Folic acid supplementation in postmenopausal women with hot flushes: phase III randomised double-blind placebo-controlled trial

OBJECTIVE

To assess whether folic acid supplementation ameliorates hot flushes.

DESIGN

Double-blind, placebo-controlled randomised trial.

SETTING

Nine hospitals in England.

POPULATION

Postmenopausal women experiencing ≥50 hot flushes weekly.

METHODS

Women (n = 164) were randomly assigned in a 1:1 ratio to receive folic acid 5 mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in a Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-week intervals.

MAIN OUTCOME MEASURES

The change in daily Hot Flush Score at week 12 from randomisation based on Sloan Diary Composite Score B calculation.

RESULTS

Data of 143 (87%) women were available for the primary outcome. The mean change (SD) in Hot Flush Score at week 12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI -5.68 to 0.87) (P = 0.149) and in the adjusted mean change -2.61 (95% CI -5.72 to 0.49) (P = 0.098). Analysis of secondary outcomes indicated an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week 8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI 1.16-9.28) and 1.88 (95% CI 0.23-3.52) for total and emotional score, respectively.

CONCLUSIONS

The study was not able to demonstrate that folic acid had a statistically significant greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo.

TWEETABLE ABSTRACT

Folic acid may ameliorate hot flushes in postmenopausal women but confirmation is required from a larger study.

Defining trajectories of response in patients with psoriasis treated with biologic therapies

BACKGROUND

The effectiveness and cost-effectiveness of biologic therapies for psoriasis are significantly compromised by variable treatment responses. Thus, more precise management of psoriasis is needed.

OBJECTIVES

To identify subgroups of patients with psoriasis treated with biologic therapies, based on changes in their disease activity over time, that may better inform patient management.

METHODS

We applied latent class mixed modelling to identify trajectory-based patient subgroups from longitudinal, routine clinical data on disease severity, as measured by the Psoriasis Area and Severity Index (PASI), from 3546 patients in the British Association of Dermatologists Biologics and Immunomodulators Register, as well as in an independent cohort of 2889 patients pooled across four clinical trials.

RESULTS

We discovered four discrete classes of global response trajectories, each characterized in terms of time to response, size of effect and relapse. Each class was associated with differing clinical characteristics, e.g. body mass index, baseline PASI and prevalence of different manifestations. The results were verified in a second cohort of clinical trial participants, where similar trajectories following the initiation of biologic therapy were identified. Further, we found differential associations of the genetic marker HLA-C*06:02 between our registry-identified trajectories.

CONCLUSIONS

These subgroups, defined by change in disease over time, may be indicative of distinct endotypes driven by different biological mechanisms and may help inform the management of patients with psoriasis. Future work will aim to further delineate these mechanisms by extensively characterizing the subgroups with additional molecular and pharmacological data.

Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial

BACKGROUND

Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large-scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology.

METHODS

LaCeS was designed as a prospective, multicentre, single-blind, parallel-group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery.

RESULTS

A total of 64 patients were recruited across five centres. The overall mean steady-state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health-related quality-of-life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30-day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open arm.

CONCLUSION

Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 ( http://www.controlled-trials.com).

AB0356 TARGETING THE RHEUMATOID ARTHRITIS SYNOVIAL FIBROBLAST VIA CYCLIN DEPENDENT KINASE INHIBITION (TRAFIC): A PHASE 1B STUDY TO DETERMINE THE MAXIMUM TOLERATED DOSE OF SELICICLIB FOR REPURPOSING IN RHEUMATOID ARTHRITIS

Background:

Current rheumatoid arthritis (RA) therapeutics target immune inflammation and are subject to ceiling effects, with non-response observed in a third of recipients together with low remission rates. Synovial fibroblasts (SFs) are stromal cells not yet targeted in RA, whose hyperplastic and proliferative properties drive inflammation and tissue destruction. Seliciclib (R-roscovitine) is an orally available cyclin-dependent kinase (CDK) inhibitor that suppresses SF proliferation and ameliorates inflammatory arthritis in rodents.

Objectives:

To determine the maximum tolerated dose (MTD) of seliciclib in patients with active RA despite anti-TNF, with or without background conventional disease modifying anti-rheumatic drugs (cDMARDs). Safety and pharmacokinetics (PK) were also evaluated.

Methods:

A restricted, one-stage Bayesian continual reassessment method (CRM) determined MTD based on a target dose-limiting toxicity (DLT) probability of 35%. RA patients (DAS28 ≥3.2) were recruited sequentially to cohorts of 3 subjects each. Cohort 1 received 400mg seliciclib daily for 4 consecutive days each week for 4 weeks, added to existing therapy. Each subsequent cohort received a dose determined by the toxicity-based CRM algorithm, calculated upon conclusion of the previous cohort. Safety was assessed through adverse event (AE) monitoring. Associations with relevant PK parameters were sought.

Results:

15 anti-TNF recipients were enrolled, 10 of whom were also taking cDMARDs (median DAS28 4.9). Application of the CRM algorithm prompted one dose increment during the study (to 600mg for cohort 2), but reversion to 400mg for subsequent cohorts (Figure 1A). After treatment of 5 cohorts, 400mg was determined the MTD, with a DLT probability of 0.35 (CI 0.18-0.52; Figure 1B). 6 patients experienced DLTs, of which two were classified as serious AEs (SAEs) in keeping with the safety profile of seliciclib; these are summarised in Table 1. Of 43/65 total AEs reported at any dose that didnotcontribute to a DLT, 26 were possibly, probably or definitely related to seliciclib; 19 of these 26 were mild, 7 moderate and none severe. The most frequent AE was mild nausea. No relationship of safety and/or tolerability with concomitant cDMARD use or PK was seen.

Table 1.

Characteristics of patients who developed HZ at initiation of baricitinib

DLTSeliciclib dose (mg)Doses receivedContributing AEsContributing SAEsDescriptionOutcomeA1400830Constipation, N+V, liver injury; fatigue.Resolved2600430Constipation, N+V.Resolved3600101BFever, N+V, renal injury.Resolved4400831BConstipation, N+V, jaundice, liver injury.Resolved5400840Fever, dizziness, liver injury.Resolved6400890Dizziness, N+V, liver injury, bilirubin rise.Persistent AST rise

Conclusion:

The MTD of seliciclib has been defined for RA. No unexpected safety concerns were identified to preclude ongoing evaluation in patients, which focuses on clinical, radiological and biological indicators of efficacy.

Disclosure of Interests:

Arthur Pratt Grant/research support from: Pfizer, GlaxoSmithKlein, Stefan Siebert Grant/research support from: BMS, Boehringer Ingelheim, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Boehringer Ingelheim, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Celgene, Janssen, Novartis, Michael Cole: None declared, Deborah Stocken: None declared, Stephen Kelly: None declared, Muddassir Shaikh: None declared, Amy Cranston: None declared, Miranda Morton: None declared, Jennifer Walker: None declared, Sheelagh Frame Employee of: Cyclacel Ltd., Wan-fai Ng: None declared, Chris Buckley Consultant of: Janssen, Pfizer, GSK, Galapagos, Gillead, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Andrew Filer: None declared, John D Isaacs Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche

P666Anti-platelet therapy in the primary prevention of cardiovascular disease in patients with chronic obstructive pulmonary disease: randomised controlled proof of concept trial (APPLE COPD-ICON 2)

Acknowledgement/Funding

Astra Zeneca (Funder reference number ISSBRIL0303)

Psoriasis treat to target: defining outcomes in psoriasis using data from a real-world, population-based cohort study (the British Association of Dermatologists Biologics and Immunomodulators Register, BADBIR)

Background

The ‘treat to target’ paradigm improves outcomes and reduces costs in chronic disease management but is not yet established in psoriasis.

Objectives

To identify treatment targets in psoriasis using two common measures of disease activity: Psoriasis Area and Severity Index (PASI) and Physician's Global Assessment (PGA).

Methods

Data from a multicentre longitudinal U.K. cohort of patients with psoriasis receiving systemic or biologic therapies (British Association of Dermatologists Biologics and Immunomodulators Register, BADBIR) were used to identify absolute PASI thresholds for 90% (PASI 90) and 75% (PASI 75) improvements in baseline disease activity, using receiver operating characteristic curves. The relationship between PGA (clear, almost clear, mild, moderate, moderate–severe, severe) and PASI (range 0–72) was described, and the concordance between absolute and relative definitions of response was determined. The same approach was used to establish treatment response and eligibility definitions based on PGA.

Results

Data from 13 422 patients were available (58% male, 91% white ethnicity, mean age 44·9 years), including over 23 000 longitudinal PASI and PGA scores. An absolute PASI ≤ 2 was concordant with PASI 90 and an absolute PASI ≤ 4 was concordant with PASI 75 in 90% and 88% of cases, respectively. These findings were robust to subgroups of timing of assessment, baseline disease severity and treatment modality. PASI and PGA were strongly correlated (Spearman's rank correlation coefficient 0·92). The median PASI increased from 0 (interquartile range 0–0, range 0–23) to 19 (interquartile range 15–25, range 0–64) for PGA clear to severe, respectively. PGA clear/almost clear was concordant with PASI ≤ 2 in 90% of cases, and PGA moderate–severe severe was concordant with the National Institute for Health and Care Excellence PASI eligibility criteria for biologics in 81% of cases.

Conclusions

An absolute PASI ≤ 2 and PGA clear/almost clear represent relevant disease end points to inform treat‐to‐target management strategies in psoriasis.

What's already known about this topic?

The most commonly used relative disease activity measure in psoriasis is ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90); however, it has several limitations including dependency on a baseline severity assessment.

Defining an absolute target disease activity end point in psoriasis has the potential to improve patient outcomes and reduce costs, as demonstrated by treat‐to‐target approaches in other chronic diseases such as hypertension and diabetes.

The Physician's Global Assessment (PGA) is a popular alternative measure of psoriasis severity in daily practice; however, its utility has not been formally assessed with respect to PASI.

What does this study add?

An absolute PASI ≤ 2 corresponds with PASI 90 response and is a relevant disease end point for treat‐to‐target approaches in psoriasis.

There is a strong correlation between PASI and PGA.

PGA moderate–severe/severe may serve as an alternative eligibility criterion for biologics to PASI‐based definitions, and PGA clear/almost clear is an appropriate alternative absolute treatment end point.

What are the clinical implications of this work?

Absolute PASI ≤ 2 and PGA clear/almost clear represent relevant disease end points to inform treat‐to‐target management strategies in psoriasis.

Linked Editorial: Takeshita. Br J Dermatol 2020; 182:1075–1076.

Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10 years

Background

Juxtarenal abdominal aortic aneurysms pose a significant challenge whether managed endovascularly or by open surgery. Fenestrated endovascular aneurysm repair (FEVAR) is now well established, but few studies have compared it with open surgical repair (OSR). The aim of this systematic review was to compare short‐ and long‐term outcomes of FEVAR and OSR for the management of juxtarenal aortic aneurysms.

Methods

A literature search was conducted of the Ovid Medline, EMBASE and PubMed databases. Reasons for exclusion were series with fewer than 20 patients, studies published before 2007 and those concerning ruptured aneurysms. Owing to variance in definitions, the terms ‘juxta/para/suprarenal’ were used; thoracoabdominal aortic aneurysms were excluded. Primary outcomes were 30‐day/in‐hospital mortality and renal insufficiency. Secondary outcomes included major complication rates, rate of reintervention and rates of endoleak.

Results

Twenty‐seven studies were identified, involving 2974 patients. Study designs included 11 case series, 14 series within retrospective cohort studies, one case–control study and a single prospective non‐randomized trial. The pooled early postoperative mortality rate following FEVAR was 3·3 (95 per cent c.i. 2·0 to 5·0) per cent, compared with 4·2 (2·9 to 5·7) per cent after OSR. After FEVAR, the rate of postoperative renal insufficiency was 16·2 (10·4 to 23·0) per cent, compared with 23·8 (15·2 to 33·6) per cent after OSR. The major early complication rate following FEVAR was 23·1 (16·8 to 30·1) per cent versus 43·5 (34·4 to 52·8) per cent after OSR. The rate of late reintervention after FEVAR was higher than that after OSR: 11·1 (6·7 to 16·4) versus 2·0 (0·6 to 4·3) per cent respectively.

Conclusion

No significant difference was noted in 30‐day mortality; however, FEVAR was associated with significantly lower morbidity than OSR. Long‐term durability is a concern, with far higher reintervention rates after FEVAR.

Identifying demographic, social and clinical predictors of biologic therapy effectiveness in psoriasis: a multicentre longitudinal cohort study

Background

Biologic therapies have revolutionized the treatment of moderate‐to‐severe psoriasis. However, for reasons largely unknown, many patients do not respond or lose response to these drugs.

Objectives

To evaluate demographic, social and clinical factors that could be used to predict effectiveness and stratify response to biologic therapies in psoriasis.

Methods

Using a multicentre, observational, prospective pharmacovigilance study (BADBIR), we identified biologic‐naive patients starting biologics with outcome data at 6 (n = 3079) and 12 (n = 3110) months. Associations between 31 putative predictors and outcomes were investigated in univariate and multivariable regression analyses. Potential stratifiers of treatment response were investigated with statistical interactions.

Results

Eight factors associated with reduced odds of achieving ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) at 6 months were identified (described as odds ratio and 95% confidence interval): demographic (female sex, 0·78, 0·66–0·93); social (unemployment, 0·67, 0·45–0·99); unemployment due to ill health (0·62, 0·48–0·82); ex‐ and current smoking (0·81, 0·66–0·99 and 0·79, 0·63–0·99, respectively); clinical factors (high weight, 0·99, 0·99–0·99); psoriasis of the palms and/or soles (0·75, 0·61–0·91); and presence of small plaques only compared with small and large plaques (0·78, 0·62–0·96). White ethnicity (1·48, 1·12–1·97) and higher baseline PASI (1·04, 1·03–1·04) were associated with increased odds of achieving PASI 90. The findings were largely consistent at 12 months. There was little evidence for predictors of differential treatment response.

Conclusions

Psoriasis phenotype and potentially modifiable factors are associated with poor outcomes with biologics, underscoring the need for lifestyle management. Effect sizes suggest that these factors alone cannot inform treatment selection.

What's already known about this topic?

Biologic therapy used in the treatment of moderate‐to‐severe psoriasis differs in its effectiveness across patients.

Previous research has indicated that patients with a higher body mass index, who smoke or who have smoked, and with a lower baseline Psoriasis Area and Severity Index (PASI) are less likely to have a good outcome with biologic therapy for the treatment of moderate‐to‐severe psoriasis.

What does this study add?

This large‐scale study in a real‐world setting confirms that weight, smoking status and baseline PASI are associated with effectiveness of biologic therapy.

There is evidence that non‐white ethnicity, female sex, unemployment, psoriasis of the palms and soles and the presence of small chronic plaques are associated with poor outcomes with biologics.

There is some evidence that men have a comparatively worse response to etanercept, relative to adalimumab, than women. Otherwise, most factors do not appear to be predictors of differential treatment response.

Respond to this article

A Case Control and Follow-up Study of “Hard to Reach” Young People Who also Suffered from Multiple Complex Mental Disorders

Aims

To describe the mental disorders and social function of the hard to reach young people (HTRYP) from the innovations project (IP) and compare to a matched sample from a community mental health team (CMHT).

Background

IP was a new multidisciplinary team based within an inner city, walk-in health centre, North East England (throughout 2011).

Methods

Phase 1 and 2: retrospective review of clinical case notes of YP who attended the IP and CMHT. Phase 3: 24-months follow-up evaluation of the mental state and social function, using Health of the Nation Outcome Scales for Child and Adolescent Mental Health (HoNOSCA) and Children's Global Assessment Scale (CGAS).

Results

Overall, 36 referrals accepted by the IP, 31 met criteria for HTRYP, 15 were offered individually tailored therapy. IP group experienced more deprivation compared to the CMHT matched sample (n = 115). At baseline, the HTRYP had more mental disorders, higher severity scores and lower levels of social function (HTRYP HoNOSCA mean: 19.1 and CMHT mean: 11.2 P = < 0.001 and HTRYP CGAS mean: 51.0, CMHT mean: 58.9, P = 0.05). The HTRYP made significantly greater improvement compared to CMHTYP; (HoNOSCA P = < 0.001 and CGAS P = < 0.002). Thirteen HTRYP attended the follow-up review at 24 months compared with nine of CMHTYP. There was great variability in terms of social function between the YP within each sample.

Conclusion

The term “HTR” describes a state, which the YP may be at a particular point their lives. A service, which utilises a developmental theoretical framework, offers regular reviews and an individualised care plan, could reduce longer-term morbidity and mortality suffered by HTRYP.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The inter-relationship of symptom severity and quality of life in 2055 patients with primary biliary cholangitis

BACKGROUND

Age at presentation with primary biliary cholangitis (PBC) is associated with differential response to ursodeoxycholic acid (UDCA) therapy. Younger-presenting patients are less likely to respond to treatment and more likely to need transplant or die from the disease. PBC has a complex impact on quality of life (QoL), with systemic symptoms often having significant impact.

AIM

To explain the impact of age at presentation on perceived QoL and the inter-related symptoms which impact upon it.

METHODS

Using the UK-PBC cohort, symptoms were assessed using the PBC-40 and other validated tools. Data were available on 2055 patients.

RESULTS

Of the 1990 patients reporting a global PBC-QoL score, 66% reported good/neutral scores and 34% reported poor scores. Each 10-year increase in age at presentation was associated with a 14% decrease in risk of poor perceived QoL (OR = 0.86, 95% CI: 0.75-0.98, P < 0.05). All symptom domains were similarly age-associated (P < 0.01). Social dysfunction was the symptom factor with the greatest impact on QoL. Median (interquartile range) PBC-40 social scores for patients with good perceived QoL were 18 (14-23) compared with 34 (29-39) for those with poor QoL.

CONCLUSION

The majority of patients with primary biliary cholangitis do not feel their QoL is impaired, although impairment is reported by a sizeable minority. Age at presentation is associated with impact on perceived QoL and the symptoms impairing it, with younger patients being more affected. Social dysfunction makes the greatest contribution to QoL impairment, and it should be targeted in trials aimed at improving life quality.

REpeated AutoLogous Infusions of STem cells In Cirrhosis (REALISTIC): a multicentre, phase II, open-label, randomised controlled trial of repeated autologous infusions of granulocyte colony-stimulating factor (GCSF) mobilised CD133+ bone marrow stem cells in patients with cirrhosis. A study protocol for a randomised controlled trial

INTRODUCTION

Liver disease mortality and morbidity are rapidly rising and liver transplantation is limited by organ availability. Small scale human studies have shown that stem cell therapy is safe and feasible and has suggested clinical benefit. No published studies have yet examined the effect of stem cell therapy in a randomised controlled trial and evaluated the effect of repeated therapy.

METHODS AND ANALYSIS

Patients with liver cirrhosis will be randomised to one of three trial groups: group 1: Control group, Standard conservative management; group 2 treatment: granulocyte colony-stimulating factor (G-CSF; lenograstim) 15 µg/kg body weight daily on days 1-5; group 3 treatment: G-CSF 15 µg/kg body weight daily on days 1-5 followed by leukapheresis, isolation and aliquoting of CD133+ cells. Patients will receive an infusion of freshly isolated CD133+ cells immediately and frozen doses at days 30 and 60 via peripheral vein (0.2×10(6) cells/kg for each of the three doses). Primary objective is to demonstrate an improvement in the severity of liver disease over 3 months using either G-CSF alone or G-CSF followed by repeated infusions of haematopoietic stem cells compared with standard conservative management. The trial is powered to answer two hypotheses of each treatment compared to control but not powered to detect smaller expected differences between the two treatment groups. As such, the overall α=0.05 for the trial is split equally between the two hypotheses. Conventionally, to detect a relevant standardised effect size of 0.8 point reduction in Model for End-stage Liver Disease score using two-sided α=0.05(overall α=0.1 split equally between the two hypotheses) and 80% power requires 27 participants to be randomised per group (81 participants in total).

ETHICS AND DISSEMINATION

The trial is registered at Current Controlled Trials on 18 November 2009 (ISRCTN number 91288089, EuDRACT number 2009-010335-41). The findings of this trial will be disseminated to patients and through peer-reviewed publications and international presentations.

Diagnostic and mechanistic implications of serum free light chains, albumin and alpha-fetoprotein in hepatocellular carcinoma

BACKGROUND

Mass spectroscopy analysis suggested low serum albumin and high immunoglobulin free light chain (sFLC) levels may have diagnostic value in hepatocellular carcinoma (HCC). Our aims were to apply quantitative assays to confirm these observations, determine their diagnostic utility, and investigate the mechanisms involved.

METHODS

Albumin, sFLC, routine liver and renal function tests were measured in patients with chronic liver disease with (n=102) and without (n=113) HCC. The discriminant performance was compared with the current standard serological test alpha-fetoprotein (AFP) using receiver operating characteristic (ROC) and area under the curve (AUC) analyses.

RESULTS

sFLC and serum albumin were each confirmed to have discriminatory utility in HCC with AUC values of 0.7 and 0.8, respectively. sFLC were strongly correlated with gammaglobulin levels and both these were inversely related to serum albumin levels. The discriminatory utility of sFLC was retained after adjusting for renal and liver function.

CONCLUSIONS

Serum levels of sFLC and albumin were strongly associated with HCC as predicted by mass spectroscopy. Discrimination of HCC by AFP was improved by the addition of either albumin or sFLC. Larger prospective studies are required to determine how AFP, sFLC and albumin might be combined in a useful diagnostic approach for HCC.

Do type 1 receptor tyrosine kinases inform treatment choice? A prospectively planned analysis of the TEAM trial

BACKGROUND

Epidermal growth factor receptors contribute to breast cancer relapse during endocrine therapy. Substitution of aromatase inhibitors (AIs) may improve outcomes in HER-positive cancers.

METHODS

Tissue microarrays were constructed. Quantitative analysis of HER1, HER2, and HER3 was performed. Data were analysed relative to disease-free survival and treatment using outcomes at 2.75 and 6.5 years.

RESULTS

Among 4541 eligible samples, 4225 (93%) had complete HER1-3 data. Overall, 5% were HER1-positive, 13% HER2-positive, and 21% HER3-positive; 32% (n=1351) overexpressed at least one HER receptor. In the HER1-3-negative subgroup, the hazard ratio (HR) for upfront exemestane vs tamoxifen at 2.75 years was 0.67 (95% confidence interval (CI), 0.52-0.87), in the HER1-3-positive subgroup, the HR was 1.15 (95% CI, 0.85-1.56). A prospectively planned treatment-by-marker analysis demonstrated a significant interaction between HER1-3 and treatment at 2.75 years (HR=0.58; 95% CI, 0.39-0.87; P=0.008), as confirmed by multivariate regression analysis adjusting for prognostic factors (HR=0.55; 95% CI, 0.36-0.85; P=0.005). This effect was time dependent.

CONCLUSION

In the 2.75 years prior to switching patients initially treated with tamoxifen to exemestane, a significant treatment-by-marker effect exists between AI/tamoxifen treatment and HER1-3 expression, suggesting HER expression could be used to select appropriate endocrine treatment at diagnosis to prevent or delay early relapses.

Abstract P3-10-04: An Integration of Biological and Pathological Marker Panel in the TEAM Pathology Sub-Study: The Impact of Different Parameters on Risk Estimation of Relapse at Both 2.75 and 5 Years

Background: Recent evidence confirms the importance of both biological and pathological risk markers in predicting early relapse for breast cancer patients treated with endocrine therapy. Most studies use a two step process integrating biological markers into a “biological predictor (e.g. Oncotype Dx, “IHC4” etc) followed by assessment of the predictive value of such tests in the context of pathological markers (grade, nodal status etc). We have taken a one step process integrating both biological and pathological markers into a single model to assess key factors for predicting outcome at 2.75 years and 5 years of endocrine therapy; to inform choices between switching, upfront and extended adjuvant treatment with AIs. Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative analysis ER, PgR, Ki67, HER1, HER2, and HER3 was performed centrally. A prognostic model, integrating data from biological and pathological markers was created to assess risk (disease-free survival) after 2.75 and 5 years of follow up in the TEAM trial.

Results: Of 4595 eligible cases samples received, 16 were excluded, and 3993 had complete biomarker data for all markers for the final biomarker analysis. In univariate analysis nodal status, grade, size, age at diagnosis, HER1, HER2, PgR, ER and Ki67 were all prognostic. At 2.75 years nodal status, age, PgR histoscore, size, grade, HER2, ER histoscore and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), Ki67 and HER3 were not included in this model. At 5 years median follow up; age, nodal status, size, PgR histoscore, grade, Ki67, HER2, and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), ER and HER3 were not included in this model. Conclusion: Combined biological and pathological marker panels are of significant value in predicting early relapse in breast cancer patients treated with endocrine therapy, however duration of follow-up may impact on the inclusion of variables in the model. This provides significant information relevant to the choice of different adjuvant endocrine therapies.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-04.

Abstract P4-08-02: A Comparison between AQUA Quantitative Fluorescent Immunohistochemistry and Conventional Immunohistochemistry for Hormone Receptors

Background: We have previous data showing that quantitation of hormone receptors can be highly informative in determining risk of early relapse in ER positive early breast cancer treated with tamoxifen or exemestane. Both quantitative immunohistochemistry (QIHC) and flouresecent immunohistochemistry (F-IHC as measured by AQUA technology) are highly prognostic over a wide expression range. We have explored the results of both assays to determine if current assays provide maximum information using current approaches.

Patients &

Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative AQUA and IHC analysis (using image quantitation) of ER and PgR was performed centrally (Edinburgh & HistoRx). Results from both assays were compared and their prognostic impact on DFS at 2.75 years examined.

Results: Both AQUA and QIHC demonstrated linear relationships between intensity of staining for either ER or PgR and DFS at 2.75 years. For both PgR and ER AQUA provided significantly greater prognostic information that QIHC. However AQUA staining explained only 29% and 68% of the variability in ER and PgR QIHC results by logistic regression. Using both AQUA and QIHC data in a forward stepwise selection survival model demonstrated that AQUA and QIHC provided similar prognostic information over 70% and 50% of the range for ER and PgR respectively. High ER QIHC and low ER AQUA scores, and low PgR IHC and high PgR AQUA scores provided prognostic information unique to either platform.

Conclusion: Both QIHC and AQUA analysis of HR expression provides significant and highly important information on DFS risk in early breast cancer. It appears that these two platforms provide overlapping prognostic information and that the range of ER and PgR expression which impacts patient outcome is wider than measured by either system alone. Further investigation of the clinical significance of this broader range of hormone receptor expression in treatment decisions is warranted.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-08-02.