the inhibitory effects of the omega-3 ethyl esters. One of the proposed mechanisms by which NF-kB is regulated is co-localization with IkB. siRNA knockdown assays suggest IkB involvement in the repression of NF-kB function by the omega-3 ethyl esters in the responding cell lines. Results from an ongoing clinical trial with omega-3 ethyl esters will help confirm if specific subtypes of breast cancers will be more effectively prevented using these agents, and whether NF-kB is the target by which they are mediating their anti-cancer effects. These studies are some of the first to use molecular profiles to identify potential responders and non-responders for dietary intervention and may provide better direction for future clinical studies evaluating the efficacy of diet and lifestyle in the preventive setting.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-06-01.

SABRE-B: an evaluation of paclitaxel and bevacizumab with or without sunitinib as first-line treatment of metastatic breast cancer

BACKGROUND

The vascular endothelial growth factor (VEGF) pathway can be targeted through VEGF neutralization or VEGF receptor (VEGFR) blockade using tyrosine kinase inhibition. Because laboratory models suggest that combining these approaches might be synergistic, we sought to evaluate the feasibility and efficacy of combining sunitinib with paclitaxel + bevacizumab (PB).

METHODS

Patients with human epidermal growth factor receptor 2 (HER2)-negative, metastatic breast cancer receiving first-line chemotherapy were randomized to PB or PB with sunitinib (PBS), with planned escalation of the sunitinib dose.

RESULTS

Forty-six patients were randomized to PB or PBS with sunitinib dosed at 25 mg p.o. daily. Patients receiving PBS encountered substantial toxicity that precluded adequate treatment. The percentage of patients with grade ≥3 adverse events was greater in the PBS arm than the PB arm (83% versus 57%), and sunitinib dosing was modified in 78% of patients, most often due to neutropenia, febrile neutropenia, and fatigue. In addition, 44% of patients had sunitinib dose reduction to 12.5 mg, and 39% required discontinuation. Patients receiving PBS had more bevacizumab treatment interruptions and discontinuations because of toxicity. Median treatment duration was longer in the PB arm compared with the PBS arm (14.1 versus 11.1 weeks), reflecting early treatment discontinuation of PBS. Because of poor tolerability of the addition of sunitinib to PB, the planned sunitinib dose escalation was halted and the study accrual was terminated.

CONCLUSION

Adding sunitinib to standard doses of bevacizumab plus paclitaxel for metastatic breast cancer is not feasible. Different strategies will be required to evaluate whether there is additional clinical benefit to combining VEGF/VEGFR-targeted agents.

Feasibility of a 6-Month Diet, Exercise, and Behavior Modification Intervention for Post-Menopausal Breast Cancer Survivors

Background: Obesity is prevalent in general population and among breast cancer (BrCa) survivors. Weight at diagnosis and weight gain after diagnosis are associated with increased risk of breast cancer recurrence and mortality. Regular exercise similarly reduces the risk of dying from breast cancer. This study was conducted to determine the feasibility of a structured diet/exercise/behavioral intervention program with a goal to achieve a weight loss of 5% or more, and to study the effect of participation in the program on serum biomarkers of breast cancer risk, measures of overall health, strength, and fitness level..Methods: Subjects in this prospective pilot study are female, overweight BrCa survivors with a BMI >25, and who were at least 3 months out of adjuvant chemotherapy. The 6-month combined modality diet/exercise/behavior modification intervention included: 225 minutes per week of cardiovascular exercise in addition to resistance training, a 1200-1500 calorie/day diet including participant purchased pre-packaged meals and low calorie shakes, and a weekly in-person group behavioral meeting. Women were recruited into groups of 10 to15 participants (total n=50), with a planned goal of 4 cohorts, and anticipated complete data collection by December 2009. Participants underwent pre and post intervention assessments including: anthropometric measures, serum biomarkers, fitness test, and questionnaires to assess food frequency, fatigue, and quality of life. Changes over time were assessed using Wilcoxon signed rank test. We present here the data on first 12 women who have completed the 6 month intervention, out of a planned accrual of 50.Results: Since November 2008, 55 women were screened and 38 women agreed to participate in the 6-month intervention (13 in cohort 1; 10 in cohort 2; 15 in cohort 3). Only 1 participant dropped out of cohort 1 due to a non-study related injury. Major reasons for not participating included: already started another weight loss program, timing, and lack of availability for the evening meeting. Mean age of the participants was 50.7 (range 40-57) and mean time from diagnosis to the time of enrollment was 45 months (range 20-132). Eight five percent of the participants received adjuvant or neo-adjuvant chemotherapy and 77% were either currently or had previously taken anti-hormonal therapy.Median weight was 230 lbs (range 165-268) at baseline .and 198 lbs (range 139.6-243.8) at 6 month (median weight loss: 32 lbs or 14%; p=0.00); median BMI was 36.4kg/m2 (range 30.3-45.4) at baseline and 31.54kg/m2 (range 26.4-40.7) at 6-months (p=0.00), median percent body fat by DEXA scan was 50.9 (range 45-58.4) at baseline and 46.3 (range 35.6-55.4) at 6-months (p=0.00). Participants increased their metabolic equivalent task hours per week (MET/HRS) of exercise from 6.6 (range 0-25) at baseline to 20.4 (range11.8-40.5) at 6-months (p=0.01).Conclusion: A 6-month diet/exercise/behavior modification intervention program is feasible and results in a significant decrease in overall weight and percent body fat among overweight breast cancer survivors.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1058.

The what, why and how of aromatase inhibitors: hormonal agents for treatment and prevention of breast cancer

The third-generation aromatase inhibitors (AIs) anastrozole, exemestane and letrozole have largely replaced tamoxifen as the preferred treatment for hormone receptor - positive breast cancer in postmenopausal women. Approximately 185,000 new cases of invasive breast cancer are diagnosed yearly, and at least half of these women are both postmenopausal and eligible for adjuvant therapy with AIs. In addition, AIs are currently being tested as primary prevention therapy in large randomised trials involving tens of thousands of women at increased risk for breast cancer. Given the volume of use, internists will increasingly see postmenopausal women who are taking or considering treatment with AIs. Physicians need to be able to: (i) briefly discuss the pros and cons of using a selective estrogen receptor modulator such as tamoxifen or raloxifene vs. an AI for risk reduction and (ii) recognise and manage AI-associated adverse events. The primary purpose of this review is to help internists with these two tasks.

Comparison of immunohistochemistry by automated cellular imaging system (ACIS) versus fluorescence in-situ hybridization in the evaluation of HER-2/neu expression in primary breast carcinoma

AIMS

Immunohistochemistry (IHC) and fluorescence in-situ hybridization (FISH) are both commonly used assays for evaluation of HER-2/neu status in breast cancer. However, there is still no consensus on which method is most predictive of patient response to Herceptin. Recently, the automated cellular imaging system (ACIS) has been shown to improve the accuracy and reproducibility in scoring IHC. Our aim was to compare the results of HER-2/neu expression and gene amplification in the same patients by IHC using the ACIS system and by FISH.

METHODS AND RESULTS

Two hundred and forty-seven breast cancer cases were studied. The concordance rate between IHC-ACIS (> or = 2.2) and FISH (> or = 2.0) was 94%. Fifteen patients were discordant; three had borderline FISH values and three had borderline IHC values. The other nine discordant cases consisted of five IHC-ACIS+, FISH- and six IHC-ACIS-, FISH+. HER-2/neu overexpression was more common in tumours that were high-grade, aneuploid, progesterone receptor and bcl-2 negative, with MIB-1 > 10%.

CONCLUSION

HER-2/neu assessment by the ACIS is reliable, rapid and inexpensive, and correlates highly with results obtained by FISH.

Breast-tissue sampling for risk assessment and prevention

Breast tissue and duct fluid provide a rich source of biomarkers to both aid in the assessment of short-term risk of developing breast cancer and predict and assess responses to prevention interventions. There are three methods currently being utilized to sample breast tissue in asymptomatic women for risk assessment: nipple-aspirate fluid (NAF), random periareolar fine-needle aspiration (RPFNA) and ductal lavage. Prospective single-institution trials have shown that the presence of atypical cells in NAF fluid or RPFNA specimens is associated with an increased risk of breast cancer. Furthermore, RPFNA-detected atypia has been observed to further stratify risk based on the commonly used Gail risk-assessment model. A prospective trial evaluating risk prediction on the basis of atypical cells in ductal-lavage fluid is ongoing. The ability of other established non-genetic biomarkers (mammographic breast density; serum levels of bioavailable estradiol, testosterone, insulin-like growth factor-1 and its insulin like growth factor binding protein-3) to stratify risk based on the Gail model is as yet incompletely defined. Modulation of breast intra-epithelial neoplasia (i.e. hyperplasia with or without atypia) with or without associated breast-tissue molecular markers, such as proliferation, is currently being used to evaluate response in Phase II chemoprevention trials. RPFNA has been the method most frequently used for Phase II studies of 6-12 months duration. However, ductal lavage, RPFNA and random and directed core needle biopsies are all being utilized in ongoing multi-institutional Phase II studies. The strengths and weaknesses of each method are reviewed.

Shakeup excitation during optical tunnel ionization

Shakeup of a two-electron system is investigated in the strong infrared laser field limit, both theoretically and experimentally. During tunnel ionization the electron shakes up a second electron to an excited bound state. Theoretically, a complete analytical theory of shakeup in intense laser fields is developed. We predict that shakeup produces one excited sigma(u) D(+)(2) state in approximately 10(5) ionization events. Shakeup is measured experimentally by using the molecular clock provided by the internuclear motion. The number of measured events is found to be in excellent agreement with theory.

Influence of sex, estrous cycle and motherhood on dendritic spine density in the rat medial amygdala revealed by the Golgi method

The medial nucleus of the amygdala (MeA), a sexually dimorphic area, contains estrogen and androgen receptors and has an integrative role in behavioral, vegetative and endocrine activities of rats. The density of dendritic spines along the first 40 microm of dendritic length was studied in neurons from the anterodorsal (MeAD), posterodorsal (MePD) and posteroventral (MePV) aspects of the MeA in males, in virgin females during the four phases of the estrous cycle and in multiparous females in diestrus. The single-section Golgi method was employed (N=48 observations per experimental group). In the three MeA subnuclei males showed more dendritic spines than virgin females (P<0.001), with the only exception being the MePD data of females in diestrus (P>0.05). In virgin females, whereas more dendritic spines were found in diestrus, a decline in these values was found during the proestrus, estrus and metaestrus in the MePD and MePV (P<0.05) but not in the MeAD (P>0.05). Compared with virgin females in diestrus, postpartum rats showed more spines in the MeAD (P<0.001) and fewer in the MePD (P<0.001) but no difference was found in the MePV (P>0.05). These data suggest that there are subregion-specific differences in the density of dendritic spines within the MeA and that they appear to be affected by sex, cyclic fluctuations in the levels of ovarian steroids and following pregnancy in rats. These findings may add to the understanding of the MeA neuronal plastic changes that affect the ongoing processing of sensory information and the organization of the neuroendocrine and behavioral basis of reproduction.

Beyond tamoxifen new endpoints for breast cancer chemoprevention, new drugs for breast cancer prevention

Although tamoxifen appears to markedly reduce breast cancer risk in women with a prior diagnosis of atypical hyperplasia or in situ carcinoma, it is not clear what other groups of women receive substantial benefit. Major breast chemoprevention priorities are to (1) develop new agents that (a) have fewer side effects, (b) are effective in ER--as well as tamoxifen-resistant precancerous tissue, and (c) are compatible with hormone therapy; and (2) develop efficient clinical strategies including prognostic and predictive morphologic and molecular biomarkers. Breast tissue may be repeatedly sampled for evidence of intraepithelial neoplasia by fine needle aspiration, ductal lavage, or needle biopsy to select candidates at highest short-term risk as well as to monitor response in small proof of principle studies prior to a large cancer incidence trial. Molecular marker expression may also be used to select a cohort most likely to respond to a particular agent. A large number of new agents are attractive as potential prevention agents and some are already in clinical prevention testing. Compounds which should be effective in ER + precancerous tissue but may have a better side-effect profile include new selective estrogen receptor modulators which lack uterine estrogen agonist activity, isoflavones, aromatase inactivators/inhibitors for postmenopausal women, and gonadotropin-releasing hormone regimens for premenopausal women. Retinoids, rexinoids, and deltanoids may be efficacious in ER+ tissue resistant to tamoxifen. Agents which should theoretically have activity in ER- or ER+ precancerous tissue include polyamine synthesis inhibitors, tyrosine kinase inhibitors, combined demethylating agents and histone deacetylase inhibitors, as well as metalloprotease and angiogenesis inhibitors. Sample Phase I and Phase II clinical trial designs are reviewed using modulation of molecular markers and breast intraepithelial neoplasia as the major endpoints.

Chemoprevention for high-risk women: tamoxifen and beyond

The demonstration by the National Surgical Adjuvant Breast Project (NSABP) that 5 years of tamoxifen therapy is associated with an approximate 50% reduction in breast cancer incidence in high-risk women was a milestone in breast cancer prevention. Because tamoxifen is associated with increased risk of side-effects such as hot flashes, menstrual abnormalities, uterine cancer, and thromboembolic phenomena, its use will not be advisable or acceptable for all high-risk women. Women over 50 years of age appear to be at highest risk for serious adverse events, such as uterine cancer and thromboembolic phenomena. Individuals in whom tamoxifen-associated breast cancer risk reduction appears to outweigh risk of serious side-effects include women with prior in situ or estrogen receptor (ER)-positive invasive cancer, atypical hyperplasia, and/or women ages 35-49 with a calculated Gail 5-year risk of > or =1.7%, hysterectomized women aged 50 and older with a 5-year Gail risk of > or =2.5%, and nonhysterectomized women aged 50 and older with a 5-year Gail risk of >5.0%. It is not yet clear whether tamoxifen can reduce breast cancer incidence in women with BRCA1 and BRCA2 mutations, although preliminary evidence favors benefit for at least those with a BRCA2 mutation. Raloxifene is a selective ER modulator with less uterine estrogen agonist activity than tamoxifen, and it is hoped that it will result in fewer uterine cancers but will be equally efficacious in reducing the risk of breast cancer. The NSABP is currently conducting a randomized study of tamoxifen versus raloxifene in high-risk postmenopausal women. Approximately one third of invasive cancers are ER negative. Tamoxifen does not reduce the incidence of ER-negative cancers, nor does it appear to be effective in preventing the appearance of one third of ER-positive cancers. Priorities in prevention research are to develop (a) biomarkers to refine short-term risk assessments based on epidemiologic models, (b) biomarkers predictive of response to specific classes of preventive agents, (c) drugs with fewer side-effects and/or effective in ER-negative or ER-positive tamoxifen-resistant precancerous disease, and (d) efficient clinical trial models to assess new agent efficacy. Breast intraepithelial neoplasia (IEN) may be sampled by minimally invasive techniques and is an attractive short-term risk biomarker. Molecular abnormalities observed in IEN may be used to select potential agents for testing/therapy, and modulation of these abnormalities may be used in phase I trials to select appropriate doses and in phase II trials to assess response. Breast density volume and certain serum markers such as insulin-like growth factor-1 are also being studied as potential risk and response biomarkers. Reversal or prevention of advanced IEN as well as modulation of other risk biomarkers in randomized phase II and phase III trials is being evaluated as a means of more efficiently evaluating prevention drugs in the future. A number of agents are being developed that target molecular abnormalities in IEN, have fewer or different side effects than tamoxifen, and may be effective in ER-negative or tamoxifen-resistant disease.

Breast cancer chemoprevention: beyond tamoxifen

A large number of new potential chemoprevention agents are available that target molecular abnormalities found in estrogen receptor (ER)-negative and/or ER-positive precancerous breast tissue and have side effect profiles that differ from tamoxifen. Classes of agents currently undergoing evaluation in clinical prevention trials or those for which testing is planned in the near future include new selective ER modulators, aromatase inactivators/inhibitors, gonadotrophin-releasing hormone agonists, monoterpenes, isoflavones, retinoids, rexinoids, vitamin D derivatives, and inhibitors of tyrosine kinase, cyclooxygenase-2, and polyamine synthesis. New clinical testing models will use morphological and molecular biomarkers to select candidates at highest short-term risk, to predict the response to a particular class of agent, and to assess the response in phase II prevention trials. If validated, morphological and molecular markers could eventually replace cancer incidence as an indicator of efficacy in future phase III trials.

Short-term breast cancer prediction by random periareolar fine-needle aspiration cytology and the Gail risk model

BACKGROUND

: Biomarkers are needed to refine short-term breast cancer risk estimates from epidemiologic models and to measure response to prevention interventions. The purpose of our study was to determine whether the cytologic appearance of epithelial cells obtained from breast random periareolar fine-needle aspirates or molecular marker expression in these cells was associated with later breast cancer development.

METHODS

: Four hundred eighty women who were eligible on the basis of a family history of breast cancer, prior precancerous biopsy, and/or prior invasive cancer were enrolled in a single-institution, prospective trial. Their risk of breast cancer according to the Gail model was calculated, and random periareolar fine-needle aspiration was performed at study entry. Cells were characterized morphologically and analyzed for DNA aneuploidy by image analysis and for the expression of epidermal growth factor receptor, estrogen receptor, p53 protein, and HER2/NEU protein by immunocytochemistry. All statistical tests are two-sided.

RESULTS

: At a median follow-up time of 45 months after initial aspiration, 20 women have developed breast cancer (invasive disease in 13 and ductal carcinoma in situ in seven). With the use of multiple logistic regression and Cox proportional hazards analysis, subsequent cancer was predicted by evidence of hyperplasia with atypia in the initial fine-needle aspirate and a 10-year Gail projected probability of developing breast cancer. Although expression of epidermal growth factor receptor, estrogen receptor, p53, and HER2/NEU was statistically significantly associated with hyperplasia with atypia, it did not predict the development of breast cancer in multivariable analysis.

CONCLUSION

: Cytomorphology from breast random periareolar fine-needle aspirates can be used with the Gail risk model to identify a cohort of women at very high short-term risk for developing breast cancer. We recommend that cytomorphology be studied for use as a potential surrogate end point in prevention trials.

Breast cancer chemoprevention trials using the fine-needle aspiration model

Selection of surrogate endpoint biomarkers (SEBs) and appropriate study design are two of the main challenges in evaluating potential chemopreventive agents. In a prospective random fine-needle aspiration (FNA) study of women at high risk of development of breast cancer, we previously demonstrated that cytologic evidence of epithelial hyperplasia with or without atypia, as well as abnormalities of several cellular biomarkers (DNA ploidy; immunocytochemical expression of p53, EGFR, ER, and/or Her-2/neu), were more prevalent in high-risk women than in low-risk controls. We also demonstrated that the subsequent development of breast cancer was best predicted by an initial presentation of hyperplasia with atypia, as well as by multiple biomarker abnormalities. These findings indicate that FNA cytology and biomarkers can be used to identify women who are appropriate subjects for chemoprevention trials, and can then be used as surrogate endpoint biomarkers to monitor efficacy of potential agents. An example of this use in an ongoing single-agent phase II trial is provided. Several options for study design of possible multi-agent breast cancer chemoprevention trials are discussed, depending upon the existing preclinical and clinical data, the questions being asked, and the number of eligible subjects available.

Incidence of BRCA1/2 germ line alterations in a high risk cohort participating in a phase II chemoprevention trial

It is unknown what proportion of women at high risk for breast cancer, entering phase II chemoprevention trials, have BRCA1/2 alterations, and whether their initial biomarker patterns or response to preventive interventions will differ between carriers and non-carriers. As part of a 6-month phase II chemoprevention trial of diflouromethlyornithine (DFMO), high-risk subjects (family history, prior precancerous breast disease or prior breast cancer), who had random peri-areolar fine needle evidence of epithelial hyperplasia with or without atypia, were offered genetic counselling and testing at the completion of their study participation. 97% of the 119 women eligible for testing underwent BRCA1/2 gene sequencing, 3 declined. 26 (22%) of the 116 women had an alteration in BRCA1/2. Known deleterious mutations were present in 3 (3%), uncertain significance mutations in 19 (16%), and probable polymorphisms in 6 (5%). There does not appear to be a difference in initial biomarker distribution between participants with and without germ line alterations.

Can a controlled-release oral dose form of oxycodone be used as readily as an immediate-release form for the purpose of titrating to stable pain control?

Two separate trials compared controlled-release (CR) oral oxycodone (administered every 12 hours) with immediate-release (IR) oxycodone (4 times a day) to determine whether patients with chronic pain could be titrated to stable pain control as readily with the CR as with the IR formulation. In one study, 48 patients with cancer pain were randomized to open-label titration with either CR or IR oxycodone (maximum dose, 400 mg/day) for a period of up to 21 days. In a study of similar design, 57 patients with low back pain were titrated with either CR or IR oxycodone (maximum dose, 80 mg/day) for a period of up to 10 days. The majority of patients in both studies were converted to oxycodone from other opioid analgesics. Results of both studies showed no difference between CR and IR oxycodone with respect to both the percentage of patients achieving stable pain control, the time to achieve stable pain control, and the degree of pain control achieved. Among cancer patients, 85% achieved stable analgesia, 92% with the CR formulation and 79% with the IR formulation. Among noncancer patients, 91% achieved stable pain control, 87% with the CR formulation and 96% with the IR formulation. The most commonly reported adverse effects in both studies were similar for the two formulations and were those anticipated with opioids: nausea, vomiting, constipation, somnolence, dizziness, and pruritus. Nausea and vomiting were the most frequently cited reasons for treatment discontinuations. These studies suggest that dose titration can be accomplished as readily with oral CR oxycodone as with IR oxycodone in patients with chronic, moderate to severe pain.

Models for early chemoprevention trials in breast cancer

Several models are being explored for use in the phase I and phase II evaluation of breast cancer chemoprevention agents. The short-term DCIS/small invasive cancer model is probably best used in late phase I trials in conjunction with agents likely to have activity in the progression phase of neoplastic development in addition to activity in earlier phases. The core biopsy or FNA hyperplasia models may be best used with drugs that are likely to have activity primarily in the promotion phase of neoplastic development and that are suitable for longer duration trials lasting several months to years. Morphology currently is the key surrogate endpoint biomarker for assessing efficacy in phase II trials. Other biomarkers that may undergo modulation will have to be validated, in that modulation will have to be shown to be directly related to decreased cancer risk in subsequent phase III trials. Only then can they be considered as validated surrogate endpoint biomarkers and used as stand-alone efficacy markers in phase II trials. Despite accrual challenges and technologic hurdles, interest in phase I and phase II chemoprevention trials is high.

Breast cytology and biomarkers obtained by random fine needle aspiration: use in risk assessment and early chemoprevention trials

In a prospective pilot study, we performed breast fine needle aspirations (FNAs) on 224 high-risk and 30 low-risk women and analyzed these aspirates for cytologic changes and biomarker abnormalities of aneuploidy and overexpressed estrogen receptor (ER), epidermal growth factor receptor (EGFR), p53 and HER-2/neu. High-risk women had a first-degree relative with breast cancer (74%), prior biopsy indicating premalignant breast disease (25%), a history of breast cancer (13%), or some multiple of these risk factors (12%). Median ages of the high- and low-risk groups were 44 and 42, respectively. Seventy percent of high-risk and 17% of low-risk women had cytologic evidence of hyperplasia with or without atypia (P < .0001). Aneuploidy and overexpression of EGFR and p53 occurred in 27, 37, and 29% of high-risk subjects but only 0, 3, and 3% of low-risk subjects (P < .0023). Overexpression of ER and HER-2/neu occurred in 7 and 20% of high-risk women but in none of the low-risk subjects. Biomarker abnormalities were more frequent with increasing cytologic abnormality. Restricting the analysis to those 3 biomarkers most frequently overexpressed in the high-risk group (ploidy, EGFR, p53), 13% of high-risk women with normal cytology, 19% of high-risk women with epithelial hyperplasia, and 49% of high-risk women with hyperplasia with atypia had abnormalities of 2 or more of these 3 biomarkers (P = .00004). At a median follow-up of 32 months, four women have been diagnosed with invasive cancer and two with ductal carcinoma in situ (DCIS). Later detection of these neoplastic conditions was associated (P < or = .016) by univariate analysis with prior FNA evidence of hyperplasia with atypia; overexpression of p53 and EGFR; the modified Gail risk of breast cancer development at 10 years; and multiple biomarker abnormalities. By multivariate analysis, later detection of cancer was primarily predicted by the number of biomarker abnormalities in the 3-test battery (P = .0005) and secondarily by the Gail risk at 10 years (P = .0049). In turn, hyperplasia with atypia was associated with multiple biomarker abnormalities, particularly p53 and EGFR overexpression. Thus, hyperplasia with atypia and cytologic markers in breast FNAs have promise as risk predictors and as surrogate endpoint biomarkers for breast cancer chemoprevention trials.

[Bone density of spongiosa and cortical bone of the lumbar spine. Relations to sex, age and spinal deformities in a regional collective of the European Study of Vertebral Osteoporosis (EVOS)]

BACKGROUND AND METHOD

In an additional bone density measurement protocol to the European Vertebral Osteoporosis Study (EVOS) separate spongious and cortical density measurements (sQCT) were carried out at the first 3 lumbar vertebrae in 293 volunteers (92 men and 201 women) in 3 Berlin regional centers.

RESULTS

The spongious mineral density decreases from proximal to distal (L1 to L3), the cortical density increases from proximal to distal, mainly in men. Men showed no significant decrease of cortical density and a lower decrease of spongious density with age compared to women. A comparison of bone mineral density with vertebral height indices of McCloskey/Kanis, Eastell/Melton and Felsenberg showed significant differences of spongious density between a group with normal vertebral height and a group with at least one pathologically degraded vertebra. Individuals with osteoporosis according to the WHO-definition showed a higher prevalence of vertebral deformities. No significant loss of cortical density was observed in these people.

The identification of genes with unique and essential functions in the development of the zebrafish, Danio rerio

In a large-scale screen, we isolated mutants displaying a specific visible phenotype in embryos or early larvae of the zebrafish, Danio rerio. Males were mutagenized with ethylnitrosourea (ENU) and F2 families of single pair matings between sibling F1 fish, heterozygous for a mutagenized genome, were raised. Egg lays were obtained from several crosses between F2 siblings, resulting in scoring of 3857 mutagenized genomes. F3 progeny were scored at the second, third and sixth day of development, using a stereomicroscope. In a subsequent screen, fixed embryos were analyzed for correct retinotectal projection. A total of 4264 mutants were identified. Two thirds of the mutants displaying rather general abnormalities were eventually discarded. We kept and characterized 1163 mutants. In complementation crosses performed between mutants with similar phenotypes, 894 mutants have been assigned to 372 genes. The average allele frequency is 2.4. We identified genes involved in early development, notochord, brain, spinal cord, somites, muscles, heart, circulation, blood, skin, fin, eye, otic vesicle, jaw and branchial arches, pigment pattern, pigment formation, gut, liver, motility and touch response. Our collection contains alleles of almost all previously described zebrafish mutants. From the allele frequencies and other considerations we estimate that the 372 genes defined by the mutants probably represent more than half of all genes that could have been discovered using the criteria of our screen. Here we give an overview of the spectrum of mutant phenotypes obtained, and discuss the limits and the potentials of a genetic saturation screen in the zebrafish.

Patterns of recurrence for advanced colon cancer modified by whole abdominal radiation and chemotherapy

Abdominal failure for colonic carcinoma patients following curative resection has been high in patients with advanced disease stage, particularly when increased numbers of lymph nodes are involved. Surgeons desire curative treatment for their patients, but they interpret local and regional lymph node recurrence as a failure of surgical resection. The effect of current adjuvant treatment protocols on modifying patterns of relapse, particularly in the abdomen, has not been well studied and is of interest to surgeons. We analyzed reported patterns of failure of patients with Stage C2 colon cancer from two colon cancer adjuvant treatment studies; 5-FU plus levamisole (SWOG 8591) and 5-FU, whole-abdominal radiation, and tumor boost. The total number of recurrences in SWOG 8591 at all sites was reduced. The percent of lung relapses was reduced from 34 per cent to 20 per cent in the treatment group, but the percentage of local relapse increased from 20 per cent in the observation group to 27 per cent in the 5-FU plus levamisole group. Similarly, the number of first relapses was fewer at a local site in the 5-FU plus levamisole group, but the percent of relapses at the local site was not reduced (18 vs. 22%). Advanced C2 patients who received regional treatment on 5FU and whole-abdominal radiation produced the lowest percent of local relapse (12%), suggesting a benefit for regional treatment. Further study of patterns of relapse after resection and adjuvant treatment in high risk C2 patients may lead to further progress in control of advanced, curative colon carcinoma.